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THE FUTURE SHAPE OF THE MENTAL HEALTH SERVICES IN THE STATE OF NEW YORK* LAWRENCE C. KOLB, M.D. Commissioner Department of Mental Hygiene State of New York Albany, N.Y.
T HE bicentennial year is an appropriate time for comparing earlier times with the present. In terms of knowledge, education, affluence, and health, the contrast is great. There has been substantial progress. But we should not use this bicentennial year merely as a period of reflection. It also should be a time to reassess our performance and to readjust our goals. Thoughtful reconsideration of objectives now is especially necessary because of the bleak fiscal prospects of the New York State government and its agencies. We no longer can afford to measure the quality of government services solely by the amount of money spent on those services. No longer is it possible to attempt to solve difficult sociomedical problems by pouring new tax monies into enthusiastically conceived but untested and unevaluated programs. The future shape of the delivery of services in the areas of mental health, mental retardation, and alcoholism must be foreseen today. These services must be erected upon the solid and tested structures which have so dramatically alleviated the suffering and improved the lives of those who have come for aid during the recent past. To sharpen our focus, let us quickly review the great change that has occurred in New York State alone in the care of persons suffering from severe mental illness or retardation. Between 1965 and 1975 the inpatient population at state psychiatric centers has decreased from nearly 85,000 to 35,000, a reduction of nearly 60% (see Figure 1). The population of these facilities reached a peak of 93,000 in 1955 and decreased by at least 9% annually in the 10-year period * Presented at a combined meeting of the Section on Psychiatry of the New York Academy of Medicine and the Council of Area II District Branches and the New York County District Branch of the American Psychiatric Association held at the Academy January 22, 1976. Address for reprint requests: Commissioner, Department of Mental Hygiene, 44 Holland Avenue, Albany, N.Y. 12229
Bull. N.Y. Acad. Med.
MENTAL HEALTH SERVICES IN NEW YORK
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Thousands
80-
~~~~~State Psychiatric 40
State
I
woman
~~~~~~Developmental
...fante~_rs
-0
1965
'70
'75
Fig. 1. Resident population of New York State psychiatric centers and developmental centers, 1965-1975. (Vertical axis indicates number of patients.)
from 1955 to 1965. The resident population of state developmental centers reached an all-time high of 27,500 in 1966 and 1967 and then declined to 20,000 in 1975, a drop of 27%. The number of individuals served in state inpatient or residential programs decreased for both psychiatric and developmental centers, but the number served by the outpatient programs of these facilities increased markedly in the 10-year period from 1965 to 1975 (Figure 2). For the psychiatric centers, the number of outpatients actually exceeded the number of inpatients in 1975. The number of community clients utilizing state developmental centers is rapidly approaching the number in residential care.
Admissions to state psychiatric centers had increased throughout the department's history, but reached a peak in 1968, decreased sharply until 1972, and has risen slightly since then (Figure 3). Discharges tend to follow admissions fairly closely. Readmissions increased considerably from 1966 to 1971 and have changed relatively little since then. First Vol. 53, No. 7, September 1977
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Thousands
Non - inpatient
Centers
Centers
Fig. 2. Number of outpatients (shaded area) and inpatients (white area) served by New York State psychiatric centers and developmental centers in 1965 and 1975.
Fig. 3. Admission and discharge of patients, New York State psychiatric centers, 1965-1975. Bull. N.Y. Acad. Med.
