This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Medicaid Financing of State and County Psychiatric HospitalsAppendix C. Profiles of Public Psychiatric Hospitals in the Five Case Study StatesProfile of Public Psychiatric Hospitals in ArkansasPublic Psychiatric Hospitals as a Component of the State's Public Mental Health System Arkansas has one State psychiatric hospital, which serves adults and adolescents (see Figure C.1). It is also the provider of last resort. Most patients there are seriously and chronically mentally ill and have little or no insurance and few assets. At the time of our visit, the State had five freestanding private psychiatric hospitals. The State hospital recently formalized its admission priorities as follows:
Children (defined as youth under the age of 12) needing inpatient psychiatric services are treated in private hospitals. Hospital Admission Process The Arkansas State Hospital has a single-point-of-entry system. All patients, including court-ordered individuals or those requesting transfer from a private hospital, must be evaluated by one of 15 community mental health centers (CMHCs) located throughout the State. As part of this admission evaluation, CMHCs try to find a community placement, which is a local hospital if inpatient services are deemed necessary. The goal is to use the State psychiatric hospital only as a last resort. Although all CMHCs receive State funds to finance "alternatives to State hospitalization," they vary in their use of these funds. Some use them to pay for local psychiatric beds, while others use them for support services, such as assisting patients with their medications, in order to lessen the need for hospitalization. Because of mounting fiscal pressure, CMHCs have recently begun to seek local hospitalization less frequently, thus raising the demand for State psychiatric hospital beds. At the same time, the demand for forensic beds has also been increasing. As a result, there are now wait lists at the State hospital. At the time of the site visit, there was a 100-person wait list for adult forensic beds and a 40-person list for adult civil beds. Major Operational Changes The existing adult forensic unit opened during the early 1990s. It was originally housed in a separate building, but the State's loss of a 1988 class action lawsuit alleging mistreatment of patients in this unit forced the State to move the unit into the main hospital building. With this change, the number of forensic beds fell from 120 to 80. The 16-bed juvenile sex offender unit, a relatively recent addition to the hospital, opened during the past 10 years. State fiscal year 2002 was the first year that the Arkansas State Hospital participated in the State's DSH program. This opportunity came as a result of and to protect an overall increase in DSH funding for the State. In 2000, the Federal Benefits Improvement and Protection Act (BIPA) helped low-DSH States such as Arkansas by setting a floor on DSH payments equal to 1 percent of total Medicaid expenditures. Arkansas' DSH funding rose to approximately $21 million in 2001, up from $2.7 million in previous years. Anticipated Operational Changes Over the next several years, Arkansas expects that several operational changes will affect the State psychiatric hospital. First, the State is contemplating either closing or reconfiguring the adolescent unit because of funding cuts. In conjunction with this, the State is reportedly exploring the possibility of refocusing the care delivered in the adolescent unit from an acute to a subacute level, as demand for the latter appears to be higher. Although Medicaid reimbursement is lower for the subacute level of care, some believe that the higher demand for these services will more than offset the rate differential. Second, the State expects changes as a result of having recently lost a lawsuit filed by the American Civil Liberties Union on behalf of inmates waiting for a bed in the State psychiatric hospital. A Federal judge ruled that the State was in error in denying inpatient psychiatric services to prisoners because there were no available forensic beds. At the time of the site visit, the State was awaiting the judge's ruling on what remedial actions would be required. Some believe that the State will be required to increase the number of forensic beds to accommodate inmates in need of services. Third, there is some concern that an Arkansas law, Act 911, may raise legal challenges on behalf of individuals needing civil commitment beds. According to this statute, people who are acquitted of a crime because of mental incompetence, after they serve their sentence, are not required to receive inpatient treatment following their release from jail, but they can be placed in a group home, a State psychiatric hospital, or another appropriate setting for a minimum of 5 years. Act 911 patients in the community who violate the terms of their release are immediately sent to the State psychiatric hospital. Because this has happened in so many cases, the State has had to place many Act 911 patients in civil commitment