Adrift, mentally ill drift into hospitals

Westchester County Business Journal, Feb 11, 2008 by Woods, Lynn

When the state of New York closed many of its psychiatric hospitals stinting in the 1970s, the intent was to house the mentally ill in alternative residential settings that were more humane and less curtly. Instead, many mentally ill people ended up on the streets or in prison. In the Hudson Valley, the hospital emergency department has become the place of last resort, and hospital beds are housing mentally ill people because there's no where else for them to go, putting a huge financial burden on those facilities.

Take Saint Francis hospital, which is the only hospital in Dutchess County that has a psychiatric ward. The demand for the care of often combative, disoriented individuals arriving at the emergency room greatly exceeds the capacity of the ward, which has 59 beds. Many patients stay far longer than is merited in an acute-care facility because of lack of space elsewhere.

"Saint Francis was never meant to be a full-term mental-home facility, but because there's no place to send people to, there's no place for them to stay but here," said Bob Savage, Saint Francis' CEO and president He said as of last August seven patients had been in the ward for as long as 69 to 229 days. That's equivalent to treating 67 patients staying 12 days, which is the hospital's average length of stay, said Savage.

He said the hospital can ill afford the cost: last year, it spent $1,325,000 more to care for the mentally ill than in 2006. That pretty much wiped out the hospital's bottom-line budget of $1.3 million, preventing the not-for-profit facility from making necessary re-investments in its facility and programs.

Savage said the hospital in some cases is absorbing mentally ill people coming from as far away as Syracuse or St. Lawrence because of lack of beds. When its own ward is full, it sends patients to facilities in neighboring counties or Manhattan, creating a hardship on the patients' families because of the distance.

Treating the mentally ill also is a drain on the staff. Savage said a mentally ill person who is aggressively resisting treatment and is physically ill may have to be watched around the clock, requiring up to a dozen employees. In addition, the hospital spends about $15,000 a month on legal fees. Lack of involvement from families and the unwillingnss of a possibly suicidal or dangerous person to be treated in many cases require a hospital attorney go to court to declare the person incompetent so that treatment can be provided. Savage said this cost is going up as the incidences of severely disturbed people showing up at the hospital is increasing.

Savage said the mentally ill patients are also getting younger, with some children as young as 3 or 4 years old arriving. The hospital won't turn anyone away, although many of the mentally ill people are on Medicaid or uninsured and therefore "generally don't reimburse well." "We have great difficulty placing patients from ED who are no-pay if we're full," said Savage, referring to the emergency department. "We see ourselves as an acute medical-surgical facility and trauma center, but at this point, our other services subsidize these services."

Dutchess County used to have two psychiatric hospitals housing up to 11,000 people, but today it has only one, the state-run Hudson River Psychiatric Center (HRPC), in Poughkeepsie, which has been downsized to 125 beds. Dr. Roger Christenfeld, research director at HRPC, said that the facility also takes patients from hospitals in Putnam and Ulster counties and is primarily an out-patient facility.

Ideally, people would stay at the psych center for a period of days or weeks and then find some type of independent or semi-independent living situation, but the bottleneck in available community residencies is leading to much longer stays, which in turn has led to a waiting list for beds, he said.

While the median length of stay is 70 to 80 days, about a third of the patients have been at the HRPC much longer, in some cases for years. Christenfeld said the state's plan to provide funds for 500 more beds for the mentally ill "isn't enough," although it will certainly help. "It takes money," he said. Adding to the challenge is the "vastly rising cost of anti-psychotic medication and housing."

HRPC is providing a new service launched by the state called Assertive Community Treatment, in which staff go into the streets to treat mentally ill people who are homeless and in and out of prison. Christenfeld said the largest de facto institution for the mentally ill is the Los Angeles County Jail, with Riker Island in New York City a close second. "We find an increasing number of patients come to us through the criminal justice system," he said.

Despite the need, Dutchess County actually lost more than 100 beds over the past four years because some private community residences could no longer afford to stay in business according to Dr. Kenneth Glatt, the county's commissioner of mental hygiene. "There is a dearth of affordable housing. in general, and for the seriously mentally ill there is even a smaller supply," he said.