631
MENTAL HEALTH SERVICES IN NEW YORK
1965
'70
'75
Fig. 4. Admissions and discharge of patients, New York State developmental centers, 1965-1975.
admissions dropped substantially after 1968. Both first admissions and readmissions increased slightly in fiscal year 1975 (possibly reflecting the difficulties in the general economy). Deaths have decreased steadily since 1968. This lower death rate resulted only in part from the decreased admissions of the elderly since that date; the decrease in deaths is much greater than could be attributed to the drop in geriatric admissions or in the total inpatient population. Admissions to state developmental centers have been reduced by 77% during the past decade (Figure 4). This reduction is attributable both to the development of community programs and to administrative decisions relating to criteria for admissions. The number of discharge patients decreased from 1969 until 1972, but has risen in the past three years. Deaths of developmental center residents have decreased by 42% since 1968, far exceeding the 27% decrease in the over-all resident population. Both state and local facilities provided a wide range of inpatient and outpatient services during 1975 (Figure 5). The staffs of locally operated facilities served more than 4.6 million outpatient visits and state staffs served another one million, either at clinics or in clients' homes. Local day-care and rehabilitation units received more than 3.4 million visits and Vol. 53, No. 7, September 1977
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Outpatienl Visits 197E
Millions2O
16
12
8
4
4
0
6
l
Inpatient Days 1975 Fig. 5. Inpatient and outpatient services provided by state and local facilities, 1975, given in number of outpatient visits and number of inpatient days. Thousamds 60
45
30
15
0
Mentally Ill
Mentally
Alcoholic
Retarded
Fig. 6. Number of inpatient admissions to state (shaded area) and local (white area) facilities serving the mentally ill, the mentally retarded, and alcoholics, 1975. Bull. N.Y. Acad. Med.
MENTAL HEALTH SERVICES IN NEW YORK
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under 16
65 & over
all ages 16 - 64
1966
'70
'75
Fig. 7. Median length of stay at state psychiatric centers by age group, 1966-1975.
comparable state facilities received more than 500,000 visits. More than 20 million inpatient or residential days were spent in state facilities and another two million in local facilities, largely psychiatric units of general hospitals. While the number of inpatient days in state facilities was 10 times the number in local facilities, there were many more inpatient admissions to local facilities which serve the mentally ill and alcoholics than to state facilities (Figure 6). There has been a marked downward trend in the length of stay for those admitted to the state psychiatric centers in each major age group (Figure 7). The median stay for admitted patients has dropped from 75 days in 1966 to 36 days in 1975. Before 1955 the median stay was eight months. The largest group, age 16 to 64, accounted for the bulk of admissions. The younger and older groups, while showing longer median stays than this group, also tended to decrease their length of stay during the 10-year period. The data demonstrate how much has been accomplished in recent years in the care of those with psychotic disorders and the profoundly retarded. Vol. 53, No. 7, September 1977
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That accomplishment is attributable to new and highly effective psychopharmaceuticals, the great increase in psychiatrists and mental health specialists, the better education of physicians at large in the detection and early treatment of psychiatric disabilities, and major changes in public attitudes toward the mentally ill-bringing them to earlier care and providing support so as to restore social functioning on their return to their communities. Governor Hugh Carey indicated in his inaugural address that he intended to make matters relating to physical and mental health the first priorities of his administration. The same message was given to me by Dr. Kevin Cahill, the governor's special assistant for health affairs, prior to my appointment as commissioner of the Department of Mental Hygiene of the State of New York. To date the statements made by the governor and Dr. Cahill have proven more than rhetorical. On the several occasions during the first month of my tenure when it appeared that the acting director of the budget was moving in directions other than indicated by the governor's message, the governor responded promptly and saved our departmental operations from what would have been a virtual freeze. From the standpoint of the budgeting process, the governor also has proved his interest in physical and mental health affairs during the past year through his actions to amend the deleterious conditions which have existed at our largest institutions-Willowbrook Developmental Center and Pilgrim Psychiatric Center. Health affairs have been reorganized at the state level to insure greater effectiveness in the working relations between the various departments involved in the delivery of health services, the development of manpower, and research. A newly established New York State Health Planning Commission, under the chairmanship of Dr. Cahill, meets regularly with various commissioners. Under Dr. Cahill's leadership the commission has gotten action on problems that in the past often became inextricably mired in lower level interdepartmental committees. I have observed seemingly insurmountable logjams rapidly dissolved. For example, a proposal to develop a joint program between the Department of Mental Hygiene and the Division for Youth, which also required the collaboration of the criminal justice system, in regard to the care of violently aggressive adolescents, was about to flounder. It took just three meetings within a single month to bring the several groups together and iron out the differences after it became evident Bull. N.Y. Acad. Med.
