Sam Morris / Las Vegas Sun
Monday, Sept. 9, 2013 | 2 a.m.
Helping the mentally ill
Mental health workers often talk about patients who “fall through the cracks” of the social safety net, meaning the severely mentally ill often end up homeless, without health insurance and a monetary burden to taxpayers who pay when the mentally ill end up in jail, emergency rooms and state hospitals.
Instead, advocates for the mentally ill say that private, public and nonprofit employees can “intercept” the mentally ill before they fall through the cracks and thereby reduce societal costs and help the mentally ill.
Here’s who can help and how that would be done:
• Law enforcement can help prevent arrests and guide mentally ill to community programs.
• Mental health courts can direct service plans to the mentally ill who are arrested for petty crimes.
• So-called “wraparound” service teams can ensure patients stay on medications, receive follow-up care and transition from a hospital or jail back into society.
• Non-profit group homes, parole and probation officers, and health teams of psychiatrists, primary care physicians, social workers and nurses can work together to put a roof over the heads of the mentally ill, keep them out of trouble and keep them on their medications.
Legislators meeting in Carson City recently asked the embattled state health department about how it’s handling all the negative media attention it’s received during a five-month-long mental health scandal that won’t go away.
“I don’t think you can find a mental health program in the nation that has seen the reviews and oversight that we’ve seen,” said Mike Willden, director of the Nevada Department of Health and Human Services.
In April, the story of one man, James F.C. Brown, sent packing with a one-way bus ticket from the Rawson-Neal Psychiatric Hospital in Las Vegas to Sacramento sparked outrage about Nevada’s mental health system.
The story, first reported by the Sacramento Bee, provided a glimpse into one aspect of the state’s troubled mental health system, but subsequent investigations have revealed wide-ranging problems in a system struggling to provide even basic services for thousands of mentally ill people in Nevada.
• Rawson-Neal has lost its independent accreditation from the Joint Commission, a nonprofit quality control agency, and could lose federal funding for not meeting minimum care standards.
• The Dini-Townsend psychiatric hospital in Northern Nevada also could lose certification, and two other state psychiatric hospitals in Nevada — Lake’s Crossing in Reno and the Desert Willow Treatment Center in Las Vegas — already lack certification, according to documents provided by the state health department.
• The ACLU of Nevada is representing Brown in a class-action suit against the state for "severe and extreme physical, emotional and psychological harm" suffered when Brown and others were improperly bused out of state after being discharged from Rawson-Neal.
• The city of San Francisco is threatening to sue the state for instances like Brown’s in which Nevada improperly bused mental health patients to San Francisco, forcing taxpayers there to pay for their care.
• The Clark County Public Defender’s office is again suing Nevada for long wait times at the Lake’s Crossing facility for the criminally mentally ill. A similar suit ended in a settlement that should have addressed wait times. Since then, however, the public defender’s office claims the problem has continued with some clients waiting months for services.
• Lake’s Crossing, a facility in Reno, is the state’s only psychiatric facility for the criminally mentally ill, meaning law enforcement in Southern Nevada must fly the criminally insane to Reno to receive evaluations and services.
• Health department officials have told legislators they’re struggling to hire doctors because medical professionals know that they can earn as much as $50,000 more with comparable benefits packages by working at places like the federal Veterans’ Administration.
• Southern Nevada’s emergency rooms are again seeing unusually high numbers of mentally ill patients, a situation that prompted Clark County to declare a public health emergency when something similar happened a decade ago.
“That piece of our system is broken,” Willden said at a legislative meeting last month.
Within this milieu, Nevada’s Democratic Party has sent more than 50 press releases slamming Republican Gov. Brian Sandoval for the widening mental health crisis in Nevada.
But the responsibility for the beleaguered system is more broadly shared.
The Democrat-controlled Legislature has presided over $80 million in cuts to mental health budgets since 2007, and the constitutional responsibility for “institutions for the benefit of the insane” lies squarely with the state.
Additionally, staff positions in the state’s mental health division decreased by 364 between 2007 and 2011, meaning about 1 in 5 jobs was eliminated either by revised staffing ratios or attrition.
During the same time period, the state reduced its adult inpatient bed capacity in Clark County from 234 beds to 190 beds, leaving Rawson-Neal as the sole state psychiatric facility in Southern Nevada.
