How to reform mental health care in Minnesotaby Dan Olson, Minnesota Public Radio
Mental health care in Minnesota many agree is badly in need of reform. That reform is now underway. Over the past two years, Minnesota Public Radio News has reported the problems -- a shortage of psychiatrists and money, layers of bureaucracy and poor coordination among caregivers, to name a few. A year ago during the last legislative session, lawmakers and the governor approved reforms and more money to address the problems.
St. Cloud, Minn. — One of the most dramatic reforms is an idea new to Minnesota, but used with success for decades in other parts of the country.
Boiled down, it's this:
Instead of at a hospital or in a treatment center or a group home, people who need mental health care are served by a team of caregivers who come to them.
The idea is called ACT, for "assertive community treatment."
St. Cloud ACT team member, psychologist Cathy LaGow, described the process on the way to one of her clients. She gave directions to the driver as she talked with a reporter, and took calls from team members about other people they serve.
The 10-member St. Cloud team works with 50 people who are mentally ill. LaGow said they make as many as 30 visits a day to their clients.
At an apartment building, LaGow introduced a client who agreed to talk about the role the team plays in his life, as long as he is not identified.
"They (the ACT team members) give me people I can call and talk to when I'm struggling with my mental health, or my urges to drink alcohol," the man said.
In the jargon of the business, this man has a serious and persistent mental illness. To further ensure his privacy, LaGow does not supply details.
By his own description, the man has been in and out of mental health treatment centers and sobriety programs.
With help from the ACT team, he's sober, and his mental illness is being treated at the efficiency apartment where he lives.
ACT team members deliver his medication, and make sure he takes it. They helped him find a part-time job.
"They provide me with transportation to my doctor's appointments, they give me a ride to work and give me a ride home from work, which is very helpful," he said.
There are many cruel side effects of mental illness. Estrangement from family can be one. The man said his more stable condition has allowed him to renew contact with family.
"I'm welcome at my parent's house, and I'm welcome to call my brothers or my sister once in awhile and talk. I'm in their life, I'm welcome in their life because I'm sober and straight," he said.
Last session, lawmakers and Gov. Tim Pawlenty approved spending $25 million more a year to help create Minnesota's 27 ACT teams and fund other reforms.
The thinking is that more money spent up front saves money later, if people with mental illnesses are identified and treated before there is a crisis. The all-too-frequent alternative is much more expensive care in a hospital.
According to the Minnesota Department of Health, there are 1,365 psychiatric care beds in Minnesota hospitals, and that number is expected to grow by 63 this year.
A stay in a hospital mental health treatment center can cost $1,000 a day. A three-month stay is not uncommon. That can cost $100,000 or more.
By contrast, a year of treatment in the community from an ACT team, officials estimate, might total $30,000.
Down the road from St. Cloud in Monticello, Minn., Tracy Hinz leads another ACT team. More of her clients live in rural areas. Hinz helped introduce the ACT idea in her previous mental health care job in Nebraska.
Her confidence in the philosophy is so high she expressed it this way -- of 100 people in a mental health institution, as many as 99, she said, could live in the community with support from a team.
There is an important qualification.
Success, Hinz said, hinges on community acceptance, meaning residents must be willing to live with, house and even employ people who have a mental illness.
"It's a huge, big deal bringing people out of hospitals who've been there for 20-some years into the community," Hinz said. "I've seen it happen, I believe in it. I've seen really, really wonderful things happen and believe in it wholeheartedly. But it has to be a multi-faceted effort."
Assertive Community Treatment is one of the reforms being put in place to improve mental health care in Minnesota. Another is getting mental health care practitioners to talk to each other.
Janet Dalgleish's 19-year-old daughter has lived with a bipolar condition for more than nine years.
After duels with insurance companies over her coverage, struggles with doctors over diagnoses and with social workers over services, and face-offs with hospitals over admissions, Dalgliesh said the reform effort gives her hope.
Dalgleish said it addresses the lack of communication that is a longstanding hindrance to effective treatment.
