AS SOUTHEAST LOUISIANA HOSPITAL PREPARES TO CLOSE, SOME OF GOV. BOBBY JINDAL'S SUPPORTERS ARE SPEAKING OUT AGAINST THE PLAN. MEANWHILE, FAMILY MEMBERS OF PEOPLE IN LOUISIANA'S PUBLIC MENTAL HEALTH SYSTEM BRACE FOR ANOTHER CHANGE.
"The merger will not affect the capacity of the New Orleans region ... "
— Then-Department of Health and Hospitals (DHH) Secretary Alan Levine in a 2009 letter to The Times-Picayune on the plan to close New Orleans Adolescent Hospital (NOAH) and transfer patients to Southeast Louisiana Hospital (SELH) in Mandeville.
"This is the right thing to do to ensure that the people of Louisiana have a sustainable behavioral health care system for the future."
— DHH Secretary Bruce Greenstein in an August statement on the plan to close SELH and transfer patients to state facilities in Jackson and Pineville
"Two years, they're going to close Pineville. Listen to what I'm telling you."
— A protester at a rally against the closure of SELH
FOUR PEOPLE, INCLUDING ME, STAND AROUND IN THE DARK on a semi-rural highway just outside the gates of Southeast Louisiana Hospital (SELH) in Mandeville. It's 5:55 a.m. on an early October morning, and we've come to watch a charter bus make a right turn. Seventy-five percent of us are employed by local press outlets, so the right turn is actually kind of a media event. The right turn is scheduled for 6 a.m., but nearly an hour goes by before we finally see headlights on Pelican Drive, the hospital campus' main thoroughfare. Then the bus approaches, pauses and pulls onto Highway 190. The whole thing lasts about 20 seconds.
The Bus Turning Right, we discover, is as visually gripping as a bus turning right. That it happens to be the first physical step in the dismantling of metropolitan New Orleans' last public psychiatric hospital is what makes it significant.
For Pat Hotard, the image of the bus leaving would have been too much to handle. Aboard the bus that early morning is Hotard's daughter, 32-year-old Shelley Hotard, a schizophrenic who has been living at SELH since 2010. Interviewed a few days after the move, Hotard says she couldn't bring herself to make the drive down from Baton Rouge to see it.
"I was just so emotional that day, it was better that I not," she says.
The bus is headed for Central Louisiana State Hospital in Pineville (aka "Central"), a three-and-a-half hour drive away. Twenty-three women who've been receiving long-term psychiatric care — also called intermediate care — at SELH left the hospital on Oct. 2, four days before the hospital would mark its 60th anniversary.
Sixteen more patients were planed on another bus the next Tuesday, Oct. 9, this time bound for Jackson, La., and the Eastern Louisiana Mental Health System (aka "East"), two hours away. Another bus will arrive the Tuesday after that, and so on until the end of the month, when the state plans to permanently cease all long-term inpatient care at SELH.
The facility's 94 long-term adult patients will go to Pineville and Jackson, while its 50 youth patients and 32-patient short-term acute capacity patients will be sent to as-yet-unidentified private providers.
The Louisiana Department of Health and Hospitals (DHH) is in very early talks with private providers. One possible outcome of those talks may be privately run mental health services on the SELH site, albeit much more limited and without any adult long-term care.
As of now, Gov. Bobby Jindal's administration plans to close the hospital entirely by the beginning of 2013, less than four years after it closed New Orleans Adolescent Hospital and transferred its patients to SELH — promising the adolescent NOAH patients and their families that care would be provided at SELH.
The latest changes will yield significant savings for the state, right after it was hit with a major cut to federal Medicaid payments, says Louisiana Department of Health and Hospitals (DHH) Deputy Secretary Kathy Kliebert.
"At Southeast, it costs us about $826 a day per individual. That's an average of the population," Kliebert says. "In the private sector we can, for the acute beds we're transitioning, we can basically buy those for at most $580 a day. In addition, our cost at East is under $500 a day. At Central, it's a little over $600 a day." Kliebert says the standard Medicaid rate for a public provider is $580 a day.
East is cheaper because it's much larger, with more than 500 total beds. And Central doesn't take juvenile patients, who push costs up, Kliebert says. Total savings are expected to reach $1.6 million this year, including $555,000 from the state general fund, and $3.5 million every year thereafter.
