Editor’s note: Heartland Health Monitor partner KHI News Service conducted dozens of interviews to chart how Osawatomie State Hospital went from a respected facility to one that federal officials deemed too unsafe for Medicare patients and how the hospital could rebuild for the future. This is the first story in a series resulting from that investigation.
The final federal inspections of Osawatomie State Hospital in 2015 painted a picture of a place where both employees and patients were in danger and low staffing levels compromised care.
It wasn’t always that way. At one time, the hospital was considered by some to be a leading light in treating people with serious mental illnesses.
The Centers for Medicare and Medicaid Services decertified OSH in December 2015 because inspections found dangerous conditions for patients and staff. Since then, the decertification has cost the state about $1 million per month in federal payments. It also has forced conversations in the Legislature and the administration of Gov. Sam Brownback about how to repair the damage done by years of underfunding and understaffing.
Federal officials started looking into safety issues at OSH because of a 2015 sexual assault, but the hospital’s troubles were hardly a sudden development. Like a bridge that collapses in a sudden twist of steel and concrete, the hospital had been under stress for years.
Reduced funding. Overcrowding. The loss of other institutions that acted as safety valves. Staffing woes and declining morale. It happened under Republicans and Democrats. In good fiscal times and in bad. And finding solutions may be no easier than determining responsibility.
From asylum to a golden age
In the early days, it wouldn’t have been surprising if a state hospital — then referred to as an “insane asylum” — wasn’t serving its patients particularly well.
In 1866, Kansas established the facility that would become Osawatomie State Hospital.
At that time, the state was part of a movement to set up more compassionate alternatives to jailing people with mental illnesses, according to Walter Menninger, former president and CEO of the Menninger Clinic, a private mental health center that closed its Topeka facility in 2003.
The state purposely put mental health patients in rural areas because it was thought a peaceful setting and farm work would act as a treatment, he said.
“The theory was at one time that mental illness was caused by the evils of urban life,” he said in a recent interview.
Unfortunately, the early asylums did little to treat mental illnesses, and patient abuse was common through the early decades of the 20th century, Menninger said. Lawmakers who visited state hospitals in the late 1940s found that patients often were restrained for long periods or forced to sit in hallways with nothing to do for hours on end, as shown in Kansas State Historical Society records.
What lawmakers saw then bothered them enough that they turned to the Menninger Clinic and Colmery-O’Neil Veterans Affairs Medical Center, which was learning to treat soldiers returning with mental health conditions linked to their service, Menninger said.
That began a process of moving people who weren’t dangerous to themselves or others to nursing homes or other supportive environments. The movement gained momentum in the early 1960s as the country began investing in community mental health centers as part of a push to increase treatment in local settings that were less restrictive. Populations at the state hospitals fell substantially, though the state still maintained psychiatric facilities in Larned, Osawatomie and Topeka. A fourth opened in Kansas City in the 1970s.
During the second half of the 20th century, the idea that a state hospital could be a place of healing emerged. Some of those working in mental health at the time remember a kind of golden age at OSH as treatment improved.
OSH’s reputation was strong enough in the 1970s and 1980s that Volunteers in Service to America, an AmeriCorps program that works in low-income communities, sent its mental health volunteers to Kansas to learn how a hospital should run, Menninger said.
Mark Ready, who started working as a nurse at OSH in 1974 and switched to training new workers before retiring in 2012, said the hospital was well-respected through at the least the first half of his career. He recalled that at one point in the 1980s, a federal inspector told him: “We sure wish we could make everybody come to Osawatomie State Hospital to see how you’re supposed to run a mental hospital.”
“Louise,” a longtime nursing employee who asked not to be identified by her real name, said it wasn’t unusual for employees to work at OSH for decades, and some got to know patients and their families quite well. The hospital had a culture that focused on holistic treatment, with outings, a greenhouse and a gym to give patients as much of a sense of normality as possible, she said.
“It was a place that people liked to work,” she said. “They were interested in taking care of the patients.”
Shift toward community care
Lawmakers saw one significant problem, however: Some people living in state hospitals seemed unlikely to ever leave.
State Rep. Henry Helgerson, a Wichita Democrat who was a leader in mental health reform in the 1990s, said he and other lawmakers toured the state hospitals and learned some patients had lived there for 10 to 20 years.
“People were basically warehoused,” he said. “They were left in the hospital because their families couldn’t cope or they didn’t have families.”
The state had community mental health centers, which provided outpatient treatment, but they varied widely in the array of services they could offer and how actively they tried to manage patients’ cases, Helgerson said. Too often, patients would leave OSH, return to their communities without receiving services they needed and be sent back to the hospital in short order, he said.
