The Vital Role of State Psychiatric Hospitals

NASMHPD Medical Directors Council Technical Reports

• Series began 1997 – This is the 18th• Goals

– Assure that policy decisions are informed by the best and most current clinical evidence

– Clearly explain complex clinical issues for non-clinician policy makers

– Provide concrete actionable recommendations for Commissioners, NASMHPD, Federal agencies Behavioral Health Care providers, and Consumers

– Provide a policy implementation resource document and toolkit

NASMHPD Medical Directors Council Technical Reports - Method

• Form a diverse Expert Panel• Identify Editors and expert writer• Planning call to clarify scope and structure of

the report• High level literature review• Day and a half Expert consensus meeting• Initial draft report repeatedly revised first by

editors then by panel

Strategic Vision according to The Moody Blues

• I'm just a wandering on the face of this earth meeting so many people who are trying to be free

• A thousand pictures can be drawn from one word. Only who is the artist. We got to agree.

• A thousand miles can lead so many ways. Just to know who is driving, What a help it would be

• If you want the wind of change to change the world and you're the only other person to know, don't tell me…..

• I'm just a Commissioner of a SMHA (Repeat Refrain)

Public Sector Mission

To Care for Persons whose behavior is so dangerous or socially unacceptable that their communities cannot tolerate their presence and no other entity can or will work with them

Public Sector Goals

• Treatment and Recovery• Public Safety

Public Sector Admission Criteria

The facility or program is the least inappropriate currently available.

State Mental Health Agency Controlled Expenditures for State Psychiatric Hospital Inpatient and Community-Based Services as a Percent of Total Expenditures: FY'81 to FY‘12

0%

10%

20%

30%

40%

50%

60%

70%

80%

33%35% 36%

38%

43%

49%

58%

66%67%

69%70%70%70%

71%72%72%73%74%

74%

63%

60% 60%59%

54%

48%

39%

32%30%29%28%27%28%26%26%26%25%24%23%

State Mental Hospital-Inpatient

Community Mental Health

Source: NRI 2012 State MH Agency Revenues and Expenditures Study

Number of State Psychiatric Hospitals and Resident Patients at End of Year: 1950 to 2012

Sources: CMHS Additions and Resident Patients at End of Year, State and County Mental Hospitals, by Age and Diagnosis, by State, United States, 2002, and NRI 2013 State MH Agency Profiles System

322

280

315

276 281

230217 213 207

0

50

100

150

200

250

300

350

1950 1960 1970 1980 1990 2000 2010 2011 2012

Nu

mb

er

of

Sta

te P

sych

iatr

ic H

osp

itals

0

100,000

200,000

300,000

400,000

500,000

600,000

Nu

mb

er

of

Resid

en

ts i

n S

tate

Psych

iatr

ic H

osp

itals

Hospitals

Residents

Source: NRI 2013 State Mental Health Agency Profiling System

Number of State Psychiatric Hospitals

18991902

19051908

19111914

19171920

19231926

19291932

19351938

19411944

19471950

19531956

19591962

19651968

19711974

19771980

19831986

19891992

19951998

20012004

20072010

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Sex Offenders

Forensics

SMHA-Controlled Forensic and Sex Offender Mental Health Expenditures As a Percentage

of State Psychiatric Hospital Expenditures, FY'83 to FY'12

Source: NRI 2012 State MH Agency Revenues and Expenditures Study

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ProhibitAllow

79% non-smoking

Percent of State Hospitals by Smoking Policy: 2011

NRI Smoking Study: 2011

State Hospitals at the Cross Roads• The public mental health system is experiencing new challenges in a

rapidly changing environment. – Health care reform, – economic restraint, – complex civil commitment laws, and – the need to ensure civil rights

• Today, most people with mental illness are served successfully in community settings.

• At times, those with the most serious mental illness need inpatient care provided at state psychiatric hospitals.

• Controversies– No one should be in hospital vs not enough hospital beds– Recovery vs public safety– Inappropriate admissions vs the ultimate experts at the most difficult

Recommendations 1.1 & 2.1

• 1.1 State psychiatric hospitals should continue to admit and care for service recipients with complex psychiatric conditions who are at risk of harm to self or others and cannot be effectively treated by existing available services in the community.

• 1.1 Persons who cannot be safely and effectively treated in another treatment setting should be considered appropriate for state psychiatric hospital admission.

• 2.1 State psychiatric hospitals should continue to admit and care for persons whose conditions are considered untreatable by other healthcare providers in treatment settings or who the rest of the treatment system considers too dangerous.

Recommendation 1.10

• Service recipients should be provided treatment in the most integrated and least restrictive environment. However, if appropriate, service recipients who are at risk of being violent should be provided a continuum of treatment security to address their and staff’s safety needs.

• It is the duty of the state psychiatric hospital to make reasonable efforts to create environments in which service recipients and staff are as safe as possible.

Recommendations 4.12 & 4.14

• 4.12: NASMHPD should develop a technical report specific to forensic service recipients.

• 4.14: NASMHPD should develop and Expert Consensus Report on Treatment Models and Standards for Persons Committed as Sex Offenders.