"A savings of $3.5 million in the state general fund is a significant savings. And remember that we're not losing any services in this. We are able to assure the same level of services provided, the same number of inpatient beds, and produce a significant savings," Kliebert says.
Jindal has long said he wants to "right-size" the state's public health system, reduce total inpatient beds and transfer services to private providers — all of which, he says, can be achieved without reducing the quality of service.
"Part of our long-term strategy is being sure that people can be served in their homes and their community," Kliebert says. "Over 30 percent additional funding has been added to our community-based services."
This argument has come up repeatedly in the past year, as the administration has stripped funding from the remnants of the state's Charity Hospital system, which is run by Louisiana State University (LSU). This month, the seven LSU hospitals in south Louisiana took a $152 million hit. Residents were assured that services would be continued through "partnerships" with private providers — though, for the most part, state officials have not even identified LSU's prospective partners.
A Southern Media and Opinion Research poll released earlier this month shows Jindal's approval rating at 51 percent — down 13 points from last year and down even more from his sky-high approval ratings of four years ago. Sixty-eight percent of respondents said Jindal has cut the operating budget enough; 89 percent said they were concerned about the LSU health cuts; and 80 percent believed state residents would lose access to service as a result of the cuts to health care.
Even some of Jindal's supporters in government are complaining about the cuts. Rep. Jerome "Dee" Richard, I-Thibodaux, has taken the extraordinary step of calling for a special emergency legislative session next month to revisit cuts and proposed privatizations to health and correctional facilities.
"Since our adjournment in June, there has been almost a billion dollars in reductions to the state budget without any input from the Legislature," Richard wrote in a letter announcing his intention to call for the session. "I believe it is time for us, as legislators, to aggressively reinsert ourselves into the budget process by using the constitutional rights given to us. We should not have to relinquish our legislative duties to the administration once we pass the budget at the end of regular session in times like this."
St. Tammany Parish President Pat Brister, a longtime Jindal supporter, says that while she still backs the governor overall — she calls him "brilliant" — she doesn't like how he handled SELH.
"It was done without notice to any leadership or any of his legislative delegation here. I think that was unfortunate and should not have been done that way," Brister says. "I have watched his political career since he first went to work for Gov. [Mike] Foster. I know he's quite bright. And I think he really does live by his convictions. I just disagree with this part of what he's doing. I won't say that it has changed my opinion on the person he is. I just disagree with him."
Asked about the special session, Brister says she doesn't think it will be effective since it's unlikely to get much support outside of south Louisiana. (Or, for that matter, maybe even in south Louisiana: Senate President John Alario, R-Westwego, House Speaker Chuck Kleckley, R-Lake Charles, and Sen. Jack Donahue, R-Mandeville, have all come out against the proposed session.) Moreover, Brister says, there's no chance of passing any budget bill with enough votes to override a certain Jindal veto.
Nevertheless, Brister adds, "I think it probably would be a good idea to try to call it. I have no reason not to call it, by any means."
The announcement of the cuts came from DHH Secretary Bruce Greenstein in July after Congress significantly reduced Medicaid reimbursements to the state last summer, leaving an $859 million hole in this year's budget.
"I was totally and utterly shocked," says Dr. Avery Buras, a child psychologist at SELH. "I work on youth services. And we were actively hiring employees ... We had kids lined up to get in. So it was kind of shocking that we get this memo, this email saying the hospital was closing down. We didn't see it coming from anybody."
There is no plan at the moment for the 82 other patients in the hospital — 32 short-term acute patients and 50 juveniles. They may stay there if DHH identifies an operator to take over the site. That's one idea that may come out of a recent DHH-issued request for information (RFI) from interested contractors. Another one would be to move them to one or more yet-to-be-identified partner(s) that run mental health facilities elsewhere.
"That's what the RFI was for ... It's just to see who's interested, who has capacity, and then we'll start talking," DHH spokesperson Kliebert says. "Our intention is to work with the parish to see we can do to keep the facility operational as a health care facility."
Kliebert says the state hopes, in a best-case scenario, to split those remaining 82 beds between the south shore and the north shore.
