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Is Kansas Mental Health System Near Breaking Point?

File photo
Admissions at Osawatomie State Hospital have been limited during renovations meant to address issues raised by federal inspectors.

The filing of a murder charge against a former patient at the Osawatomie State Hospital is prompting questions about the state’s mental health system.

On May 14, Brandon Brown, 30, was released from a five-day stay at Osawatomie. He was sent to the state hospital after threatening other patients at the Haviland Care Center, a nursing facility in Kiowa County that specializes in treating adults with serious and persistent mental illness.

Brown, who has long struggled with schizophrenia, was returned to Haviland and on May 17 allegedly assaulted Jerry Martinez, 61, another patient there. Martinez was flown by air ambulance to Wesley Medical Center in Wichita, where he died 18 days later.

Brown, who now is being held in a locked security unit at Larned State Hospital, has been charged with second-degree murder.

“The allegations are that he pulled the victim out of bed and slammed his head to the floor several times,” said Kiowa County Attorney Scott James.

The Haviland incident and a recent report in the Topeka Capital-Journal about staffing shortages are intensifying concerns about operations at the state’s two hospitals for the mentally ill. The newspaper report said that nearly 40 percent of the full-time staff positions at Osawatomie State Hospital and 35 percent of those at Larned State Hospital recently were vacant.

“I’ve had a few incidents like this now,” James said. “I have to say they do lead me to wonder if the pressures — whether they be staffing pressures or budget pressures — are really starting to tax these mental health entities to a degree that’s not healthy for the state. I mean, if the state hospital isn’t there to house Mr. Brown, who is it there to house?”

 Preserving the safety net

James’ question is at the center of a long-simmering debate over the role of the state’s mental health hospitals in Osawatomie and Larned since lawmakers in the mid-1990s decided to close Topeka State Hospital and expand the state’s network of community-based programs.

This shift from institutional care to in-community care was driven by a desire to provide treatment that is less expensive, more effective and more humane.

But there are growing concerns about the adequacy of the safety net for those who continue to need intensive, inpatient care.

“This is all about having enough ‘ports in the storm’ for when people are in crisis,” said Frank Denning, sheriff of Johnson County. “When 17 percent of the people in (Johnson County) jail have been diagnosed as having a serious and persistent mental illness, it means we don’t have enough ‘ports.’ And when Osawatomie stopped taking voluntary admissions, it leaves us with fewer ‘ports.’”

KDADS officials limited voluntary admissions at the Osawatomie hospital late last year  after federal inspectors cited the facility for having too many patients and inadequate staffing levels, and for not doing enough to protect potentially suicidal patients.

Patients admitted voluntarily are those who have been deemed to be potentially dangerous to themselves or others but have not committed a crime and haven’t been sent for treatment under a court order. The limit on voluntary admissions was intended to reduce the patient census at the 206-bed hospital, which had a record 260 patients in October 2014.

Angela de Rocha, a spokesperson for the Kansas Department for Aging and Disability Services, said the effort to lower Osawatomie’s census created an opportunity to move patients who didn’t need to be in the hospital to more appropriate treatment settings.

“There had been increasing numbers of people who would be admitted, would get stabilized, would get on the right drugs and no longer be in crisis, but for whatever reason they were still at the hospital,” de Rocha said. “We were providing long-term hospitalization to folks who might be able to do better or who would be OK in the community.”

Over time, de Rocha said, these patients were moved to nursing homes or residential facilities that specialize in caring for people with mental illness, like the Haviland Care Center, or to drug and alcohol treatment programs.

“What we found was that these people still need care and support, but they don’t need acute care,” she said.

New urgency

In recent months state officials have worked more aggressively to lower the patient count at Osawatomie so that contractors could begin $3.1 million in renovations intended to address some of the issues raised by federal inspectors.

Those renovations are under way. As a consequence, KDADS was forced to halt admissions to ensure that the number of patients doesn’t exceed 146. That required the first-ever use of a 1986 law that allows officials to refuse involuntary admissions — patients that a court has ordered into treatment.

The freeze on admissions has added new urgency to concerns about the adequacy of the mental health system. But it also has led to innovations and greater coordination among state officials, community mental health providers and law enforcement.

The state has increased funding to community-based mental health programs in Sedgwick and Shawnee counties in an effort to replicate its success in converting Rainbow Mental Health Facility, once a 50-bed state-run hospital in Kansas City, Kan., to a 22-bed crisis-intervention facility that opened in April 2014.

The facility, now called Rainbow Services Inc. or RSI, found that many patients who earlier would have been admitted to the Kansas City or Osawatomie hospital instead could be stabilized and treated in a community-based setting.

KDADS data show that in its first year of operation, RSI diverted 125 would-be patients from the state hospitals, 132 from jail and 766 from emergency rooms in Wyandotte and Johnson counties.

Wyandotte, Johnson, Shawnee and Sedgwick counties account for 60 percent of admissions at Osawatomie State Hospital. Sedgwick County alone counts for a fourth of Osawatomie patients.

Marilyn Cook, executive director at COMCARE, the community mental health center in Wichita, said facilities like RSI provide a stable setting for mental health patients.

“So many individuals benefit from having a little time to be in a safe, calm environment and being able to settle, rather than immediate decisions being made to have them go somewhere,” Cook said.

Even prior to the reduction in Osawatomie admissions, she said the effort to redirect patients who didn’t need to be hospitalized was resulting in fewer referrals.

