"The layoff plan for the Interim LSU Public Hospital and the other 6 LSU Health Care Services Division Hospitals was approved by the Civil Service Commission and it went into effect March 5th (today). — best, Marvin"
—Marvin McGraw, spokesmann for the LSU Health Care Services Division, in an email to Gambit last week
With that, a series of major cuts to Interim LSU Public Hospital (ILH) — decried as an impending public health crisis for the city of New Orleans — are no longer "impending" — not that they ever were for very long.
In late 2011, the state diverted millions in federal money typically allocated to LSU's hospital system to the Louisiana Department of Health and Hospitals instead. That meant a $30 million midyear reduction to the Louisiana State University public hospital system. Of that, $15 million in cuts would come from ILH. The layoffs notice went out in mid-January. The plan was released in detail in early February.
The cuts to the city's public hospital include more than 100 active employees (including 12 emergency room nurses) plus the elimination of more than 100 more inactive positions, for a savings of nearly $5 million; the closure of 24 medical inpatient beds as well as four general emergency beds; and $2 million in reductions to medical services to prisoners.
And all this would be to a hospital whose emergency department had been operating at capacity, if not over capacity, says Dr. Peter DeBlieux, director of emergency services for LSU Interim, who spoke to Gambit March 1.
"Eighty percent of the time, from Nov. 1 until last week, there was a greater than one hour delay in offloading a paramedic stretcher," he says. "It's not just the beds were full. We were promising you it would be more than an hour if you showed up with an ambulance patient."
Then there are the losses to mental health services: the elimination of the hospital's 20-bed chemical detox unit, closure of nine out of 38 inpatient beds at its Depaul Unit, 10 emergency mental health beds and 23 emergency mental health technicians and nursing assistants.
"As we're having this conversation, I am down to 15 [emergency mental health beds]," DeBlieux says. "You know this is a misnomer. I've got a room with six chairs and I call them beds. So, just so that we're talking about the same thing, I have nine true beds, like you could sleep in them beds. And that's what I have right now. And that's what I will have going forward."
What the cuts amount to, DeBlieux believes, is a loss of the city's safety net. ILH is the only inpatient public mental health provider in the metropolitan area, serving a population of more than 1 million people. It's also the city's only level 1 trauma center. According to DeBlieux, mentally ill patients are bumped ahead of other (non-trauma) patients for treatment when separate mental health emergency facilities have reached capacity. Between mental health and general emergency, capacity has been reduced 20 percent in the emergency department.
On top of that, the cuts in staff will mean patients will take longer to treat. DeBlieux fears incoming patients will face even longer wait times to receive treatment and quicker stays when they do. Worse is what could happen to trauma care for severely wounded patients. As it stands, the hospital always keeps at least one operating room open for incoming trauma patients and can get them into treatment, typically, within five minutes.
"You have to understand, a system that's operating at capacity 80 percent of the time typically isn't cut," DeBlieux says. "When I talked to my colleagues nationally, cutting emergency department beds is one of the final things that you do. It's not one of the first things that you do," he says. "We've had focused behavioral health cuts before. We've had focused inpatient cuts before. There have been generalized salary cuts before ... I've never, in my experience here for 25 years, seen them eliminate emergency department beds.
"The more it's delayed, the worse that result is," he adds. "If our capacity is so hampered that we discontinue trauma services and have to go to trauma diversion, that impacts our region. That impacts the health of our region, profoundly."
News of the cuts came as a shock to city government as well. In a city that saw 199 murders in 2011 — a murder rate of nearly 60 per 100,000 population — the cuts, particularly to mental health would be "devastating as we fight an epidemic of violence," wrote Mayor Mitch Landrieu in a Feb. 4 letter to Gov. Bobby Jindal and LSU President John Lombardi.
"They are all the more nonsensical, as we struggle to meet the mental health and substance abuse needs of a community still recovering from the blows of Hurricane Katrina, Rita, Gustav and Ike as well as the BP oil spill," Landrieu's letter continues. "The closure of behavioral health services is a step backwards in what was to become a restored and enhanced mental health and substance abuse system."
