When the mental-health headlines started piling up this summer—"Mental Health Crisis Called County's Worst," "Funds for Psych Patients to Run Out" (Las Vegas Sun), "Hospital Closing Mental Health Center" (R-J)—it seemed that a sudden tragedy had befallen the region.
But there was nothing sudden about it. The shortage of mental-health services in Southern Nevada is a longtime problem, and one that health-care advocates have been telling policy-makers about—indeed pleading with them about—for over a decade. In fact, the problem goes at least as far back as a gutting of the mental-health budget in Gov. Bob Miller's recession-era administration ('89-'97).
Even this most recent installment of the saga—the overcrowding of ER rooms with acutely mentally ill people—made headlines four years ago. And shortly thereafter, was forgotten by many.
That it took the persistent and recurring discomfort of the mentally well, namely those who were in need of physical health care at emergency rooms and couldn't get in because the beds were full of the mentally ill, to recharge interest in the issue is evidence of the ongoing disrespect for those suffering from psychiatric disorders.
At one time, the state might have managed the problem before it became a public health crisis, but today the dilemma involves local governments, hospitals, police, emergency vehicle providers, social-service agencies, for-profit and nonprofit entities, and, still, the state. It's a fine mess.
With that in mind, we're taking a look at the components of a significant and significantly complicated issue, as simply as we can:
Approximately 1,200 mentally ill people who are a threat to themselves or others seek help in Clark County each month during the summer, according to Jonna Triggs, director of the state's Southern Nevada Adult Mental Health Services.
Roughly 10 percent of the clients served by SNAMHS are homeless, Triggs said; the other 90 percent are primarily working poor who lack mental-health insurance coverage.
Many more do not seek treatment, or seek it and get discouraged with the system before getting help.
Mental illnesses are biological disorders of the brain characterized by changes in thinking, mood and behavior, ranging from anxiety and depression to bipolar disorder and schizophrenia. In any given year, 23 percent of adults suffer from a diagnosable mental disorder, but only half of those report impairment in their daily functioning, according to the National Alliance for the Mentally Ill (NAMI).
The people at stake in the crisis in Southern Nevada, Triggs says, "are not the worried well"—the mildly depressed or anxious. "They are people who have either not gotten treatment or gone off of their medication and are in serious need of help."
Five to seven percent of the adult population suffers from such serious, debilitating mental illness.
Southern Nevada Adult Mental Health Services operates the only publicly-funded psychiatric hospital in Southern Nevada.
The 103-bed facility at 6161 W. Charleston is run under the state's Division of Mental Health and Developmental Services. SNAMHS has a $57 million annual budget, employs about 400 full-time workers, pays for medication for the uninsured and distributes that medication and services at four local outpatient sites around Las Vegas.
Recently, plans have been made to build another state psychiatric hospital near Jones and Oakey in Las Vegas. Despite the protests of neighbors, the state expects to add another 150 beds with it in 2006.
There are far more acutely mentally ill people seeking help than beds and professionals to serve them. A bottleneck at SNAMHS' 23-bed crisis/intake unit—a bottleneck which has been on the record at least since 2000—means in-crisis patients typically end up in other hospital emergency rooms, either as walk-ins or via police cars and ambulances. A boiling point was reached on July 9, when there were 105 mentally ill patients in 11 ERs in Clark County hospitals, filling 20 percent of the county's total ER beds. People with other physical health problems were waiting long hours, sometimes 40 or more, for emergency health care. With nowhere to send the psychiatric patients and no in-patient beds for them, hospitals were keeping them in ERs an average of 80 hours before a state mental-health bed became available.
The County finally declared the situation a public-health crisis.