beds, thus reducing its capacity to serve civilly committed patients. Respondents fear that this shift in capacity may spawn legal challenges brought on behalf of individuals who need civil commitment beds. A final change that may take place relates to IMD optional services. Arkansas State Hospital does not currently receive Medicaid funding for patients over the age of 64 because the State has not elected this optional IMD service. Some discussion is taking place between the mental health and the Medicaid divisions about moving forward with a State plan amendment that would allow Medicaid to fund services for the 65 and older population receiving services in the State psychiatric hospital. At the time of the site visit, however, no final decision had been made. At the time of the site visit, the retirement of the director of the mental health division was imminent. A permanent replacement had not yet been named. Profile of Public Psychiatric Hospitals in CaliforniaPublic Psychiatric Hospitals as a Component of the State's Public Mental Health System The responsibility for administering and managing mental health services in California is delegated to the State's 58 counties (see Figure C.2). Each county's mental health department provides care for Medicaid-eligible and uninsured patients using (1) earmarked funds from a portion of the State sales tax and the vehicle licensing fee, and (2) a distribution of funds from the State for Medicaid mental health services. Most inpatient psychiatric services are provided by psychiatric units of general hospitals, private psychiatric hospitals, and skilled nursing facility IMDs. In addition to these facilities, California has 16 psychiatric health facilities (PHFs), 10 of which are county owned. PHFs are essentially the equivalent of freestanding acute care psychiatric hospitals, although licensing requirements differ from those of a psychiatric hospital. (For instance, the scope of ancillary services required to be on site is smaller for PHFs.) PHFs are primarily used for short-term stays (5 to 7 days), usually for crisis stabilization. Most PHFs have 16 or fewer beds and may be eligible for Medicaid reimbursement, as they do not meet the criteria for an IMD. A few of the PHFs are larger but are not eligible for Medicaid funds for 22- to 64-year-olds under the IMD exclusion.30 California's four State psychiatric hospitals represent a specific niche in the public mental health system. These facilities serve a predominantly forensic population. Only two of the four State hospitals—Napa and Metropolitan—accept civil patients (i.e., long-term, chronic patients who have no alternative community treatment options because of the severity of their illness and because they are a threat to public safety). All civil patients in the State psychiatric hospital system must meet civil commitment requirements (i.e., be a danger to themselves or others). To accommodate residents in need of State psychiatric hospital beds, counties lease beds annually from the State at a per diem rate. Hospital Admission Process State hospitals often represent "the end of the road" for civilly committed patients. The patients are typically transferred from other treatment settings in which they could not be cared for appropriately. All civilly committed patients must meet the involuntary commitment requirements and are hospitalized through the courts. Forensic patients are hospitalized for a number of different reasons, including being found guilty by reason of insanity, being incompetent to stand trial, and committing sexually violent predatory behaviors. In sharp contrast to the State psychiatric hospitals, the PHFs provide short-term care, often in the form of emergency crisis stabilization. While PHFs accept both voluntary and involuntary patients, their target population is individuals who meet medical necessity criteria for acute psychiatric care. For instance, Fresno County's PHF defines its target population as "those with a suspected or established mental disorder diagnosis or who may pose a danger to themselves and/or others, have impaired judgment or are exhibiting uncooperative behavior to the extent that they cannot reasonably be assured a lower level of care or cannot provide the basic necessities of living such as food, clothing or shelter."31 Major Operational Changes In 1991, California went through what it calls "realignment." The major operational change during this time was the designation of portions of the sales tax and vehicle license fees to counties specifically for the provision of mental health services, including inpatient psychiatric care at the State hospitals. Realignment essentially shifted the responsibility for public mental health services to the counties. The realignment funds were intended to serve what the State identified as the target populations: seriously and persistently mentally ill (SPMI) adults and seriously emotionally disturbed (SED) children. For patients receiving Medicaid, the county became responsible for funding the State match. Four years later, in 1995, the State added