Association of Community Mental Health Centers of Kansas, Inc. 534 S. Kansas, Suite 330, Topeka, KS 66603 Telephone (785) 234-4773 Fax (785) 234-3189 Website: www.acmhck.org Kyle Kessler Executive Director Testimony to Senate Ways and Means Social Services Subcommittee February 3, 2015 Mister Chairman and members of the Committee, my name is Kyle Kessler, I am the Executive Director for the Association of Community Mental Health Centers of Kansas, Inc. The Association represents the 26 licensed Community Mental Health Centers (CMHCs) in Kansas that provide behavioral health services in all 105 counties in Kansas, 24-hours a day, seven days a week. In Kansas, CMHCs are the local Mental Health Authorities coordinating the delivery of publicly funded community-based behavioral health services. As part of licensing regulations, CMHCs are required to provide services to all Kansans needing them, regardless of their ability to pay. This makes the community mental health system the safety net for Kansans with mental health needs, collectively serving over 120,000 Kansans. The State Mental Health Hospitals (SMHHs) including Osawatomie State Hospital (OSH) and Larned State Hospital (LSH) serve persons experiencing serious symptoms of severe mental illness who require inpatient care. The individuals referred to these hospitals are typically those that CMHCs cannot safely and effectively treat in the community. The Association is supportive of the budget recommendation to include an additional $1.0 million from the State General Fund in both fiscal years to be used to increase intermediate or transitional facility capacity. For a number of years, our SMHHs have reached their maximum capacity and are often significantly over census on a continual basis, sometimes at very alarming rates. This situation has forced the philosophy of the use of SMHHs in Kansas to change. The utilization of these hospitals has evolved from serving as long-term residential treatment facilities to the role of short-term acute care treatment facilities. If Kansans cannot voluntarily admit themselves to SMHHs, then their only choice is to ensure a worsening of their psychotic episode, decompensate further, and to put themselves or others at risk of harm or even death. In that event, it may be necessary for a court to order them to be admitted involuntarily to the hospital. However, by that time they may have spiraled out of control and would be significantly harder to treat successfully. Alternatively, they may have ended up in a jail or prison, at a much higher cost to both taxpayers and the person in need of treatment. Page 1 of 5
The Importance of Inpatient Resources The vast majority of persons treated in the CMHC system are either indigent or low income with few resources to pay for private care. Because CMHCs function as an out-patient safety net resource for large numbers of persons with the most severe forms of mental illness, it is vitally important that we, in turn, have access to a safety net resource for those consumers whose illness simply cannot be managed in a community setting, and who have no resource to pay for private care. For us, and those consumers, the SMHH is the safety net. It is important to note that between 40 and 50 percent of all admissions to CMHC crisis services are new to the Kansas mental health system. If we cannot stabilize them in the community, they would then require inpatient psychiatric care. There is a longstanding partnership between the SMHHs and CMHCs. Each CMHC designates a liaison to their respective SMHH. Liaisons work with hospital staff to coordinate services upon discharge. This coordination helps to reduce the length of stays by ensuring that community based services are available. In addition, CMHCs are required to plan for and implement mechanisms to deal with emergency service needs. Throughout Kansas, CMHCs work to quickly respond to mental health emergencies by stabilizing crisis situations and providing follow-up services. I had the opportunity to witness this work last fall at the height of the census crisis at OSH. I observed leaders from KDADS Central Office along with OSH staff and CMHC staff working together to find resources for persons who they collectively believed could be served either in or at least closer to their home communities. My belief is that it was much more than discharge planning or census management. I would characterize it as intensive case management in that all at the table were thinking about what was best for the patient and arriving at quality solutions for the next phase of treatment in the community for each patient. Factors Impacting Increased Admissions at SMHHs The Governor s budget narrative acknowledges, while long term hospitalization is much less frequent, the widespread closure of inpatient mental health facilities at community hospitals along with the difficulty in maintaining continuity of services to outpatients has shifted a much larger population to the state mental health hospitals than was previously projected. This led to not only higher average daily census numbers, but to substantially increased admission rates. Community providers are serving more individuals and those individuals are challenging patients with more intense needs. Since FY 2002, there has been a 39 percent increase in the total number of individuals served. This growth is consistent with national data that is outlined later in this testimony. Funding for community-based mental health services for those who are uninsured or underinsured has been cut drastically. The chart below shows SMHH admissions against Mental Health Reform funding. You see the trend in increased admissions, and the spike that occurs in FY 2008, which is the beginning of the funding reductions. Page 2 of 5
