Jun 8th, 2017
This article was originally published in the Baton Rouge Business Report.
Joe, 55, suffers from schizophrenia. He lives in a Baton Rouge retirement and assisted living community, sees a psychiatrist and a social worker every six months, and takes three medications that help him sleep.
For 30 years, he has made regular visits to the Alliance House Drop-In Center on North 12th Street. Other than his family, he says, the staff are his closest friends.
When asked what he would do if the center didn’t exist, Joe, whose full name is being withheld to protect his privacy, looks down at his lap.
“I don’t know,” he says after a moment. “I have friends here. I have things to do. It keeps me stable.”
The center hosts members with serious mental illnesses—mostly schizophrenia, schizoaffective disorder or bipolar disorder—each weekday morning until midafternoon. There’s a computer room, a small library, and a rec room with two pool tables, air hockey and a recently donated piano.
Monday through Thursday, members compare notes about their lives in a morning meeting, followed by classes, workshops and afternoon exercise. Depending on the day, the agenda could include personal finance, music appreciation or an F. Scott Fitzgerald short story. On Fridays they take field trips; they might see a movie, go bowling or have a meal out.
Members learn about their illnesses, how to manage their emotions, and how to advocate for themselves with benefit and health care providers. Up to two dozen people might drop in on a typical day, and about 200 members will use the center over the course of a year.
“If we see something that may not be quite right, we can give the doctors and the social workers a call,” says program director Brenda Philson. “I think we really keep them out of the hospital.”
Program manager Katherine Anders says their members seem to be sicker since Earl K. Long Medical Center closed in 2013. The hospital was an important referral point for low-income residents with mental health problems, Philson says, and now it’s harder for them to figure out what services are available.
The drop-in center is one piece of what ideally would be an unbroken network of care. Melissa Silva, executive director of the Mental Health Association for Greater Baton Rouge, which oversees the drop-in center, says the region already lacks enough mental health services to meet the need, and state budget cuts continue to eat away at the resources that do exist.
“When you cut mental health services, you might save a dollar, but it’s going to cost you $12 down the road for the hospitalizations or the prison stays,” says Jenny Ridge, the association’s development director.
Silva is dealing with a recent $50,000 cut in state funding. The association does private fundraising, but mental health isn’t the most popular charity, and last year’s flood will make raising money even more difficult. She says 93 cents of every dollar the association receives goes directly into services, so there’s not much fat to cut.
Drop-in center members depend on the psychiatrists and social workers of Capital Area Human Services, which also suffers annual budget cuts. CAHS provides those clinical services while going beyond its intended mission to help people in severe crisis.
Meanwhile, law enforcement officers, asked to be de facto case workers for those who fall through the cracks, often are left with two options: The emergency room or parish prison. Last fall, 51% of East Baton Rouge Parish voters rejected a proposed 1.5-mill property tax that would have generated about $5.8 million a year for the Bridge Center for Hope, a project meant to divert people with mental health and substance abuse issues away from ERs and the parish prison and into treatment.
But even if some version of the Bridge Center eventually comes to fruition, it would still represent only one link in the care network. The national mental health crisis is a microcosm of the challenge of health care in general: How to get people the right care in the right place at the right time, before it’s too late.
A ‘PERFECT STORM’
Dr. Robert Blanche has worked in mental health care in Baton Rouge for more than three decades. Recently, he has seen “unprecedented numbers of people facing mental health crises” thanks to a “perfect storm” of disturbing trends.
“It’s the major social problem of our time,” he says.
Addiction often contributes to psychiatric illness, and vice versa. Five years ago, Blanche says, he might have seen one substance-induced psychosis out of 20 patients. Today, about half of Blanche’s patients at Seaside Health System behavioral hospital have substance abuse issues. Methamphetamine, usually associated with rural areas, has become more prevalent in Baton Rouge, as have synthetic drugs, he says.
For several decades, there was a national push to deinstitutionalize the mentally ill. In Louisiana over the past five years, Blanche says, state budget cuts have led to a dramatic reduction in the number of psychiatric beds available for lengthy stays.
Many of the people who filled those beds ended up homeless or in lightly regulated, possibly unlicensed group homes where their health may not be well monitored, he says. When they have a psychotic break, they often end up in an ER. Blanche says most ER doctors aren’t trained to deal with seriously mentally ill patients, whose presence ties up staff and beds.
“We work diligently to get the resources these people need,” says Denise Dugas, executive director of mental and behavioral health at Our Lady of the Lake. “We’ll hold onto those people in our inpatient units. It creates a bottleneck.”
There is a nationwide shortage of mental health providers, says Dr. Lee Tynes, who serves on the faculty of the LSU-OLOL psychiatry residency program. Many private-practice psychiatrists in Baton Rouge don’t take insurance, let alone Medicaid, and it can take several weeks to schedule an appointment even if you can afford to pay cash.