to the counties' mental health responsibilities under a plan called the Medi-Cal specialty mental health services consolidation. At the time, Medi-Cal, the State's Medicaid program, was moving toward a managed care model, and there was concern in the State, particularly among the advocacy community, that this model of care would not be appropriate for the financing and delivery of mental health services. Consequently, the State redirected the money that had historically been spent on Medi-Cal "specialty mental health services" directly to the counties. Respondents defined specialty mental health services as any mental health service not provided by a primary care doctor. Phase One of the Medi-Cal specialty mental health consolidation, which occurred in 1995, involved transferring the responsibility for all inpatient mental health services to the counties. Previously, counties were responsible for inpatient services under realignment only for SPMI adults and SED children. The Medi-Cal consolidation added to the county responsibility for services to Medi-Cal-eligible individuals outside this target population. Phase Two of the Medi-Cal specialty mental health consolidation in 1997–98 involved the transfer of outpatient services to the counties. For all Medi-Cal services, the counties now fund the State match out of their realignment and mental health consolidation funds. The county-level assumption of responsibility for inpatient mental health services prompted a dramatic shift in civil commitments from the State hospitals to what counties perceived as a more cost-effective setting—local providers. In turn, the State hospitals shifted their focus from a civilly committed population to a forensic population. Before realignment, the State psychiatric hospitals housed approximately 70 percent civil commitments and 30 percent forensic patients. Now, the reverse is true. Care for forensic patients is funded through State appropriations based on the established per diem rate. The payments go to the State Department of Mental Health. Anticipated Operational Changes The trend toward treating primarily forensic patients in California's State hospitals is expected to continue. In fall 2001, California's Department of Mental Health began construction on its fifth State hospital, Coalinga State Hospital. This facility is slated to have 1,500 beds and serve only sexual offenders. Construction is expected to be completed in fall 2004. In addition, construction recently was completed on a 64-bed inpatient mental health treatment center inside Salinas Valley State Prison. The California Department of Corrections and the Department of Mental Health will operate the Salinas Valley Psychiatric Program jointly. The two departments currently run a similar program at Vacaville State Prison. Profile of Public Psychiatric Hospitals in IowaPublic Psychiatric Hospitals as a Component of the State's Public Mental Health System Each quadrant in Iowa is served by one of four State psychiatric hospitals known as mental health institutes (MHIs). Each MHI also provides specialty services that cut across the entire State (see Figure C.3). For example, Clarinda MHI (in the southwest) draws from the entire State for its geropsychiatric program; Mt. Pleasant MHI (in the southeast) does the same for dual diagnoses and substance abuse care. Two facilities specialize in psychiatric care for children and adolescents—one in the eastern part of the State (Independence MHI) and the other in the west (Cherokee MHI). Independence MHI also has a Psychiatric Medical Institute for Children (PMIC), which is a stepdown unit from acute care but provides a higher level of service than residential treatment. There are no private freestanding psychiatric hospitals in Iowa, which limits the alternatives for patients needing inpatient services. As a consequence, the MHIs are responsible for a large segment of the treatment continuum, from acute to long-term care. However, most MHI patients are short-term cases (length of stay fewer than 30 days). The MHIs admit voluntary patients, meaning that patients do not necessarily have to meet the more rigorous commitment requirements of being a danger to themselves or others. Another attribute unique to the public health system in Iowa is that the MHIs are included in the Medicaid managed behavioral health care network. Under Iowa law, the State pays for 20 percent of the per diem in MHIs, while the county of legal responsibility pays the remaining 80 percent and any costs of care beyond those covered by the per diem rate. Counties reportedly view the MHIs as a good buy, since they deliver relatively inexpensive care and generally do a "good job" of filling a need. Major Operational Changes The past 10 years have ushered in a greater emphasis on specialization among the four MHIs. As mentioned, each hospital has a specialty and draws patients from across the State in that specialty area. The State has also stepped up efforts to avoid institutionalization when possible and to reduce the length of stay. With regard to deinstitutionalization, MHIs