Mental Health Reform Funding (in millions) State Mental Health Hospital Admissions $35 $30 $25 $20 $15 $10 $5 $0 Mental Health Reform Funding by State Mental Health Hospital Admissions FY2005FY2006FY2007FY2008FY2009FY2010FY2011FY2012 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 MH Reform Funding State Mental Health Hospital Admissions There has been a significant decline in private psychiatric hospitals. In the May 2006 issue of Communicator, a newsletter of the University of Kansas School of Medicine Wichita, Department of Psychiatry, Dr. Sheldon Preskorn, Chair of the Psychiatry Department, wrote in his article, Mental Health Care Crisis Brewing for Kansas, that there were seven inpatient services in Sedgwick County in 1990, with more than 350 beds and today there is one, the Via Christie inpatient psychiatric facility, with approximately 100 beds. He cites the loss of this capacity is due to the eroding of financial support for that level of care over the last 15 years and the inability for many to continue supporting this level of care. He goes on to say the State needs to support inpatient beds in urban centers for its citizens suffering from acute exacerbations of psychiatric illnesses who have no means to pay for that care. Based on a 2006 SMHH survey conducted by the National Association of State Mental Health Program Directors (NASMHPD), 80 percent of the States report experiencing shortages in psychiatric beds as a result of hospital downsizing and the closure of general hospital psychiatric units and private psychiatric hospital beds. The number of inpatient psychiatric beds per capita has declined substantially. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the total number of inpatient psychiatric beds per 100,000 civilian population has decreased between 1986 and 2004 - from 112 to 71 (a 37 percent reduction). Over this same period of time, State and county psychiatric hospital beds per 100,000 civilian population has decreased from 50 to 19 (a 62 percent reduction). Private psychiatric hospital beds per 100,000 civilian population has also decreased from 13 to 10 (a decline of 23 percent). What is happening in Kansas is not unique to Kansas. State hospitals in most states are seeing increased admissions. Increasing admissions can co-exist Page 3 of 5
with a shrinking bed supply because of the continued drop in the length of stay and an increase in average occupancy rates, according to the Commission. Temporarily shutting off voluntary admissions is a tool other States have used to address this same trend. In 34 states, the result is a shortage of acute care beds; in 16 states a shortage of long-term care beds. In response to this trend, States are reporting undertaking a variety of activities to address these problems, including: expanded contracts with private hospitals to provide acute psychiatric care; expansion of emergency and community treatment facilities; adding additional state hospital bed capacity; as well as other initiatives. In September 2011, the NIMH published trends in psychiatric hospitalization rates. The data showed that hospitalization rates increased for all age categories, with the exception of the elderly. The study indicated the trends reflect an increase in clinical need rather than overuse of hospital resources. It cites impairments appear to have grown more acute. It also indicated surveys among SMHAs indicate they were worried about a shortage of beds for acute care. Importance of Sustaining and Expanding Local Inpatient Resources The Association believes it is very important to recognize that Mental Health Reform, the closure of Topeka State Hospital and other measures have left the state with approximately 340 state-operated psychiatric beds statewide for adults and children. With the diminished capacity of local inpatient resources in our communities, added to a 65 percent reduction in Mental Health Reform funding since FY 2008, the most critical concern we are facing is having an adequate supply of state hospital beds to provide for an inpatient safety net for the public mental health system. We believe a major reason for the diminished capacity of local inpatient resources is in part tied to how they are funded. General hospital psychiatric specialty units may be shifting the designation of beds from psychiatric to other, more financially lucrative uses. While reimbursement for psychiatric clients has eroded, reimbursement for cardiac and other medical/surgical patients has climbed, providing a clear financial incentive to reduce availability of general hospital psychiatric unit specialty beds. We would be remiss in not explaining that the federal government s enforcement of what is known as the IMD Exclusion in which no hospital with more than sixteen beds for persons aged 18-64 can receive psychiatric treatment and receive reimbursement by Medicare and Medicaid has been a deterrent to building private inpatient capacity. Without access to inpatient psychiatric resources, consumers and families will end up accessing emergency rooms. Because the emergency room can only provide a limited crisis response to the individual s symptoms, treatment is not very effective. The repeated use of emergency rooms in lieu of hospitalization is an expensive and ineffective means of treating individuals with mental illness. Page 4 of 5
Conclusion and Recommendations: One of our most pressing immediate needs is adequate inpatient capacity so that inpatient care is available timely. This need is further highlighted by the cuts in funding that have occurred in grants to CMHCs that serve the uninsured and underinsured. Without funding being restored to Mental Health Reform grants, the State will continue to see even greater increases in reliance on inpatient services as we face challenges in meeting all the needs of the uninsured who are mentally ill. Our Association appreciates the work done by the Governor s Mental Health Task Force last year and looks forward to a full review of the study that is being commissioned by KDADS to explore the adequate costs of treatment for persons with mental illness. We hope that inpatient treatment and attempting to identify the adequate number of inpatient beds that Kansas should have will also be part of the study. Lastly, we appreciate very much the leadership of KDADS and the legislature in looking at intermediate or transitional inpatient services including Rainbow Services in Kansas City. This truly may be a blueprint for not only other parts of Kansas but also other states around the country to follow. We look forward to continued success in these public/private partnerships and again appreciate the work and collaboration of all involved. I appreciate the opportunity to testify before you today to discuss these issues of importance to the public mental health system here in Kansas. I would be happy to stand for questions. Page 5 of 5