Delivery of Care

Do not expect that there will be a sanity clause

The broken system of the community mental health network is now emerging as a major crisis in Rhode Island, but resources keep getting cut at the state level

By Richard Asinof
Posted 1/23/17
The state of the state for the delivery of community mental health services is broken and getting worse, according to mental health advocates. The bad situation has been further exacerbated by the closing of Eleanor Slater Hospital to new civil admissions, according to advocates.
What is the current state road map for the delivery of behavioral and mental health services in Rhode Island? Who is in charge of directing coordination of such planning at the state level? Who is the decision-maker? How much is the state willing to invest in new resources to support better coordination of the community mental health network? Will this become a priority of the Raimondo administration?
The interconnectedness between substance use disorders, the epidemic of overdose deaths, the de facto reality that the state correctional facilities are serving as the state’s mental hospital, and the continued drop in state investment in community mental health facilities, all point to an approaching train wreck. It is not just a public health crisis, it is a major economic crisis for Rhode Island and its future. And, it may require the R.I. General Assembly to step up to the plate and invest new resources to fix a broken system, even if it means increasing taxes.

PROVIDENCE – If you listened to Gov. Gina Raimondo and her state of the state speech on Jan. 17, Rhode Island is strong and getting stronger every day, a positive message.

However, when ConvergenceRI recently sat down to talk with two advocates about the state of the state when it comes to mental health in Rhode Island, they painted a much darker picture.

In their view, everything appeared to be broken about the state’s mental health and behavioral system – and getting worse.

Their descriptions brought to mind to ConvergenceRI the lyrics from the Bob Dylan song, “Everything is Broken”:

Broken bottles broken plates
Broken switches broken gates
Broken dishes broken parts
Streets are filled with broken hearts
Broken words never meant to be spoken
Everything is broken.

In horrible shape
Ruth Feder, the executive director of the Mental Health Association of Rhode Island, said that Rhode Island was in “horrible shape” when it came to community mental health.

Feder pointed to the most recent rankings from Mental Health America, which had Rhode Island ranked second to last in the nation in the prevalence of mental illness.

[The rankings are based upon six measures: adults with any mental illness; adults with dependence or abuse of illicit drugs or alcohol; adults with serious thoughts of suicide; youth with at least one past year major depressive episode; youth with dependence or abuse of illicit drugs or alcohol, and youth with severe major depressive episodes.]

Feder also talked about the fact that the Eleanor Slater Hospital has been closed to new civil admissions for the last six months, a policy decision that had apparently been made with little or no public or legislative input.

Feder also talked about the ripple effect by the lack of resources being invested by the state in community mental health programs. “The amount of money being invested by the state in the mental health system has progressively gone down,” she said.

As a result, the state correctional facilities have become the de facto mental health institution for the state. “The prison system has become our go-to mental health facility,” Feder said.

“We have slowly done away with support for community-based services,” Feder said. “What ends up happening is that people get sicker and sicker and sicker until they end up having to be in a hospital. That’s not a community mental health system.”

Feder also expressed concerns about what happens to children when they age out of state programs and transition to adult programs, and the lack of transitional programs and funding to support them.

Rhode Island turned down for demonstration program
Feder said she was disappointed to learn recently that Rhode Island had been turned down for a federal award to be one of eight states to participate in the two-year Certified Community Behavioral Health Clinic demonstration program, with the goal of integrating behavioral health with physical health care, as well as to improve access to high-quality care for people with mental and substance use disorders, clearly a great need in Rhode Island.

Feder said that she worked closely with state officials to coordinate the proposal and to garner support from the state’s Congressional delegation. She expressed some worry that state officials may not have been as strong advocates as they could have been, because the federal match for adults was not 90 percent, but around 65 percent, which would have required more resources to be invested by the state.

When federal awards are made, there are often news releases that accompany the announcement; when federal awards are turned down, there is often little explanation.