The number of people showing up at OLOL’s ER with mental health issues has doubled over the past four years, Tynes says. Though OLOL is now being asked to care for poor patients who used to go to the Earl K. Long charity hospital, he says that change alone doesn’t nearly account for the increase.
Tynes laments state budget cuts that eliminated beds for people who need intermediate levels of care at places like Central Louisiana State Hospital, a psychiatric facility in Pineville. One such patient might now spend three or four months occupying an acute-care bed where 10 or 15 people facing an immediate crisis could have been treated.
The region also needs more “community-level services,” he says. Not just walk-in health clinics, but transportation, affordable housing and job programs. People who struggle to meet other basic needs obviously have a hard time managing their health conditions.
“The issues all intertwine,” Tynes says.
Dr. Harold Brandt, an internal medicine physician at the Baton Rouge Clinic, says the clinic doesn’t have a psychiatrist. They’re developing a mental health solution, he says, but it’s hard to make the numbers work.
Ideally, primary and mental health care are integrated, and a patient’s primary care doctor can make an immediate “warm handoff” to a mental health specialist when needed, Brandt says. But the fee-for-service payment model—which rewards volume more than effectiveness—still dominates health care, and it isn’t cost-effective to have a psychiatrist sitting around waiting for referrals.
CAHS provides behavioral health care for adults and children, substance abuse prevention and treatment, developmental disability support and other services in seven parishes to people with or without insurance, often on an income-based sliding fee scale. The quasi-public, state-affiliated organization, which served 10,643 people in 2016, sees its state allocation cut every year, says Executive Director Dr. Jan Kasofsky, including $1.3 million this year.
“Capital Area was never funded, nor was it part of our contract with the state, to provide crisis services,” she says. But with fewer state beds available and emergency rooms inundated, CAHS is left to pick up the slack, developing a mobile crisis team and staging social workers in the parish prison.
“It’s not right for people who are sick to go to jail,” Kasofsky says.
‘NOWHERE ELSE TO TAKE THEM’
On the morning of Feb. 13, 2016, Baton Rouge police received reports of property damage and shots fired in the area of Harry Drive and Monet Avenue. According to East Baton Rouge Parish District Attorney Hillar Moore III’s public report, an officer spotted Calvin Smith, 23, who had fled the scene in a gray Dodge Avenger. Smith led the officer on a five-minute high-speed chase before stopping the car in front of a house, where a second officer arrived.
Smith got out of the car and began firing a stolen AR-15 semiautomatic rifle, the report says, and the officers returned fire. Both officers were injured, and Smith was killed.
Smith had been suffering from mental health issues, including severe depression, exacerbated by the end of his relationship with his child’s mother, the report says. He was off his medications, and had discussed committing murder or suicide.
While reviewing recent domestic violence incidents and officer-involved shootings, Moore says, it became clear that mental illness is often a significant factor.
“That was eye-opening to us,” he says.
After Hurricane Katrina, CAHS helped develop the Mental Health Emergency Room Extension for Earl K. Long. Housed in a doublewide trailer in the back of the hospital’s parking lot, the federally funded facility saw almost 4,000 patients in 3.5 years, says Blanche, who directed the unit. About two-thirds were directed to appropriate outpatient care and didn’t need to be admitted to the hospital.
Earl K. Long provided medical care for parish prisoners and was well-secured. When law enforcement officers arrested someone they suspected was mentally ill, they could drop them off at the MHERE and get on with their shift.
When Earl K. Long was closed, MHERE closed with it. Now, officers might spend four hours waiting for the person in their custody to be admitted to an area ER, Moore says.
The East Baton Rouge Parish Prison typically houses about 1,600 inmates, and about 20% to 30% suffer from mental illness, says Lt. Col. Dennis Grimes, the prison’s warden. For the past two years, he had two social workers provided by CAHS to work with incoming prisoners, but that contract was a casualty of city-parish budget cuts.
Often, when the cops are called to arrest someone with a mental illness who has committed a minor crime, the person who made the call doesn’t actually want the other person to go to jail, Grimes says.
“There’s nowhere else to take them except to jail,” he adds. “When people come to prison and they’re mentally ill, we’re tasked with something that we don’t have the capability to do.” Grimes has started providing training for his officers to recognize mental health issues and to de-escalate confrontations that may be caused by those issues, but there’s only so much they can do.
“The jail has become the default mental health facility,” says Dr. William “Beau” Clark, East Baton Rouge Parish coroner and president of the Louisiana State Medical Society.
The coroner’s office conducts mental health investigations and can order someone suffering from mental health or substance abuse issues to be detained and treated to protect themselves or others. In 2011, the office issued 473 orders of protective custody and 3,152 emergency certificates. In 2016, those totals had increased to 1,024 and 8,201, respectively.