have been more or less successful, depending on the other providers and community resources in their area. In terms of their mission, MHIs are trying to make the transition to becoming short-term facilities that focus on acute psychiatric care. Until recently, lengths of stay in the MHIs were becoming shorter, but they are now on the upswing. For example, at the Clarinda facility, stays are becoming longer because of the difficulty of returning patients to the community for continued care. Eighteen months before the site visit, the average length of stay for adults was 8 days; 4 months later it was 12 days, and at the time of the site visit in April 2002, it had risen to 20 days. The pattern is similar for the average daily census (at least at one of the hospitals), initially on the decline but now beginning to rise again. From 1985 through 1995, the average daily census at the Independence facility was 170 patients. Beginning in 1995 and continuing through the late 1990s, the average daily census began to fall, hitting a low of 113 in 1998. Much of this decline was a function of the introduction of Medicaid managed care, which emphasizes less restrictive treatment settings, and the advent of new psychotropic drugs, which made it increasingly possible for patients to be maintained outside of an institutional setting. However, patients who once responded well to psychotropic medications are reportedly relapsing with greater frequency and returning to the MHI. Respondents also said that many of these individuals have not been able to be maintained appropriately in the community. The MHIs' organizational relationships within Iowa's Department of Human Services (DHS) have changed in several ways in recent years. Four years ago, the MHIs were part of the Mental Health Developmental Disabilities Division, but the Administrator of that division did not report directly to the director of DHS. The MHIs are now under the Operations Division, whose deputy director reports directly to the director of DHS. Respondents believe that the change has made the MHIs more accountable to DHS. Over the past 10 years, the MHIs have been exploring opportunities to reduce administrative costs by sharing services with other organizations. For instance, the Clarinda and Mount Pleasant facilities co-located with a State prison. The Independence MHI shares its campus with a private adolescent center, and the Clarinda facility does the same with a private academy for nonviolent delinquent youth. Iowa has a very large managed behavioral care carve-out contract with Magellan (formerly Merit). Under this contract, launched in 1995 and known as the Iowa Plan, all four State psychiatric hospitals contract with Merit to be network providers. The carve-out covers both the voluntary (noncommitted) adult population over 21 and under 65 who are Medicaid eligible and Medicaid-eligible children, whether voluntary or involuntary. Anticipated Operational Changes Net budgeting was recently introduced as a new accounting method in the State. The PMIC at the Independence MHI is piloting the new methodology. Previously, the PMIC used the same accounting system as the State psychiatric hospitals; operations were 100 percent State appropriated, and any payments received from third parties were deposited to the State general fund to offset the appropriation. Under net budgeting, the PMIC receives a State appropriation for the total operational budget less anticipated collections/receipts. The facility, in turn, keeps all collections from third-party payers and others. Because net budgeting is a change only in accounting technique, it does not affect billing or admission processes. Several respondents believe that the State eventually may close one or more of the MHIs. Historically, local politicians have reportedly fought against this because these facilities employ many people in rural areas where the employment base is relatively small. However, the inpatient psychiatric hospital operations on the Clarinda and Mount Pleasant campuses are now smaller and co-located with much larger correctional facilities. Consequently, the psychiatric hospitals no longer employ as many people as they once did. Profile of Public Psychiatric Hospitals in MarylandPublic Psychiatric Hospitals as a Component of the State's Public Mental Health System Maryland has eight State psychiatric hospitals, most of which serve a mix of patients: acute, long-term, and forensic (see Figure C.4). However, the Carter Center serves only acute care patients, and the Perkins Hospital serves only forensic patients. Five years ago, the State hospitals stopped admitting children under the age of 12. They are treated instead in private hospitals or in one of the three State-run residential institutes for children and adolescents (RICAs). Only two State psychiatric hospitals accept adolescent patients. The hospitals have specific catchment areas, but in recent years, when the hospitals have been operating at full capacity, new admissions sometimes have been sent to any hospital that has an open bed. The State, which views