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By Phyllis Hanlon
Editor's note: Although deinstitutionalization is most often
thought to pertain to state hospitals, private facilities have in
recent years also begun a process of discharging patients after
short-term stays and helping them reintegrate into the larger community.
The Massachusetts Department of Mental Health (DMH) spent eight
months analyzing the problems of inpatient care, community-based
services and costs relating to maintaining and/or upgrading its
current mental health facilities. In March 2004, the DMH released
its report with several cost-cutting suggestions and an eye toward
deinstitutionalization.
The report notes that in 1993, Massachusetts had an inpatient bed
capacity of 1,444, which was reduced to 900 in 2004. Adult community
residential services, mental health treatment and supervision climbed
from 3,903 bed capacity in 1993 to 6,500 bed capacity in 2003. Additionally,
in the 1990s, DMH obtained affordable housing for more than 5,600
individuals with chronic mental illness who were previously homeless,
living in restricted inpatient settings or in substandard housing.
To further the mission of deinstitutionalization, streamline the
delivery of quality mental health care and develop a continuum of
care system, DMH suggested the creation of a new inpatient facility
and the shuttering of two existing facilities: Westboro and Worcester
State Hospitals.
Westboro currently houses 198 patients while Worcester has 156
adult beds. In addition, Taunton State Hospital has another 169
beds. There are also 269 beds in the DMH-operated units at Shattuck
and Tewksbury, 78 at DMH state-operated community mental health
centers (CMHC) at Fuller and Lindeman and 30 beds under DMH contract
with Park View and Springfield Hospitals for a total of 900 adult
beds. Recommendations from the report call for reducing that number
to 740.
Continuing care inpatient services at any of the state hospitals
cost approximately $128,329 per bed per year, according to the report.
That figures drops significantly - to $65,000 - when patients are
discharged and served in the community. The DMH report notes that
closing 160 adult beds will generate $17.4 million, which will then
be reinvested to create community programs and services for the
newly released.
According to Patricia A. Cutting, RNC, assistant superintendent
at New Hampshire Hospital, changing social policy, regulatory demands
and evolving healthcare needs have prompted the state to shift from
chronic, custodial, geographically-based healthcare to "an integrated
delivery system" that includes diagnostic and therapeutic, needs-based
services.
In 1982, New Hampshire Hospital's Psychiatric Nursing Home Service
peaked at 288 long-term care beds. By 1999, transitional housing
services were created and the Service completely closed. In a news
release, Cutting says that the current average daily census across
all program areas at the hospital is 205, which represents seven
percent of the rate 50 years ago.
At the Brattleboro Retreat, a private psychiatric hospital in Vermont,
the whole model of treatment revolves around deinstitutionalization,
says director James E. Adams, M.D. Current thinking, he says, promotes
decreased length of stay, which, in turn, decreases the patient
census. Adams adds that this philosophy allows the Brattleboro Retreat
to serve more patients. As for programs to offset the practice of
deinstitutionalization, he cites the Community Residential Treatment
(CRT) program. "Teams of psychologists, social workers, nurses,
mental health technicians and doctors go out and visit patients
in their homes," he says. "Different patients receive different
therapies."
Maine has undergone "enormous" downsizing throughout the last 20
to 30 years, according to Girard Robinson, M.D., chief medical officer
at Spring Harbor Hospital in collaboration with the Department of
Psychiatry at Maine Medical Center, which serves the greater Portland
area and is a tertiary care center for northern New England. For
example, Augusta Mental Health Institute eliminated 200 of its 1,000
beds over the course of several years, he reports. With such reductions
comes the need for transitional and/or community services and programs.
"A lot of work has been done to enhance community-based treatment,"
he says, "but it's an ebb and flow situation depending on the latest
state budget."
In the span of five years - from March 1999 to March 2004 - Spring
Harbor has reduced its average length of stay from 25 days to eight
days. This dramatic decrease has enabled the hospital to double
the number of patients it serves each year. To help avoid hospitalization
in the first place, Spring Harbor has instituted assertive community
treatment programs for adults and adolescents as well as partial
hospital programs as part of a continuum of care.
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