The Free Press, Mankato, MN

May 28, 2012

Suffering in Silence, Part 3: Core services remain, but professionals are spread thin

By Dan Linehan
The Free Press

— When Irvin Schaefer left the hospital, the first thing he did was sign up for day treatment. It’s a kind of step down from the hospital for people who aren’t ready to live on their own.

“It’s really good to speak with people who know where you’re coming from,” the St. Peter man said.

There were counseling and classes to teach skills, such as cooking, to help people live on their own. They’re less likely, the thinking went, to wind up back in the hospital or worse.

But the state no longer pays for day treatment, so people who can’t afford it don’t go.

“It’s too bad they don’t have something like it for people today,” Schaefer said.

He still attends the sole meeting offered, a weekly self-help group.

His experience is typical.

Counties — the last line of defense for mental health — are required by the state to treat people who are what’s called “severely and persistently mentally ill” or SPMI. And they still do.

But all the extras have been shorn away. A bottom line remains.

“We can’t, and don’t, turn people away,” said Dr. Michael Farnsworth, a Blue Earth County psychiatrist.

Mental health, like the rest of medicine, is typically paid for by private insurance or the government. Because most insurance is tied to work and someone with severe mental illness will probably eventually lose their job, the public sector tends to see the worst cases.

“We refer the well insured to the private sector,” Farnsworth said. “We’re the no-money people.”

The no-money people in south-central Minnesota have formed what they say is an innovative approach that relies on long-distance consultations to dispense medication, a practice called “telemedicine.” The client checks in at one of 30 or so satellite locations, then talks to a doctor at a county site.

The nine-county South Central Community Based Initiative, also called the “hub,” is not for long therapy sessions; the meetings-by-screen are for prescribing medication. It might seem like a lot of trouble just for some quick one-on-ones, but prescribing medication is a very expensive part of mental health.

Though it operates its own clinic, Blue Earth County employs only one full-time psychiatrist. Instead, it relies on advanced practice nurses, who can also prescribe medication.

One problem is there are too few psychiatrists. And, being wealthy and well educated, they tend to prefer city life.

“We were desperate to get anyone, for how long they could stay, anywhere they would go, at any cost,” Farnsworth said.

Some counties (Blue Earth included) have hired out-of-state doctors who fly in.

The community based initiative, which is led by Blue Earth County, has a budget of about $5.5 million, of which $3 million is doled out to member counties. As elsewhere in mental health, officials have tried to limit the cuts’ effect on the core service of treating the very ill. Still, wait times are increasing. It takes about two to three weeks for a new patient to be seen.

A change, and a deal

To understand the public mental health system in Minnesota, you’ll have to go back to the mid-’90s and a big word: deinstitutionalization. Developmentally disabled people had already been ushered out of state-run hospitals and into their communities. The mentally ill patients were next.

As former medical director and 18-year employee at the Regional Treatment Center in St. Peter, Farnsworth saw it firsthand.

At its peak, the RTC had more than 3,000 patients. By 1997, only about 300 were left, and they started leaving over the next several years. Now, only a 16-bed facility remains.

The state didn’t drop the responsibility to care for them. There was an explicit deal with counties that there’d be state help in exchange for the added duties of helping the mentally ill live in their homes.

“We’ve beefed up this system,” Farnsworth said.

Part of that deal involved the formation in 1995 of the state-funded South Central Community Based Initiative, or SCCBI, a 10-county partnership. There are 16 such groups statewide and every county belongs to one.

“Instead of investing in the inpatient RTC (Regional Treatment Center), they took part of the funds used for that and said, ‘Let’s serve people in their own homes,’” program manager Angela Youngerberg said.

Counties are a big part of this strategy, though repeated cuts are wearing away at their ability to provide these so-called “community-based” services.

Instead of one large cut, legislatures have been chipping away piece by piece.

Those cuts largely started after 2007, when the state added $34 million to its mental health system, according to the National Alliance on Mental Illness in Minnesota.

Mental health grants were cut by $15.6 million in the 2010 budget, and the next budget saw those grants cut by another $14 million.