Those closest to the mental health world in Nevada say it’s unsurprising that the state’s mental health system is facing crises on multiple fronts.
They say Nevada has a culture of not providing adequate health services. Brown isn’t the only patient sent out of Nevada with just a bus ticket and encouragement to seek care elsewhere.
“People have been advised for decades that if you really want social services, you should go to California,” said former state Sen. Sheila Leslie, who advocated for more mental health funding during her time at the Legislature. “That is not new. ... It’s the Nevadan way. It’s just not a surprise to anybody that this finally came out.”
What is surprising, though, is the degree to which politicians, hospital officials, state employees, and mental health advocates agree about what the state should do to fix the mental health system.
Mental health officials know the system’s woes begin with the mentally ill population that doesn’t have health insurance or family support. These people end up homeless and get arrested for petty crimes such as trespassing. They’re taken to the jail, the state psychiatric hospital, the emergency room or a combination of the three, and taxpayers ultimately pick up the tab.
They are then released, and often the cycle starts again when they stop taking their medications.
Over the years, the state’s mental health system has reflected the same cycle endured by mental health patients themselves, oscillating between making progress and receding into crisis.
While state officials have known about solutions for decades, economic recessions and budgetary constraints have kept them from fully and consistently implementing mental health programming.
This year, some of the programs and facilities the state is seeking to implement or open are in fact reinstatements of programs or facilities the state shuttered during the most recent recession.
For instance, the Legislature’s recent decision to open a second psychiatric facility in Las Vegas comes three years after the Legislature’s decision to close such a facility.
The governor’s decision this year to pay for a second “Program for Assertive Community Treatment” team in Southern Nevada follows a recession-era decision to cut that team of doctors, social workers and nurses who provide home health services for the severely mentally ill.
This year, Sandoval added more than $23.4 million to the state’s mental health system in the budget approved by the Legislature in June.
Facing further scrutiny and the specter of the Rawson-Neal Psychiatric Hospital in Las Vegas losing millions of dollars in federal money, the governor and Legislature poured $7 million more into the system after federal inspectors found the facility didn’t meet minimum standards of care to participate in the federal Medicare program.
Sandoval has also added new programs such as a home visitation and transitional housing program for mental health clients with co-occurring substance abuse or other disorders who are returning to society after spending time in jail or prison.
As a further indication that Sandoval is taking the situation seriously, the governor’s office reminded the Sun that it was the governor who brought in nationally recognized experts to evaluate Rawson-Neal and issue a report.
“The state of Nevada remains committed to treating our most vulnerable members of society with dignity and care,” said Mary-Sarah Kinner, Sandoval’s spokeswoman.
In 2015, Sandoval and the Legislature would also have to add more money to the mental health budget if the state wants to staff the second state-run mental health hospital in Southern Nevada.
But critics say the money isn’t enough.
“If you’re adding money for mental health services where cuts have already occurred, where does that leave you?” said Tod Story, director of the ACLU of Nevada. “You could still be in a hole or spending less than you had been previously because certainly you aren’t keeping pace with inflation and the rising costs of health care. Unless you are providing enough to make up that difference, you’re still spending less than you may have been previously.”
Even though health care costs are rising more slowly than before the recession, they still grew 4.6 percent between 2008 and 2012.
So a full restoration of the $80 million in cuts to the mental health system during the past seven years would require spending beyond that level, Story said.
While state health department officials argue that some of the budget reductions represent cost savings and efficiencies, there is precedent for adding large sums of money to the mental health system.
After Democratic Gov. Bob Miller slashed the mental health budget in the early 1990s to all-time lows, the Legislature added $177.5 million to it during the 1997 legislative session, a 48 percent increase.
Since then, the Legislature has added new programs such as the PACT teams and the mental health courts, which advocates say have been successful in keeping the mentally ill off the streets.
But such programs exist by legislative fiat, and they’re often the first on the chopping block when recessions hit. In 2011, for instance, the Sandoval administration and Washoe and Clark counties squabbled over who should assume responsibility for paying for mental health courts.
Politically, mental health advocates say it’s easy for politicians to ignore the mentally ill because elected officials face few electoral repercussions for threatening to remove services or voting to remove them.
