Remarks for

GOVERNOR’S COMMISSION ON COMMUNITY

SERVICES AND INPATIENT CARE

Tuesday, November 30, 1999

VCU Alumni House, Richmond, Virginia

Historical, National and Clinical Perspectives on the Restructuring Plan

Jeffrey Geller, MD, MPH

Professor of Psychiatry

University of Massachusetts Medical School

55 Lake Avenue North

Worcester, MA 01655

508-856-6527 (phone)

508-856-3270 (fax)

jeffrey.geller@umass.med.edu (e-mail)

I. The Care of the Insane in Virginia¹

The dependent insane of colonial Virginia were classed as paupers, and regarded as especial objects of charity. That the colony early felt the dependence of these unfortunates upon her bounty is clearly shown by an act passed by the House of Burgesses in the tenth year of the reign of King George III, 1769, entitled "An Act to Make Provision for the Support, Maintenance of Idiots, Lunatics and Other Persons of Unsound Mind." "The Publick Hospital for Persons of Insane and Disordered Mind," which had been incorporated the previous year, 1768, was, as a result of this act, opened for the reception of "idiots, lunatics and persons of unsound minds," on October 12, 1773.

On Tuesday, the 14^th day of September, 1773, James Galt was appointed keeper of the hospital, and he was referred to the General Assembly for such salary as his services should be thought to merit. Thus began the long connection of the Galt family with the hospital, which ended in the death of Dr. John Minson Galt in May, 1862.

From the beginning "free persons of color" were admitted to the Eastern State Hospital on the same terms as the whites, and it thus became the first hospital in America to care for the colored insane. An act of the Legislature, passed on January 16, 1846, permitted the Board of Directors to receive insane slaves as patients.

From the time of its incorporation up to 1841 the institution was known as the Publick Hospital, sometimes as the Lunatick Hospital, and at times spoken of as the Mad House. In the library of the College of William and Mary there is a map of the City of Williamsburg, dated 1780, on which the hospital is designated as the "Mad House or Bedlam." By an act of the Legislature, passed March 6, 1841, the name was changed to the Eastern Lunatic Asylum; not until February 22, 1894, was this name, which was so obnoxious and in many respects objectionable to patients as well as their friends, changed to the Eastern State Hospital. Similar name changes were occurring at state psychiatric facilities throughout the United States at this time.

In January, 1908, the Legislature passed an act providing that all patients received at this institution should be state patients, and should be supported and cared for by the state.

1. Trust Fund Concept²

"Memorial of D.[orothea] L. Dix, Praying a grant of land for the relief and support of the indigent curable and incurable insane in the United States, June 27, 1848." Excerpts

