Waiting Lists Balloon

Years after mental health overhaul, new picture of needs emerging
Waiting lists have ballooned.

By Andrea Ball
AMERICAN-STATESMAN STAFF
Sunday, December 06, 2009

Six years ago, Texas leaders knew the state mental health system was in bad shape.

They knew it couldn't help everyone; that patients got few services; that community mental health centers didn't consistently measure how well programs worked; that care varied from center to center.

They knew it was bad. But they couldn't tell exactly what was happening at the 39 state-funded community mental health centers, which serve indigent, low-income or uninsured people.

Now they know.

In 2003, in an effort to improve the state's mental health system amid a budget shortfall, Texas legislators transformed the public mental health system. First, they rationed state-provided services, focusing on people with schizophrenia, bipolar disorder and major depression. People with other illnesses, such as anxiety and post-traumatic stress disorder, rarely received help unless they went into crisis and threatened to harm themselves or others.

Officials say new requirements for data collection and patient tracking that were part of the change have given them the clearest picture yet of the state's mental health needs — and how well Texas is meeting them.

According to the Department of State Health Services, that picture shows:

Waiting lists for services, which were not widespread in 2003, are now filled with thousands of people who sometimes wait more than a year to get medication, therapy, substance abuse care and other services from community centers. More than 6,800 adults and children with schizophrenia, bipolar disorder and major depression are on waiting lists. Of those, 4,550 are receiving no services; the remainder are in the system but waiting for additional care.

Because of the 2003 changes, centers routinely deny care to people who don't have schizophrenia, major depression or bipolar disorder.In 2003, the Texas system served about 14,800 people with primary diagnoses such as panic disorder, borderline personality disorder or anxiety, whom centers rarely accept as patients. Today, the centers serve about 3,900 with such diagnoses. People who are no longer accepted have to get help from other agencies, such as nonprofit or private providers.

Patients who are ready to transition out of the state system often have nowhere else to get help. At Austin Travis County Integral Care — the local public mental health center — more than 500 could be getting care elsewhere, but officials say there are not enough nonprofit and private providers willing or able to help them.

People who are getting care are getting better. According to Department of State Health Services statistics, 82 percent of adults who received mental health services in fiscal year 2008 improved or stabilized. Many got housing, found jobs or were arrested less often.

Having that kind of information is critical when asking politicians for more money, said Mike Maples, assistant commissioner for the department's Mental Health and Substance Abuse Division. It has also helped the state see what additional services people need, such as trauma therapy, supportive housing and job assistance.

"Just knowing is golden," he said. "Before, we didn't know anything."

But whether the changes in the statewide system — which standardized the quantity and types of services people receive at the 39 mental health centers — have improved the quality of care is still unclear because the centers never tracked data the way they do now, said Jim Van Norman, medical director at Austin Travis County Integral Care.

"We're five years out, and we still don't know if the system is better than it was before," Van Norman said.

More state funding

Advocates for people with mental illness say the need for reform stemmed from Texas' long history of underfunding psychiatric services.

In fiscal year 2006, Texas ranked 50th in the country in per capita mental health spending at $34.57, according to a 2009 report by the Henry J. Kaiser Family Foundation, which ranked the 50 states and the District of Columbia. The only state below Texas is New Mexico, which spends $25.58. The national average is $103.53.

The limited funds have forced centers to limit the number of people it can serve.

There are more than 453,000 adults in Texas with serious and persistent mental illnesses, according to the Department of State Health Services. Not all seek care at the state-funded centers. Last year, the centers served more than 115,000.

The new rules, implemented in 2004, required centers to provide a minimum number of hours of state-approved services to each patient. It forced them to routinely reassess patients, carefully track services provided and report such information to the Department of State Health Services.

"We hoped that it would be a triage tool, that it would ensure the most limited resources were used on the most seriously ill," said Joe Lovelace, former executive director of the National Alliance on Mental Illness Texas, which advocated for the changes.

Since then, the state has ramped up spending on mental health care. This year, legislators allocated $55 million to expand services at local mental health centers. That money will fund additional services, such as psychiatric follow-up, case management, housing assistance, peer-support programs, at-home life skills training, physician visits and medication.

This fiscal year, community mental health centers will receive $341.8 million from the state. That does not include the $55 million.

The money is the second shot of cash to the system in recent years. In 2007, legislators approved $82 million to the centers for additional crisis services, which is immediate care for people who are suicidal or potentially violent. The money paid for things such as mobile outreach units, crisis hotline improvements and pay for specially trained mental health law enforcement officers.

The new money has allowed more people to get help, Maples said.

Between September 2006 and August 2007, 8,890 people received care through Psychiatric Emergency Services, the crisis center run by Austin Travis County Integral Care. Between September 2008 and August 2009 — after the center had received $4.6 million in crisis funding — the center served 10,707 people.

Statewide, the number of people being served by community mental health centers increased from 111,000 in 2007 to almost 116,000 in 2009, a jump Maples attributes partly to the new crisis services.

