In 2004, following a national de-institutionalization trend, Nebraska fundamentally changed the way it delivered state-sponsored behavioral health care through the law LB1083.
Today, mental health care experts and state administrators are evaluating the effectiveness of LB1083 and the subsequent changes. The law emptied beds at the state regional centers, increased community-based services and, critics say, has allowed some individuals to fall through the cracks.
In 2003, then-Gov. Mike Johanns and Nebraska Sen. Jim Jensen championed legislation to transfer money from the three state psychiatric hospitals to six mental health regional communities that divide the state.
The move permanently changed the way Nebraska delivers mental health care to afflicted individuals and the purpose of the state regional centers.
The old system was too expensive and didn’t meet the needs of patients, said Vicki Maca, the behavioral health administrator of community services for the Nebraska Department of Health and Human Services, or DHHS.
“Experts across the country said serving people in institutions isn’t the best for them,” Maca said. “Mental health care can be administered just as well in the community because (individuals) have their family support system.”
Nebraska’s push followed a national trend of de-institutionalizing, said Bob Glover, executive director of the National Association of State Mental Health Program Directors. He said 6.1 million individuals a year receive care through community-based services, while at any time, only 47,000 people are in the 235 state psychiatric hospitals.
“In 1983, two-thirds of all (state mental health) expenditures went to state hospitals,” he said. “Now, that’s in reverse: 70 percent of all funds go to community mental health services” as a result of mandated legislative changes.
THE CHANGE TO COMMUNITY CARE
Nebraska has three state psychiatric hospitals, called regional centers, located in Norfolk, Hastings and Lincoln. In the hospital hey-days of the 1950s, the Lincoln Regional Center had 2,000 patients, according to Bill Gibson, the behavior health administrator of the regional centers for the Nebraska DHHS.
The national trend of releasing patients and decreasing the number of beds at state hospitals started in the 1970s when effective psychiatric drugs began to replace in-patient treatment. As a result, only 500 patients remained at the Lincoln Regional Center in 2000.
In 2003, state administrators at the regional centers began identifying patients who would be able to live successfully in the community with an adequate support system in anticipation of behavioral health reform.
In 2004, LB1083 passed.
The bill shifted money within the DHHS from the regional center budgets to community services, forcing the centers to reduce inpatient capacity and allowing communities to expand or initiate outpatient and therapeutic services.
“There was lots of resistance at Norfolk – a lot of people stuck in the old way of doing things,” Gibson said. “They believed (a patient) would never be able to survive if he was placed in the community. But with community support, they’ve stayed there.”
The increased effectiveness of community support resulted in the reduction in voluntary commitments, and now the regional centers are reserved for involuntarily admitted individuals.
“Today, there are 300 people at the regional centers, and almost everyone here has a legal issue,” Gibson said. “We take people who are at a low point in their lives and have gotten in trouble with the law or are a danger to you and me.”
He said there are two paths an individual can take to end up at a regional center, both involving the legal system.
First, if police think someone is having a mental episode or crisis that makes that person a danger to him or herself or to other people, they will place him or her in emergency protective custody before sending him or her to the mental health board.
Involuntary commitments from the board can result in admission to certain hospitals, but the more severe or persistent patients end up at the Lincoln Regional Center, Gibson said.
Of 200 patients at the center, 80 were committed by the mental health board.
The other path does not involve a public safety issue. If, before a court hearing, jailers notice a person in custody is not behaving normally, or if the individual becomes incapable of participation in his or her own hearing, then the individual is involuntarily committed until the episode passes and he or she is able to stand trial.
There are 40 patients admitted to the Lincoln Regional Center for that reason, Gibson said.
“This is an absolutely devastating experience to come here,” he said. “They’re on a downhill spiral, and we’re the last thing to catch them.”
The criteria for people who are experiencing a mental health crisis to receive admission to a regional center are now very limited, and every aspect of community care is explored before a commitment is granted, Maca said.
“The community service increase means less waiting for the regional centers. So when someone needs to get in, they can get in faster,” she said. “People are still going if they truly need to go, but they’re also getting served in the community.”
She pointed to a graph with a downward-sloping line, detailing time from Jan. 7 to Dec. 23, 2008. The graph illustrates the number of people on a waiting list for admission to the Lincoln Regional Center, and the numbers range from a high of 25 – at the beginning – to a low of 0, which is where the graph ends.
Maca said moving monetary resources to community-based mental health care has helped the “frontier” regions in Central and Western Nebraska.
“We’re able to serve more people at home with their connections and relationships,” she said, rather than requiring them to drive through half of the state for psychiatric services.
She said the proximity of care makes up for the criticism that some of the community services are inadequate.
“Do they want more (services)? You bet,” Maca said. “But we’re still doing better than we were under the old system.”
Gibson agreed that the mental health care system doesn’t work perfectly.
“Not by a long stretch. Not everyone gets treated, either. The health care system in America is one of the best in the world, but it’s also one of the most unfair,” he said. “Do people fall through the cracks? Absolutely.”
Gibson maintains that the standard of mental health care in Nebraska is still better after LB1083.
“The success of LB1083 legislation is a whole new paradigm in the way state-sponsored care was delivered,” he said. “For the majority of citizens, today’s system is better than it was eight years ago.”
YET PROBLEMS PERSIST
Critics say some of the problems in Nebraska’s mental health care system are self-inflicted.
