As a licensed counselor in charge of AltaPointe Health System’s more than two-dozen group homes in Mobile and Baldwin counties, David Beech has seen first-hand what he says is the success of a more community-based approach to mental health care in Alabama, after some of the largest state-run hospitals, including Searcy, have closed their doors.
Beech was over the counties’ group homes where patients are rehabilitated when Searcy discharged its last patient about a year and a half ago and remembers the story of a male patient, who was transferred to Tuscaloosa’s Bryce hospital, the state’s largest mental hospital, before being able to come closer to home.
The man was still under an involuntary commitment order when he was placed in a secure facility run by AltaPointe, Beech said. He worked with staff there until he was released to a lower-security site.
“To me, that’s a big success,” Beech said.
The local health system’s 25 group homes are used commonly as step-downs from the system’s two hospitals, where patients learn every day skills necessary for full integration into the community, Beech said. These homes are owned by AltaPointe, but can look just like regular homes and are placed in neighborhoods throughout the counties.
The number of these facilities didn’t increase when the state closed the Searcy facility, Beech said, but changes were made to one such home to accommodate patients who weren’t quite ready for lower-security facilities.
In another example, Beech recalled a female patient with a history of hospitalization, who upon entering a group home had the goal of living in her own apartment. Beech said AltaPointe staff worked with her on budgeting and financial issues because she would have to pay rent and live by herself at her own place. Not only has she been living in her own apartment for three or four years, Beech said, but she has a part-time job as well.
“She had family support, her son was very supportive,” Beech said. “That had a big impact on her.”
The state looks positively on this shift to a more community-based approach to mental health, but some argue that getting rid of the big state-run hospitals is leaving a gap for some of Alabama’s mentally ill.
Patients as inmates
Treatment Advocacy Center Legislative and Policy Counsel Kathryn Cohen said there are too many mental care patients in jails and prisons in Alabama and other states. She blames the shutdown of psychiatric hospitals as a reason for the problem.
“The biggest issue nationally and in Alabama is that the mentally ill should not be in the jails and prisons,” she said. “Many of these individuals need intensive treatment and it’s now falling on our jails to treat them. The root cause of the problem is the continuing closure of state psychiatric hospitals and the failure of mental health officials to provide appropriate aftercare for the released patients.”
At issue for the Treatment Advocacy Center is a survey they performed revealing there were more mental care patients in prisons and jails in Alabama than in state hospitals.
The survey stated that about 483 of the 2,413 inmates at the Jefferson County Jail in Birmingham are thought to have serious mental illnesses. The jail houses more patients than Bryce, which has 283 beds. The study also compared the number of mentally ill inmates from 1971 and 2007.
Before the landmark U.S. District Court decision in Wyatt V. Sawyer, which held that overcrowding in state psychiatric hospitals had become a problem, it was estimated only five percent of state prisoners suffered from mental illness, but the survey claims that number had risen to 20 percent by 2007.
The survey also found the state ranks 27th in the amount of money spent on public psychiatric treatment programs. And it suggests all states, including Alabama, implement several of the advocacy group’s recommendations in order to help minimize the problems.
These recommendations include: providing proper mental health treatment for inmates, promoting jail diversion programs, promoting the use of outpatient treatment, establishing better intake screening and mandating release planning.
Locally, about eight to nine percent of inmates — that’s about 90 out of a little more than 1,300 detainees in the Mobile County Metro Jail — are on psychotropic drugs, said Sheriff Sam Cochran.
Psychotropic drugs are used for a number of disorders, from anxiety to other, more serious, problems. Cochran said these inmates are treated by a full-time psychiatrist and psychiatric nurses, who are contracted by the jail.
Everyone booked into the jail is screened for health issues, including mental health, Cochran said. Inmates can petition Probate Judge Don Davis’ office for an AltaPointe evaluation. AltaPointe evaluates all of the patients that come via petition from the jail, said CEO Tuerk Schlesinger.
“They don’t wait to get a bed with us,” he said.
Patients admitted on an involuntary basis by court order or petition to AltaPointe’s EastPointe hospital in Daphne are evaluated and stay, on average, 10 days before being released, Schlesinger said.
“That’s a longer length of stay than other acute care hospitals in the state,” he said.
Those patients receive “wrap-around care,” either in group homes, or through a jail diversion program, which is now completely funded by AltaPointe.
“It’s not like we discharge them and they have no place to go,” Schlesinger said.
An issue, for Cochran, is a number of unregulated group homes that aren’t operated by AltaPointe, or the state that have popped up recently. He said law enforcement in some areas of the county are sometimes called to handle issues in these homes, where an individual will rent out space to patients suffering from mental illnesses. He said he’s heard of problems in Chickasaw, specifically.