ConvergenceRI reached out to the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals for an explanation of why they thought the grant may have been turned down, and whether the agency would consider applying again. Here is the response:

“In late 2015, 24 states received planning grants for the two-year Certified Community Behavioral Health Clinic, with the understanding that eight states would be invited to participate in the demonstration,” said Rebecca Boss, acting director at BHDDH. “The demonstration was not a grant but an increase in Federal Medical Assistance Percentages for Medicaid,” Boss explained. “It is unclear whether the demonstration phase of the grant will be available again.”

While it was unfortunate that Rhode Island was not named a demonstration state, Boss continued, there were some concepts from the grant that the state was hoping to implement in 2017, including a 24-hour mobile crisis team to meet people where they are in the community and avoid the trauma and expense of going to an emergency department.

Potential solutions, moving forward
Feder suggested that the state consider developing a road map similar to those developed under the Olmstead U.S. Supreme Court decision, a plan for community integration, something that Rhode Island does not currently have for mental health.

Under such a road map for the mental health system, the plans would show how services would be integrated, including outpatient services, housing and transportation services.

“An Olmstead-like plan is not a 100 percent solution, but it would go a long way to establish that there would be appropriate supports in place here in Rhode Island for people with disabilities, including people with serious and persistent mental illness,” she said.

A slow-moving train wreck
Reed Cosper, a board member of the Mental Health Association of Rhode Island, and the former mental health advocate for the state who retired in 2013, likened the state of the state to a slow-moving train wreck that was about to happen, set in motion for more than a decade by a steady lack of investment of state resources.

Cosper was part of the free-wheeling conversation with Feder at Olga’s Cup + Saucer. Cosper brought to the table a long-term knowledge of the evolution of the mental health system, or, has he might put it, the devolution of a system of community-based care.

The shutting down of Eleanor Slater Hospital to new civil admissions, as well to the fact that some 600 patients in the state correctional facilities are on “neuroleptics,” a class of antipsychotic medications primarily used to manage psychosis, was a travesty, according to Cosper.

Cosper described the connection between the state’s correction facilities and the state’s mental hospital as a minuet – a dance, a mutual back-scratching.

“The prisoners [with severe and persistent mental illness] are in state custody, but they belong in a state hospital,” Cosper said. “We have a statute that authorizes their transfer to a state hospital.” But the discussion about having to do that, he continued, just doesn’t happen.

“If it did happen, they have a marvelous set of civil rights in a hospital that they don’t have in prison,” Cosper continued, calling the current situation “a collaboration of neglect.”

The people in prison who have serious and persistent mental illness, Cosper emphasized, were sent there by a judge.

Any solution to the problem has to start with the fact that their liberty has been taken away from them, which is not a path to a community-based solution, according to Cosper.

What was the solution?

“The path is to move them to an inpatient facility from which they can be discharged when it is appropriate,” Cosper answered. “If they are in the prison system, they have failed the community, and the community has failed them.”

Part of the problem, according to Cosper, is that there are unrealistic expectations placed upon a system that doesn’t ever seem to talk about how it is going to allocate scarce public funds.

Bridging the gaps
ConvergenceRI also spoke to a long-time professional in the delivery of mental health services to get an additional perspective. The professional, who spoke off the record, talked about the differences in the approaches being taken by the Raimondo administration for economic development and for behavioral and mental health.

With economic development, the professional explained, the state is providing all sorts of transitional funding to grow the job sector and to bridge the gap between the economy of today to the economy of tomorrow, with a level of resources for transition.

Those resources to support transitions within the system of community mental health care do not exist, according to the professional. “The philosophy that the government clearly applies to economic development is not flowing through to the health care side,” the professional said.

New developments
This week, former Providence Mayor Joseph Paolino is scheduled to announce plans to repurpose the former St. Joseph Hospital property to serve as a center of service coordination to provide care and support for the homeless population in downtown Providence, according to news reports.

An embargoed press briefing is scheduled for Monday, Jan. 23, with a news conference scheduled for Tuesday, Jan. 24.

The St. Joseph’s Hospital property had been purchased by Paolino from CharterCARE in 2016, according to sources.

The plans for the new initiative may provide opportunities to broaden the conversation to include a more inclusive exploration of the state of the state when it comes to mental health and behavioral health coordination and investment in resources.


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