Nor is there a plan for the 64 addictive disorder beds that the Florida Parishes Human Services District runs on the hospital's grounds; or for the Louisiana Methodist Children's Home, which has 20 resident spaces there; or for the National Alliance on Mental Illness (NAMI) St. Tammany offices there.
"There are two schools there. St. Tammany School Board has one, the Jumpstart program, and the other one is the school for the patients there. They have to go to school, too," Brister says. "Those type of services in addition to the addictive disorder services, the alcohol abuse services. There are many, many services that I'm hopeful we'll be able to keep."
SELH provides 476 filled full-time jobs right now. Add contractors and the nonprofits that work on site, and the number is well over 500. DHH has offered some SELH employees the chance to work at one of the other two facilities.
"We have currently more offers than people have accepted. So if someone wants one of those positions, and it's a position they qualify for, we will automatically give those positions to those individuals," Kliebert says.
But accepting jobs at facilities located several hours away might be difficult if not impossible for some employees, says SELH psychiatrist Dr. Janet Bradley.
"Some people, even when positions were offered, cannot afford to relocate a family of four to those remote locations," Bradley says. "Most of the direct clinical care staff want to stay until the end, until the last patient is gone. So they're really making a lot of personal sacrifices. They could be looking for jobs right now. By the time they do start looking for jobs, there may not be jobs left."
Bradley and Buras helped found the Committee to Save Southeast Louisiana Hospital, along with a handful of staff members. Other supporters include Save Charity Hospital veterans Derrick Morrison and Brad Ott and Mandeville Mayor Donald Villere, the group's first major political supporter. Villere lets the group meet in City Council Chamber at Mandeville City Hall. State Treasurer John Kennedy gave a speech at the group's "speak out" last month, as did several state legislators, including Donahue. The event was packed. DHH did not send a representative.
Community support — and the possibility of a special session — yields varying degrees of optimism among the group's members.
Ott is dogged and thorough. A expert on state government, he makes the phone calls to Baton Rouge, tries to keep tabs on the possible special session signees and explains legislative procedure to the other group members. But he's been in similar fights before and lost. During a group meeting late last month, he ended an enthusiastic presentation on Richard's call for the session with this: "This is a rare event. It will be a momentous occasion, even if we don't win the thing."
By contrast, psychiatrist Bradley's confidence appeared shaken only once, when she was asked what she plans to do if, as seems likely, the hospital does close or transitions to a much smaller private operation. Her face drops, and she admits she hasn't thought about it.
Buras has. He says he will be open-minded about a private operator proposal. Unlike the long-term adult beds moving to Jackson and Pineville, the state wants to keep the juvenile beds near New Orleans, provided someone else runs them. If that doesn't work out, he has some prospects in Mississippi. Buras says he'll commute there from Louisiana until his son graduates from high school.
"Then I'm getting out," he says.
Many in the group and among its sympathizers suspect that the cuts are less about fiscal pragmatism more about Jindal's political ambitions and ideology.
"This proposal is supposed to be because we don't have enough money, and that's just not accurate, folks," Kennedy said at last month's speak-out. "I've read that Louisiana has as many as 19,000 consultant contracts. ... You want to save money? That's where you start."
There are other areas where revenue could be mined.
A July report by the Associated Press found the state only collected $198 million in corporate taxes last year, 12 percent of about $1.7 billion it could have collected — if not for the state's many corporate exemptions. An August Louisiana Budget Project analysis found that the state's film tax credits cost $231 million last year. And in September — two months after Greenstein said SELH would close and LSU hospitals would soon see another round of large cuts — the state announced a $130 million budget surplus for the fiscal year ending June 30.
"You would think $3.5 million wouldn't be that difficult to come up with out of it," Brister says. "I don't think it's just financial. It's a policy decision. I think if it were just financial, we'd be having more discussion on how to fill that gap."
Along with SELH's closure, the federal Medicaid reduction led to $152 million in cuts — including 1,500 jobs and more than 100 inpatient beds — to LSU's hospital system, according to a plan developed by Dr. Frank Opelka, newly appointed head of the LSU Health Care Services Division. Opelka presented his plan to the LSU Board of Supervisors earlier this month. The board approved his plan unanimously and enthusiastically. Chairman Hank Danos said it will take the state's health system from "good to great."
