In psychiatry, the main historical tool of managing violent behavior has always been psychiatric hospitalization. During the hospital stay, a wide range of treatment interventions are utilized to stabilize the patient and to decrease the risk of violence upon discharge. Violence management thus becomes a central and critical aspect of admission, continuing hospitalization and discharge. (1,2,3)
Traditional managed care used a number of “tools” to prevent and decrease the length of time of psychiatric hospitalization. These “tools” to limit hospitalization include strict criteria – “medically necessary treatment” - for authorizing payment for inpatient admission and strict criteria for paying for a continued stay in the hospital. When it comes to paying for psychiatric hospitalization, the imminent risk of violent behavior is the criterionthat justifies admission, continuing stay and discharge in an inpatient psychiatric unit. The goal of managed care is to encourage the shortest stay possible by monitoring the progress of the patient on the unit. The impact of traditional managed care on the length of stay in psychiatric units in Arizona and the United States has been to tremendously decrease hospitalization from nearly a month in the early 1980s to approximately a week by 2010. (1,2) The new crisis center managed care model implemented in Tucson in 2011 is continuing to minimize and shorten length of stay mostly by avoiding hospitalization in the first place.
In Tucson, Arizona, there have been four major players in this story of the transformation of services from a traditional managed care model to a centralized managed care crisis model. These players are the State of Arizona, the Community Partnership of Southern Arizona, Pima County and the Medical School of the University of Arizona. (4,5) The State of Arizona contracts with the Community Partnership of Southern Arizona. The Community Partnership contracts for managed care mental health services in Pima County, a population area of over one million. Pima County owns the health care campus that includes a general
medical hospital, a psychiatric hospital and the Crisis Response Center. The county also operates the Pima County Jail. This county jail houses the largest institutionalized group of people with mental illness: 25%
of the estimated 2000 inmates have a mental disorder. This was two and a half times the total number of psychiatric hospital beds in Pima County (200). Pima County is also financially responsible for mentally ill patients involved in involuntary psychiatric commitment. Pima County contracts with the Medical School of the University of Arizona for operating and staffing both hospitals. The Community Partnership runs the Crisis Response Center.
Change often requires crisis. The ongoing perceived crisis predicament of Kino Hospital – the original name of the county hospital - was the main match igniting the change from the traditional model to the crisis center model. In the 1980s and 1990s, the occupancy of the psychiatric units in Kino Hospital was always near 100% while the general medical units averaged less than 50% and often around 25%. The county thus was essentially supporting a near empty medical hospital and overwhelmingly full psychiatric units. The hospital was financially failing and the county was responsible. The local media – newspapers and television news - criticized the county for decades for this financial albatross. (7)
In the early 2000s, a series of high profile scandals hit Kino Hospital: a psychiatric patient died in the process of being restrained and the pharmacy suddenly had a million dollars of drugs disappear. An investigation by the state nearly resulted in the hospital’s closure. The county arranged in 2004 to turn over management of the hospital to the physicians’ group of the University of Arizona Medical School.
The County entered into a twenty-five year lease agreement with University Physicians Healthcare in 2004. The purpose of this unique public/private partnership was to transition the hospital from one focused mainly on psychiatric services to a full-service hospital that provided comprehensive medical services to an underserved population, and to reduce taxpayer support of the hospital. (4,5,7)
The development of both a new psychiatric hospital and a new crisis center were also part of the agreement.
A master plan was developed that included an upgraded and expanded psychiatric facility, state-of-the-art research and training programs and a crisis response center. The need for these new psychiatric facilities was justified by the large number of people in Pima County with mental disorders— an estimated 60,000 with 30,000 currently enrolled in services. Further justification made clear the lack of psychiatric care facilities as a regional issue that impacted not only mental health service providers and jail and juvenile facilities, but also hospital emergency rooms and law enforcement personnel throughout Southern Arizona.
