Iowa Mental Health Law Fills Residential Treatment Gap

The Iowa Psychiatric Society, a district branch of APA, played a big role in the passage of a sweeping mental health bill that aims to improve access to treatment, particularly for individuals in crisis, in Iowa.

Gabriel Butler Klein

House File 2456 (HF 2456) provides for six mental health “access centers” offering immediate short-term crisis care, 22 Assertive Community Treatment Teams, and the development of intensive residential service homes, among other provisions. The blueprint for the bill was based on the recommendations made by a stakeholder workgroup, explained Jerome Greenfield, M.D., who served on the workgroup and is outgoing president of APA’s Iowa Psychiatric Society. He is also the health services administrator for the Iowa Department of Corrections.

The Iowa Senate had been receiving a lot of feedback from the public about problems accessing mental health care and policies that weren’t meeting their needs, said Greenfield. For example, law enforcement officers were frequently called upon to transport individuals in crisis to a facility six or seven hours across the state, because none was available in the community. Patients were hospitalized many hours away from their families and had no follow-up resources upon discharge. Others in need of mental health treatment languished in emergency rooms for days while waiting for a bed to open on a psychiatric ward.

The state has faced a critical shortage of acute psychiatric services since the closure in 2015 of two of its four state mental hospitals when then-Gov. Terry Branstad declared them outdated. Iowa ranks last in the country for state mental hospital beds per capita, with just two beds for every 100,000 Iowa residents, compared with a national average of 12 for every 100,000 people, according to a 2016 report by the Treatment Advocacy Center. Making matters worse, a string of local hospitals has also trimmed or shuttered their psychiatric units in recent years, citing financial losses.

The workgroup, convened by the Iowa legislature, came together in late 2017 to address the lack of treatment and support options for people with complex mental health and substance use needs. Greenfield was one of two psychiatrists serving on the workgroup, along with other mental health professionals, advocates, law enforcement personnel, and public health officials. The workgroup’s recommendations, made in a December report, were enacted into HF 2456, which was signed by Gov. Kim Reynolds March 29.

“It’s very exciting,” Greenfield said. “It’s a privilege to serve on a committee like this. When you see something get approved unanimously, 98-0 with bipartisan support, we need more of this.”

As recommended by the workgroup, the law creates six mental health “access centers,” to be located strategically throughout Iowa by the end of 2019. “The idea is, no one should have to be transferred more than two hours away from their home,” he said.

The access centers will accommodate as many as 16 patients each and provide immediate, short-term care, including assessment, treatment, and the arrangement of follow-up care in the community. Instead of beds, there will be reclining chairs. “They will be far more comfortable than an emergency department, but not like a private room,” explained Greenfield. Examples of services include suicide intervention, medication management, and nursing care.

“The idea is, instead of sitting in an emergency department waiting for an open psychiatric bed, patients can start treatment right away,” Greenfield said. “Detox and stabilization can be done in the access center, but if not, staff can work on finding a hospital bed.”

However, prior to treatment at an access center, prospective patients would need to be medically cleared first, Greenfield explained. The centers may also play a role in jail diversion, with law enforcement dropping charges against individuals with mental illness who agree to treatment there.

“Given the tight budget situation we already have, the idea was to create a system not totally reliant on inpatient psychiatric hospitalization to meet the needs,” explained Emily Piper, a lobbyist for APA’s Iowa Psychiatric Society. “It won’t work for everyone, but there are certain times a patient doesn’t need to be in an inpatient setting. This provides more opportunities for treatment.” The access centers were modeled after similar care options in Texas and Tennessee, she said.

Other provisions in HF 2456 recommended by the workgroup include the development of the following:

• Twenty-two Assertive Community Treatment (ACT) teams to be in operation by the end of 2019 (up from 10 ACT teams), which will provide intensive case management services to people with serious mental illness by visiting them as often as daily in their homes to help them manage their daily living tasks.

• Small intensive residential service homes throughout the state to house a total of 120 people by the end of 2019. These are for individuals who have the most serious and persistent mental illness and need intensive, 24-hour-a-day supported community living.

• Mental health crisis services, including mobile-response crisis services and a 24-hour crisis hotline.

Iowa Democrats have raised questions about whether the Republican-led legislature will provide sufficient funding for implementation of the mental health bill, since the state GOP has proposed a budget cut of more than $1 billion per year, according to the Des Moines Register.

Iowa’s 14 existing mental health regions will fund the bill initially with existing cash reserves. Greenfield said he expects the bill to be cost-effective for the state because it will reduce psychiatric hospitalizations and incarceration for people with mental illness. ■