In 1990, Kansas lawmakers passed the Mental Health Reform Act, agreeing to adequately fund the state’s community mental health centers in exchange for their help in diverting would-be patients from the state-run hospitals in Osawatomie, Kansas City, Larned and Topeka.
In the early 1990s, Kansas had 1,003 beds in state psychiatric hospitals. When Topeka State Hospital closed in 1997 as part of the movement away from institutional care, the state’s hospital bed total dropped to 340 — or about a third of what it had been seven years earlier.
The goal of mental health reform was to direct resources to community programs so that fewer people would be hospitalized, Helgerson said.
“We had a dysfunctional system,” he said. “What I was looking for was a way of providing better services in a less restrictive environment.”
Funding falls short
However, within a year of the closure of Topeka State Hospital, questions arose about the state’s commitment to funding the community-based system.
University of Kansas researchers Robert Lee and Ronna Chamberlain said in a 1998 report that more Kansans were receiving mental health care in community settings, but a “significant number” still didn’t have access and the quality of care varied widely.
Housing and other support services were particularly difficult to find, Lee and Chamberlain said, and it wasn’t clear if the Legislature and administration, then under Republican Gov. Bill Graves, had the political will to expand funding for those services.
“History suggests that other claims on resources will eventually divert resources from the (community mental health) centers and from (severe and persistently mentally ill) clients,” they wrote. “Even maintenance of the progress to date is far from assured.”
Their concerns turned out to be justified. Just a few years later, community mental health centers weren’t getting their promised funding.
“(The increased funding) happened for a very short while,” said Dave Johnson, CEO of Bert Nash Community Mental Health Center in Lawrence. “It had ground to a halt before I came here in 2001.”
A decade after the reform bill was signed into law, Helgerson said, many Kansas lawmakers no longer seemed to understand that scrimping on community mental health care eventually would force the state to spend more on prisons and psychiatric hospitals.
“Legislators just didn’t understand it made better financial sense and it made better policy sense,” he said.
The lack of support for community mental health centers increased the pressure on state hospitals. Unlike private facilities, community mental health centers and state hospitals can’t turn patients away if they have the space to treat them. That makes them a safety net for people in crisis. If community mental health centers couldn’t treat all of those in need, state hospitals would have to absorb more patients.
Steve Feinstein, who was superintendent of OSH from 1994 to 1998, said the pressure to manage the number of patients at the hospital increased during his time there.
“We guarded the front door and we guarded the back, and what happened in between suffered,” he said. “You’ve got a certain number of beds. You’ve got a lot of pressure at the front door.”
Factors beyond the state’s control also added to the mounting pressures on the system.
Private psychiatric facilities began closing shortly after mental health reform, though not because of it, said Bill Persinger, CEO of Valeo Behavioral Health Care in Topeka. As outpatient care improved, insurers reduced reimbursements for inpatient care and limited the number of days they would pay for care, making psychiatric units unprofitable, he said.
“There was money to be made, and then insurance reform happened,” he said.
Menninger Clinic officials cited the need for a more affluent population base able to pay for the clinic’s type of long-term psychotherapy when it moved to Texas in 2003. Lawrence Memorial Hospital closed its psychiatric unit in 2004, and a lobbyist for Via Christi Health System told the Kansas Department of Social and Rehabilitation Services in 2006 that its psychiatric unit was losing about $660 per patient each day because reimbursements weren’t keeping up with the cost of treatment. Other hospitals later would shut down their psychiatric units.
The closings put more pressure on hospitals that still took psychiatric patients, including OSH, Persinger said. The state probably had more mental health beds than it needed before mental health reform, he said, but it soon was left with too few.
“We went from a situation in the ’90s where we had plenty of beds,” he said. “Eight, nine years later, suddenly we didn’t have enough beds.”
Still, there was general agreement that patients at OSH were getting needed care in a safe environment. The effects of underfunding the state’s mental health system wouldn’t become apparent for a few more years, as overcrowding became a frequent problem at the hospital.
Budgets and staffing were sometimes tight, Feinstein said, but OSH benefited from having long-standing mental health practitioners and well-trained direct care staff. That helped minimize the effect on patients, even as stress on hospital employees increased, he said.
“There were people there who had worked there their entire lives, and their parents and their grandparents had worked at the hospital,” he said. “So there was a camaraderie, there was a level of training and awareness and motivation that allowed us to overcome some pretty severe issues in terms of resources at the time.”
Up next: As overcrowding and funding cuts strain Osawatomie State Hospital, federal officials become concerned that patients aren’t getting needed treatment.
Megan Hart is a reporter for KHI News Service in Topeka, a partner in the Heartland Health Monitor team. You can reach her on Twitter @meganhartMC