It turns out the "sea change" occurred in 1974. It occurred in Wisconsin and not Minnesota. That was the year that Len Stein, MD and a group of dedicated clinicians came up with the idea that patient with severe mental illnesses could be maintained outside of hospitals as long as they were provided with appropriate housing, support, and in some cases vocational services. I know because I trained under Dr. Stein. He was a personal supervisor and I did a training rotation at the Dane County Mental Health Center. I can still remember the slide from his community psychiatry presentation that showed the overcrowded conditions at the state hospital - one of the reasons behind the community psychiatry movement. My training occurred about a decade later and at that time there were three different models of care that all involved community support. The most well-known of those models is Assertive Community Treatment or ACT. I was well versed in these models and providing the necessary care and for the first three years out of training I was the medical director at a community mental health center and spent have of my time working with the community support team. That team provided crisis services and support on a 24/7 basis to patients with severe mental illnesses. That was 30 years ago.
After the community mental health center, I moved to the Twin Cities where I spent the next 23 years working in a metropolitan hospital primarily running an inpatient unit. My focus for the first 10 years was trying to get people interested in community support services for patient we were discharging to the community. At first, there was a patchwork of public health nursing and large housing units with nursing supervision for our discharged patients. But eventually there was nothing. I was told point blank by various administrators that they really were not interested in hearing how things worked in Wisconsin. They did things differently in Minnesota. When I could no longer ask public health nurses to check on discharged patients - there was no help for them at all, except for an appointment to see a psychiatrist if they did not forget it.
That changed slightly when the state decided to shut down state hospital bed capacity and one of the psychiatrists there was able to get funding for ACT teams. The rationale by the state was that some of the money to maintain state hospital beds would be diverted to the ACT teams. Eventually that initiative increased but there was still not enough capacity. There was still a large patient population without adequate housing or assistance. The economic plight of many of these people was worsened by "spend down" provisions implemented by the state. That meant that even though their income was 100% disability payments, they could be expected to pay up to 60% of it for medications. That typically meant that the person went from poverty status to worse in order to continue recommended medications for their psychiatric disability.
Another problem was the bed situation and approaches that were being used to manage those beds. That last half of my inpatient career, there was a continuous large pool of patients flooding Twin Cities emergency departments. That resulted in initiatives to admit and discharge as soon as possible. The entire focus of admissions and discharges was on "imminent dangerousness" even though there is no such legal standard. It was a business standard of care. Many people seeking admission because they were miserable realized this and said they were suicidal in order to get admitted. Conversely, many people who still had significant problems and no good way to resolve them were discharge because they no longer met the "imminent dangerousness" criteria. There were no quality approaches to care only a focus on rapid discharges of very ill people.
So I have to shake my head when I read about the "new" approach to treating mental illness and helping people to maintain themselves in the community. There is really nothing here that was not done in Wisconsin nearly 40 years ago. In the meantime there is a severely deteriorated infrastructure with fewer beds in both designated hospitals but also supportive housing. I have significant doubts about the funding of these services since we know that managed care companies don't do community support services. Who is paying for these social workers and psychologists? Will they have to submit billing documents that are not practical to complete? Even if they are being paid for by the state, that doesn't necessarily guarantee future funding. At one point all of the public health nurses I was working with in the 1980s were told they could no longer see patients with psychiatric problems. And what about the continued rationing by managed care companies now being made to look like it is innovation?
Welcome to 1974.
George Dawson, MD, DFAPA
Chris Serres. Strategies shift for treating mental illnesses. Star Tribune January 19, 2016.