“In April of 2014, we did 109 state-hospital screens, and we approved 83,” Cook said. “This year, in April, we did 51 screens and approved only 23.”

To provide community mental health centers with additional options, Kansas lawmakers recently gave KDADS the authority to spend up to $3.45 million to cover the cost of treating patients refused admission to a state hospital at psychiatric units operated by hospitals in eight cities: Hutchinson, Garden City, Kansas City, Newton, Salina, Topeka, Merriam and Wichita. However, these units typically don’t admit involuntary patients.

No tracking system

For a variety of reasons — the admissions freeze and better planning among them — fewer people discharged from state hospitals for the mentally ill are ending up back in the hospital.

Still, it’s unclear how many former patients — Brandon Brown, for example — are ending up in jail or homeless and on the streets.

“All I can say, really, is that we’ve put them in appropriate, safe support situations,” said de Rocha, the KDADS spokesperson. “Now, these are folks who have a mental illness, and sometimes they make irrational decisions about where they’re going to be and what they’re going to do.”

The tendency to make irrational decisions, de Rocha said, doesn’t mean they need inpatient care at a state hospital.

The state has no system for tracking what happens to mental health patients once they leave treatment facilities. But there is plenty of anecdotal evidence that many continue to struggle.

“The national average is that somewhere between 16 and 20 percentof the people (in jail) have a mental illness,” said Brian Cole, head of the Shawnee County Corrections Department. “We’re close to 18 percent here in Shawnee County.”

Cole said he’s not noticed “a drastic increase” in the numbers of mentally ill inmates at the jail since the state hospital began limiting admissions.

“I think law enforcement, Valeo (mental health center) and the community of Topeka have done really well in diverting people from Osawatomie and in getting them services in the community,” Cole said. “We still see our fair share of people coming out of Osawatomie who become violent out in the community and end up coming to jail. But again, I wouldn’t say that we’ve seen an increase in that.”

He added: “We divert far more (mentally ill) people away from jail than we have come to jail.”

Similarly, Denning, the Johnson County sheriff, praised his office, neighboring police departments, Johnson County Community Mental Health Center and Rainbow Services for their collective efforts in keeping people out of jail and out of Osawatomie State Hospital.

“Law enforcement, I think, has a very good relationship with the community mental health center and with RSI,” he said. “We’ve been able to do some really good things.”

Breaking point

Despite the increased cooperation and coordination, there are indications that the Kansas mental health system is stressed and perhaps near a breaking point.

Janice Early, a spokesperson for Lawrence Memorial Hospital, said it recently has become more difficult to find placements for patients with mental illness who show up in the emergency room.

“We’ve noticed that since Osawatomie stopped taking voluntary admissions, we have, on occasion, had to hold (mentally ill) patients for more than 24 hours,” Early said. “That’s a new experience for us.”

Tim DeWeese, executive director at Johnson County Mental Health Center, said it’s only a matter of time before the system, as it’s currently funded, runs out of placement options.

“In my opinion, this is a crisis waiting to happen,” DeWeese said. “We’ve underfunded the state hospitals. We’ve underfunded community services. We’ve just downsized, downsized, downsized. And now we’re saying, ‘OK, how can we keep folks out of jail? How can we keep them out of the state hospital?’

“And my question is, ‘Where are the resources to do that and to keep doing that?’” he said.

DeWeese said he knows of several instances of state hospital patients being discharged to nursing homes “inappropriately” or ending up in jail because they were released “without having had enough time to stabilize.”

He said the freeze on admissions at Osawatomie will increase the number of people with mental illness who end up in jail or on the streets.

Sandy Horton, head of the Kansas Sheriffs’ Association, agrees with that assessment.

“That’s why the best advice we can give sheriffs is to be proactive: Meet with your county attorney, get legal advice and start coming up with some local solutions, because this is going to happen,” Horton said. “It’s going to be 3 o’clock in the morning, and your deputy is going to be dealing with someone who has no place to go but can’t be left on the street. Hopefully, the solution won’t involve jail, but a lot of times I’m afraid it will.”

Cindy Luxem, executive director at the Kansas Health Care Association, the group that represents the state’s for-profit nursing homes, said the 11 facilities like the Haviland Care Center that specialize in caring for people with severe mental illnesses don’t provide much of a safety valve. That’s because they too are at capacity.  

“They’re full and they have waiting lists,” Luxem said.

KDADS officials have said they intend to raise the Osawatomie State Hospital target census to 185 patients after the renovation work is finished, probably in early November. Whether it stays there remains an open question.

“Half the people in our hospitals have co-occurring substance abuse issues,” de Rocha said. “We don’t know if the drugs caused the mental illness or if the mental illness led them to self-medicate and to the use of drugs. But if we could get those folks back on the right track, maybe we don’t need that number of beds? I’m not saying we don’t, I’m saying we don’t know.”

To find out, the agency last month appointed a 30-member committee to critique the state’s mental health system and, perhaps, clarify the role of the hospitals.

The fourth of the committee’s five meetings is set for Thursday. The group will finalize its recommendations during a July 16 meeting.

Horton said he’s telling his sheriff association members to prepare for more calls involving people with mental health issues.

“KDADS has done a good job of notifying law enforcement about what’s going on at Osawatomie and in getting some things going on the community level,” Horton said. “But the concern I have is what happens when we get to that point where (Osawatomie) isn’t taking ‘involuntaries,’ because that’s who we’re dealing with on the street.”

Dave Ranney is a reporter for KHI News Service in Topeka, a partner in the Heartland Health Monitor team.

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