BY: CLAYTON CIHA, M.S.
It's unfortunate that it took such a tragedy as the December, 2012, mass shooting at Sandy Hook Elementary School in Newtown, Conn., for us as a nation to look more closely at how we address mental illness. Yet this tragedy has created a unique opportunity to build a better mental health care system. We, as Catholic health care providers — and as citizens — must seize the moment and advocate for change on behalf of people who suffer from mental illness.
Specifically, we must promote an integrated care model to eliminate the gap that now exists between treating the mind and treating the body. We must champion a continuum of mental health and addiction services, including expanded community-based models.
Before examining these remedies, let's look first at what has gone wrong with our system and how it happened.
DECREASING ACCESS, RISING DEMAND
America's mental health care system is in crisis. Continued closures of state-run psychiatric facilities, significant cuts in state funding for mental health services and the reduction or elimination of psychiatric services at many community hospitals have caused this perfect storm of rising demand with decreasing access.
From 2009 to 2012, states cut more than $1.6 billion in funds for mental health services, according to the National Alliance on Mental Illness (NAMI), resulting in significant reductions in hospital and community services for people with serious mental illnesses.
The timing of these cutbacks could not be worse. Findings from the National Institute of Mental Health (NIMH) indicate that 26 percent — more than 1 in every 4 adults — suffer from a diagnosable mental disorder in a given year. NIMH also reports that 45 percent of these individuals have more than one disorder at a time. America also is experiencing a suicide epidemic. The rate of suicides is twice the rate of homicides.
The economic burden of mental illness is extreme, with estimates as high as $317 billion per year. If these statistics were associated with any other medical condition, there would be outrage.
In many ways, the history and current status of Illinois' mental health system serves as a microcosm of today's crisis. The following facts illustrate what has happened in Illinois:
- In the 1950s and 1960s, state-operated psychiatric hospital beds totaled more than 35,000; by 2009, only 1,400 such beds remained, according to the Illinois Hospital Association (IHA) — a startling statistic.
- Between 2009 and 2012, Illinois slashed $187 million — nearly 32 percent — from its mental health budget, a reduction that ranked fourth among all states by percentage, according to NAMI. These cuts have decimated the safety net of community-based services intended for people once treated at state hospitals.
- The number of licensed psychiatric beds at other hospitals decreased 28 percent, from 5,350 in 1991 to 3,869 in 2010 alone, according to the state hospital association. More than half of Illinois' 102 counties did not have a single hospital with inpatient psychiatric services, according to IHA.
- Suicide is now the third leading cause of death in Illinois.
Alexian Brothers Behavioral Health Hospital, a 141-bed facility in suburban Chicago, has worked hard to pick up the pieces from this fragmented system of care. The hospital ranks as the nation's seventh-largest behavioral health provider by Modern Healthcare, running at capacity 94 percent of the time. Because its beds often are full, Alexian Brothers Behavioral Health Hospital refers thousands of people elsewhere each year. Its day-hospital, outpatient and community-based programs also have experienced sharp increases in demand in recent years.
THE TURN TO EMERGENCY CARE
With access to mental health care services decreasing, emergency rooms have become the primary avenue for individuals with mental illness to receive care. But the declining number of inpatient options and growing demand for treatment are delaying the transfer of psychiatric patients from the emergency department to appropriate facilities. At some inner-city and rural hospitals, patients can wait three or four days in the emergency department before they are transferred to an appropriate behavioral health facility.
Because of the dramatic reduction in community mental health services, psychiatric patients are more acutely ill when they arrive at the emergency department. Left untreated, psychiatric disorders lead to significant functional and social impairment, increase the likelihood of co-morbid disorders and complicate existing medical disorders. The trend is apparent in referrals from the emergency departments of two sister hospitals, Alexian Brothers Medical Center in Elk Grove Village, Ill., and St. Alexius Medical Center in Hoffman Estates, Ill. Caring for more acutely ill patients requires more resources to insure the safety of patients and associates.
Providing charity care also has become more common because many patients with mental illness are either uninsured or under-insured. This financial drain, along with the challenges associated with caring for these patients, are key reasons why many community hospitals have discontinued psychiatric services.
Though many people with mental illness seek treatment in emergency departments, many others end up in homeless shelters — or jails. Cook County, Ill. Sheriff Tom Dart has been a vocal critic of closing the state's mental health centers, saying more than a third of the Cook County Jail's inmates have mental illnesses. He has called Cook County Jail one of the largest providers of mental health services in the country.