the hospitals as providers of last resort, attempts to place patients with insurance in private facilities first. However, long-term patients, even if insured, typically end up in one of the State psychiatric facilities when the insurance is exhausted or no longer covers treatment. Lengths of stay vary as follows: about one-third of patients are discharged in fewer than 30 days, one-third are discharged in 31 to 90 days, and one-third are discharged after 90 days or longer. The length of stay has risen in recent years because of an increase in the severity of illness and in the number of forensic patients. At the time of the site visit, 100 patients in the State psychiatric hospital system were reportedly ready to be discharged to another setting, but an appropriate community placement was not available. Respondents say that the dually diagnosed (persons with a developmental disability and mental illness) are the most difficult to place. Hospital Admission Process Patients must be referred by some other facility or organization. Referrals come primarily from emergency rooms (60 percent), courts (14 percent), jails (11 percent), acute care hospitals (7 percent), and other facilities (primarily adolescent patients). The State psychiatric hospitals do not admit walk-ins, but they do accept voluntary admissions. At the time of the site visit, 82 people were waiting to be admitted to a State psychiatric hospital bed; 55 of those waiting were in other hospitals. Major Operational Changes Maryland has a Section 1115 waiver that carves out mental health services for Medicaid eligibles. The waiver gives the State IMD expenditure authority, which is primarily used for services rendered in private psychiatric hospitals. Under the waiver, these hospitals receive payment for 30 days per episode, up to 60 days per year and 120 days in a lifetime for adult Medicaid patients (age 22 through 64). This policy relieves some pressure on the State psychiatric hospitals and reinforces their role as safety net providers. The State hospitals admit patients from private hospitals when the patients exhaust their Medicaid coverage. The number of patients served by the State psychiatric hospitals has declined steadily over the past 10 years. For example, Springfield Hospital had 900 patients in 1990, 400 in 2000, and 325 at the time of the site visit. One respondent said that the downsizing stems from several changes that began about 10 years ago. First, a State recession forced facilities to downsize due to budget constraints. Second, there was a concurrent push toward the use of community-based services. And last, a gubernatorial commission recommended the closure of one of the three largest State psychiatric hospitals in central Maryland. To comply, however, the State needed to increase funding for community-based services while continuing to operate the State psychiatric hospital that was scheduled for closure. But because the State did not have the money to fund this dual system of care, it developed a 5-year plan to reduce the patient load to 1,150 individuals Statewide. The plan called for the State psychiatric hospitals to be streamlined and remodeled to run more efficiently. Although three facilities have reduced the number of beds and remodeled, the State has not yet met this patient load goal. During the same 10-year period, there was a dramatic shift in the types of patients served by the State psychiatric hospitals. While the total number of forensic patients remained relatively steady, the number of civilly committed patients fell. At the time of the site visit, only 500 of the approximately 1,400 beds in the State were for nonforensic patients. This disproportionate shift in patient mix towards the longer-term forensic patient has increased the length of stay across the State psychiatric facilities. Hospital downsizing prompted the Mental Hygiene Administration to look at ways to use patient buildings for other purposes. For example, some facilities have leased the space to compatible community services, such as substance abuse treatment facilities or office space for State agencies, such as the Mental Hygiene Administration. The Eastern Shore Hospital sold a large parcel of land to Hyatt Hotels, and the State used the proceeds to build a new Eastern Shore Hospital, reducing the number of beds from 300 to 80. Anticipated Operational Changes Many respondents said that Maryland's current fiscal crisis has fueled the debate about whether the State should close one of the three largest State psychiatric hospitals, as recommended by a gubernatorial commission several years ago. To date, political pressure has prevented closure, and unions representing State employees have opposed such a move. Still, one of the goals of the current administration reportedly is to reduce the size of the hospitals such that none serves more than 250 patients. Another option, according to one respondent, would be for the State to run more specialized rather than "generic" psychiatric hospitals. Under such a system, one large hospital would serve as the core facility, providing