Access: The TAC Blog
The number of state institutional psychiatric beds, which were once the primary setting for psychiatric treatment, has gone down dramatically nationwide. Community psychiatric hospitals, private hospitals, and nursing facilities filled the gap in the 1980s and 90s, but inpatient capacity in these settings, too, has recently been on the decline. There is widespread concern — given ample voice by the media — that we need to restore our nation’s psychiatric bed capacity, both to reduce the risk of violence perpetrated by people with untreated mental illness, and for their own safety and health.
In reality, however, inpatient treatment should form only one part of a robust system of mental health care. For comparison, note that treatment for even the most serious medical conditions now frequently occurs in outpatient and in-home settings. However, recent findings from the Healthcare Cost and Utilization Project reveal a widening gap between our country’s approaches to hospitalization for mental and for physical health conditions: Between 2005 and 2014, the rate of inpatient stays per 100,000 people for all causes decreased across all age groups, while the number of hospital stays for mental health/substance use actually increased by 12.2 percent.
To examine these trends and their implications, the National Association of State Mental Health Program Directors recently commissioned a series of working papers on the question: “What is the real need for inpatient psychiatric beds in the context of a best practice continuum of care?” In this series, researchers and policy leaders describe ways to improve mental health and substance use disorder treatment at many different points in a community’s system of care so as to necessitate fewer psychiatric hospitalizations, of shorter duration, with better and more equitable outcomes.
Increasing the number of psychiatric inpatient beds is not the solution in most communities. As my colleague Kevin Martone and I argue in our contributions to the series, investments in care and services can create alternatives to inpatient beds that are both more effective and less costly. “Beyond Beds: The Vital Role of a Full Continuum of Psychiatric Care” lays out specific public policy recommendations to minimize the human and economic costs associated with severe mental illness by building and invigorating a robust, interconnected, and evidence-based system of care. And as “The Role of Permanent Supportive Housing in Determining Psychiatric Inpatient Bed Capacity” shows, stable and affordable housing combined with voluntary services can contribute to improved outcomes in both physical and behavioral health, while reducing incarceration and homelessness. Furthermore, the cost of serving a person in supportive housing is half that of a shelter, a quarter that of incarceration, and one-tenth the cost of a state psychiatric hospital bed.
Advances in medical research and technology, chronic disease management programs, and alternative treatment settings such as walk-in urgent care centers — along with payment approaches that support medical care in outpatient settings — have all helped reduce hospitalizations for physical health conditions. Evidence-based mental health care options, especially when provided in the communities where people live, offer the potential to bring down psychiatric hospitalizations as well. Private insurers rarely cover these services, however, and state and federal mental health funding are drastically insufficient to meet demand. Medicare and Medicaid together fund approximately 60 percent of inpatient care in the United States. Unfortunately, Medicare funds very few evidence-based mental health practices, and Medicaid funding for housing transition and tenancy-sustaining programs — a critical component of permanent supportive housing for people with mental health disabilities — is not yet fully incorporated into services.
We don’t need to re-create massive numbers of psychiatric inpatient beds. Rather, policymakers must prioritize funding for the evidence-based preventive treatment and services that people with mental illness need and desire. With these effective and cost-saving resources available and truly accessible in every community, hospitalization will play an appropriate role in a balanced system.
Providers Gather to Focus on Rapid Re-Housing
At the end of October, 800 service providers and Continuum of Care leaders focused on making rapid re-housing (RRH) a key component in their efforts to prevent and end homelessness came together for two intensive days of workshops, presentations, and teamwork. Two Rapid Re-Housing Institutes were held a few days apart in Duluth, GA and Los Angeles, CA, coordinated by TAC in partnership with the Department of Veterans Affairs' Supportive Services for Veteran Families program, the Department of Housing and Urban Development, Abt Associates, the National Alliance to End Homelessness, and the National Coalition for Homeless Veterans. The U.S. Interagency Council on Homelessness and the Department of Labor were also represented at the Institutes.