MENTAL HEALTH SERVICES IN NEW YORK
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that both the governor and Dr. Cahill were insistent on joint departmental effort. Two other advisory bodies recently were established in relation to the New York State Health Planning Commission. One is a Health Planning Advisory Council, made up of various leaders in the health field, including some who would be classified as consumers. The other is the New York State Health Research Council, which was established by recent legislation. The Health Planning Advisory Committee might be called a "think tank"; it provides the offices of the governor with guidance on such highly controversial social issues as legislation regarding marijuana and narcotics. The state Health Research Council functions much as do similar councils which operate under the federal government and the City of New York. Within the New York State Department of Mental Hygiene, spurred on by my own thoughts on the proper constituents of living systems and assisted by a management-analysis report of ongoing operations and the recommendations of Dr. Cahill's task-force reports to the governor, we have reorganized to meet the needs of our mental health system of the future. The state department, I am convinced, must be continually concerned with all persons and elements contributing to the service-delivery systems, whether public, voluntary, or private. It must recognize and sustain the efforts of each of these sectors, aid them, and, finally, evaluate the services rendered. It must transcend-far more than it has in recent years-its preoccupation with the work carried on by its own operating facilities. The primary goal of the new administration of the department will be the social rehabilitation of all its patients and clients. All treatment programs will be directed toward the achievement by each patient and client of effective functioning in a dignified position in the family and community; this will be done by providing each with the maximum opportunity to develop his or her talents and social attributes as recognized by those groups. To these means, the department, at my direction, has established an Office of Social Rehabilitation in connection with the office of the commissioner and his first deputy commissioner. That office offers the commissioner and each regional and local director advice and technical assistance on the means to most effectively aid in socialization, housing, and vocational and avocational rehabilitation. That office seeks to maintain an Vol. 53, No. 7, September 1977
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active input from all related community organizations through an established council. It advises on appropriate budgeting for alternative methods of care and rehabilitation to prevent reinstitutionalization by preparing people for a successful return to community living. It is developing recommendations relating to foster-family care, halfway-house and hostel care, day care, intermediate health care, and habilitation. The recommendations concern themselves with the number of such units needed for each population area, the appropriate density of placements, and the education of community groups to support and accept the clients and patients. The Office of Social Rehabilitation also is concerned with assuring the availability of necessary medical, pediatric, and psychiatric support services; the development of care and rehabilitation centers in the community, as well as the existence of necessary communication, transportation, and evaluation procedures to assure the humane treatment of all those incapable of returning to the community-now approximately 25% of those discharged from the facilities of the Department of Mental Hygiene. This newly stated departmental goal is far from being centered solely upon the correction of psychopathology. It recognizes the deficiency and impairment in social functioning which derives from experiental deprivation. But it does not deny the social impairments which accrue as the result of inhibitions derived from psychopathological processes. Beyond this major goal, the department is seeking the maximum assistance to all those admitted to mental health, mental retardation, and alcoholism facilities operated both locally and by the state. Local facilities now generally provide initial diagnostic, emergency, crisis-intervention, and short-term care. Yet, in certain rural and suburban areas, state facilities continue to offer these early forms of intervention as well as necessary long-term care and habilitation. The department reaffirms its traditional charge to care for those who remain so severely impaired by brain damage or personality disturbance that they are incapable of independent existence outside its facilities and require continuous care. It shall, however, press vigorously for the placement of all who are capable of living in alternative treatment sites outside of institutions. Changes also are underway within the departmental divisions The care of the young and adolescent has received insufficient attention in the past. A new, separate Office of Children and Youth has been established and charged with the development of preventive programs, the over-all proBull. N.Y. Acad. Med.