The short version:
In 1999, police and health officials became concerned with chronic inebriates filling jails and ER beds. "What happened, though," says Janelle Kraft, Metro budget administrator, "is we began getting dual diagnoses." That is, once the people sobered up, the psychiatric problems they'd oftentimes been masking with alcohol and illicit drugs became apparent. By 2000, the press and community started becoming more aware of the problem of psychiatric patients filling the ERs, and a group of policy-makers started trying to come up with a crisis-intervention plan. Local hospitals, local governments and the state entered into an agreement that would fund a community triage to stabilize patients until they could get care at the psychiatric hospital. By 2002, WestCare Nevada, a nonprofit drug and alcohol rehab center, had agreed to run a triage based on this funding plan: Each of the three entities—hospitals, local governments and the state—would fund one-third of the total $3.8 million operating cost for 18 months, ending June 30, 2004. The hospitals coughed up their share (by and large, with a few snags), the local governments also paid up (with justifiable complaints that some of them, such as Henderson, didn't need the services as much as Las Vegas), but the state failed to pay its full share.
When June 30 rolled around, WestCare asked for commitments to further fund the triage, saying it couldn't stay open without additional funding.
"About $677,000 of the state's share got lost in the 2003 legislative session," said Dan Musgrove, lobbyist for Clark County, who's been working on negotiating another solution.
Before we cast the state as a 100 percent villain, let's note that the 2003 Legislature did pass, in the overall budget, a 35 percent increase in funding for the mental-health division. But the WestCare triage money wasn't included in that package and was instead requested on a separate appropriation bill that would have given WestCare the $670,000 for 40 new beds. However, it was a rancorous session and the bill died in a political battle in the Republican-dominated Senate without a vote, and never made it to the Assembly.
Nope. In November, proponents of the triage went to the Legislative Interim Finance Committee to request $194,000 to keep it open. The committee rejected the request. The chairman of the Interim Finance Committee, Assemblyman Morse Arberry, D-North Las Vegas, told the Las Vegas Sun in voting to reject funding that he feared approval would "open the floodgates" to requests by other groups that did not get money from the 2003 Legislature.
A new funding plan for WestCare's triage. Based on the intake there thus far, the county projects that 8,000 people will come into the triage next year. Statistically, 24 percent will be sent by hospitals, 24 percent by police, and the rest by community referral. (And within those categories, some hospitals sent more than others: In the last 18 months, UMC sent 28 percent of the hospital portion of patients, and Sunrise sent 22 percent, while Mountain View sent only about 2 percent.)
County lobbyist Musgrove is pitching a user-driven funding formula for Westcare's triage, in which each entity would pay according to how much it benefits from the triage's existence. Local governments pay for the police's share, and everyone splits the community referrals.
A final deal is expected to be agreed upon by mid-September—one that would keep the center open through the spring legislative session, in which a more permanent solution may be created.
After the county declared a state of emergency, the state released $100,000 in emergency funds for a temporary facility. The Interim Finance Committee was again asked for cash: this time, for $1.9 million from the state's $3.3 emergency fund pot for another 28 beds at SNAMHS. On August 12, lawmakers approved just $500,000 to cover some costs of those 28 beds, and gave the state Mental Health Division approval to shift other funds to cover additional costs. As for more funding, the panel said, the division also will have to wait till the 2005 legislative session. SNAMHS got busy opening the extra beds.
Yes, yes, yes. Many people who enter the system in an acute episode of mental illness will ultimately be put back on the street. Some are sent off with the promise of outpatient follow-up, but there are waiting lists for counseling, psychiatric appointments and case management. If a client has a repeat slip into an acute state, they may have to start the process all over.
"That's the most significant problem," says Vic Davis, representative of NAMI of Nevada. "People who are not being treated properly end up being treated over and over."
The state is expected to increase funding to the Division of Mental Health and Developmental Services this session. Many legislators on both sides of the aisle recognize the importance of funding the system, but an important bit of support could come when the governor releases his budget. The amounts he allots for alleviating the short- and long-term problems in Southern Nevada may set the tone for the funding debate.
A mantra among some problem-solvers in the field is "meds, not beds," meaning that money should be spent making outpatient treatment more accessible rather than building more inpatient hospitals.