"When we don't fund services properly, they end up in my jail," Dart said in a Sept. 5, 2012 speech to the Logan Square Neighborhood Association in Chicago. "What we are, in fact, doing is criminalizing mental health."1
According to the National Alliance to End Homelessness, more than 14,000 people are homeless each night in Illinois, and 84 percent of those people live in shelters and transitional housing. People with severe mental illness account for 32 percent of the state's homeless, and 48 percent of the state's homeless have substance-abuse issues. The Alexian Brothers Center for Mental Health, which provides a wide variety of community-based services, has seen an exponential increase in requests for placement in its transitional and permanent housing programs.
Meanwhile, Illinois relies more than any other state on nursing homes to house young and middle-aged adults with mental illnesses. Nearly 5,000 mentally ill adults live in private, for-profit nursing homes designated as Institutions for Mental Disease (IMDs), and thousands more live with the frail elderly in more traditional nursing homes. Under a 2010 federal court settlement, the state has launched an effort to enable people to move out of IMDs and into community-based supportive housing programs. But with Illinois' drastic cutbacks in funding for community mental health services, this effort and other nursing home reforms face an uphill climb.
STEPPING BACK FROM WHAT WORKS
The great irony is that our current mental healthcare system, which is largely a creation of non-strategic budget cutbacks, depends heavily on costly non-psychiatric treatment providers such as emergency departments, jails and nursing homes. A concerted effort must be made to address and maintain a person's behavioral health needs in the least restrictive level of care.
Alexian Brothers Behavioral Health Hospital strives to effectively treat mental illness at the lowest level of care. For example, if inpatient hospitalization is necessary to stabilize someone in a psychiatric emergency, the plan is to quickly move that person to a less restrictive day-hospital setting, and then to an outpatient therapist/psychiatrist team in the community. The goal is to provide a range of services across the continuum of care to treat and support someone to live independently in the community. Support at the community level can reduce repeated use of emergency departments and prevent the functional impairment that often leads to placement in jails or nursing homes.
During the last 30 years, our understanding has advanced exponentially regarding how to care for the mentally ill and how to help them become independent, contributing members of society. We know that the best approach requires a comprehensive continuum of care, including a combination of psychotherapy and medical therapy, multi-tiered levels of care for specific stages of mental illnesses, community-based services and supportive housing options. This approach offers an opportunity for people with mental illness to experience a substantially better quality of life. It's also cost effective. And it works.
Yet in recent years, we as a society have stepped back from this accumulated knowledge and are now eliminating low-cost solutions with proven outcomes and relying on high-cost defaults with unknown or even negative outcomes. This trend reflects the continuing stigma of mental illness and misperceptions that influence lawmakers' perspectives on mental health issues.
HOPEFUL SIGNS APPEAR
So where do we go from here?
My hope is that our mental health care system has reached its nadir and that with growing public concern about behavioral health issues in Newtown's aftermath, we can begin to reshape the system. We have the ability to provide high-quality, cost-effective, evidence-based care for people suffering from mental illness.
In addition to increased public discourse about mental health issues, other signs indicate the time is right for this type of change. We're seeing increased use of mental health terms in our vernacular and the appearance of characters with mental illnesses and substance use in movies and television. These trends indicate growing awareness, acceptance and an overt attempt at destigmatizing those disorders.
The Affordable Care Act (ACA), meanwhile, identifies mental health as one of the types of care that must be covered in health plans offered to consumers. The ACA also requires parity between mental health care reimbursements and those for other types of health care. ACA's emphasis on preventive and cost-effective health care bodes well for reviving the community-based programs that have proved to be so successful.
In Illinois, Alexian Brothers worked closely with State Rep. Fred Crespo, (D-Hoffman Estates), to draft a 2011 law requiring the state to develop a comprehensive five-year strategic plan for improving its mental health system. Scott Burgess, executive director of the Alexian Brothers Center for Mental Health, served on a task force that has developed the plan for consideration this year by the legislature and Ill. Gov. Patrick Quinn.
These developments point to growing recognition that mental health is a vital component of overall health and that we can't have effective health care without effective mental health care.
