CHARLESTON -- More than a dozen people testified during two days of an evidentiary hearing into problems in West Virginia's mental health system, but most of them on both sides of the case expressed one recurring theme: The state needs to restore the types of community-based mental health services it once had.
Circuit Judge Duke Bloom called the hearing in his Kanawha County courtroom after he received a report last summer from David Sudbeck, ombudsman for behavioral health, that found overcrowding, understaffing and other problems at Bateman Hospital, a state psychiatric facility in Huntington. The hearing was delayed several months after the Department of Health and Human Resources appealed to the West Virginia Supreme Court, but the justices ruled unanimously in January that Bloom should proceed with the hearing.
The hearing on April 24 and April 27 occurred at a time when many people were waiting to learn whether Gov. Joe Manchin would sign or veto Senate Bill 672, the Mental Health Stabilization Act of 2009. That bill, which passed unanimously in both the Senate and the House of Delegates, declares that the "community mental health system is in a state of crisis."
During the hearing, witnesses and Bloom referred several times to the bill, which proposes restoring many community services by putting $1.5 million a year in state money and three times as much in matching federal money through Medicaid into the system. Despite the bill's strong support from lawmakers and people in the mental health care community, DHHR has recommended that the governor should veto it.
In light of that recommendation, leading plaintiffs' attorney Dan Hedges suggested to Bloom at the end of the hearing that, if the governor would veto the bill, the judge should require DHHR to redirect $1.5 million from another portion of its budget and put it toward community mental health services. Bloom responded that he doesn't like to anticipate what the governor might do, but he said he would take any necessary action at the appropriate time.
Although the hearing centered on conditions at Bateman, it also dealt with conditions at the only other state psychiatric hospital, Sharpe Hospital in Weston, and other aspects of West Virginia's mental health system. Many witnesses testified that the state hospitals would not be so overcrowded and the state would not have to divert many psychiatric patients to private facilities if West Virginia still had a strong system of community mental health services. They said such services would prevent the mental health problems of many people from worsening to the point they need to be hospitalized and would give others somewhere to go after their hospitalization.
Mary Beth Carlisle, chief executive officer at Bateman, testified that her hospital is certified for 90 beds but it typically has a census of 100 to 115 patients. Another 45 to 63 patients each day are diverted to other hospitals, she said. The cost of treating a patient at Bateman is about $500 a day, Carlisle said, but a patient diverted to another facility usually costs the state about $750 a day, although the cost can go as high as $1,200.
When Bateman is overcrowded, three persons are put into rooms meant for two people and others are put into rooms without adjoining bathrooms, she said. When the hospital is overcrowded, "the chaos increases," Carlisle said. "We've seen an increase in psychiatric emergencies."
Although she said she had taken several steps during the five years she has been in charge of Bateman to improve conditions and respect for patients, Carlisle agreed with Judge Bloom that the heavy influx of patients at the hospital make conditions inadequate. "In a perfect world, I do not want to see more patients committed to state facilities," she said.
Judge Bloom asked whether having additional beds at community-based treatment facilities would help. Carlisle said they would. She said many patients must stay at the hospital longer than necessary because there aren't enough community-based facilities to send them to.
Dr. Shahid Masood, clinical director at Bateman, testified that the hospital is supposed to have six psychiatrists, but it is down to five, and two of those are scheduled to leave in two months. Just three psychiatrists won't be able to cover all the shifts, he said.
"You're impaired because of exhaustion," Bloom told Masood.
"It takes a heavy toll on us," Masood replied.
Of the pending loss of two psychiatrists, Bloom later said, "That appears to me to be a catastrophe waiting to happen."
Upon further questioning, Masood said the overcrowding at Bateman began several years ago just as the availability of community-based services decreased. In regard to the state's plans to expand the number of beds at Bateman and other facilities, he said, "Having increased acute beds, I don't think, is the solution."
The state has been building an addition onto Bateman and hopes to open it soon to provide 30 more beds, but plaintiffs' attorney Jennifer Wagner asked whether it will be possible for it to open when the hospital is so understaffed. "We can't staff the existing unit, so it is going to be very difficult," Masood said. He said Bateman's salary range for psychiatrists is 35 percent to 40 percent below that of other facilities, so it is hard for him to recruit them.
Charlie Dunn, the lead attorney representing the state, asked Masood if Bateman provides patients with good quality care.
"We are doing our best," Masood replied. "My fear is how long we can sustain this."
Tamara Handley, an advocate for Legal Aid based at Bateman, testified that there were only nine days during January, February and March when the hospital did not have patients above its licensed capacity. The overcrowding problem has been increasing, she said, and she blamed it on the lack of community-based services. She said many patients who are ready to be discharged must stay at Bateman for days, weeks or months longer because there are no facilities to place them in.
Mark Games, president of the West Virginia Behavioral Healthcare Providers Association and chief operating officer of Northwood Health Systems, testified that there is a simple relationship between conditions at state psychiatric hospitals and the availability of community-based mental health services. More people are sent to state hospitals when community services are not available, he said, because community services are more proactive and help to avert crises for some people.
"They have been reduced dramatically over time," Games said. When Judge Bloom asked why, Games responded that there have been few meaningful increases in reimbursement rates and costs have gone up for mental health centers.
Bloom asked what happens when centers can't afford to offer those services. Games said some programs have been shut down, and in a few cases, providers have gone bankrupt and out of business. In addition, he said, tightly managed utilization under very strict guidelines set by APS Healthcare, the state's managed care contractor, have meant that the mental health centers can't get authorization for services they want to offer.
Games testified that if Senate Bill 672 would become law, it would increase Medicaid reimbursement rates for many community-based services and help keep people from being committed to Bateman.