"The well-meaning social workers don't know very much about housing, or about jobs, and the jobs people don't know about housing," Dalgleish said. "And the psychiatrists are very unfamiliar with services outside of hospitals, so I think they're still living in silos."
Another reform in the works is a financial incentive for health insurance companies to do a better job of covering the treatment of people with mental illness.
Still another reform is better training for first responders -- the police, firefighters and paramedics who often respond to the 911 calls when someone is having a mental health crisis.
Even the reformers agree some people with mental illness need hospitalization.
John Gray, psychiatric nursing manager at Hennepin County Medical Center, unlocks the doors to HCMC's secure psychiatric unit and leads a tour of the new rooms.
"The bathrooms are very high-risk areas for suicide attempts. We try to walk the line between privacy and dignity and safety, and they sometime conflict," Gray said.
They are bright with sunlight, but spartan -- with only a bed and chair, and as many precautions as possible taken to reduce the harm patients in the unit might do to themselves.
If the reformers believe some with mental illness will need hospitalization, they strongly believe early intervention can reduce the need for hospital visits.
Take the man HCMC's Shari Otterblad helped not too long ago. Otterblad directs the hospital's acute psychiatric care service.
The man had lost his job, which means he lost his health insurance, and that meant he couldn't afford his medications.
"They were $950 so he couldn't pick them up, so he came here," Otterblad said.
Hospital emergency rooms, by law, must treat people. They are often the doctor's office of choice for those without insurance, or whose coverage is skimpy.
HCMC treats 700 to 900 mental health patients a month. Its psychiatric ward beds are full all the time.
Even before the current reform movement, the goal of HCMC staff was to get patients out of the psychiatric treatment center and back to their homes, or some other more genial and less expensive setting.
But the longstanding problem, then and now, is where they will live and how they will get care. HCMC's Dr. Eduardo Colon, vice chief of psychiatric care and director of the outpatient clinic, said there is a shortage of places in the community where patients can be released to.
"The ones who are sicker or who have special needs stay in the hospital a very long time, because it's very difficult to find an appropriate disposition for them, a place to go that will accept them, that will provide them the structure and supervision that they need," Colon said.
Most of HCMC's mental health patients come from the Twin Cities area. The reforms include creating dozens more community beds for the mentally ill outside the metro area.
However the problem has been, and continues to be, Minnesota's shortage of psychiatrists.
There are several reasons, but one is pay. Psychiatrists in Minnesota earn considerably less than doctors in other specialties.
Minnesota's mental health reform movement will affect a lot of people. Arriving at a precise number isn't easy.
Advocates say one in five, or 20 percent, of the population face a mental illness sometime in their lives. The state's largest health insurance companies say as many as 250,000 state residents with health coverage are receiving treatment for mental illness.
Many of the reforms will reach the 110,000 Minnesota residents on Medicaid and other public programs.
Their treatment and care totals $593 million a year, paid for by state, federal and county taxpayers. However, state officials say recent rule changes and cutbacks have reduced the federal government's contribution by $40 million.
Some reforms can't be legislated. One is the public's attitude toward mental illness.
Kathie Prieve, executive director of Vail Place, a Twin Cities nonprofit which offers mental health services, said the view that people with mental illness should just snap out of it is particularly vexing to her.
"'If you just pulled yourself up by your bootstraps and went to work everything would be just fine,'" is how she characterized the view.
Prieve said there is growing -- but by no means widespread -- understanding of research which shows mental illnesses, like other diseases, have a biological root.
Some early results from the reforms should be apparent fairly soon.
Every day, St. Cloud Assertive Community Treatment team member Cathy LaGow and her colleagues file a blizzard of paperwork, to keep the accountants and decision-makers up to date on what her team is doing and the outcome.
LaGow said she will measure the success of the reforms with the perspective of someone who has delivered mental health care in this state for 25 years.
"We're going to know if it's working when people are able to say that their lives have benefitted from interaction with the mental health system, as opposed to stories about how the mental health system has made their lives impossible," she said.
- All Things Considered, 03/11/2008, 4:49 p.m.