Testimony Before DMH Inpatient Commission Delivered by Karen Coughlin
Massachusetts Nurses Association
Testimony Before DMH Inpatient Study Commission
Delivered by Karen Coughlin, RN
Vice-President, MNA Unit 7 of RNs and Health Professionals
Thank you members of the Inpatient Study Commission for the opportunity to speak to you this afternoon. My name is Karen Coughlin and I am the Vice- President of the Massachusetts Nurses Association Unit 7 of RNs and Health Professionals, which represents more than 1,800 health professionals who work in state agencies and state-operated facilities. Our members include all state-employed registered nurses, physicians, psychiatrists, pharmacists, psychologists and occupational therapists, who work in the Department of Mental Health inpatient facilities under review by this Commission. I am a psychiatric nurse who has worked at Taunton State Hospital for the last 25years.
We bring a unique and important perspective to this process, as we are the clinical professionals on the frontlines of the DMH system; we are the professionals who are personally accountable for the health and well being of the clients served by the Commonwealth. Because we are on the frontlines, we see more and understand more of what works and doesn’t work in the current system. In addition, because of this perspective, we have a greater sense of the potential impact of the decisions of this commission as we plot the future of inpatient psychiatric services in the Commonwealth.
We come here today with a sense of great urgency and with a deep concern about these proceedings and the work of the department. Our concern and our urgency has been fueled by statements made by officials at various facilities last week about a current plan to close up to 100 inpatient beds within the system by July 1st, as well as other unofficial reports of plans to close an entire facility within the coming months.
Given the prospect that either of these drastic measures is being seriously considered, we are here to tell you that we believe that such a decision will have a dramatically negative impact on the care of individuals with mental illness and greatly increase stress to their families and to the communities in which they live. The loss of these beds, or of an entire facility, combined with the recent dramatic cuts to community services and supports for the most vulnerable mentally ill, will adversely affect thousands of individuals and family members. Mental health consumers who have relied on these facilities and these services for years will surely suffer. We cannot change how things were done in the past. We learned then that closures without the appropriate planning and supports profoundly affected the clients we served. Many became homeless, others ended up in the correctional system, and many more found themselvesat greater risk to themselves and others. Then, as now, we faced difficult economic times. It is because of that, we urge you, please, do not let what happened in the past dictate our future.
First and foremost, the MNA is committed to the position that wherever, and whenever possible, people suffering from mental illness or other chronic conditions should be cared for in community settings, with the greatest independence possible, and with access to the services and supports needed to ensure their independence and well being. In fact, we have played a major role in helping those that should be in the community, move to the community where they are best served. Further, through the efforts of our members who serve in transitional programs, we have worked for years to provide the supports needed to keep people in the community for as long as possible.
However, there are members of this population that require a level of clinical care that is best provided in state-run facilities designed to provide a higher level of care. Just as some frail elderly reach a point where they cannot sustain themselves in the home and must be cared for in a nursing home environment, so too do some of our severely mentally ill clients require more intensive services in a more protective environment. To understand the role and value of our inpatient facilities, one needs to have a clear picture of the clients we serve. At our inpatient facilities, particularly at my facility, Taunton State Hospital, we take care of a significant number of forensic patients, which means they come to us from corrections facilities or the court system, with varying levels of criminal involvement and some with violent behaviors and histories. At all of our facilities, we have many frail elderly mentally ill patients who can’t be cared for in nursing homes. A large percentage of our patients have a dual diagnosis of mental illness and substance abuse which complicates their placements in community settings. We have a number of women suffering from serious trauma who are self abusive and suicidal and need intensive mental health monitoring and care. These are patients that often have nowhere else to go in the system.
In fact, there is a shortage of psychiatric beds throughout the entire health care system in our state, including the public and private sector. I would point to the recent DMH decision to allow Cambridge Health Alliance to close 35 of its acute psychiatric beds, as well as their substance abuse treatment unit. Other facilities have closed beds in the last decade, and we know that St. Vincent Hospital in Worcester was prepared to close its psychiatric unit, and may do so within the next two years.