MENTAL HEALTH SERVICES IN NEW YORK
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grammatic administration of the ongoing children's facilities of the department (which heretofore operated under the Division of Mental Retardation), and the development and support of programs undertaken with two other state agencies: the Division for Youth and the Education Department. While we may be heartened by the falling death rates in our institutions, my surveys of health records or certain practices in the prescription of drugs and of the level of medical and surgical practice in certain of the institutions have provided convincing evidence of the need to strengthen our health services. Accordingly, we have established an Office of Health Services with major responsibility for the development of procedures for all aspects of the care of the physically ill within the departmental population. We foresee additional contracting for medical and surgical assistance and the updating of our diagnostic processing, particularly through the regionalization and use of automatic analytic techniques for laboratory testing. Some of these will operate under departmental auspices and others through outside contractors. In recognition of a number of pressing needs for change and modernization in the delivery of mental health services with the departmental facilities, in the past year I called upon many people within the state to serve on various task forces. The reports of these task forces are now available. The Task force on Alternative Methods of Care for the Aged and Chronically Ill reported that at the end of fiscal year 1975 46% of the patients in our state psychiatric centers were 65 years of age and over. Of this group, 78% had been residents in psychiatric centers for more than two years. Moreover, 40% of the geriatric patients had been institutionalized for 30 years or longer. About half were aged 65 to 74 years, more than one third were 74 to 84 years, and about one eighth were 85 years of age or older. From the viewpoint of physical condition and mental capabilities, neither the chronically mentally ill nor geriatric patients are homogeneous groups. A recent survey of hospital patients has shown that patients in psychiatric centers varied in functional capacity, from those able to pursue a fully independent life to those completely dependent on others; various intermediary levels of function were observed also. The task force has recommended the conversion of certain psychiatric centers to multipurpose use. Where the numbers and types of patients justify it and where an existing facility may be adapted to different uses Vol. 53, No. 7, September 1977
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without great expense, the facility may be subdivided into a variety of units, each providing a different level of care and, of necessity, staffed differently. The variations in staffing promise to be exceedingly important in these days of shortages of highly trained medical personnel. Therefore, the task force recommended a wider usage of new professional categories such as physicians' assistants and nurse-practitioners. In addition, the task force suggested, as a long-term program, the full exploration of new modes of management of chronically mentally ill and geriatric patients, with emphasis on programs which will enable patients to remain in their normal settings. Examination of the following possibilities was suggested: 1) The conversion of parts of community nursing homes or healthrelated facilities into units for subacute care of mentally ill persons as a substitute for mental hospital care. In this arrangement, the home would provide boarding care, while therapeutic staff might be supplied by a responsible mental-health agency directly by contract with the home or through staff sharing. 2) For the ambulatory, mentally disabled, elderly person with minor behavior problems, the potential should be sought for humane care in free-standing homes or as a part of a generic proprietary home for adults or home for the aged. To support this system clinically, the task force suggested that the development of related crisis-intervention centers which would respond immediately to the requests of caretakers in providing for the medical, psychiatric, and social needs of the patients be tried. Since two thirds of all admissions to state facilities are readmissions, it seemed obvious that an immediate assessment should be undertaken to determine the characteristics of the repeaters, the illness justifications for re-admission, and the clinical or social means necessary to reduce recidivism. In considering the serious problem of multiple admissions and ways of improving the care of patients caught in this recycling process, a task force under the chairmanship of Dr. Elizabeth Davis has advised in its report to the commissioner as follows (I report here only its most salient recommendation): "It is important to distinguish between recycling resulting from deficits in treatment and appropriate rehospitalization in the context of a treatment program." The task force recommended that state and local officials adopt a policy mandating review of the treatment program for multiple-admission inpaBuU. N.Y. Acad. Med.