It is a fact, not less certainly substantiated than it is deplorable, that insanity has increased in an advanced ratio with the fast increasing population in all the United States. This terrible malady, the source of indescribable miseries, does increase, and must continue fearfully to increase, in this country, whose free, civil, and religious institutions create constantly various and multiplying sources of mental excitement. There are twenty State hospitals, besides several incorporated hospitals, for the treatment of the insane, in nineteen States of the Union, Virginia alone having two government institutions of State and also incorporated hospitals. Well organized hospitals are the only fit places of residence of the insane of all classes; ill-conducted institutions are worse than none at all. It may be suggested that though hospital treatment is expedient, perhaps it may not be absolutely necessary, especially for vast numbers whose condition may be considered irrecoverable, and in whom the right exercise of the reasoning faculties may be looked upon as past hope. I have myself seen more than nine thousand idiots, epileptics, and insane, in these United States, destitute of appropriate care and protection; and of this vast and most miserable company, sought out in jails, in poorhouses, and in private dwellings, there have been hundreds, nay, rather thousands, bound with galling chains, bowed beneath fetters and heavy iron balls, attached to drag-chains, lacerated with ropes, scourged with rods, and terrified beneath storms of profane execrations and cruel blows; now subject to gibes, and scorn, and torturing tricks—now abandoned to the most loathsome necessities, or subject to the vilest and most outrageous violations. In Virginia, very many cases of extreme suffering now exist. The most observing and humane of the medical profession have repeatedly expressed the desire for additional hospital provision for the insane [in Virginia]. In every county through which I passed were the insane to be found—sometimes chained, sometimes wandering free. In the report upon the Western State Hospital of Virginia, at Staunton, for the year 1847, Dr. Stribling feelingly remarks upon the very insufficient means at command for the relief of the insane poor throughout the State. "We predicted," he says, "that during the present year, those seeking the benefits of this institution would far exceed our ability to receive. This anticipation, we regret to say, has been painfully realized, and we are now called upon to report the fact that within the last nine months one hundred and twenty three applications have been received, whilst only thirty nine could be admitted. What has become of the remaining eighty-four, it is impossible for us to report." I regret to say there is but one conclusion deducible from this statement: the rejected patients are suffering privations and miseries in different degrees in the narrow rooms or cells of poorhouses, or in the equally wretched sheds, stalls, or pens attached to private dwellings, while some have been temporarily detained, for security, in the jails. Humanity requires that every insane person should receive the care appropriate to his condition, in which the integrity of the judgment is destroyed, and the reasoning faculties confused or prostrated. Hardly second to this consideration is the civil and social obligation to consult and secure the public welfare: first in affording protection against the frequently manifested dangerous propensities of the insane; and second, by assuring seasonable and skilful remedial cares, procuring their restoration to usefulness as citizens of the republic, and as members of communities. Insanity prevails, in proportion to numbers, most among the educated, and, according to mere conventional distinctions, in the highest classes of society. But those who possess riches and a liberal competency are few, compared with the toiling millions; therefore the insane who are in necessitous circumstances greatly outnumber those whose individual wealth protects them usually from the grossest exposures and most cruel sufferings. Should your sense of moral responsibility seek support in precedents for guiding present action, I may be permitted to refer to the fact of liberal grants of common national property made, in the light of a wise discrimination, to various institutions of learning; also to advance in the new States common school education, and to aid two seminaries of instruction for the deaf and dumb. But it is not for one section of the United States that I solicit benefits, while all beside are deprived of direct advantages. I entertain no sectional prejudices, advance no local claims, and propose the advancement of no selfish aims, present or remote. I ask of the Senate and House of Representatives of the United States, with respectful but earnest importunity, assistance to the several States of the Union in providing appropriate care and support for the curable and incurable indigent insane. I ask, for the thirty States of the Union, 5,000,000 acres of land, of the many hundreds of millions of public lands, appropriated in such manner as shall assure the greatest benefits to all who are in circumstances of extreme necessity, and who, through the providence of God, are wards of the nation, claimants on the sympathy and care of the public, through the miseries and disqualifications brought upon them by the sorest afflictions with which humanity can be visited.

2. Role of the Federal Government³

From the veto in 1854 by President Franklin Pierce of Dorothea Dix’s land grants bill to make the Federal Government responsible for the care of the chronic insane, into the early decades of the twentieth century, the Federal Government was basically disinterested in the psychiatric and substance abuse populations. The Federal Government turned to the issues around the care and treatment of this population due to concerns about the widespread use of street drugs and resultant drug addiction. In 1914, the Harrison Narcotics Act allocated funds to study drug use; in 1929 two Federal hospitals were established to treat drug addiction. At this same time the Narcotics Division within the United States Public Health Service was created, and renamed two years later the Division of Mental Health. The Federal Government more directly addressed Mental Health with the passage in 1946 of the National Mental Health Act. This Act had three basic goals: to support research, train mental health personnel, and award grants to states for demonstration projects. The National Institute of Mental Health (NIMH) was also established under this legislation. But nowhere was there to be found any mention of how care and treatment for those with chronic mental illness would be financed. From the Federal Government’s point of view it would appear, the status quo was as it should be. The poor, chronically mentally ill of the 1940’s should be funded for treatment no differently than the indigent insane of a century earlier--they were the responsibility of the states.

