Fewer psychiatric beds leads to more community services



Butler Hospital in Rhode Island has 117 licensed inpatient beds according to Paul Malloy, Ph.D., assistant clinical director of the Providence-based facility (photo by Tom Croke)

By Phyllis Hanlon

The push for deinstitutionalization in 1979 combined with more effective antipsychotic medications, care in the least restrictive setting, active therapy and other advances, has resulted in fewer inpatient beds. While integrating individuals into the community appears to be the best option, adequate support programs and services must be in place in order to facilitate a safe and successful transition.

Marcia Fowler, J.D., assistant commissioner of mental health services for the Department of Mental Health (DMH), says Massachusetts has taken a systematic approach to downsizing inpatient capacity. "As you take down beds, you have to develop community-based services," she says. "We need 1.3 community placement services for each discharge." Fowler explains that this "hard-to-understand concept" represents the financial aspect and program capacity.

Massachusetts currently has an inpatient capacity of 802 and the DMH serves approximately 21,000 individuals, says Fowler. Just under 400 case managers offer medical management and social support services, and 900 PACT (Program on Assertive Community Treatment) teams provide evidence-based services for the most acute population living in the community.

DMH operates six service areas and 28 sites from which services are contracted/delivered. "We believe services should be locally based," Fowler says, adding that outpatient treatment has proven more cost effective and is more likely to achieve the most desirable outcome. The state is also replacing the group home model with independent living and home-based supports. "The concept is that people do recover with appropriate supports," says Fowler. "People can become integrated into the community."

David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems (MABHS), indicates that the issue of psychiatric beds is a "moving target." He says, "There is a seasonal fluctuation. We're not seeing the crunch we did a year ago, particularly for kids." February, March and April tend to see higher census numbers for children's units, while admissions dip sharply in the summer, according to Matteodo. "We don't need more beds, but should work on keeping the ones we have well staffed and vibrant."

Michael Hartman, Vermont's commissioner of mental health for the Department of Mental Health, says that admissions to the state hospital have decreased from 500 in 1990 to approximately 250 currently.

As of January 2009, Vermont had a total of 167 beds, which includes 54 at the State Hospital. To enhance service delivery, Vermont's legislature created the "Futures Plan." Hartman says, "The Futures project creates a range of care built on the most basic building blocks." Plans call for 25 to 30 acute care inpatient beds, integrated with or located close to general medical center services and infrastructure; 15 secure residential beds, and 20 to 22 residential recovery beds. He adds that "23-hour crisis beds" will provide "almost everything an inpatient bed does but cost between $300 and $500 less."

"It would be a formula for disaster to get rid of beds without anything else in place," says Hartman. "You can't just look at numbers; you have to look at context. It's necessary to have different beds, not fewer. This will allow us to match care needs to the person."

Paul Malloy, Ph.D., assistant clinical director at Butler Hospital in Providence, R.I., reports that Butler currently has 117 licensed inpatient beds. "Last year, the hospital shifted some of its beds from the children's treatment program to adult services. This was in response to a growing need for adult psychiatric inpatient beds," he says.

Butler houses the majority of inpatient adult and adolescent psychiatric beds and most of the pediatric inpatient beds are at Bradley Hospital. Some general medical hospitals also have a small number of adult inpatient psychiatric beds, according to Malloy.

The Rhode Island Department of Mental Health, Retardation and Hospital (DMHRH) maintains more than 200 group home beds and 150 supervised apartment settings, he adds. "Plus, there are a number of independent, not for profit agencies that provide various level of community intervention for psychiatric disorders and/or addictions in a variety of community settings," says Malloy. The Rhode Island Chapter of the Alliance on Mental Illness (NAMI) and the Rhode Island Chapter of Mental Health America, as well as other state-supported and independent agencies, operate a variety of support groups and education programs for people and families affected by mental illness and addictions, says Malloy.

Wayne F. Dailey Ph.D., senior policy advisor in Connecticut's Department of Mental Health & Addiction Services, emphasizes that inpatient bed need "cannot be driven in a simple ratio," but rather should reflect an interdependent system that includes community-based resources, including residential placement, mobile crisis units, psychosocial rehabilitation, outpatient and intensive outpatient services. He says the strength and viability of the community system and the vigor, training and turnover in the workforce should drive the need for inpatient beds. Dailey adds that any formulation that creates an equation of so many beds per 1,000 individuals is "not on solid ground."

While some individuals may require brief hospitalization to stabilize, Dailey promotes rehabilitation in the community. "According to learning theory, learning best occurs in the setting where it will be applied," he says.

Fewer psychiatric beds leads to more community services (May 2009 Issue)

Fewer psychiatric beds leads to more
community services
(May 2009 Issue)