Cuts muddle mental care releases

Plans for downsizing Western State Hospital rely on spending more money in the world outside the hospital grounds. But in the same breath as state government promises to find treatment for discharged patients, it’s talking about deep cuts in the places they would go.

Outpatient mental health treatment would take a hit in state agencies’ outline of how they would make 10 percent cuts. So would the private residential facilities where some hospital patients might end up living.

“It looks like they’re cutting community services at the same time they’re expecting folks who have been in the hospitals to survive without the support they need,” said Donna Obermeyer, a parent of two adults with mental illness and founder of Family Alliance for Mental Health in Thurston and Mason Counties.

It’s not as if agencies are advocating for these cuts. With a budget that is $1.3 billion bigger than what the state now expects to have to spend, they were forced to draw up options for Gov. Chris Gregoire and state lawmakers.

Social and Health Services Secretary Susan Dreyfus, as she laid out the possible cuts to the public at a meeting in Tacoma last week, called the deepest of them “unconscionable.”

COMPLICATES RELEASE

That worst-case scenario for Dreyfus includes an agency-wide reduction in eligibility affecting more than 80,000 people, including 17,000 elderly or disabled people in home care or private residential facilities who don’t require extensive help with daily activities. Nearly all drug and alcohol treatment for adults would be abolished. In the mental health system, more than 3,000 people would be completely cut off from treatment and 29,000 more could see that care reduced.

If that $340 million cut in state funding is the nuclear option, the proposed discharge of up to 150 patients from Western State Hospital represents some of the less drastic cuts in the eyes of state officials.

Those patients have been decertified, Dreyfus said in an interview, meaning they aren’t pulling down federal money and they are ready for release if there were a place for them to go.

“We should not be housing decertified mental health patients at $560 a day. It isn’t right, and it fiscally makes no sense,” she said.

In particular, finding private facilities for older patients with dementia – who account for roughly 60 of the 150 targeted slots – is a priority for the hospital.

But Dreyfus acknowledged the release of the other, younger patients back into communities would be “very difficult” if the big reduction in eligibility materializes. In that case, the safety net “will have been so decimated,” she said, that “those home and community-based options aren’t there.”

No one will be discharged until it’s determined their needs will be met, Dreyfus said.

Even if thousands are turned out of nursing homes, adult family homes, assisted living and home care, DSHS says the most medically complex patients would continue to receive money. And that surely would include the former Western State patients – some of whom have histories of violent behavior.

Cuts to residential facilities could, of course, lead to reductions in staffing or even threaten the homes’ ability to keep their doors open. But MaryAnne Lindeblad, assistant secretary for aging and disability services, said the department with its list of options avoided hitting the most vulnerable by mostly staying away from cuts to the facilities’ per-resident payment rates.

“This is all about trying to maintain enough capacity in the system to try to serve folks who are still eligible,” Lindeblad said.

HOSPITALS, JAILS

DSHS acknowledges in its description of reductions that those cut off from treatment likely will end up being paid for by the government in other ways. They could clog mental health crisis centers, emergency rooms and jails.

“If they don’t receive that short-term treatment because they’re no longer eligible, some of them will likely turn into a more chronic issue and their condition deteriorate,” said John Masterson, CEO of Olympia-based Behavioral Health Resources. “And the outcome of that process would mean more-expensive hospitalization.”

In Pierce County, the only place in Washington where mental health treatment is managed by a for-profit company, fewer patients are being hospitalized since Minnesota-based OptumHealth took over. The county has focused heavily on a quick response to patients in crisis.

But crisis services are funded mainly by money that comes from the state outside Medicaid, funding that DSHS says has taken a 14.5 percent cut and in one scenario stands to be sliced 3 percent more.

FINDING HOMES

Pierce County’s community mental health professionals in particular have had success moving patients out of Western State, said Dick Towell, CEO of Lakewood’s Greater Lakes Mental Healthcare. They helped find places for dozens of them between January 2008 and June 2009 before the OptumHealth changeover, and the hospital’s population from Pierce County has stayed low since then, Towell said.

Patients were matched with roommates or families that would take them in, and connected to outpatient treatment, Towell said.

That bodes well for the proposed closure of five wards, said Towell – but the history of ward closures doesn’t.

“In the past when they’ve closed the wards, they just haven’t sent the money to the community,” Towell said.

At the meeting where Dreyfus laid out her agency’s ideas, Ghasem Nahvipour told officials he is developing a plan to find housing. The CEO of Tacoma-based Comprehensive Mental Health said he figures independent housing for some of the patients being targeted could cost the state $30,000 a year, compared with $200,000 at the state hospital.

Nahvipour said his agency, which is renaming itself Comprehensive Life Resources, has helped find places to live for hundreds of Western State patients over the years, including some longtime residents who some had figured would be there for good.

Other possibilities are nursing homes, assisted living and other facilities.

DSHS calls for designating part of the money saved by the downsizing to go to such long-term care. Nursing homes might use it to train their staff to calm potentially aggressive residents, or to boost their certification or insurance in light of a riskier population.

But it’s unclear whether the Western State patients under consideration would even be eligible for nursing homes, said Rich Miller, president of the Washington Health Care Association – an advocacy group for nursing and assisted-living homes.

And nursing home owners might be reluctant to mix them with their other residents and train all their employees how to deal with a very different population that would mix with the current residents.

“That’s why places like Western State were created,” Miller said, “because you’re providing a very specialized level of care.”

Jordan Schrader: 360-786-1826
jordan.schrader@thenewstribune.com
blog.thenewstribune.com/politics

MENTAL HEALTH CUTS

The Department of Social and Health Services laid out options for how state lawmakers could cut, ranking them into three tiers. Tier 1 cuts are part of the department’s strategy. The agency considers Tier 2 cuts “difficult but doable,” while saying Tier 3 cuts should be done only if the agency has no other choice but to cut 10 percent of its budget. Here are some of the cuts affecting mental health care.

Tier 1

• Close two wards at Western State Hospital that house mostly elderly patients with dementia.

• Consolidate 13 regional agencies that manage mental health spending into four, five or six.

• Delay an expansion of eligibility for involuntary commitment to hospitals.

Tier 2

• Downsize state hospitals further by closing four more wards, including three at Western State.

• Reduce funding for community mental health services by about 4 percent by cutting Medicaid rates.

• End funding for programs that help patients find jobs and provide support to their caregivers.

Tier 3

• About 3,550 people with less-severe conditions would no longer be eligible for community mental health care, and up to another 29,000 could have their care reduced. State-only funding for community care would be trimmed 3 percent on top of previous cuts of 14.5 percent. These cuts would be part of an agency-wide DSHS cut affecting more than 80,000 people.

Other agencies

The state Health Care Authority says 10 percent cuts would require suspending Medicaid prescription drug coverage, with patients in nursing homes and hospitals among the few exceptions. This would include psychiatric drugs.