In the 1950 Social Security Act Amendments, payments on behalf of those in institutions for mental disorders (IMD'’) were excluded from old age assistance. This exclusion continued unchanged until the enactment of Medicaid under the Social Security Act Amendments of 1965. For the first time states could use Federal Financial Participation (FFP) for a population in

IMD’s--in this case those 65 years of age or older and for services to the mentally ill in general hospitals. The 1965 changes to the IMD exclusion opened the first door to the states to begin to cost shift care and treatment for the mentally ill from the states to the Federal Government. In a state hospital, the state bears 100% of the cost of care and treatment. In any facility that is eligible for Medicaid reimbursement, each state pays considerably less than 100%, according to the FFP formula:

nonfederal percentage = 45% x (Per capita state income)²

(Per capita national income)²

As is clear from this formula, less well off states receive greater Federal contributions. Historically the range of Federal participation has been between 50% and 83%.

In 1966, the Handbook of Public Assistance Administration first defined an IMD. This definition has been modified several times. One significant modification occurred in 1988 when Congress, as part of the Medicare Catastrophic Care Act indicated that a facility needed to have more than 16 beds before it is an IMD. In 1972 Congress expanded FFP for inpatient psychiatric treatment in IMD’s to individuals under 21 years of age and to those over 65 years of age.

By 1989, any residentially-based program of more than 16 beds, no matter what its treatment modalities, its licensure, or its length of stay (including acute treatment) could be an IMD if it were predominantly engaged in delivering services to individuals with mental disorders. The states were provided all the invitation they needed to serve as many individuals with mental disorders in any facility that was not an IMD as they could possibly manage. Why use state dollars if Federal dollars could be garnered?

In the 1990’s, waivers that broaden the Medicaid population and redefine how they can be cared for, and hence give states further incentive to cost shift to community-based care, have been granted to states throughout this decade. The sequela of another piece of legislation that has had ripple effects on the IMD exclusion throughout this decade is the Medicaid law in OBRA 87; it requires states to make disproportionate share payments (DSH) to hospitals serving a disproportionate percentage of Medicaid and low income patients (CRS, 1993). DSH payments, particularly as they allow states to essentially flim-flam the Federal Government through "creative financing", and mostly recently their use by states in IMD’s have continued to irk Congress. One result has been a provision in the Balanced Budget Act of 1997 which creates a progressive deduction in DSH allotments to IMD’s between FY’98 and FY’2002.

3. Considerations at Eastern State Hospital

1. Closure and consolidation in the name of greater efficiency and better care and treatment is the national norm.⁴

1. 232

1. ESH could be considered 3 facilities

1. Acute/Admission

• 15% of population
• 70-90 beds
• could privatize to maximize Federal reimbursement

1. Geriatric Population in Geriatric Unit

• 40% of population
• 190-200 beds
• Of the geriatric population, 50% have a primary diagnosis of dementia
• Throughout the hospital, there are 140 patients with a primary diagnosis of dementia, or 30% of the hospital population
• Therefore, could have a 140+ bed nursing home which would require no waiver since no one in the facility would have a primary psychiatric diagnosis

1. Intermediate – Long-term Psychiatrically Disabled.

• Population needs psychosocial rehabilitation
• Currently 170 patients without primary diagnosis of dementia in this program.
• Adding patients who would need this program from other locations in the hospital, and assuming no community expansion, means about 200 beds would need to be established for this purpose ideally near the center or centers of population of the catchment area. The facility would be predominantly, but not exclusively, state funded.

1. Geriatric patients with primary psychiatric diagnoses could be served locally in either of the nonacute facilities above, or in another Virginia state psychiatric hospital currently underutilizing its resources available for care and treatment to the geriatric population.

1. System-Wide Considerations

1. Fear of Unfunded Mandates
2. Current System of Funded Unmandates
3. Eligibility Determination to establish "Client of the Department." Massachusetts example:

1. The Department is responsible for providing or arranging for DMH continuing care services to adults with serious and long term mental illness and children and adolescents with serious emotional disturbance who are determined eligible and are prioritized for such services.
2. Services will be provided to individuals who have been determined eligible for DMH continuing care services subject to the availability of services, funding, and the Department’s determination of the priority of an individual’s need for services.
3. The goal of service planning activities is to:

1. identify the full range of services that a client needs;
2. facilitate or provide access to those services; and
3. ensure that the provision of DMH continuing care services is consistent with the client’s needs and preferences and provided in the least restrictive setting possible.