Right now, we have psychiatric patients clogging our emergency rooms across the state, some waiting for 72 hours or longer for a psychiatric bed placement. We also know that in tough economic times and times of recession, the incidence of mental illness, depression, suicide and substance abuse increase, necessitating a greater need for all levels of psychiatric care.
I would also point to the Commission’s own documentation on its web page which shows that the census at the facilities under study by this commission was running at an average census of 97 percent as of May 13, 2009.
The same DMH document, concerning the scope and purpose of the Commission, points to, and I quote, “an already significant reduction to DMH community services with the elimination of day and employment services and a reduced case management work force.” It further states that, and again I quote “more than 200 of the 788 adult patients in DMH continuing care facilities are ready for discharge but appropriate community services are not available.”
Right now we know it can take up to two months to transition a client from one of our facilities to a community residence.
So if you admit that the community system cannot accept clients promptly now, how can it be done without the risk of harm to our clients? Because that is exactly what you will be doing. And in so doing, you are only going to increase the rate of homelessness, further clog up and destabilize our hospital emergency rooms, allow patients who are currently stabilized and safe to be placed in jeopardy, and in the end, drive up the cost of health care throughout the system, as we are forced to deliver care in more expensive settings, including our overcrowded jails.
We urge you to make different choices. Specifically we offer the following principals for our position on the future of inpatient services in the commonwealth:
- Put Careful Planning for the Clients Before Any Other Consideration -- No closing of beds or facilities should be contemplated unless and until a comprehensive process of evaluation and planning takes place as to what is best for those served by these facilities. We hope that this process will include a truly objective analysis of the current and future needs of the population being served by the facilities, an evaluation of how, where and at what costs alternative services will be provided, with specific funding allocations to allow those services to be delivered.
- Guarantee Equal or Better Care -- No closing should take place unless and until every client or patient impacted by the decision is guaranteed equal or better services as defined by the clients themselves, their families and guardians, as well as by the clinical team overseeing their care.
- Provide Transitional Care -- Any client displaced by a bed or facility closing, should receive appropriate transitional services and care to ensure the process of transition is conducted in a manner that will not cause undue harm or distress to the client.
- Make True Cost Assessments – No closing should take place until a realistic, comprehensive and independent analysis of the total societal cost of the closing is completed. Cost benefit analysis driving these decisions should factor in all costs, not just the cost of maintaining the particular asset in question. This should include the costs to state government for the impact closings will have on unnecessary emergency room visits, increases to the Medicaid budget due to poor management of conditions in an inappropriate community placement, and the cost of creating multiple community residences to replace the facility in question.
- However Services are Provided, State-Operated Services are Preferable to Privatized Services – The record of privatizing state services is spotty at best and in many cases, highly detrimental to the care of those placed in these systems. Studies have clearly shown that state-run facilities, with services provided by unionized health care professionals provide better care, with dramatically less turnover of staff, which reduces costs and prevents increased cost associated with poor care.
- An increase in state revenue to fund the system – The MNA has been quite clear that we cannot maintain our health care safety net through cost cutting alone. Protecting the mental health of our communities will require an investment of new revenue. We support an array of revenue generating measures proposed by the legislature and urge passage of those measures.
- If closures occur, they should be focused on removal of beds, as opposed to the closure of an entire facility. As stated above, the demographics of our society, as well as recent trends in utilization of inpatient services, shows that the need for inpatient care will continue to increase and that we need to protect our sources of bed capacity to meet future demand. It is less costly to close and then open units or wards within a facility, then to build a new facility at a later date. This is particularly critical if privatization of services is being considered. Once the state eliminates the infrastructure needed to provide the services at all, private vendors will dramatically increase their costs. So it is far more fiscally prudent to close beds or wards than it is to close facilities.
We all want and strive for a system of care that is determined by the client, that is community based, and which fosters optimum independence. My entire career, and those of my colleagues, is based on that premise, but creating that system calls for an investment in resources that does not yet exist. As frontline caregivers, we can’t abandon our clients to a system based on false promises. Our professional licenses demand that we be honest with our clients and the public about the consequences of our actions and yours. We hope you will use this commission to make a thorough and objective analysis, one that provides a plan based on the needs of the residents of the Commonwealth, and that you fight for the resources to meet those needs.