“They will put several in a house together and they’re not regulated or anything else and sometimes they cause problems in the community where they’re living and police are called and there’s nothing the police can do,” Cochran said. “The neighbors are wondering how’s this – what appears to be a for-profit business – going on in their neighborhood housing several people that have mental illnesses.”
Cochran said these unregulated group homes could have an impact locally on the number of patients in the jail.
“Alabama is not providing as much mental health care as they used to, so we think because of that we’ve seen an uptick in the number of incidents both in the community as well as the number of people coming into our jail,” Cochran said.
AltaPointe spends about $300,000 a year on a jail diversion program to help patients get the care they need and stay out of jail, Schlesinger said. The program started with jail diversion grant money, but has been funded recently by the non-profit health care agency itself.
“It’s one of those things you start and see the positive impacts of it,” Schlesinger said.
Cochran said the jail has given AltaPointe access to a computerized booking database and they will cross-reference that with a database of patients they’ve previously cared for to see if they can help in any way.
“They’ll look into the case and if it’s someone they think they can provide treatment to they’ll then go to the hearing where they’re arraigned and meet with the prosecuting attorney and offer assistance to the judge and the court,” Cochran said.
Schlesinger said AltaPointe then keeps track of that patient and helps them get through the court system. They follow the patient for up to six months.
“It’s our attempt to help the city and county with jail overcrowding,” he said.
Another issue for Cochran are patients ruled not guilty by reason of mental disease or defect being stuck in jail, waiting on a bed at Taylor Hardin, the state’s only hospital for the criminally committed.
“That’s a huge, huge problem for us,” Cochran said. “That’s the problem that we don’t have an outlet here locally to send them to.”
Cochran said patients waiting on a bed at Taylor Hardin tend to be “more high maintenance types of prisoners.”
The psychiatric hospital in Tuscaloosa has 114 beds and handles two types of patients those sent there after a trial and those sent there for pre-trial evaluation to see if they are competent to stand trial, said Jim Reddoch, Alabama Department of Mental Health commissioner.
The hospital usually has a wait list of about 15 patients. Reddoch said the department tries to move people through the system as quickly as possible and keep the list relatively short, but it can swell to as many as 30 or 40 patients.
“Sometimes we’re able to discharge patients at the same rate we bring them in and sometimes we can’t,” he said. “That’s an area we need to do a little more work on.”
Also significant is the length of time a patient is waiting in jail for a bed at the hospital, which could be several months, Reddoch said. Patients that have been ruled not guilty by reason of mental defect or disease are released through a court order and can then be placed at a step-down location, such as Bryce, or within the community, Reddoch said.
Number of beds
According to a 2012 bed study by the Treatment Advocacy Center, Alabama has 23.4 beds per 100,000 people, which the group says is only half the recommended amount for the state. But Reddoch said he doesn’t believe the state needs more beds.
“We’ve made provisions to take care of that,” he said.
For instance, when Searcy closed the state increased this areas allotment of beds at Bryce, which currently has a total of 238 beds.
Schlesinger agrees, for the most part, that the state has enough beds to serve those in need.
“It’s my feeling overall that the state has enough beds,” he said. “There may be a few small pockets in the rural and northern part of the state that could use more beds.”
AltaPointe’s EastPointe hospital, which treats adults, has a total of 82 beds, of those 30 beds are used for patients committed on an involuntary basis by a court order or petition, 36 beds are reserved for patients who are voluntary committed and 16 beds in the hospital are reserved for patients with less serious mental health issues.
The state operated a 220-bed facility at Searcy Hospital in Mount Vernon, before it was shut down in October of 2012, Reddoch said.
Searcy, which opened in 1900, was one of a number of state-run hospitals at the time. At its height in 1970, Searcy had 2,500 patients, while Bryce in Tuscaloosa, had 5,500, Reddoch said.
In 1971, the state began to downsize its mental care hospitals, due to the decision in Wyatt V. Sawyer.
“Downsizing became the name of the game, Reddoch said. “Those things continued on so by 2000 we had significantly downsized.”
Reddoch said the state was left with six hospitals by 2000.
In 2012, the number of state hospitals dropped from six to four. Greil Hospital in Montgomery and Searcy both closed that year. Reddoch said there are two main reasons for the closures. The first was a 1999 Supreme Court decision about the rights of mental health patients.
The Olmstead decision stated that patients had the right, when appropriate, to live in the community and not in large hospitals. The decision in Olmstead started a shift nationwide from institutional care to community-based care, Reddoch said.
Another reason for the closures was state funding. Proration hit the Department of Mental Health hard and resulted in a $40 million slash to the general fund over a four-year period, starting in 2009, Reddoch said.
