Two sides of LB1083: community care vs. psychiatric hospitals

There is no talking to patients at the Lincoln Regional Center; no one is here by choice.

At the Goodwill Industries complex for education, training and treatment in Grand Island, fewer than two hours away, clients go from class to seminar to support group, too busy to speak.

Although the Lincoln Regional Center, or LRC, and Goodwill Industries are worlds apart in day structure and program objectives, the two represent the dual aspects of the state-run behavioral health program: psychiatric hospitals and community-based care.

The institutions manifest the behavioral health changes the 2004 law LB1083 mandated – such as moving civilian patients from state regional centers to community-based services – and assist individuals with mental illnesses to lead productive, normal lives.

LB1083 organized the transfer of money away from the regional centers to the six behavioral health regions, reducing the amount of people who could be served in regional centers but enabling community-based behavioral health care to assist an additional 9,000 people last year.

“The intent of 1083 … was to serve better,” said Vicki Maca, the behavioral health administrator of community services for the Nebraska Department of Health and Human Services. “Choices weren’t available before.”

Lincoln Regional Center

At the LRC, the challenge is patient stabilization prior to their initial court appearance. It was built in 1874 and is a sprawling institutional complex surrounded by an arboretum on 2705 S. Folsom St., far from the heart of Lincoln and the University of Nebraska-Lincoln.

“It’s not a mystery as to why it was put out on West Prospector,” said Bill Gibson, the behavior health administrator of the regional centers for the Nebraska Department of Health and Human Services. “It was all marsh back then. If someone ran away, it would be difficult to get into town.”

Now, there is a neighborhood subdivision adjacent to the LRC, and somewhere in the middle of the homes is a historic graveyard, filled with patients who lived out their lives there.

Their life and death records are kept in old, leather-bound books in a little hospital museum in the administration building, along with sports trophies, straightjackets and electroshock therapy boxes that look like record players.

“This just shows you how independent hospitals were,” Gibson said. He picked up a pole with a wooden block on the bottom, covered with leather.

“They didn’t have drugs to help people with their issues. If someone had energy – these old buildings all had hardwood floors and they’d give them this,” he said. “The patients would put candle wax on the bottom and push them for hours. They spent hours waxing the floor.”

While some therapy was harmless, others could be painful. Electroshock therapy was performed without anesthesia or painkillers applied to the area prior to the shock. Boxes showing the progression of technology are on another table: a vintage 1930 model, two from the 1950s and 1960s. Two straightjackets hang from pegs the wall.

“Those restraints were pretty traumatic, especially to females. It made them vulnerable,” he said.

Patient therapy has advanced since the days of wood waxing blocks and straightjackets, and building No. 10, across the street from the little museum in the LRC Admission building, is one example.

At the LRC, the men and women are kept in separate buildings with identical available services and similar interiors.

“That way, they can focus on therapy with less distraction,” said Barry Burumen, the assistant director of nursing for the male unit, housed in building No. 10.

The first floor houses a piano, the recreational room and the resource room. Patients don’t live on this floor but are allowed to visit as they gain more privileges, he said. Patient-produced finger paintings in bright neon colors are hung on the walls outside the rec room. Inside, there are tables, mismatched chairs, a long shuffleboard table and a pool table.

“Patients can do painting and artwork or work on their leisure skills,” Burumen said. “Leisure skills are important, and patients work with our recreational therapist.”

Around the corner from the rec room and down the hall is another popular room: the resource center, headed by Tom Schmitz. It’s a small room with books lining every available shelf of the walls, tables for reading, a large magazine selection and a computer, tucked neatly into the corner.

Schmitz said most of the collection is professional non-fiction, and many patients choose to research their illness or diagnosis.

Most of the books are out-of-date, so he works with Lincoln City Libraries through the inter-library loan program. Patients can use the computer to send e-mail or apply for jobs.

“We don’t refuse a patient any information, but I call their wards so they can go over the information with them,” he said. “We’ve got hometown newspapers, a big self-help section and sports and health magazines in English, Spanish and Vietnamese” to cater to all the native languages of LRC patients.

“There’s something for everyone here.”

The second floor elevators open to a common room with        ng hallways leading to the cafeteria and dormitories. Thirty-six beds and 35 patients reside in Building No. 10. The nurses’ station is in the middle of the common room, adjacent to a wall full of board games that reaches the ceiling.

“Everyone here has a schedule: 40 hours of active treatment and then self-directed time,” Burumen said.

Recreation is one of the center’s strongest areas, said Gayle Resh, head therapeutic recreational specialist.

Teaching leisure skills helps build or rebuild cognitive, psychiatric, emotional and social health.

“Some of our clients have never developed these skills,” she said. “We try to teach them where to go, what to do and how to do it so they can be functional when they go back into the community. The programming is about learning how to interact with other people.”

Resh said recreational therapy used to consist of a large room and Bingo cards.

Now, she said she’ll spend a week teaching patients games involving dice or how to use Nintendo Wii video game consoles to play tennis or bowling. There are a lot of board and table games.

A crochet class is full, and with a waiting list.

Patients do these activities for their health, and she said it isn’t uncommon for patients to spend 10 to 20 hours a week in therapy.

“What made someone mentally ill and dangerous in the first place?” she said. “They need to have the skills not to be dangerous,” like anger management, crisis coping and the ability to self-direct time.