Lee Wigert is an ordained United Methodist minister, licensed professor counselor and psychology professor at Hastings College. He’s also a member of the mental health board for the 10th judicial district of Nebraska.
Since the beginning of the mental health transition in 2003, he has been an outspoken critic of a movement that “put the cart before the horse.”
“With community-based reform, it was clear to me that it was about money,” he said. “The move to community-based care, the state wanted to get out of the mental health business and privatize it.”
Wigert became an outspoken “agitator” in 2003.
“I’m not against community-based services,” he said, explaining he’s instead against how fast the state closed the regional centers to the community.
He said the transition discharged individuals from regional centers before adequate community services were available; as a result, more people are left out in the cold now than before the reform.
“Scot Adams (the head of the division of behavioral health for DHHS) says we’re able to provide services to more people after the reform than before,” Wigert said. “But there are fewer services for acutely mentally ill patients than before.
“In our most severe cases, we are letting them down.”
The farthest regional center is in Hastings, which is about three hours from Lincoln. Wigert said the center stopped accepting voluntary commitments for psychiatric treatment in 2003.
“Police started advising people to go out and act like you’re going to kill yourself because then you could get an available bed,” he said.
The mental health regions were able to use the increase in money to contract private companies to provide services; Wigert said this was supposed to save the state money, but it didn’t.
“How were we going to save money by paying private providers $600 a day when the state could do it for $382 a day? One year later, private providers said they needed more money,” he said. “Private providers can’t do it cheaper than the state of Nebraska. They can’t afford to.”
The loss of the regional centers meant the loss of a safety net private providers relied on.
Wigert said sometimes mentally ill individuals in the community would stop taking medication and relapse into a crisis situation. The mental health board would place an individual into the regional centers for immediate stabilization and then move him or her to a nursing home for longer-term care.
When the regional centers’ voluntary inpatient residential psychiatric services closed, so did the nursing homes’ willingness to accept stabilized patients because the patients lacked a backup option if they relapsed.
Now patients in the community who relapse go to regional hospitals that have been contracted to provide such services. This creates the second problem of dual diagnosis.
Dual diagnosis is a condition where some mentally ill individuals also struggle with addictions to drugs and alcohol.
Currently, Wigert said, facilities to treat both are lacking, forcing psychiatrists to recommend treatment for one problem and ignore the other. As a result, the treatment is not as effective as it could be, and patients often return to the mental health board to be rediagnosed.
“We need more inpatient residential facilities for dual diagnosis,” he said. “Every psychologist and police officer from Hastings and Lincoln has said the system doesn’t work.
“The (behavioral health) reform movement is causing more severely mentally ill persons to fall through the cracks. It is forcing psychiatrists to go against their ethics and only partially diagnose someone,” Wigert added. “And we are releasing patients before they are fully treated.”
He said the primary residence of mentally ill individuals is in the backseat of a police cruiser, looking for a place to drop them off; turns out he was only mildly exaggerating.
WHEN THE POLICE HAVE TO STEP IN
On Christmas Day, Lincoln police conducted nine mental health investigations, which was not out of the ordinary, Police Chief Tom Casady said.
LB1083 also had a large impact on the police department: Fewer and fewer officers are choosing to take individuals into emergency protective custody, or EPC.
The most common location for an EPC is perhaps a surprising one: area hospitals’ emergency departments. Emergency room departments used to call police for assistance with restraining a patient having a psychotic episode or trying to leave against doctor’s orders.
“The state was billed over $800,000 by hospitals (for placing individuals in EPC),” Casady said. “A few years ago, we had a very high number of EPCs, and that’s gone steadily down on purpose. We’ve had training to reduce EPCs.”
In 2006, 470 individuals were taken into EPC, or 31 percent of mental health investigations. Two years later, 19 percent of all mental health investigations, or 355 individuals, were taken into EPC.
A departmental policy change now means LPD officers no longer take individuals in a care facility (such as a hospital) into EPC.
“I believe there was an increased usage of non-emergency protective custody and police were no longer the shortcut,” Casady said. “EPC was intended for emergencies, not as an easy button into involuntary commitment.”
It is tough for Wigert to say where the mentally ill should go, if not to a regional center through involuntary commitment.
He wanted to make it clear he is not anti-reform.
“I’m very much in favor of reforming behavioral health,” he said. “But it has to be done in the proper way and keep in mind the people we’re serving.”
As a theologian, Wigert said he can’t escape what he sees as the moral undertones in the mental health debate.
“Am I my brother’s keeper? The answer is yes,” he said. “Does it put tax on the system? I’d gladly pay on the behalf of those who can’t for themselves.”
kiahhaslett@dailynebraskan.com
Nebraska re-routed funds for psychiatric health care; Now state evaluating decision
Change followed trend of de-institutionalization
Published: Sunday, March 8, 2009
Updated: Monday, March 9, 2009
1 comments
Topher Hansen
This article is incomplete and lacks any balance in the reporting. You missed talking to consumers, providers, and Regional administrators. Mr. Wiegarts views will hardly represent the picture consumers can tell you or the State's tracking system for those discharged from Regional centers pursuant to LB 1083 can tell you. The cost scenarios are not fully informative as they represent hospital costs, rather than community based non-profit costs, the bulk of where the services are being offered across Nebraska. My grade for your work: D . Please learn from it and offer us reporting on the next story that is more balanced.