SEIZING THE MOMENT
We as Catholic health care providers can seize the moment and work toward building a better mental health care system by using our collective power to speak out loudly on behalf of those who are seldom heard; who, unlike other special-interest groups, do not have a huge lobbying presence on Capitol Hill or in state capitals. Our efforts must focus on three priorities:
1) Asking, "do we view behavioral health care as the same or different from any other medical condition?" — If we view the two accordingly, then we know that some conditions can be addressed in one episode of care, while other conditions may be persistent and require long-term treatment and management. For example, bipolar disorder should be given the same resources necessary for long-term treatment and management that are given to the treatment and management of diabetes or high blood pressure. As with any medical condition, behavioral health care requires treatment adherence, regular physician visits and periodic adjustments. If we recognize the equality of mental illness with other disease states, then we should expect to see parity in reimbursement, ease of access and reduced stigmatization of mental health conditions.
2) Eliminating the gap between treating the body and treating the mind — In coming years, we must move toward a more integrated care model that fosters greater collaboration among primary-care physicians, medical specialists, psychiatrists and psychologists so that physical and mental illnesses can be treated together.
Alexian Brothers has adopted such a model and has found that it enhances outcomes by more quickly connecting patients with the level of care that is appropriate for them. Understanding that 1 in 4 people is likely to suffer from a mental illness, specialists within the health system now collaborate with psychiatrists on patient care. This model also helps to remove the stigma of receiving behavioral health services and puts into action the Catholic health care value of holism.
Similarly, Alexian Brothers Behavioral Health Hospital has assigned psychologists to some primary care physician practices owned by the parent organization, Alexian Brothers Health System. The idea has worked so well that the plan is to eventually team psychiatrists with primary care physicians in their offices.
Alexian Brothers also has extended its integrated care model to the community, collaborating with area nursing homes to connect residents with its psychiatrists for treatment of conditions such as depression and dementia.
3) Championing a continuum of mental health services — It's vital to meet people with mental illness where they are on their journey. A comprehensive continuum of care includes several components. First, multiple levels of care must be provided, including inpatient, partial hospitalization, intensive outpatient and traditional outpatient services. Second, we need to provide disease-specific care, such as specialty programs for major depression, anxiety, substance use, eating disorders, self-injury and severe and persistent mental illness. Third, services should be appropriately targeted to specific age groups, such as children, adolescents, adults and older adults. Fourth, a range of services must be provided to meet the varied needs of our most complex patients, such as individual and group psychotherapy, medication evaluation and management, vocational programs and supportive housing options.
The unwavering support of the Alexian Brothers, whose ministry to the sick, the poor and the mentally ill dates back more than 800 years, has enabled Alexian Brothers Health System to offer this type of continuum of care for people of all ages. The Alexian Brothers are committed to ensuring that the people they serve have access to behavioral health care, regardless of their ability to pay for it. Because of this commitment, the system performs more than 16,500 free level of care screenings each year at Alexian Brothers Behavioral Health Hospital and at the two sister hospitals' emergency departments. Our continuum of care and particularly our community-based services also benefit greatly from the generosity of our foundation supporters.
4) Supporting mental health education in the community — This priority will be vital to eliminating the stigma of mental illness and to battling America's suicide epidemic. Mental health education must start in our schools. We must ensure that young people understand what mental illness is — and what it isn't. This includes funding for school social workers, counselors and psychologists who are trained to recognize behavioral issues in children and adolescents. We must work with our youth to break down the myths, fears and misperceptions about mental illness.
The Alexian Brothers Center for Mental Health and Parish Support services have embedded mental health counselors in several area schools, and the program is helping break down stigmas and identify and treat mental health issues at early stages. We also have developed the Center for Professional Education, which provides thousands of hours of continuing education credits to area professionals.
A MISSION-BASED OBLIGATION
With the public and lawmakers focused more than ever on mental health issues, now is the time to push these priorities forward. As Catholic health care providers, we have a mission-based obligation to make our voices heard. Ensuring access to quality mental health care embodies compassion, dignity of the person, care of the poor, holism and partnership — all of the values that the Alexian Brothers and other Catholic health care providers hold dear. There is no greater need in health care today. So act now, and speak loudly.
CLAYTON CIHA is president and chief executive officer of Alexian Brothers Behavioral Health Hospital in Hoffman Estates, Ill. The 141-bed facility in suburban Chicago is part of St. Louis-based Ascension Health.
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Copyright © 2013 by the Catholic Health Association of the United States
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