In the basement of Building No. 10, there is a canteen staffed by paid patients, a storage area and the entrance to the enclosed outdoor area, which features a gazebo and a basketball hoop attached to the side of the building. Patients use chalk to draw on the sidewalk and concrete walls.

“We come out twice a day to shoot hoops or give chalk for different kinds of drawing,” Burumen said. “It’s been wearing off since the last time we came out.”

He said the area is a good opportunity fo patients to go outside while still under supervision: nurse technicians can’t give male patients privileges to be out  beyond the concrete walls of Building No. 10.

Community-Based Care and Services

Outside regional centers like the LRC, the Department of Health and Human Services contracts with each of the six behavioral health regions. The directors of each region decide which services to provide and who will provide them. Feedback from clients is vital to program formation, she said.

A formula based on a region’s population and poverty level distributes the funds.

“Places like Omaha and Lincoln receive more funding than the frontier and rural areas, and (the frontier and rural areas) have to be very creative to make it work,” Maca said. “They might put money into transportation, telehealth (using phone calls to check up on patients) or use providers outside of Nebraska in surrounding states.”

The department grants each region the independence to decide what is best for the area.

“We try to work collaboratively to set a vision and direction and provide technical assistance,” Maca said. “It’s not us versus them. We try to be ... connected to the community.”

Grand Island is Region Three. The area relies heavily on the services provided by Goodwill Industries of Greater Nebraska for day programming and employment support, said regional administrator Beth Baxter.

At the Goodwill “Victory House,” clients attend classes to practice self-expression or manage crisis, participate in mental self-help groups or apply for a job. Clients utilize numerous areas and classrooms past the large cafeteria area, including a comfort room for individuals who need a break. The program serves 130 people.

“Goodwill uses evidence-based employment support, and it provides a good outcome,” said Kelly Arends, employment services program manager. “Employment builds self-worth and reaffirms that a person with a mental health diagnosis can work competitively, provide for (himself or herself) and reduce the stigma.”

The mission of Goodwill Industries is to help improve the lives of individuals and enable them to live at their fullest potential, said Earl Umbenhower, the community support program manager for Goodwill.

“It used to be if you had a mental illness, there were a few choices that were very limited,” he said. “Now we have a variety of choices.”

Goodwill offers support groups and 12-step programs, including a recently developed dual diagnosis program called “Double Trouble” that addresses problems of patients with both mental illness and substance abuse.

“It’s the region’s responsibility to understand (the needs of the individuals in their area) and work with the system,” said Tonya Ingram, day service program manager for Goodwill. She said Region Three works with other regions to provide a critical mass for providers – enough individuals to make care financially feasible.

Baxter said that like many   other regions, transportation is sometimes difficult, in addition to other challenges.

“Living in a rural area, an individual may have burnt a lot of bridges,” she said. “A stigma is prevalent, and we have to advocate for the individual – redeem them. Say they’re recovering and are more responsible.”

Community-based health care providers are also utilizing peer specialists to encourage and challenge individuals to take control of their mental health, employment and life. Peer specialists are individuals who also have mental health issues, have gone through crisis situations and therapy and serve as a testimony to treatment.

“A peer specialist is unique in that the experiences are very similar to the people served,” said Patti Linbteigen, a peer specialist with Goodwill who also leads four classes. “The empathy goes a little deeper. Being there ourselves, we understand the barriers.”

The big role for Linbteigen is a model of recovery. She is bi-polar and became a peer specialist after burning out from her last job and quitting.

“It’s a great fit. There’s enough change in my day and challenges that it’s allowed me to grow,” she said.

Being a peer specialist puts her on common ground with the people she serves and allows her to practice what she preaches.

“It adds a door that I’ve been there. I was unemployed, not able to afford food or rent. The role modeling piece means getting up every day and keeping the routine. They see our wellness and know they can have the same wellness, can have recovery and can stay well, too,” she said. “I never say ‘I’ve been there’ unless it’s true.”

In an effort to avoid police-run emergency protective custody for crisis patients, Region Three built a voluntary-commitment crisis center with diverted funds in 2003.

“This is the only center in the state,” Baxter said. “It’s a unique concept to roll several crisis services into one location.”

All staff members are trained to assess an individual, and admitted persons are formally evaluated by a psychiatrist within 24 hours. The crisis center treats both patients having a mental crisis as well as individuals who need to detox.

“A crisis doesn’t last forever,” Baxter said. “A peer specialist can help them get on their feet, on the ground, and go back out.”

Wendy Piercy, program manager at the crisis stabilization unit, said her staff performs about 80 risk assessments a month and admits about 25. Out of 12 beds, six are reserved for mental illnesses.

She said individuals can stay at the crisis unit for a few days and focus on therapy, coping and social skills and life assessment. They are required to create a recovery plan to avoid a relapse.

The center operates on a sliding pay scale based on a patient’s income. The rates are extremely reasonable, Piercy said.

“All a patient needs to do is talk to us,” she said. “(Cost is) another stigma. It’s not a primary question we ask.”

Goodwill’s efforts and institutions like the crisis center seem to be working. Baxter said at the start of behavior health reform, 49 individuals from Region Three were in a regional center; today there are only seven.

“That’s a very minimal number of individuals and a demonstration of success that they don’t have to go back to regional centers,” she said. “They can self-direct their own care, and I see that as another milestone of success.”

kiahhaslett@dailynebraskan.com