Clinical Criteria for DMH Continuing Care Services.

1. To meet the clinical criteria to be eligible to receive DMH continuing care services, an adult must have a mental illness that:

1. Includes a substantial disorder of thought, mood, perception, orientation or memory which grossly impairs judgment, behavior, capacity to recognize reality of the ability to met the ordinary demands of life; and
2. Has lasted, or is expected to last, at least one year; and
3. Has resulted in functional impairment that substantially interferes with or limits the performance of one of more major life activities, and is expected to do so in the succeeding year; and
4. Meets diagnostic criteria specified within the current edition of Diagnostic and Statistical Manual of Mental Disorders, which indicates that the individual has a serious, long term mental illness that is not based on symptoms primarily caused by substance related disorders, mental retardation or organic disorders due to a general medical condition not elsewhere classified.

Need for DMH Continuing Care Services. If an individual is found to meet the clinical criteria for eligibility, the Area Director or designee will make a determination as to whether the individual requires DMH continuing care services in order to be appropriately served in the community. This will be based on the following:

1. contact with the applicant and his or her legally authorized representative, if any, to review the applicant’s request for services and his or her current status;
2. determination of whether the individual’s needs are such that he or she requires a DMH continuing care service;
3. assessment of the individual’s current medical entitlements and/or insurance that allow for provision of appropriate services in the community;
4. assessment of the availability of appropriate services from other public or private entities.

Determination of Priority Status. If an application for eligibility is approved, the Area Director or designee shall make a determination of the individual’s priority for DMH continuing care services, based on the current severity of need, the individual’s circumstances, and the availability of services.

1. Client status. If the Area Director or designee determines that the individual has a high priority for services and some or all of the needed DMH continuing care services are immediately available, the individual will be placed on client status.
2. Pending services status. If the Area Director or designee determines that the individual has a high priority for services but none of the needed services is immediately available, the individual will be placed on pending services status.
3. Low-priority status. If the Area Director or designee determines that the individual does not have a high priority for services, relative to other individuals who were placed on client or pending services status, and DMH services are not available, or expected to become available within a year or more, to meet his or her needs, the individual will be placed on low-priority status.

Case Management Services (a state provided service)

When an individual has been determined eligible and some or all of the needed DMH continuing care services are available, he or she will be assigned a case manager. If a case manager is not immediately available, such assignment shall take place as soon as possible thereafter.

Case management services shall include: arranging for and completing the comprehensive assessment of client needs; convening the service planning meeting; developing and reviewing the individual service plan; reviewing the program specific treatment plans to ensure each client’s program specific treatment plans are compatible with the client’s individual service plan; and coordinating services to the client, and/or monitoring the coordination of DMH continuing care services provided to a client.

In addition to these services, case management services may include the following: (a) assisting the client to obtain other services, in addition to DMH continuing care services, that are identified in the client’s individual service plan but are available from public or private entities; (b) providing outreach, as needed; and (c) providing intensive support and advocacy, as needed.

1. Conclusion

I thank you for another opportunity to address the Commission, and to participate in Virginia’s evolving delivery system of care to treatment for those Virginians whose needs fall within the purview of the Department of Mental Health, Mental Retardation, and Substance Abuse Services.

1. Hurd, HM (Ed): The Institutional Care of the Insane in the United States and Canada. Baltimore, MD, Johns Hopkins Press, 1916-1917.
2. Memorial of D.L. Dix, Praying a Grant of Land for the Relief and Support of the Indigent Curable and Incurable Insane in the United States. June 27, 1848. (30t^h Congress, 1^st Session, Miscellaneous Senate Document No. 150).
3. Geller JL: Geller JL: The institution for mental disorders (IMD) exclusion: The federal government’s impaired vision in the care of its citizens with chronic mental illness, in Lewin M (Ed): Unintended Consequences of Major Health Programs and Policies: Some Case Studies. Washington, D.C., National Academic Press, in press.
4. Geller JL: The last half-century of psychiatric services in Psychiatric Services. Psychiatric Services, January, 2000.
5. Massachusetts Regulations, 104 CMR 29.00: Department of Mental Health: Service Planning.