"The rates would be sufficient to stimulate interest by providers?" Judge Bloom asked.
"Yes," Games replied. He added that the proposed $1.5 million of funding matched with federal Medicaid funds at a three-to-one ratio would help reestablish services the state once had, but it would be just the first step toward revitalizing the community-based mental health system.
When asked about Mountain Health Choices, the state's Medicaid redesign program, Games said mental health services have been reduced dramatically or are non-existent under the program. When people covered by Mountain Health Choices need mental health services, the only recourse often is to commit them to a psychiatric hospital, he said.
Bloom asked what it costs the state to give a patient "the whole gambit of services" in a psychiatric hospital. Games said he didn't know that, but he knew that the cost for a patient in an eight-bed group home with "wraparound services" is about $85 a day, which is far less than the cost of treatment in a hospital.
Although DHHR has said it has increased funding for mental health services in recent years, Games said the increases have come primarily in services that few mental health centers offer or in services that have been defined in such a way that they provide little real benefit. For example, he said, case management services have been defined in such a way that they are mainly administrative in nature.
Further, he explained that about 120 group homes that existed in communities around the state have closed because of the decline in funding. Senate Bill 672 would help to restore many of those group homes, which would help many people avoid mental health crises that would cause them to need more expensive hospitalization, he said. The need for psychiatric hospital services would drop dramatically if Gov. Manchin would sign it, Games said.
"We had a great system with robust community service," he said. "This is not speculation on my part."
Bloom asked if there were any correlation between the availability of community services and incarceration. Games said that, with more community-based services, many people could be helped so they could avoid committing crimes that cause them to be jailed. Bloom wondered if such services also would reduce the number of forensic patients – those assigned by court orders – in the state hospitals. Yes, Games said.
Bob Hansen, executive director of the Prestera Center, the community mental health provider in the Huntington-Charleston area, called it "disheartening" not to be able to provide the level of service people need.
"The needs are still there, but the ability to provide services has been reduced dramatically," Hansen said.
Dr. Perry Stanley, a licensed psychologist and clinical director at Northwood, said that community services are needed because many people with mental illness are unable to take care of their daily activities without help.
"If we can keep people in the community, that would seem to save a lot of money," he said. "Group home beds need to be restored."
Renate Pore, a health policy researcher for the West Virginia Center on Budget and Policy, testified that federal stimulus money provides West Virginia with the opportunity to "shore up community services."
"You could save money that way," she said. "In the last few years, there has been a squeezing of state funding in Medicaid."
Freda Smith, whose 39-year-old daughter has been a consumer of mental health services for 23 years, said, "It was terrible" when her daughter was in Bateman Hospital. She said her daughter has done better when she has received community services such as those at a crisis unit in St. Albans that has been shut down.
The last time her daughter was in Bateman, she had to wait a long time to be released because of a lack of community-based facilities where she could be placed, Smith said.
"There was no community services," she said. "There was nowhere for her to go."
The second day of the hearing was devoted mainly to witnesses presented by the state's attorneys. One of those witnesses was Dr. James Stevenson, professor of behavioral health and psychiatry at West Virginia University and state medical director for mental health services. He said he has been working on a telemedicine project to help mental health centers provide more services to people scattered around the state.
But upon questioning, Stevenson agreed that the state won't permit Medicaid reimbursement for most mental health services that can be provided through telemedicine. "Any service we can render that would be reimbursable would be good," he said. "We have no idea how successful we'll be with this service."
Carl Hadsell, managing director of the Center for Entrepreneurial Studies and Development, testified about the Comprehensive Behavioral Health Commission for which he served as a facilitator. He explained that the commission had developed a series of proposals to improve the mental health system in the state, but he faced some sharp questions from the judge.
"Are you shocked that nothing has been done about the crisis situation that has been identified?" Bloom asked. "Are you aware that what you're basically proposing is really what existed in West Virginia 10 to 15 years ago that the department did away with?"
Hadsell responded that he couldn't speak about what was available 10 to 15 years ago. He said he was not an expert in behavioral health and that his only contact with the subject had been through his work with the commission.
"You paint a pretty bleak picture for the state of behavioral health in West Virginia," Bloom said. Hadsell responded that he saw it as positive that the commission had identified ways to improve the system.
Craig Richards, deputy commissioner for administration in the Bureau for Behavioral Health and Health Facilities, testified about the bureau's budgeting process, but his knowledge was limited, because he had been in that job for only two months.
When asked whether it would be cheaper for the state to invest in long-term community-based mental health care instead of paying for overtime at state psychiatric hospitals and for patients diverted to private facilities, Richards responded, "Yes. I would say so."
Vickie Jones, deputy commission for operations in the Bureau for Behavioral Health and Health Facilities, testified that state psychiatric hospitals typically had about 60 unused beds in 1996. Today, those hospitals are routinely overcrowded and many patients are diverted to other facilities. She blamed the overcrowding partly to the "increase in the forensic population eating away at our civil capacity."
But when Bloom asked whether the overcrowding is a result of a lack of community services, Jones replied, "We have seen a decrease in community supports, which has undoubtedly led to an increase in our civil commitments."
At the end of the hearing, Bloom ordered both sides to submit proposed findings, conclusions and recommendation to him by June 1 and have their responses to each other's filing to him by June 8. But he also said, "You all need to urgently submit yourselves to mediation."
Bloom said he wants a mediator's report by June 8 and advised DHHR to make all officials necessary to make decisions available to participate in that process. He said it would be better for the parties to develop their own solutions rather than have him impose solutions. He called the testimony he heard "startling."
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