"I would say that prior to these cuts, we were still inadequate in our inpatient bed care," says Cecile Tebo, former head of the New Orleans Police Department's Mobile Crisis Unit and a mental health expert. "I know firsthand that families are constantly trying to get their loved ones into a psychiatric bed. And it's near-impossible to do."
In 2010, the city released an analysis of psychiatric bed capacity in New Orleans compared to five other similarly sized and situated U.S. cities: Atlanta, Cleveland, Memphis, Tenn., St. Louis and Washington, DC.
At that time, the report found, there were 165 inpatient psych beds in New Orleans, a rate of 46.5 per 100,000 population — down from 364 total and 78.9 per 100,000 pre-Katrina. Of those, 60 were adult inpatient beds — fewer than the 77 at Charity Hospital alone prior to August 2005 — 16.9 per 100,000 population. Of course, these numbers were based on a slightly inflated pre-Census estimate population of about 354,000. Based on the actual 2010 population of 343,000, the rate is about 17.5 adult beds per 100,000.
The disparity was huge, the report found, compared to those other cities. Atlanta had 100 total beds per 100,000 population, 57.1 adult. Memphis: 74.7 total/ 63.5 adult. St. Louis: 59.1 total/46.3 adult. Washington: 62.5 total/52.4 adult. "We're at a huge deficit," says Tebo.
The only city that even came close to New Orleans was Cleveland. That city had a rate of 47.7 total beds and 25.1 adult beds per 100,000 people.
Cleveland may be a bellwether for what's about to happen in New Orleans. As William Denihan, CEO of Cleveland's publicly funded Alcohol, Drug Addiction and Mental Health Services of Cuyahoga County (ADAMSHCC), explains, that city has recently experienced its own closure of publicly funded mental health beds, with the shuttering of NorthCoast Behavioral Healthcare's Cleveland campus, which moved its services to another campus in adjacent Summit County.
"The previous administration — city administration — had agreed to build a brand-new state mental health hospital in Cleveland. The new administration, which came in about a year and a half ago, shelved it, said there will be no new mental health hospital in Cleveland. They closed the old one, and they're moving all mental health inpatient facilities into the next county south. We're not very happy about that," Denihan says.
The results in Cleveland have been clogged emergency rooms and a reluctance on the part of local judges to order mental health evaluations for defendants, which now take longer without a facility inside the city.
Still, says Denihan, even without that hospital, the city — with a population of 396,000, very similar to New Orleans — has 124 adult inpatient beds, more than twice New Orleans pre-reduction number of 60.
In 2010, the state of Missouri announced that it would close the Metropolitan St. Louis Psychiatric Center (MPC), which at the time had 50 inpatient beds.
"MPC — they still have mental health services in their building. The trick is they shut down their acute services. They're still using that building for long-term forensic patients," says Robert Fruend, CEO of the St. Louis Regional Health Commission. "We don't have money in our state to build new facilities. ... The state decided that the less-than-10-day stay, folks who needed a psych [evaluation] would get picked up somewhere else. The thought was that community hospitals would just step up and do that — like, 'They're coming your way, so here they come.'"
Bed capacity was tight — not crisis-level tight, but still tight — in the St. Louis region, Fruend says. His organization put up $1.5 million in startup funds to open the St. Louis Regional Psychiatric Stabilization Center, which has an emergency room and 16 inpatient beds. Fruend says the center did a "soft opening" last month, treating about six patients per day. Asked whether it had a positive effect on the overall capacity problem in the region, he says, "Not yet."
But there's one more statistic which makes things in New Orleans even worse. Neither Northcoast's nor MPC's closure figures into the inpatient rates shown in the 2010 New Orleans report, because they were state-run facilities. In fact, no state-run hospitals in other cities were counted in the per capita rates in the report, even though ILH was. That's because those state-run hospitals "tend to be regional hospitals that attract residents from other areas of the state" and they often include a number of forensic beds used for state-ordered commitments. (The Louisiana equivalent is the state forensic hospital in the East Feliciana Parish town of Jackson.) And that means that the true deficit is even greater.