"When you expand crisis services, you're all but advertising them to come," he said.

Robert Wittmer credits that kind of care with keeping him alive.

Wittmer, who is 41 and suffers from major depression, was living in his car, hotels and homeless shelters when he connected with Integral Care in 2007. The center gave him medication, supportive housing, substance abuse services, counseling and other services, he said.

He still struggles, he said. He's been suicidal and spent time at a local psychiatric hospital. But he says the local mental health center gives him whatever he needs to stabilize.

"For me, it's been great," Wittmer said.

Waiting lists grow

But thousands of others are still waiting.

Integral Care's waiting list hovers between 800 and 900 people and takes about 13 months for patients to reach the front of the line. The Bluebonnet Trails Mental Health and Mental Retardation Center in Williamson County has a 100-adult list that takes six to eight months to get services. The Mental Health and Mental Retardation Center Authority of Harris County has a list of more than 600 people. Though the average patient there waits about three months for service, some have waited up to a year.

Requiring the centers to create formal waiting lists "finally (put) a spotlight on the scope of the need," Van Norman said. "We've got a better sense of services offered and where the gaps were."

But it's hard to move people out of the system — and off the waiting lists and into services — because of the shortage of mental health care for the indigent in communities throughout Texas, he said. Few psychiatrists take Medicaid, and many primary care doctors refuse to prescribe psychiatric medications because mental health is not their specialty. In Travis County, the CommUnityCare clinics, which provide medical care to low-income people and are funded by the Travis County Healthcare District, are overwhelmed. That puts more pressure on the state mental health centers, which often serve more people than the state is paying them to help.

Integral Care, for example, is paid by the state to serve about 3,000 adults, Van Norman said. They are serving 4,800, which they accomplish by increasing staffers' caseloads.

"It's not a good situation, because then things fall through the cracks," Van Norman said.

Advocates say serving so many people has not only made it difficult for patients to get into the system, it's also easier to get kicked out.

"If you miss an appointment, you get dropped right away," said Shannon Carr, executive director of the Austin Area Mental Health Consumers, which provides classes, support groups and other services for people with psychiatric illnesses.

Carr says she knows of multiple cases in which this has happened.

But it shouldn't, Van Norman said. When someone has missed an appointment, center staffers are supposed to try to contact the patient several times to reschedule, he said.

However, he said he knows staffers don't always do that because they are overwhelmed with other duties. The center recently stepped up efforts to ensure staffers make a "good faith effort," to contact patients, he said.

Patients say it can be difficult to reschedule.

Jodi Tidwell, a 38-year-old Wimberley woman with bipolar disorder, receives services though the Hill Country Community Mental Health Mental Retardation Center. In April, Tidwell, a part-time communications assistant who does not have insurance, missed an appointment because her daughter was in the hospital. Tidwell says she tried to reschedule in June, but employees were sick, appointments were cancelled and it was finally determined that the psychiatrist could not see her until January.

In early September, Tidwell ran out of medicine. She says she bought Cymbalta from a friend. She used Lamictal a family member no longer needed. She rationed her drugs.

By late November, Tidwell said, she was depressed and teary. Two days before Thanksgiving, Tidwell said, center staffers gave her a prescription for one of her medications. They also moved up her appointment to December.

"The individual doctors, nurses and coordinators care, but policies keep them from being able to treat us as patients," Tidwell said. "They see us as binders full of perfectly filled-out records."

Linda Werlein, chief executive officer for the center, which is in Kerrville, said privacy laws prohibited her from discussing Tidwell's case. But in general, she said, "if someone consistently does not come to the clinic and make appointments" then they have to wait to see a doctor before they get their prescriptions.

People who are in crisis can be served quickly during emergencies, she said.

Filling in the gaps

But many will never get into the public mental health system at all. Thousands have been transitioned out of services because they did not meet the new diagnosis criteria.

So where did they go? Some were likely recategorized so they fit into services at the centers, Van Norman said. Others have gone to the public health clinics or local nonprofits.

After the new system began, other community organizations started putting more money into mental health services to help fill the gaps.

The Travis County Healthcare District now funds 18 psychiatric hospital beds, which serve about 1,000 people a year. Since 2006, the St. David's Community Health Foundation has given more than $7 million to nonprofits that provide mental health services.

"This is part of who we are in the community and we need to start addressing the unmet need," said Bobbie Barker, the foundation's vice president for grants and community programs.

Some end up in the criminal justice system.

Eric Willard, a board member with the National Alliance on Mental Illness Texas, is also chief of the mental health unit for the El Paso County public defender's office. Of the 500 new clients he sees each year, about half have disorders that would likely make them ineligible for services, he said.

"I think it's a travesty," he said. "I think the state of Texas needs to be horsewhipped for what it's done to the mentally ill."

State Rep. John Davis, R-Houston, who has lobbied for more mental health money, said he hopes legislators will continue to increase funding.

"Sometimes it's a hard sell, but you just keep with it because it's important," he said. "These are the most vulnerable people."