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Concord Monitor: N.H. Hospital holds some who could go: draft report outlined in 2004

Concord Monitor, May 28, 2006
By SARAH LIEBOWITZ
Monitor staff

Many patients at New Hampshire Hospital, a public institution for those with mental illness, are ready for discharge. But they have nowhere to go. A dearth of housing and treatment options outside the hospital keep patients from leaving, according to a 2004 draft report commissioned by Health and Human Services Commissioner John Stephen.
In June 2004, more than 40 percent of patients had nowhere to live outside the hospital, making them effectively homeless, the report said. On any given day, there are between 15 and 20 patients who could leave the hospital if they had housing, said Chester Batchelder, the hospital's superintendent and a member of the group that created the report. There are 224 beds in the hospital.
The report never made it beyond the draft phase, but Stephen did review the document, members of the group said. Stephen didn't return repeated calls for comment. Neither did Gregory Moore, the director of public affairs at the Department of Health and Human Services. Nicholas Toumpas, the department's deputy commissioner and a member of the 2004 task force, also didn't return calls.
The report's findings may raise legal questions. In 1999, the U.S. Supreme Court ruled in Olmstead vs. L.C. that states need to integrate patients with mental disabilities into the community, housing them in the least-restrictive settings possible. The decision gives states some leeway, taking resources into account.
" We've always felt that there are a number of people at New Hampshire Hospital who don't need to live" there, said Richard Cohen, executive director of the Concord-based Disabilities Rights Center. "Unless the state can show that this would cause a huge alteration to the system and be far more expensive, they do have the obligation to provide the supports necessary for these people to get out."
Legal questions aside, housing people outside the hospital makes economic sense, according to the report. Two years ago, keeping a patient in the hospital for one day cost $609. In contrast, living in a group home carried a daily price tag of less than $280. Adults living in their own apartments with mental health support cost $32 a day.
The state funds the hospital. Patients have to pay for treatment, but no one is turned away for lack of money. In 2003, for example, the hospital spent $15 million more than it took in. Group homes get some Medicaid funding; New Hampshire and the federal government pay the reimbursement rate. Independent apartments are often run by community mental health centers, which contract with the state to provide services, or by separate nonprofits. At Fellowship Housing in Concord, for example, many residents use Section 8 housing vouchers to pay for their apartments.
" It's extremely frustrating to me that the importance of housing has not been adequately addressed by our system," said Ted Drummond, associate medical director at the Seacoast Mental Health Center and a member of the group. "It would be cheaper and far better care."

History
In the past 20 years, alternatives to New Hampshire Hospital, which cares for patients who are a danger to themselves or others, have dwindled.
Lakeshore Hospital closed. Portsmouth Pavilion downsized. The number of beds outside New Hampshire Hospital for patients who need to be involuntarily committed shrunk from 101 in 1998 to 22 in 2002, the report said. In residential acute psychiatric programs, the number of beds plummeted from 52 to 17 between 2000 and 2003 because the reimbursement doesn't cover costs.
The state sets reimbursement rates for treating Medicaid-eligible clients, said Michael Cohen, executive director of the National Alliance on Mental Illness New Hampshire. The federal government and the state pay the cost.
" Across the state . . . we've lost most of those beds," said Rep. James MacKay, a Concord Republican. "There's much more pressure on New Hampshire Hospital." The hospital also runs less restrictive housing for patients transitioning back to the community. A 2003 audit of of the hospital listed 43 beds in its transitional housing
The state hasn't built new housing to counter the loss. The number of beds in group homes for adults with mental illness has remained nearly stagnant, going from 178 beds in 1998 to 182 beds in 2004, according to the report. In 2004, the daily reimbursement rate for group homes, which are staffed throughout the day, was $81 a day per client. Mental health centers spent three times that amount providing the service.
" Group homes are operated at a huge loss by the mental health center. We do it, but nobody's going to start more," Drummond said.
The lack of housing has a domino effect. More patients stay at the hospital. People stay longer in transitional housing, which is supposed to be a stepping-stone to independent living. Population growth and rising housing costs have only compounded the problem.
The picture isn't all bleak. Many drugs have improved. Mental health care workers are helping clients develop practical skills. More people are sticking with treatment programs, according to the report. But overall, "current trends in our mental health system point to an increasing number of people who require intensive mental health services within a system that has fixed to a declining number of beds," the report said.