In Washington D.C., for example, the report shows 370 total beds, of which 310 are adult beds. However, counting the 200 nonforensic beds at the district-run psychiatric hospital Saint Elizabeths, that number goes up to 570 — more than 96 beds per 100,000 population at a pre-Census estimate of about 591,000.
According to Steve Baron, who directs Washington D.C.'s Department of Mental Health, Saint Elizabeths now has about 110 non-forensic beds. Take into account that reduction and a current population estimate of about 618,000, and if Washington had no other inpatient facilities other than Saint Elizabeths, it would still have nearly 17.8 nonforensic adult beds per 100,000 population.
That one hospital by itself would make for a better per capita rate than the rate for all New Orleans hospitals combined —16.9 in the report and 17.5 in reality — even before the LSU cuts.
In September 2011, the state of Louisiana contracted with Magellan Health Services, Inc. to coordinate mental health care for Medicaid recipients and uninsured residents, groups that account for a large proportion of LSU's patients. The contract became active on March 1. Tebo believes, and state officials have suggested, that Magellan's goal will be to get more patients into outpatient programs — which isn't necessarily a bad thing, DeBlieux says.
We've had a number of patients who frequently present to the emergency department seeking behavioral health services ... in excess of 100 visits in the past six months. Specific individuals, super-users of the emergency department, if you will," who drive up costs, he says.
The hospital already has been working with the Metropolitan Human Services District to get some of those patients into outpatient programs when outpatient services would be appropriate for them. DeBlieux hopes Magellan will provide additional support. "The ray of hope is that the connectivity of outpatient services should be enhanced through the emergency department," DeBlieux says.
Some, including Tebo, however, don't believe that the city's outpatient programs will be nearly enough to compensate for the loss of hospital beds. Even if outpatient services improve, Tebo says, that doesn't accomplish very much for patients with severe mental illness, who often resist treatment.
"I liken it to kidney disease. Kidney disease may be able to be treated with pills. But for others, there is an acute level where they need dialysis as well," Tebo says.
The result, she says, is often early death for mentally ill people — and research backs up that contention.
A 2006 national report, led by Dr. Joe Parks of the Missouri Department of Mental Health found that mentally ill patients treated in public facilities — 90 percent of whom receive outpatient care, Parks was quoted as saying in a 2006 USA Today article — are dying at about 51 years of age. That's an average of 25 years earlier than the general population.
"It's not because of their mental illness," Fruend says. "They're dying from diabetes. They're dying from diabetes [and] chronic conditions that are going untreated because of the underlying mental illness."
When these medical needs are unmet elsewhere, Tebo says, the local criminal justice system is forced to meet them.
NOPD procedure for a potential mental health service call demands five officers, two two-man cars and a ranking officer, she says. That could mean dispatching half, or sometimes, all available officers in a district for a single call. Often those patients will end up seeking treatment at what is now the city's largest single mental health facility.
"It's the 10th floor of the [House of Detention] building," says Dr. Sam Gore, chief psychiatrist for the Orleans Parish Sheriff's Office (OPSO), describing the jail system's acute mental health inpatient unit, HOD-10. "It has the mental health clinic where the physicians sit and the nurses have their nurses' station, right there on the tier. So that is the central medical hub, and then there's four tiers."
Each tier has 15 beds, for a total of 60 — 22 more than LSU's DePaul unit had before the cuts, 31 more than it has now.
Gore doesn't have data, but he estimates about 45 percent of the inmates at Orleans Parish Prison (OPP), of an average daily population of 3,200, have indicated during an entrance screening that they may have some form of mental illness, albeit not medically diagnosed in many cases and not severe in most. He can't say how many acute cases he has, but says between seven and nine percent of OPP inmates have a prescription for psychotropic drugs.