"What happens is, a person needs help, so they walk in in a noncrisis state and ask for help, and they're told to wait two weeks to see a psychiatrist. Within that period, they deteriorate to the point that they end up in the hospital," says Davis. "Walk-in centers where you could get on-the-spot appointments would solve a lot of the hospitals' problems. Specialty clinics. They can be set up by private companies who apply for Medicaid designation."
In 2000, there were 165 beds in local private hospitals for adults with mental illnesses. But Southern Nevada lost 133 private beds in the last few years, with the closure of Charter Hospital (a psychiatric facility) and the mental-health services at Valley Hospital and North Vista.
Now, there are only 36 private beds at Montevista Hospital, a private mental-health facility.
So apparently this hasn't been a consistent money-maker for health-care organizations in Southern Nevada. Mental-health care is often not covered under insurance policies. A few lawmakers and administrators have suggested that the state encourage privatization, and a bill to that effect is expected to be introduced in the legislative session. In particular, state officials have expressed interest in reviewing the Medicaid policy: Nevada may need to raise the rates at which it reimburses hospitals for psychiatric patients using Medicaid. Right now it pays about $390 a day.
Nevada has been notoriously low in mental-health funding since the 1970s, according to the National Association of State Mental Health Program Divisions in Arlington, Virginia. The state has ranked at the bottom in dollars per capita for mental heath, despite having among the highest suicide and substance-abuse rates.
Nevada has six public psychiatric beds per 100,000 residents, according to the National Association of State Mental Health Program Directors Research Institute. California has 12.6, Oregon has 17.6, Utah has 16.9. Clark County has 5.1 beds, according to the state
In 2001, the national average of per capita public mental-health funding for inpatient psychiatric hospitals was $25.62; in Nevada, it was $15.49.
After the state weathered the recession in the early 1990s, it regrouped a bit. Since 1995, funding to the Division of Mental Health and Developmental Services has rebounded. It has received increases in funding every budget since. The 2003 Legislature funded mental health at 35 percent over the previous year.
Many. One is that for years there was a law requiring patients to be medically cleared for other possible health problems prior to being admitted to the mental-health facility or a jail. Thus, patients were actually being transported from SNAMHS to the emergency rooms for medical clearance, and back. (Additionally, SNAMHS won't take patients if they're inebriated, which means hospitals hold 'em while they sober up.) A bill passed last session that allows mental-health service facilities to accept them with less of a medical screening, says Kraft, Metro budget director, but there has been some hesitation and confusion in setting up regulations that are acceptable to all involved: the police, the triages, the mental-health care providers. Those problems are expected to be ironed out next spring, as well.
At WestCare's triage, the original plan was to provide medical screening onsite, but the shortage in funding prevented that plan from coming to fruition.
The triage at WestCare had to stop taking walk-ins without a referral from a social-service agency or health-care provider because of new budget constraints. Davis says walking in at SNAMHS means a long, long wait. Ditto for the emergency room—unless, of course, it's a life-or-death situation, in which case you'll hopefully be triaged faster.
For lesser problems—but nonetheless problems that prevent you from functioning—that's the present situation. If you call a private sector psychiatrist, it's unlikely you'll get a walk-in appointment that day, and extremely unlikely that you'll get an appointment if you don't have insurance or a good bit of cash: An initial appointment at a local psychiatrist can cost as much as $150. Thus, getting help requires some tenacity.
It's an interesting question, because part of the confusion in negotiating a solution to the crisis has been a sluggishness among some entities to step up to the plate. Some hospital representatives believe the state should be paying for all of the services; but some government officials ask, "Who's benefitting from unclogging the ERs?" (the general public and the hospitals), and see that as indication that the hospitals have a responsibility to help pay, too.
Not at all. A lot of people are working overtime trying to solve this problem. Not surprisingly, public policy somewhat accurately reflects the will of the public, the willingness of the majority to recognize an issue as significant, to destigmatize it.
The state's mental-health services have increased; progress—albeit not enough—is being made. Everyone involved says the more the public keeps the pressure on, the more likely it is that better services will be established.
"They're inching along. We just got so far behind in the late 1980s, when mental-health services were cut," says Kraft. "We got 10 years behind the curve."