general services. This "nucleus" would be surrounded by a number of specialty hospitals, each providing a distinct set of services geared, for example, toward children, adolescents, or geriatric patients. Although some are concerned that such a system would create a hardship for families in terms of travel, others believe that Maryland's relatively small size makes travel a "nonissue." In addition to raising the possibility of closing or restructuring State psychiatric hospitals, the State fiscal crisis has prompted other changes that are likely to affect hospital operations. For instance, the State Senate recently passed a bill calling for the elimination of 3 to 8 percent of personnel in all State agencies and departments. For the State psychiatric hospitals, this translates into 210 to 290 positions. One respondent noted that the hospitals could adjust staffing by approximately 100 positions, but cuts beyond this would require an overall reconfiguration of the hospitals. Another respondent said that Mental Hygiene Administration staff would have to absorb the remaining cuts. A final decision on how to respond to the budget cuts had not been made at the time of the site visit. Under the present public mental health system, the State pays community mental health centers, or core services agencies, through a fee-for-service system for care to uninsured, or "gray zone" patients. At the time of the site visit, there was language in the budget bill that would change the funding for these patients such that they would be covered by a grant, and providers would limit services to the amount of the grant. As a result, gray zone patients would not be able to receive outpatient services on demand if the grant funding was depleted. Restrictions in such services might, in turn, raise demand for inpatient services from the State psychiatric hospitals. Furthermore, if the State also decides to limit pharmacy services as part of the new arrangement, the provision will apply only to new patients; current patients will be grandfathered in. The final change observed at the time of the site visit was that the longstanding director of the Mental Hygiene Administration was in the process of leaving his position. A permanent replacement had not yet been named. Profile of Public Psychiatric Hospitals in New JerseyPublic Psychiatric Hospitals as a Component of the State's Public Mental Health System In New Jersey, the State and county psychiatric hospitals serve primarily as intermediate- and long-term care facilities (see Figure C.5). Short-term care is provided through a State-designated system of short-term care facilities (STCFs), which comprise psychiatric units in general hospitals. The State psychiatric hospitals primarily serve their regional catchment areas, although specialty units (such as Ancora's dual diagnosis unit for individuals with a mental illness and a developmental disability) sometimes serve the entire State. Brisbane Child Treatment Center is the only State hospital for children, so it draws from the entire State. The six county hospitals/units serve essentially the same population as the State hospitals, although their catchment area is generally limited to the county in which they are located. Although these hospitals report directly to their respective county boards of freeholders, who are elected officials, they must submit a business plan every year to the State Division of Mental Health Services for review and approval. Patients in the State and county psychiatric hospitals are primarily indigent persons with serious and chronic mental illness. All must meet the involuntary admission criteria—that they pose a threat to themselves or others. According to one State respondent, about 73 percent of the patients in State psychiatric hospitals are discharged within 6 months of admission, while the remaining 27 percent require longer-term care. The State psychiatric hospitals are gross budgeted through the State's regular appropriations process, meaning that their entire budget is funded by the State. All hospital revenues, including Medicaid funds for services and DSH payments, go directly to the State treasury to offset the State appropriation. Counties are responsible for funding a portion of the cost for county residents in State and county psychiatric hospitals. County payments are also sent to the treasury to offset the State appropriation. New Jersey's 90/10 State Aid program reimburses counties for the services provided to indigent persons in county hospitals. For county residents, the State pays 90 percent of the per diem, and the county picks up the remaining 10 percent.32 For individuals not meeting the county residency criteria, the State pays the full 100 percent. If a patient is Medicaid eligible, the county psychiatric hospital must accept the Medicaid rate as payment in full even if it is less than the rate for indigent persons.33 Approximately 87 percent of patients in the county hospitals are covered through the State Aid program. Hospital Admission Process All individuals receiving inpatient psychiatric