The solution to this problem was the construction of a second building that would function as a psychiatric urgent care crisis center. When it came to savings for the taxpayer, it was estimated that the potential cost savings, because of diversions from the jail, could amount to $6.5 million a year. The Crisis Center was thus seen as a way to prevent people with mental disorders from entering and being warehoused in jails, also as a way to decrease involuntary commitment and, finally, a way to decrease psychiatric hospitalization. The marketing campaign by the county for the bond promised 80 to 100 psychiatric beds in the new psychiatric hospital. The bond was successfully passed with 60% voter support. (4,5,7) The new psychiatric hospital and the Crisis Response Center were opened in 2011. One year later over 12,000 people had been served. The Community-Wide Crisis Line had answered 135,390 calls resolving 95% of the crises over the phone. Other emergency rooms had transferred over 2,700 people to the Crisis Center. The Center saw thousands of people without any insurance as well as being the crisis gateway for the vast majority of mentally ill people who were seen in the community. The Community Partnership instructed its providers to use the Crisis Center for all their clients who were in crisis or might need hospitalization. Everybody was served, including children, adolescents and adults. There were eight beds for children. There were also an additional fifteen beds for longer-term stabilization. In addition, the Center coordinated outreach services to help the police in complex mental health situations. The Center was particularly critical for law enforcement as it was designed to provide a quick drop off point for mentally ill patients picked up by police officers. Specialized construction allowed officers to drive up directly to the facility and quickly transfer their patients to the Crisis Center. (5)
Thus the Center became the new gateway to virtually all emergency psychiatric services, especially, inpatient psychiatric beds. Open 24 hours a day, 7 days a week and 365 days a year, comprehensive mental health crisis screening provided triage services for clients. 23 hour holding chairs were also available. These were comfortable reclining chairs that allowed people to sleep in them overnight. The 23 hours provided a short period of cooling off time to see if the crisis could be resolved before an inpatient hospitalization was required. The client could also be transferred by car back to the provider agencies of the Community Partnership or other service locations in the community. (5)
On February 26th 2013, the Community Partnership submitted to Pima County leadership the Crisis Response Center Annual Report. (5) The summary of the operation of the facility included the following
points: Crisis behavioral health services for adults and children were achieving many of the goals envisioned for the facility which were to reduce jail incarceration of individuals with mental illness and/
or substance abuse issues, reduce Emergency Department visits in hospitals, reduce inpatient psychiatric hospitalizations and reduce incarceration and hospitalization of children and youth. Required program service components such as the call center, mobile acute crisis teams, crisis stabilization services, sub-acute inpatient care for adults, secure and rapid law enforcement/first responders transfers, nonemergency crisis transportation services and peer support were successfully operating, Their report ended with the conclusion that in a very short period of time, the Crisis Response Center had become a national model.
Consequences
The Crisis Response Center – the new engine of second-generation managed care – has now been opened for two years. What are the consequences of this new program? As noted in the annual report, in terms of heavy consumer use, the Center was a clear success. In terms of decreasing psychiatric hospitalization the Center was also a success. There were some promises that the County had not kept, however. The new psychiatric hospital built by the County had only 48 beds, not the initially recommended 80 to 100. The county further saved money by decreasing the number of days they would pay for involuntarily committed patients. While the number of new people who were initially involuntarily committed skyrocketed, the number of these same involuntary commitments that were eventually dropped – one of the goals of the new system - also skyrocketed: increasing to nearly 75%. (8) Thus 75% of all people involuntarily committed became either voluntary patients or were immediately discharged. This fact caused serious concerns for both families and community providers. Many people who had their involuntary commitments dropped were subsequently recommitted because they had become much sicker in the community as a result of not being compliant with treatment and not being stabilized in a hospital. Many of these, who were recommitted, once again, had their involuntary commitment proceedings dropped. Many of the commitment proceedings were dropped because of the lack of psychiatric beds and the huge demand for them. Thus the total lack of psychiatric beds in the system created pressure to both drop involuntary commitments and to prevent psychiatric hospitalization. Before the Crisis Center was built many Emergency Rooms in town would just hold on to these patients till a psychiatric bed was available. The new Crisis Center simply released them. The county was not the only entity responsible for decreasing psychiatric beds. The Community Partnership closed sixteen long-term psychiatric beds when the Crisis Center opened to help finance the Center. Within Pima County there was also no expansion of crisis residential beds or other housing alternatives. Thus the decisions by the county and the Community Partnership both significantly decreased the number of available psychiatric beds and prevented many patients from ever entering the hospital. The effect of these strategies, decreasing the total number of psychiatric beds, observing patients in 23 hour holding beds then discharging to the community and dropping involuntarily committed patients, significantly decreased inpatient psychiatric hospitalization.