Gore and Tebo both say they're aware of patients, unable to receive treatment elsewhere, who turn to OPP for medication and daily inpatient care. Though police will deliver very obvious mental health patients to ILH, "borderline" cases often end up in OPP, in Gore's care. He says he believes the population of mentally ill inmates has increased in the years after Katrina. With the cuts to ILH, he thinks it will increase even more in borderline cases. "Because it's a scarce resource we need to prioritize who's going to be hospitalized," Gore says. "So he's going to be coming to the jail," Gore says.
A higher population of unstable people in the criminal justice system presents a number of risks.
The first is that patients will start to rely on the criminal justice system for care, which both Tebo and Gore say is happening already.
"I know firsthand that families are constantly trying to get their loved ones into a psychiatric bed. And it's near-impossible to do. It was not uncommon for a family member to say to me, you know, we're not going to do this revolving door thing anymore, we want our loved one arrested," Tebo says.
Mentally ill inmates are eventually released from OPP. Without proper care, they tend to cycle back into the system. In recent testimony before City Council, New Orleans Municipal Court Judge Paul Sens said that in a recent 16-month period, he and other Municipal Court judges had ordered 246 mental health evaluations for defendants. 160 of them were found incompetent to stand trial. Of those, Sens said, 23 had cycled back into the court a total of 75 times.
Then there's the risk inside jail. As first reported by the nonprofit journalism organization The Lens, OPSO alleges that in late December, inmate Edwin K. Lee broke out of his cell and attacked a guard with a broken broomstick, chipping the guard's tooth and possibly breaking his jaw. According to OPSO's online records, Lee had previously been released to Northwestern Human Services — a mental health provider that works with the Metropolitan Human Services District — after a 2010 charge of battering a correctional officer. Records show that last month a judge ordered Lee to undergo a state mental health evaluation in East Feliciana before facing trial.
Gore says he's unaware of Lee's case and could not comment as to whether mental illness played a role in the alleged incident, but he said OPP staff will have to be more wary of their own safety, and the safety of inmates, should jails have to accept additional unstable patients.
"I think with our experience, if we could identify statistical trends and increased numbers, then that's something we could say 'Yes, we're getting more of these types of inmates. We need to be on our guard. We need to be careful. We need to make sure we do a good, thorough intake screening,'" he says. Gore stipulates that personal security has never been much of a concern for medical staff because inmates see doctors and nurses as their advocates: "So usually we have a very good relationship.
"But if someone's psychotic, logic goes out the window, of course."
The potential that mental health service cuts presents for increases in violence in jails and throughout an already violent city is what has city government and community leaders most concerned. Tebo points to published studies by Tulane University professor of psychiatry Mordecai Potash on the consequences of poor inpatient care directly after Katrina, when the city's capacity was even lower, down to 17 acute psychiatric beds in 2006.
A 2008 article by Potash, "The Struggle for Mental Healthcare in New Orleans —One Case at a Time," details specific criminal cases involving mentally ill defendants, including Bernel Johnson, a paranoid schizophrenic charged with killing NOPD officer Nicola Brown in 2008 — just after he was released from Southeast Louisiana Hospital in Mandeville. In 2010, Johnson was ruled incompetent to stand trial and was committed to state psychiatric care indefinitely, The Times-Picayune reported.
"We're dealing with very combative — and you don't want to stigmatize mental illness — but the reality is that there is a group that is so chronically mentally ill that they're non-compliant with their medication; they're not going to engage in a community based program," Tebo says.
As to whether the ongoing situation will resemble the crisis levels of 2005-2008, Tebo says she's not sure. She says she wants to be optimistic about the managed care partnership with Magellan, but the city will simply have to wait and watch. DeBlieux agrees.
"It's impossible for me to tell you with 100 percent assurance that these cuts are idiotic, foolish, dangerous, because you have to see what the evidence shows," he says. "We're all going to be reacting and waiting for the evidence."