services in a public psychiatric hospital must be admitted through a State-certified screening center.34 There are 23 such centers (one in each county other than Essex County, which has three). Individuals can be assessed at the screening center or by a screener who travels to where the individual is located. The screeners evaluate potential admissions based on the involuntary commitment criteria. If the screener recommends admission, a psychiatrist must personally evaluate the patient and must approve the admission. The screening process focuses on placing individuals in the least restrictive treatment setting, which is often an STCF. New Jersey has approximately 300 STCF beds in approximately 15 facilities throughout the State. These STCFs primarily serve patients with stays shorter than 2 weeks. If an STCF bed is not available, or if the screener knows the patient's history and believes a longer-term placement is necessary, the screener may refer the patient to a State or county psychiatric hospital. Individuals needing longer-term treatment are typically transferred to a State or county psychiatric hospital. The majority of State and county psychiatric hospital admissions are transfers from STCFs. The State facilities have no licensed bed capacity per se and must accept all patients admitted through the screening centers. There is little movement of patients between State and county psychiatric hospitals, since the latter are intended to serve their respective counties exclusively. Residents of counties with a county psychiatric hospital would normally go to a State psychiatric hospital only if they met the admission criteria for one of the special treatment programs (e.g., having a dual diagnosis) or if the county facility was full. While all patients in the public psychiatric hospital system must initially meet the involuntary admission criteria, they may change to a voluntary status following admission. Major Operational Changes In 1987–88, New Jersey changed its policy such that the preferred place of treatment for individuals with acute psychiatric problems was no longer a public psychiatric hospital, but a community-based setting.35 The STCF system was developed in response to this policy change. As mentioned, STCFs are intended to serve patients needing short-term care, provide services closer to the patient's homes, and to reserve the State and county hospitals for intermediate and long-term patients. As originally developed, STCFs served patients needing stays of up to 28 days. The average length of stay is now 10 to 11 days. In 1995, New Jersey launched the Redirection plan, the purpose of which was to close a State-owned facility, Marlboro Psychiatric Hospital, and redirect all of the $65 million used to operate that facility to community-based services. This operational change was the largest in the State inpatient mental health system in the past 10 years. At its peak in 1994, Marlboro had 780 beds. Resources from its closure were used to finance 480 community placements (including approximately 388 community residential beds) and approximately 280 additional inpatient beds at the remaining State psychiatric hospitals. Marlboro officially closed in June 1998, after which time the Statewide admissions dropped by over 30 percent and overall State hospital census fell, although it has begun to rise slightly in recent years. Anticipated Operational Changes New Jersey is in the early stages of the Redirection II program, under which the State plans to construct a smaller replacement facility for Greystone Park Psychiatric Hospital. Greystone's replacement facility will initially have 400 beds, a reduction of 138 beds from its current capacity, although there will be the potential for expanding by an additional 50 beds. Under this plan and with additional State appropriations, the State plans to expand community-based mental health services, including supportive housing placements, which are expected to relieve some of the pressure on discharge planning at the State psychiatric hospitals. At present, the State estimates that nearly 400 patients in the entire State psychiatric hospital population are appropriate for discharge to another treatment setting, but the absence of placement options essentially keeps them in the State psychiatric hospital system. The State has committed to funding both the inpatient and outpatient components of the Redirection initiative so that the expansion in the community-based infrastructure takes place before patients are discharged. As the hospital census declines, the State does not intend to reduce overall hospital staffing so as to improve the staff-to-patient ratio and improve staff recruitment and retention at all of the State hospitals. A major component of the Redirection II Plan is to improve statewide quality of care in both community and hospital services. Despite New Jersey's current budget problems, funding to initiate this plan was provided in State fiscal year 2003 and additional funding is anticipated for fiscal year 2004. |
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