“From a political standpoint, the mentally ill don’t vote,” said Dale Carrison, chief of staff at University Medical Center. “What’s the easiest place to take money where nobody complains? You take it from mental health because the crazy people, quote, unquote, don’t complain.”
Still, fixing the mental health system isn’t just a money game.
State officials currently are focusing on adding capacity to the system in Southern Nevada, mainly by adding beds to mental health facilities.
But they also know that’s not the end game.
“There’s no way not to do this holistically,” said Sen. Justin Jones, D-Las Vegas, chairman of the state Senate’s health committee. “You have to look at the court system, the jail system, the preventive mental health system, the treatment system. You can’t do it independently.”
The uninsured, homeless and severely mentally ill might encounter a county police officer, a private ambulance operator, an emergency room doctor, a state hospital employee, a charity volunteer or any number of people as they receive piecemeal services.
The sheer number of agencies and people a typical homeless, mentally ill person may encounter means there’s ample room to assess blame and point fingers at who’s responsible for the state’s failing mental health system.
The state Democratic Party blames the Republican governor.
Advocacy groups such as the ACLU of Nevada blame both parties’ representatives in the Legislature and governor’s office.
“We actually have to fund a comprehensive approach,” Story said. “We have to ask ourselves: What kind of state do we want to be, and are we willing to provide the necessary services for those in these situations who cannot provide for themselves?”
Farther down the line, residential group home providers for the mentally ill say hospitals are partially to blame for the type of improper discharges that led to Brown’s out-of-state bus trip.
“Emergency rooms are putting pressure on Rawson-Neal to get the clients out so they can alleviate having clients waiting to get into Rawson,” says Barry Wicklund, a mental health group home operator.
But hospital operators say that they shouldn’t even have these clients in the first place.
“Why are we sending all of these people to the emergency departments?” Carrison said. “Ninety percent of these people don’t have a medical problem. They have a mental health problem.”
Richard Whitley, director of Nevada’s mental health division, said state data show that many mentally ill patients in Clark County erroneously arrive at the emergency room via ambulance. But it’s law enforcement that usually calls the ambulances.
That’s a point where mental health workers could “intercept” the mentally ill, Whitley said.
“The intervention point isn’t just in the community where an ambulance goes, but it’s really with law enforcement on the street,” he said. “One program that they don’t have in Clark County that they do have in Washoe County is a crisis intervention team that rides around with law enforcement.”
Whitley said the state is developing that program in Clark County.
Instead of clogging up the emergency rooms in Clark County at taxpayer expense, the mentally ill need somewhere else to go.
Conveniently, that’s where the Sandoval administration’s new 24/7 drop-in center for the mentally ill enters the stage. The new facility is exactly the place where advocates say law enforcement can send people who don’t need to go to jail but do require stabilization and possible in-patient treatment.
But that requires a change in behavior from multiple agencies that encounter the mentally ill.
“Nobody figured out how to get them to the 24/7 drop-in center,” Carrison said. “They’re now saying, ‘Hey, what is our plan to get them to the drop-in center?’”
That plan remains a work in progress.
Here’s another one: Once a patient’s mental health crisis subsides, he or she is discharged from state inpatient facilities such as Rawson-Neal.
So what’s an impoverished, chronically mentally ill person to do? Get on a bus to California?
Mental health officials and advocates have identified another “intercept” point to help the mentally ill in Nevada: housing.
“Housing is the underpinning for the stability of this entire population,” Whitley said. “Having a living arrangement that is stable, that is what the biggest issue is.”
Improper discharge plans allowed state health workers to send patients such as Brown on a Greyhound bus to Sacramento without support. Revised discharge plans could include transitions to local housing.
But while mental health group home operators such as Barry Wicklund say finding room for patients in Clark County is a constant struggle, the state runs surpluses in its budget for state-supported mental health housing.
“We have underspent that budget as much as a couple million of dollars each year,” said Willden, the director of the Nevada Department of Health and Human Services, at a legislative meeting last month. “We have been working and have brought some additional providers online, but that is absolutely critical to having that fully maximized.”
These are community-wide problems that require community-wide solutions, and the old practices of either officially shipping patients out of state or unofficially neglecting them so that they’ll leave won’t work anymore, Leslie said.
“We’re getting to a point that we’ve got to change,” she said. “We can’t keep ignoring the fact that people need services and other states are waking up to the fact that we’re shipping our problem people to them.”