The Bridge Center was touted as a means to “decriminalize mental illness.” Consultants estimated it could save the parish almost $55 million in direct costs during its first decade, along with more than $288 million in indirect savings through higher productivity among the mentally ill and reduced homelessness.
But voters last fall narrowly rejected the tax that would have paid for startup and operations, and the Metro Council so far has decided not to put it back on the ballot. Kathy Kliebert, the former state health secretary who chairs the project’s board, says it’s still possible the tax will appear on a ballot in the future, but she doesn’t expect the council to change direction in the short term.
A board retreat to regroup and figure out the next steps was planned for early April. The Bridge Center project envisioned assessment teams, inpatient beds, a sobering center and other services under one roof, Kliebert notes. Maybe some of those pieces still could be funded through grants or existing funding streams.
And perhaps the Capital Region could get better results if leaders and providers could figure out how to better leverage assets the community already has.
“There are resources that are there, but they are scattered, and sometimes people don’t know the appropriate resources,” Kliebert says. “The more we can do to coordinate and publicize those resources, certainly I think we’ll have better outcomes.”
Oceans Healthcare provides inpatient and outpatient behavioral health services throughout Louisiana and Texas. None of the communities the company works with are satisfied with the amount of services available in their regions, says CEO Stuart Archer.
“Everybody struggles in their own way,” he says.
Oceans was established in 2004 and arrived in Baton Rouge in 2006. It started out treating seniors, but has begun branching out to younger adults. The company currently has 20 beds in Baton Rouge, and hopes to break ground this year on a project that would add another 20 to 24 beds.
Republicans in Congress are trying to repeal and replace the Affordable Care Act. While it’s impossible to know for sure if they will pull it off this year or what the results will look like, Archer worries about losing the mandate to cover mental health and substance abuse treatment. He says a proposal to charge 30% higher premiums to people who let their coverage lapse could price out people with chronic mental health issues, because they often have trouble maintaining steady employment and staying insured.
Pretty much any discussion about providing health care for vulnerable populations involves Medicaid, so losing the ACA’s Medicaid expansion is a huge concern. Medicaid is the single largest payer for mental health services in the nation, according to the federal government, and plays a growing role in the reimbursement of substance abuse disorder services. However, there has been talk of turning Medicaid into a block grant program, which could allow states more flexibility.
“The president is saying that more people will have coverage,” says Kasofsky, CAHS director. “We’ll just have to wait and see what that means.”
Blue Cross and Blue Shield of Louisiana is working with its partner, New Directions Behavioral Health, to build a strong network of mental and behavioral health care providers, says Dr. Paul Murphree, interim chief medical officer with Blue Cross. Using a value-based reimbursement model—that is, paying for good results, not just volume of services—Blue Cross is embedding behavioral health professionals within large groups of primary care physicians, while working with smaller primary care practices to facilitate referrals, he says.
Baton Rouge General Medical Center has 50 inpatient beds at its inpatient behavioral health center in Mid City. The campus would be a workable site for an intervention program like the Bridge Center, says Dr. Kenny Cole, the hospital’s chief clinical transformation officer.
The General largely runs its inpatient and outpatient businesses on a fee-for-service basis. But for their self-funded employee health plan, they’ve created an “innovation center” that embeds behavioral health providers such as social workers into primary care, Cole says. If a diabetic has a problem with binge eating, an on-site behavioral therapist is there to help.
“You sort of have the traditional behavioral health model, which is a fee-for-service model that is underfunded and undervalued, and then you try to do things that are innovative,” Cole says.
A new $50,000 MacArthur Foundation grant for 18 months will pay for a social worker to help identify low-risk parish jail inmates who can be released into treatment, District Attorney Moore says. They will be tracked to see if they reoffend. While the project may only be able to help a small portion of those who could benefit, it could be expanded if it’s successful and funding is available.
Moore says a lot of people are doing good work in the mental health field. But like almost everyone interviewed for this story, he says there should be more collaboration. For example, when someone with mental health issues gets out of jail, judges and district attorneys would like to know if that person is getting help and whether they’re getting better.
“How can you connect everybody together?” he wonders. “Do we even know each other, and what each other does?”
Dugas, the OLOL executive, says the Mayor’s Healthy City Initiative—a public-private collaboration launched under former Mayor Kip Holden to promote health lifestyles—is working on a website that would list the community’s mental health resources, so health care professionals can refer consumers to the right places. Dr. Tynes says having a health care “dashboard,” updated daily with new information about available beds and other resources, was incredibly valuable after Hurricane Katrina, adding something similar would be helpful in Baton Rouge today.
The Bridge Center project, or something like it, might still be needed, but it’s never going to cure all the region’s mental health ills. And if the project dies, that only makes the broader conversation more urgent.
“I think all of the different providers have pieces of the continuum that they’re working on,” Kasofsky says. “It’s important now to pull everyone back together.”
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