Nevada’s Mental Health Services: Choose between safety and services?

Nevada Legislature BuildingInteresting thing:  There are politicians among us who never tire of telling their audiences how important it is to Cut Taxes.  How important it is to curb government spending. How important it is to put more ‘bureaucrats’ off the public trough and out to pasture.  Until reality kicks in.

So Nevada pared its budgets down, and left positions unfilled in various parts of government… until the Sacramento Bee published this on page A1, April 14, 2013:

“In recent years, as Nevada has slashed funding for mental health services, the number of mentally ill patients being bused out of southern Nevada has steadily risen, growing 66 percent from 2009 to 2012. During that same period, the hospital has dispersed those patients to an ever-increasing number of states.

By last year, Rawson-Neal bused out patients at a pace of well over one per day, shipping nearly 400 patients to a total of 176 cities and 45 states across the nation.”

At this point the glossy generalizations met the unburnished realities of providing public health services.   What might we have expected when in 2009 Nevada allocated $226 million for mental health care services and in 2011 $186.8.  A cut of  $39.2 million, or 17.3%?  [NAMI pdf]   This might have been understandable if the number of people seeking mental health care services and treatment had been reduced.  It wasn’t.

There were 2,997 people treated in Nevada hospitals for mental illness in 2007, in 2009 there were 3,103 receiving hospital mental health treatment. [NAMI pdf]   In short, we knew — before the 2011 budget was developed — that we were treating an increasing number of patients.

We knew, or should have known, that in 2007 some 28,513 Nevadans were treated by the State Mental Health Authority in its several forms. By 2009 that number increased to 32,035, an addition of 3,522.  [NAMI pdf]  The number of individuals needing treatment went up, while our budget allocations went down.

If we were waiting for the federal reinforcements to show up in the form of federal funding — don’t restrain the breathing:

“The House and Senate have pieced together two distinctly different Labor, Health and Human Services (HHS) and Education FY 2013 Appropriations bills. The House version (no bill number yet) would gut funding for public health agencies, including a whopping 10 percent cut to the Substance Abuse and Mental Health Services Administration (SAMHSA) – a crippling, irreversible cut that would take years to recover. Whereas, the Senate version (S. 3295) provides a funding increase of $20 million each for both the Mental Health Block Grant and the Substance Abuse Block Grant, as well as a $100 million increase for the National Institutes of Health.” [MHA]

On August 6, 2013 the Nevada Legislature’s Interim Finance Committee authorized $2.1 million in emergency funding to address problems at the Rawson-Neal facility.  However, the financial juggling act was on stage yet again:

“Lawmakers tabled a second proposal to renovate an old psychiatric hospital in Las Vegas to relieve Rawson-Neal and Lake’s Crossing for consideration later this month. Legislators worried that approving the proposed renovation would divert $3 million in funds now earmarked for other Lake’s Crossing projects deemed critical for patient safety.” [LVRJ]

There was a reason for that decision. The meeting materials (pdf) explain the expenditures for the Lake’s Crossing facility were to upgrade the fire alarm system, the sprinklers, replace or repair metal doors, the upgrading of smoke barriers and safe walls, and the upgrading of exit lighting.   In simpler terms, the Interim Finance Committee was called upon to juggle the necessity of ameliorating the conditions which created the “patient dumping” solution at Rawson-Neal with the necessity of fixing the “fire trap” situation for patients and staff at the northern Nevada facility.   This is not a decision which should be faced by anyone.  One Assemblywoman summed up the morass:

“It’s going to take a whole evaluation of the system” to get Rawson-Neal back on track, said Assemblywoman Maggie Carlton, D-Las Vegas. If the state wants a good mental health system, then it has to pay for a good mental health system, she added. [LVRJ]

It’s going to take an evaluation of the entire system, and the funding thereof, in order to satisfy investigations and actions from several directions.  First, the federal government:

“The U.S. Health and Human Services Department agency warned the hospital in April that it was in violation of Medicare rules governing discharge of patients and gave the facility until May 6 to come up with a remedy.

“We’ll continue to inspect the hospital until we’re convinced that it’s in full compliance with Medicare rules that protect the health and safety of patients,” said Jack Cheevers, spokesman for the Medicare and Medicaid Centers. “If the hospital fails to comply, it could lose its federal funding.” [KELO May 24’13]

Next, the city of San Francisco, which totaled up the costs for dealing with 500 patients dumped in California, 24 of whom ended up in San Francisco.  City Attorney warned what was to come:

Herrera wrote that San Francisco has spent nearly $500,000 on medical care and housing for those patients, all of whom were homeless and suffering from mental illnesses.

He wrote that the busing practices were “inhumane and unacceptable,” noting that they were allegedly transported without escorts, without adequate medication or food and without arrangements for someone to receive them at their destination. [SFAppeal]

By September 10, 2013 Herrara made good on his promised litigation:

“San Francisco City Attorney Dennis Herrera today filed a class action against the State of Nevada on behalf of California local governments to which indigent patients were improperly bused from the state-run Rawson-Neal Hospital in Las Vegas.  The lawsuit filed in San Francisco Superior Court this morning seeks a court-ordered injunction barring Nevada from similar patient discharge practices in the future, and reimbursement for San Francisco’s costs to provide care to the patients bused there.” [SFBJ]

Nevada pushed back in correspondence from the Attorney General’s office indicating that Herrara’s suit lacked sufficient evidence to substantiate the claims, and did not specify how the 20 patients were identified. [LVRJ]

Dumped patients form a third element reacting to the practices at Rawson-Neal.

“The complaint filed Tuesday in U.S. District Court in Las Vegas seeks class-action status for Brown and as many as 1,500 people his lawyers claim were bused since 2008 from Nevada to almost every state in the U.S.

Brown is the only named plaintiff. The lawsuit that makes nine claims, including negligence and breach of fiduciary duty. It seeks an immediate court order to stop Nevada from sending psychiatric patients out of state, unspecified damages for Brown and others, and a declaration that patients’ civil rights were violated. […] Defendants are six state agencies including the Nevada Department of Health and Human Services, the Division of Mental Health and Development Services and the Bureau of Health Care Quality and Compliance, plus eight individual hospital and state agency administrators.” [KTVU, June 24’13]

What did we get for our parsimony with funds for mental health care services?  More stringent federal oversight, litigation from the patients, and more litigation from California — the site of many “deposited” patients.

What we have not gotten is a full evaluation of the adequacy, much less the quality, of our mental health and substance abuse treatment in Nevada.   And, what we have not yet achieved is a system in which we adequately address the numbers of adults and children in the Silver State who are in need of mental health or substance abuse treatment — we know the number who are in waiting for treatment in the community (see the working papers from IFC), we know the numbers in Emergency Rooms, but do we have a firm grip on the numbers who need assistance and find it unavailable on a timely basis?

What we have not gotten is a system in which we don’t have to choose between understaffed services in one region and unsafe conditions for patients and staff in another.

Assemblywoman Carlton is correct — we will get what we are willing to pay for.

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