At each gathering, a Practice Track offered service practitioners direct training in the core components of RRH and effective service delivery strategies. Concurrently, a System Track designed for leaders with planning and implementation responsibilities covered community-wide practices relevant to RRH as a primary response to homelessness. Along with working sessions, Nan Roman, president and CEO of the National Alliance, and Elisha Harig-Blaine, Principal Housing Associate for the National League of Cities, gave plenary addresses - and for a little extra fun, groups competed in rapid re-housing Mad Libs and bingo! For more highlights, check out #RRHI2017.
TAC Staff in Action
Senior Policy Advisor Francine Arienti and Senior Associate Gina Schaak traveled to Hickory, NC to train providers on assessing people's needs and preferences before helping them move into supportive housing; Senior Associate Jon Delman presented on "Improving Work Conditions for Peer Specialists" at the annual gathering of the International Association of Peer Supporters; Jon also joined Associate Jenn Ingles, Senior Associate Melany Mondello, and Senior Consultants John O'Brien and Jim Yates in Montgomery, AL to help launch a statewide strategic housing initiative; In October, Managing Director Marie Herb and consultant Jake Mihalak facilitated the first on-site meeting of the Violence Against Women Act - Housing Opportunities for Persons With AIDS (VAWA-HOPWA) Demonstration Program initiative; Senior Consultant Sherry Lerch presented to the National Coalition of State Housing Agencies on "The Supportive Housing/Health Care Nexus"; Executive Director Kevin Martone brought a national perspective to a recent article in Mental Health Weekly on New York state's efforts to fund supportive housing; Senior Consultant John O'Brien gave the opening presentation at the National Dialogues on Behavioral Health conference, and spoke on "Strategies for Outcomes and Value-Based Payment" at an American Public Health Association roundtable on systems transformation; and Associates Phillip Allen, Lauren Knott, Ashley Mann-McLellan, and Douglas Tetrault, Senior Associates Melany Mondello, Gina Schaak, and Liz Stewart, consultant Naomi Sweitzer, TA & Training Coordinator Kyia Watkins, Federal Contracts Assistant Kim Wilder, and Housing Intern Madison Tallant all hit the road to put on the first Rapid Re-Housing Institutes in Duluth, GA and Los Angeles, CA (see above).
The Trump administration’s interest in addressing the opioid epidemic is heartening, and last week's proclamation is a welcome acknowledgment that opioid addiction and overdoses do indeed constitute a major public health crisis in our nation. While there is no immediate prospect of a significant cash infusion (millions are touted, versus the badly needed billions) to address the crisis, there has at least been the promise of statutory and regulatory relief — with a particular focus on allowing states to waive the Institutions for Mental Diseases exclusion. This 52-year-old statute bars Medicaid payments for mental health and addiction treatment provided to individuals in large treatment facilities, and some advocates assert that waiving it will allow Medicaid funds to flow for thousands of substance use disorder (SUD) treatment beds that currently lie empty.
All efforts to expand access to treatment are important, but the push to open up large facilities for SUD care as the first priority should be kept in perspective. Empty beds in such institutions may be the result of many causes. For instance, a community with a strong array of community-based treatment options may not need additional beds. In some cases, beds go unused if private payers don't refer patients to a facility because it lacks a modern, evidence-based approach to treating addiction (for instance, if no-one on staff is qualified to provide medication-assisted treatment). And finally, some facilities have never participated in either Medicaid or commercial insurance programs simply because they don’t have to, as their private fee structure allows them to maintain empty beds; these providers may have neither the financial motivation nor the business operations know-how to bill insurers, or to train their staff to meet the quality standards of states and commercial payers.
So, states — before you rush off to the Centers for Medicare and Medicaid Services asking for IMD waivers, make sure your request is going to make a true difference in getting people high-quality care. We won’t turn this crisis around by assuming that any treatment is better than no treatment.