“Closing two hospitals made the difference,” he said.
Once the decision to close Searcy was made, the hospital stopped admitting patients and began to work on plans to release its 220 patients, Reddoch said.
“We didn’t just dump 220 patients out to become homeless,” he said. “Every patient left with a well-though-out discharge plan.”
The department also helped fund community-based mental health agencies in the 16-county area affected by the closure of Searcy, Reddoch said. These agencies, including AltaPointe, received a total of $16 million.
AltaPointe evaluated all the patients at Searcy before the hospital closed, Schlesinger said.
About half of the 220 patients in Searcy were from the three-county area AltaPointe now serves. Only about 25 of those patients needed hospitalization, and AltaPointe could absorb those patients into its new EastPointe hospital, Schelsinger said.
The patients who didn’t need to be hospitalized any longer were either placed in the community by themselves, in a group home with others, were sent to live with loved ones or needed long-term care and were sent to Bryce, Schlesinger said.
Schelsinger believes the state’s closure of Searcy was successful and that patients are receiving better, more efficient care now than they were when Searcy was open. He added running a huge state hospital with some 1,700 acres and its own water system was expensive.
Running big state hospitals, like Searcy, cost the state, on average, $350-$400 per patient per day. The hospital also had a full staff of mental health workers including nurses and psychiatrists, Reddoch said.
“The great part about this is that the cost of Searcy Hospital was so high we were able to actually place more beds in the community than what we actually had in Searcy because of the cost differential,” Schelsinger said. “We were able to run things far more efficiently here. The other part that was very important is that in this setting, we are able to provide far more direct service care to the patients than was able to be given in a state institution.”
Schlesinger said the care at the local level is better because of the logistical challenges faced with hiring and keeping qualified doctors on staff at the Mount Vernon hospital. He said the age of the facility was also a challenge in a building that dated back to the pre-Civil War era.
“The (patients) needed to be treated with respect and dignity and not with run down old facilities that the bathrooms didn’t work and so on and so forth,” Schlesinger said.
Reddoch agrees that the 24 individual, community-based centers around the state are doing a good job at meeting the needs of patients statewide.
“I think they’re doing their jobs well,” he said. “The transition has been seamless.”
On April 1, AltaPointe merged with Baldwin County Mental Health System. The resulting agency will be known as AltaPointe on either side of the bay.
The move was intended to make both agencies more efficient, Schelesinger said, which would allow them to strengthen their provider network.
“If we have a larger organization and administrative structure it gives us a chance to expand our provider size and take care of more patients,” he said.
Schlesinger said Baldwin County is already seeing better access to care and AltaPointe expects to double the number of providers in the county within the next two years.
The merger won’t affect the demand on beds, Schlesinger said, because AltaPointe hospitals, including EastPointe and BayPointe in Mobile, were already taking patients from all over the state. The local hospitals average about 60 percent capacity.
“Adding Baldwin County to the organization does nothing to increase demands on beds,” he said.
Cost of service
In addition to private insurance from patients seeking voluntary commitment, AltaPointe is also funded publically by the state, county and city. The city contributes close to $1 million, of that, nearly $600,000 goes toward the involuntary evaluation process needed to take care of patients within the jail population, Schlesinger said.
County cigarette taxes contribute $782,526 go toward the process at EastPointe, while another $504,000 in county funds go toward BayPointe hospital. The county contributed close to $2.5 million total to AltaPointe for various services in the 2013-2014 budget, said spokeswoman Nancy Johnson.
A total of $1.3 million in city and county funds are used exclusively for the 30-bed involuntary unit at EastPointe, which evaluates and provides beds for patients from the jail.
“Of those 30 beds, we average 12-15 beds for city and county residents,” he said. “The city and county funding is crucial for us.”
The full unit costs about $5 million to keep the unit running and that doesn’t include the cost of physicians, Schlesinger said.
“We get virtually no insurance money for involuntary patients,” he said. “We get some Medicaid money, but it adds up to about $200,000 a year. The whole process is losing millions of dollars.”
EastPointe supplements the cost of involuntary patients with 36 beds reserved for patients who are committed on a voluntary basis. Insurance can pay for the care of these patients, Schlesinger said.
Future of care
While the state is continuing to move toward a more community-based approach to mental health care, AltaPointe is working to further integrate its system into local hospitals and primary care facilities.
AltaPointe’s 21 doctors already consult at many Mobile area hospitals including Springhill Medical Center, Mobile Infirmary, USA Children’s and Women’s Hospital and the Mitchell Cancer Institute.
Schlesinger believes working more closely with primary care facilities in the future will result in more proactive care, which should result in cost savings.
“That’s very exciting and it’s on the horizon,” he said.