Not everyone agrees.
Kliebert, the DHH spokesperson, says the administration does have an ideology when it comes to public health — but it's not what its critics believe.
"We still do feel strongly that we have to be a safety net of services," Kliebert says, adding that DHH is moving long-term patients to other state facilities because state government is better equipped to care for them than private operators. "We try and always figure out, is this something we need to be doing as a state? Is this something the state needs to be providing? And clearly it is in the case of the intermediate care beds," she says — as opposed to the acute beds, which Kliebert says can be operated by private groups for less money and without a drop in quality.
"We're doing it in a sustainable way, so that we can assure those services are sustained in the future. That's our only ideological investment in this. We want to make sure we have the ability to sustain mental health services in the future," she says.
Hotard, whose daughter will be relocated because of the cuts, disagrees.
"[Jindal]'s done nothing but close down everything that smacks of public health care," she says. "If it's public funding, we're not taking care of anybody."
Since finding out that she'd be moving again, Shelley Hotard has been guarded and less willing to speak to or even see her mother.
"I made the drive down on Saturday, driving in a rainstorm, got there, and she would not come out of the unit to see me," Pat Hotard says.
Shelley's social worker has told Hotard that it might be the stress of the move. Bradley worries that the move could be traumatic for some of her patients, and that's one of the reasons she's speaking out.
"For the long-term patients, and the children as well, a lot of them are unable to advocate for themselves," Bradley says. "I think, ethically, we are obligated to be their voices. For most of my patients, Southeast is their home, albeit a temporary home. And the large majority of them don't want to go to Central and they don't want to go to East."
Two uninterrupted years in one place has been about the maximum stay anywhere for Shelley Hotard. That's how long she was in East Louisiana State Hospital, until 2010, when 118 inpatient beds were eliminated there.
"She was there about two years before our governor made the decision that East should close," Shelley's mom, Pat Hotard, says. "The folks at East told me that they were discharging as many people as possible."
Because Shelley has been found to be a potential harm to herself and her mother, she was on the "do not discharge" list. She was transferred to Mandeville, where she had lived previously, again for two years (from 2003 to 2005), but was discharged shortly after Hurricane Katrina. The intervening years, between her discharge from SELH, and 2008, when she went to East, were difficult.
A social worker at SELH called to inform Pat Hotard that Shelley was ready to be released into the community. She was placed at the Women's Community Rehabilitation Center in downtown Baton Rouge, Hotard says, but it didn't work out. "She was there about a week-and-a-half before she was dismissed from the program for lack of following the rules, compliance," her mother says.
Her case manager put Shelley up in a homeless shelter, saying that she would find her a more permanent situation, possibly in another nearby group home.
"So that didn't pan out," Pat Hotard says. "She ended up coming back home, because they were ready to put her out of the homeless shelter. I'm not really sure where she went after that. Her placements have been so many, that if I told you I could keep up with all of them, I would be telling you a lie, because I can't."
Hotard tries to remember: Possibly Greenwell Springs [later closed], then Our Lady of the Lake, then St. Charles Parish Hospital, where, she says, a doctor recommended seeking a judicial commitment for Shelley.
And now, Central.
"I've been around the world, OK?" Hotard says, then rattles off the names of hospitals her daughter has called "home" to prove it. "West Monroe, Luling, Lake Charles, Allen Parish. You name it."
She faces continued uncertainty with the move to Central, itself in flux. In February, DHH announced plans to phase out operations at the current Central site, building a new $6 million, 60-bed facility on state-owned land nearby. Construction on the proposed hospital is yet to begin. And, as an August article in the Alexandria Town Talk noted, the current proposal replaces an earlier plan to build a larger $27 million facility on Central's current grounds. Now, with the transfers from SELH, Central will have twice as many patients as designers had anticipated.
Hotard says she worries that the Jindal administration's long-term plans are the closure or privatization of all state mental facilities.
"I have emailed, I have written letters. You have no idea how many letters. I've gotten all my friends. I've probably sent 60 letters down to Southeast," she says. "I think right now, I guess, an autocratic government would be what I'd call it. It's a one-man band ... He is not open to suggestions. He's not listening to his people, to the voters."