Replacing the Broken State Hospital System with One Proven to Work
Authored by Sandra Oxx
July 7, 2021
When are we going to learn in Rhode Island that when we do not make proper investments in infrastructure and institutions that we pay for it dearly? Whether it is our roads and bridges, Eleanor Slater Psychiatric Hospital or RI’s community behavioral health centers, it costs us more in human lives and money if these necessary State responsibilities are underfunded.
A case in point is the abysmal state of the Eleanor Slater Hospital and the fact that it is not any one person’s fault—not just the former governor, not the former director of the state’s Behavioral Health Developmental Disabilities and Hospitals (BHDDH), and not the hospital’s union. If blame is needed, and that appears to be the public consensus, we need to start with the long held but deliberately ignored knowledge that the state owned and operated psychiatric hospital was not funded adequately for decades and has been in shambles for years.
Legislators knew it, past governors, and bureaucrats, too. Why nothing was done before now is anyone’s guess, but it most likely has to do with the outlay in expenditures needed to overhaul and/or close the facility and figure out ways to manage its existing 222 patients, some of whom have landed there for mental health treatment from the criminal courts or have sustained long-term injuries from accidents or overdoses. Very concerning is that some of these patients no longer need a hospital level of care.
One of the most stunning pieces of information comes from a 2010 Substance Abuse and Mental Health Services Administration (SAMHSA) report that prominently lists RI as the only state in the U.S. that does not have a stand-alone psychiatric hospital. We are also the only state that has not invested the appropriate level of dollars needed to run a state psychiatric hospital. Instead we try to game Medicaid to skirt the Medicaid’s Institution of Mental Disease (IMD) exclusion that does not provide reimbursement to institutions if more than half the patient population is psychiatric.
To work around this situation, Rhode Island houses individuals with mental health needs from the judicial system with individuals with medical and mental health needs in the same hospital, the Eleanor Slater Hospital. The State is thus able to collect Medicaid dollars. Not to exacerbate an already roiling mix of outrage and anger, the entire Rhode Island behavioral system of care is an underfunded mess.
Having spent 25 years as a superintendent or behavioral health official responsible for state-funded psychiatric hospitals with responsibility for downsizing psychiatric hospitals, I am distressed at the condition of Eleanor Slater Hospital, but I am not surprised by it.
In 1963 when the paradigm for treating mentally ill patients for long periods of time in psychiatric hospitals shifted to treating them with an eye toward recovery as outpatients in federally and state funded community mental health agencies, the population in state-run psychiatric hospitals in the U.S. declined by close to 70 percent from the 1960s to 2005 and continues to do so. Eleanor Slater Hospital’s patient population has followed the national trend, with the hospital’s bed occupancy at 426 at one point. Now the occupancy stands at 222.
Why the shift?
All sources point to the fact that people with mental health conditions are better served and more apt to recover when they are living, getting treated, and working in their communities instead of being isolated from them.
Paradoxically, the answer to this situation is not more beds. We already hospitalize more people than any other New England state. What is needed is investment in a full community behavioral health system of care, which at this time receives not one dollar of state funding other than Medicaid. The need for funding a streamlined system of community-based behavioral health centers is clear. Newport Mental Health along with Thrive Behavioral Health and the Community Care Alliance are three partners involved in a federally grant funded Certified Community Behavioral Health Centers (CCBHC). This means that anyone, child, adult, or older adult, who comes in our doors will receive the highest quality of behavioral health care possible. All programs are thoroughly vetted and backed with valid, scientific data. Each CCBHC, has evidence based treatments for young adults with severe mental health conditions, for example. This, too, is not enough as CCBHC only funds outpatient services. The State needs to fund more adult group homes, child and family services, and substance use disorder treatment beds; a full continuum of community-based care.
The national CCBHC grant funding has a shelf life, however, and even this part of the behavioral health system that is working will end if the State of Rhode Island doesn’t adopt CCBHC as part of its Medicaid system.
All the evidence points to the fact that keeping people among people in the least restrictive environment works best. Isolating them only makes the situation worse, as we have seen at the Eleanor Slater Hospital. That said we will always need some state run psychiatric and forensic hospital beds. Let’s make sure that they are properly funded in safe environments. It is time we divert our attention away from a broken system that cannot be fixed to a system of scientifically proven, recovery-oriented community mental health centers and a full community-based continuum of care.