About 25 staff psychiatrists at Eastern State Hospital in Williamsburg, Va., are opposing the state-backed plan to downsize their acute services admissions unit. Despite meetings with legislators and the state mental health commissioner earlier this year, the plan to close 43 beds this year and eventually close the entire unit is proceeding. Once the unit is closed, patients will be diverted to private psychiatric hospitals in their communities for acute care.
"Because we are committed to caring for our patients, we will not stage a walkout or formal protest," staff psychiatrist Mahmood Rahman, M.D., told Psychiatric News. "And, next month, we will stop admitting new patients, as asked. But we will discharge only those patients who are ready and have appropriate community placements."
The plan for Eastern State Hospital was proposed by its hospital administrator with input from local government agencies responsible for community-based services.
The medical staff at Eastern—from psychiatrists to clinical social workers—contend that they were not asked for input until after the plan was developed. Their main criticisms of the plan are the existing shortage of public and private psychiatric beds, inadequate funding, and lack of intensive and comprehensive services to meet the needs of the seriously mentally ill population they treat.
"We already don’t have enough psychiatric beds in our region," said Rahman. "Last year, there were 1,295 admissions to our 90-bed admissions program. With a service population of 1.7 million in our region, and only about 280 acute adult private beds, we cannot afford to close any acute beds. We also have a waiting list of patients to be admitted at Eastern."
"Just last month, when our admissions unit was full, we found that yet again there were no available beds to buy in the community."
James Reinhard, M.D., believes that the Virginia plan "minimizes the impact on direct patient care and hospital staff," despite being budget neutral.
Rahman and 24 other psychiatrists expressed their concerns in a July letter to James Reinhard, M.D., commissioner of the state’s Department of Mental Health, Mental Retardation, and Substance Abuse Services. Reinhard is a former director of a community-based psychiatric hospital and a member of the Psychiatric Society of Virginia (PSV).
Rahman added, "We routinely admit patients that are acutely psychotic, violent, and destructive from jails, private psychiatric hospitals, and sometimes the streets. Our experience is that most private psychiatric facilities aren’t equipped to provide the comprehensive services these patients need."
Founded in 1773, Eastern State Hospital in Williamsburg, Va., was the first public facility in the United States constructed solely for the care and treatment of the mentally ill. With the growth of Colonial Williamsburg, by the mid-1960s many patients had been moved from the hospital’s downtown site to a site three miles west at Dunbar Farms. In 1985 a replica of the original hospital was built on its original site and today gives visitors an idea of what it was like to be mentally ill in colonial times.
Eastern—the oldest public psychiatric hospital in the United States—is one of five state facilities being downsized over a two-year period to divert funds to community-based services (see box
), said Reinhard in an interview with Psychiatric News
He proposed the reinvestment concept to Gov. Mark Warner (D) last year after being told to cut his agency’s budget.
Virginia’s budget deficit in Fiscal 2004 is $1.5 billion, according to the governor’s Web site.
"I was pleased that the governor approved the proposal, which is budget neutral and minimizes the impact on direct patient care and hospital staff," said Reinhard.
"Virginia ranks seventh in the nation in spending per person on inpatient psychiatric beds, yet we rank 41st in spending per person on community mental health services," Reinhard noted. "It makes sense to reinvest a portion of the resources at Eastern State and try to serve those and even more patients in the community."
He estimated that in January about $6 million in funds for Eastern will be diverted during Fiscal 2004 and available for reinvestment.
"Similar reinvestment projects have been very successful in other regions of Virginia [see story below]. I am confident that the same success in maximizing state hospital resources can occur in the region around Eastern State Hospital."
Rahman responded that Eastern’s plan doesn’t have the same level of funding or intensive services being implemented at Central State Hospital, which Reinhard promoted as a model.
At a town-hall meeting at Eastern State Hospital in April, private hospital nurses and physicians told officials that the acute-care admissions beds were vital for providing adequate care to the indigent mentally ill, according to a June 6 Associated Press article.
Richard Kaye, D.O., medical director of behavioral medicine at Obici Hospital, a private psychiatric hospital in Suffolk, Va., and immediate past president of the Tidewater Academy of Psychiatry, has been an outspoken critic of the reinvestment plan.
He told Psychiatric News, "Deinstitutionalization is neither cost-effective nor does it improve services. The results are that the chronically ill end up homeless, in jail, or die. It is the threat to human life that is most troubling."
These concerns were echoed by Valerie Marsh, executive director of the National Alliance for the Mentally Ill-Virginia. She told Psychiatric News that she believes "the funds allocated to reinvestment are grossly inadequate. The amount of state funding is not comparable to what other states have allocated to transition from facility care to community care."
She was referring to the approximately $500,000 in "bridge money" each region received from the state mental health department.
"The reinvestment plans seem to focus on inpatient and emergency care. I thought the whole point was to prevent inpatient care and intervene with adequate treatment and supports. Changing beds from public to private or from long term to short term is not true investment," said Marsh. She also complained that consumers and families were not consulted until long after the planning had begun.
Community psychiatrists who favor the reinvestment plan include James Krag, M.D., president of the Virginia Association of Community Psychiatrists, which represents more than 200 psychiatrists working in the state’s 40 community mental health centers.
Krag commented to Psychiatric News, "We believe that we can and should provide better care than the current system allows. Continuity of care is often lost as the person is transferred from one hospital unit to the next and then finally discharged to a community team that had little say during the person’s hospital stay."
Krag added that community psychiatrists are concerned about the state shifting patients to them without redirecting the dollars from closed state hospital beds into community care.
Mary Ann Bergeron, executive director of the Virginia Association of Community Services Boards (CSB), said, "New funds are needed to create a broad array of mental health services." She plans to propose increasing the CSB budget by $18 million for Fiscal 2005 and $21 million for Fiscal 2006.
Reinhard said that Medicaid will relieve some of the state’s cost burden for community-based services, which wasn’t an option when patients stayed in state hospitals. Medicaid does not pay for state psychiatric hospital care. Virginia officials are, however, considering substantial cuts in Medicaid funds.
Reinhard emphasized that the reinvestment project moves Virginia closer to complying with the 1999 Supreme Court decision in Olmstead v. L.C. The ruling upheld the constitutional right of people with mental illness to live and receive treatment in their communities if there are adequate placements and services, among other conditions.
A description of Virginia’s restructuring process, including the "community reinvestment project" and regional updates, is posted on the Web at www.dmhmrsas.state.va.us./R&R/defaultR&&R.htm. ▪