Separately, cuts forced the shutdown in 2010 of the Mankato Crisis Center. Sheran intervened and helped it reopen, although its $1.3 million budget was cut by 54 percent.

Services like these are expensive, largely because stabilizing a severely mentally ill person requires lots of specialists like psychiatrists, psychologists, nurses and social workers.

“(People who are severely mentally ill) can’t manage their diseases well without a lot of support,” said Sheran, who has extensive history in the mental health field.

Blue Earth County’s own clinic has lost therapists in the past five years due to these successive cuts. It has gone from more than five full-time spots to two, plus contracted time for supervision and testing.

The number of therapy slots has likewise fallen, from a monthly average of 276 in 2008 to 98 in 2011.

Doctoring by TV

The problem is simple, Farnsworth says.

“In the rural region, it’s very difficult to get a limited resource, which is what psychiatry is, and small communities have a hard time attracting general practice doctors,” and specialists are even harder.

It would be possible, in other words, to hire psychiatrists in each of the nine counties in the initiative, but the cost would short other parts of the budget.

Blue Earth County believes it has a relatively inexpensive solution in the South Central Community Based Initiative (or “hub”) that it administers.

People who want a prescription show up to one of 30 or so sites, then are hooked up with a doctor or advance practice nurse in Mankato. The appointments last perhaps 20 minutes. They’re so short because the initiative does not provide therapy — it’s all about prescriptions.

While county therapy slots have declined, the hub has gotten busier. It’s gone from fewer than 600 appointments per months in early 2010 to more than 800 per month in 2011.

The growth comes from a refined business model, not more demand, County Human Service Director Phil Claussen said. The hub sites created a standard where doctors see three patients an hour and advanced practice nurses see two. A no-show policy also has helped the hub get its no-show rate down to 17 percent, compared to 25 percent for typical community mental health centers.

Medicine causes change

It’s no coincidence that moving people out of the Regional Treatment Center coincided with the creation of an entity to prescribe medication.

It was advances in pharmacology that helped, says Sue Serbus, a social service supervisor with Nicollet County. Serbus said sufferers shouldn’t expect drugs to do the heavy lifting in their recovery, though.

Despite the efficiency of centralizing psychiatry, they’re seeing longer wait times, said Youngerberg, the SCCBI director.

It’s a matter of math; X number of dollars can hire Y number of staffers who can see Z number of patients.

Farnsworth has 400 patients, a nurse practitioner can see 300 patients, and a part-time nurse can see 150. A private clinic — or a typical business, for that matter — could hire more staff to respond to higher demand. But the SCCBI cannot.Psychiatrists such as Farnsworth do the sort of essential work that has been protected. He said he hasn’t seen the impact of recent cuts.

“The pendulum seems to swing back and forth on that issue,” he said. “When something terrible happens in a community and it turns out the person might be mentally ill, there’s a cry to embrace the need for mental health services. Then that dies down and people start looking at their budget, and the first thing people want to cut is mental health service,” he said.

One example of the non-essential services cut was a driving reimbursement given to each county in the state. The money, so-called “flexible funds,” could help someone repair a car. The idea is that it’s worth it to spend a small amount of money to help keep a client independent.

While the nine-county SCCBI handles prescriptions, each county also has its own mental health unit. Counties are required by state law to provide (or pay others to provide) health care for the uninsured. Nearly all of its patients are severely and persistently mentally ill, a medical diagnosis.

‘We’ll fit you in’

If you’re making budget cuts in a city, you can make publicly noticeable cuts to draw attention to your plight. You might, say, close a pool instead of drawing on reserves. A move like this would get the attention of residents without endangering them.

In social services, there is an added ethical consideration.

“We don’t say ‘no’ to anyone,” Claussen, the human services director, said. ... “We’ll fit you in somehow.”

But the loss of other services, such as day treatment, is felt.

For Schaefer, it was the difference between just being treated and living a full life. The difference between the two, like most things in life, is less a stark difference and more a matter of degree. He still remembers how it felt to feel capable, all those years ago, when he learned even a seemingly simple skill.

“Oh, I can actually cook something,” he said.