Recommendations
Building housing for adults with mental illness outside the hospital could pay for itself within several years, according to the report. The state should create 24 new group home beds, the report says, which would cost about $1.6 million a year to operate, plus the initial cost of building the housing. If the hospital could move 25 patients into the group home, it could close a wing, which would save the state $4 million annually, the report said. Since the draft proposal dates to December 2004, the costs are likely higher today.
A year and a half after the report was shown, New Hampshire needs both the hospital beds and housing in the community, task force members said.
The report praised the level of care at the hospital. But without housing in the community, the hospital struggles to accommodate every patient.In 2002, before additional beds were added, hospital staff were forced to turn away patients who should have been admitted, according to the report.
Since 2002, the hospital has added beds; there are now 202 beds for adults and 22 for minors. "We haven't refused admissions for a number of years now, but we're always very close to capacity,"Batchelder said. But each year, the number of patients the hospital admits climbs by 6 or 7 percent. In 1992, the hospital admitted 947 patients; this fiscal year, which ends in June, they'll have admitted about 2,000. The number of empty beds is shrinking.
" I think our report clearly showed that it's a hell of a lot cheaper to invest in beds in the community, where people actually live," said Michael Coughlin, executive director of Genesis Mental Health Center in Laconia, one of 10 outpatient mental health centers throughout the state. Coughlin was a member of the task force. "It's more humane."
New Hampshire doesn't have to look far for models. In Concord, the nonprofit Fellowship Housing runs the 10-bedroom Fellowship House, which has around-the-clock supervision. The group also manages affordable apartments for adults with mental illness. Riverbend manages housing for adults with varying degrees of mental illness.
" The model makes sense. The resources are really often where the challenge is," said Steve Bartels, who previously served as the medical director of the state's Bureau of Behavioral Health and was a member of the task force. He is a professor of psychiatry and community and family medicine at Dartmouth Medical School.

Whatever happened
" The report was presented to leadership within the department of both the bureau of mental health and the department of Health and Human Services," Bartels said. But the response, many members of the task force said, has been silence. But some members said that's not surprising; the document was meant to be an internal review, not a public report, they said.
Money ground the findings to a halt, said Michael Cohen. Cohen knew about the report, but he was not on the task force. "The state has not put the dollars toward these things that it could. . . . We have interest on the part of providers to make it work. It's a matter of getting the will from the commissioner's office and the Legislature."
The state, working with a mental health center, could likely apply for federal grants to cover the cost of building new housing, Coughlin said. "I believe, at the time, it was felt that there wasn't the money to fund it," he said. "I'm not sure we have to accept the fact that we don't have enough money to build these things."
But some of the report's findings may get a second audience. In 2005, Rep. MacKay, who used to practice as a psychotherapist, inserted a plan to create a mental health commission into successful Medicaid legislation.
The commission - which has grown to 29 members - will likely finish its report on how to deliver mental health services in the middle of next year. Five work groups are studying various aspects of mental health. Once the report is complete, MacKay, who heads the commission, plans to draft legislation. The hospital's capacity is one of his biggest priorities. Building housing outside the hospital "helps to maintain dignity and progress," he said.
Convincing legislators to fund new programs won't be easy. "The whole issue of stigma and mental health is still very alive in our country," MacKay said. "You've got to work very hard in the Legislature to try to turn that around."

(Sarah Liebowitz can be reached at 224-5301, ext. 254, or by e-mail at sliebowitz@cmonitor.com.)