To date there are no studies of the total impact of the Crisis Center. Anecdotal information, however, reveals a number of problems. (8) In a panel that I participated in on mental health at a local Catholic Church, a clearly distraught and angry woman told the story of her son who had multiple visits to the Crisis Center, was never hospitalized and committed suicide. Another member of the audience also angrily commented about not being able to get services for his son who had been violent towards himself and others with multiple calls to the police and multiple releases from the Crisis Center.
Many providers, patients and family members are concerned with the rapid revolving door turnover from the Center. Providers from the agencies are often dismayed when patients they send to the Center for assessment are immediately sent back to them in the same clinical state that they were sent to the Center to treat. For example, when I asked a group of 30 providers at a medical staff meeting of a local provider agency how many had benefitted from the Center, not one of the providers raised their hand. In talking to patients the reaction is mixed. Some patients feel the Center has been helpful. They speak of a less stigmatizing environment then the emergency rooms in general hospitals. Many others however are frustrated by the revolving door reality. Many patients do not like the 23-hour holding chairs and will not return again. Ironically, this frustration contributes to the goal of decreasing psychiatric hospitalization. In addition, many homeless who go to the Center report being discharged back to the streets. (8)
The Center was recently fined by the state of Arizona because of a series of violations. (6) These violations included not having consent forms signed, concern of an overuse of chemical restraints, lack of training in staff who restrained patients, inappropriate structural problems that resulted in several attempted hangings, and low employee to patient ratios. As a result of inappropriate medical care there has been at least one death. Former employees comment about the high level of violence at the Center with multiple injuries of nurses and psychiatric technicians occurring after being attacked by patients. There has been significant concern about extremely low staffing ratios that put the employees at higher risk of being injured. The
most evident problem of the Center, however, is the revolving door phenomena: many patients, rather than being stabilized, were being seen repeatedly.
Conclusion
The Crisis Center was conceived during a time of both government crisis and the ability to obtain new financial resources through the passage of a County bond. It was implemented in 2011 during the second greatest economic contraction in the last hundred years. The Crisis Center has certainly been successful in some goals such as volume management and decreasing psychiatric hospitalization, but it has failed at any semblance of stabilizing chronically ill clients. Inpatient hospitalization is becoming less and less of an alternative in managing violent risk situations for the mentally ill. A significant percentage of the thousands of people who are discharged from the Center are not psychiatrically stable. The Crisis Center has become a partially successful, but also a problematic model for these recession era times. Despite these problems, this second generation managed care model will certainly be looked at as a solution for centralized, crisis-based mental health care because of the significant cost savings achieved by minimizing psychiatric hospitalization. Is this savings truly worth the costs and consequences for the surrounding community?
References
1. Kongstvedt, Peter R. The Managed Health Care Handbook 4th Edition, Gaithersburg, Maryland: Aspen Publishers, Inc.
2. Sadock, Benjamin J. et al. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry 9th Edition. Chapter 55. Public 2001 Psychiatry. Wolters Kluwer/ Lippincott Williams and Wilkins: 2009
3. Ovsiew, Fred and Munich, R.L. editors Principles of Inpatient Psychiatry. Philadelphia. Wolters Kluwer: 2009 4. Bond Implementation Plan May 16, 2006 Special Election Ordinance No. 2006 – 29, Passed April 18th, 2006
5. Memorandum February 26, 2013 Crisis Response Center Annual Report Pima County Board of Supervisors for Fiscal year 2012 from Community Partnership Southern Arizona
6. Busy mental crisis center fined, but officials see bigger picture May 5, 2013 Arizona Daily Star 7. Tucson Citizen Morgue, Newspaper articles 1993-2009
8. Anecdotal information was obtained from a number of interviews with consumers, lawyers and providers over the first 6 months of 2013
Correspondence
Virgil Hancock M.D., M.P.H.
6701 N. Los Leones Drive Tucson, Arizona 85718 USAhermestri@mac.com