MENTAL HEALTH SERVICES IN NEW YORK
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tients. It defined criteria for the retention of such persons in an appropriate 24-hour-care facility, e.g., a psychiatric inpatient facility, a nursing home, or a chronic-disease hospital. For the individual who is admitted for the third time in a period of 12 months, retention in an inpatient psychiatric facility or transfer to an appropriate 24-hour in-care facility should be required if any of the following criteria apply: 1) The patient is significantly dangerous to himself or others because of mental illness. 2) The patient shows no improvement in the psychiatric symptoms which necessitated admission nor is there improvement in the critical support systems (social network and care facilities) available. 3) The patient lacks basic self-care skills in one or more of the following four functional areas: a) Control of bowel and bladder and ability to manage other bodily functions such as eating, menstruation, etc. and personal hygiene such as dressing, bathing, and dental hygiene b) Ability to use the available resources to obtain transportation to critically needed aftercare services c) Awareness of and ability to use daily living tools such as eating utensils, grooming tools, money, and the telephone d) Social skills sufficiently stabilized to be able to utilize recommendations for postdischarge treatment 4) The patient is not sufficiently stable to be able to utilize recommendations for postdischarge treatment. 5) Before discharge a sufficiently available and accessible social and treatment network to support existence outside the institution must have been identified and linkage to this network established. 6) If, after a third discharge within 12 months, the social network refers a patient for readmission, the responsible hospital must readmit the patient or assume total responsibility for treatment pending review by the local treatment-review body. In order not to admit the patient to 24-hour care, the hospital must have and use resources for a) crisis intervention, b) continuity of care in the form of individual assignment of responsibility for coordinating treatment and follow-up, and c) provision or arrangement for needed medical or surgical care. From the standpoint of the public, violence in the streets and lenience toward the aggressively violent are now, and have been for some time, significant social issues. Highly critical evaluations of the effectiveness of Vol. 53, No. 7, September 1977
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so-called rehabilitation or treatment programs as practiced in some correctional systems have been published recently. Our specialty is accused of the incapacity to predict violent behavior and, thereby, of certifying individuals for inpatient care unnecessarily, while, from another quarter, we find outselves attacked for the release of aggressively violent people, thereby contributing to the insecurity in the streets. Past studies showed that previously hospitalized mental patients were less aggressive and less likely to commit felonious acts; yet, samples of the general population in several more recent reports suggest otherwise. The latter reports cannot be ignored; today we release at an earlier period more persons who are hospitalized than in the past, usually on drug therapy, and we cannot give assurance that continuance of treatment is certain. Dr. Hugh Butts headed a task force to address the problem of the management of the aggressively violent. That group made many recommendations, one of which was the establishment of an Office of Forensic Psychiatry in the department. Indeed, the present state administration charges us with the total care both of those who have been convicted and have then become psychotic as well as of those who have committed assault and have been released by reason of insanity or certified to the department as incapable of standing trial. It seems likely that we shall have to expand the departmental effort here. The department's position is that the two groups should be treated in a similar way. A significant change in the criminal law to judging commission of a crime without consideration of the mental state of the individual (a move I consider highly desirable) does not seem imminent. For the immediate future we are recommending the establishment of more forensic units throughout the state similar to the Hutchings Psychiatric Center at Syracuse for diagnostic and therapeutic attention to court-related patients not convicted of crimes. Also, the department looks forward to the establishment in five correctional facilities of diagnostic, evaluation, and treatment units (Clinton, Elmira, Auburn, Attica, and Bedford Hills). Of these two, the department's first priority is the development of the services at the correctional institutions; the second priority is for the new forensic units. I have long believed that a state department of mental hygiene should recognize its role as one of several governmental units concerned with maintaining an effective level of social homeostatis-a level which allows the vast majority of citizens in each community to realize their maximum Bull. N.Y. Acad. Med.
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potential. Institutional care in a governmental facility has a dual social function: providing therapy and security for individuals and society. Some individuals must be confined somewhere to maintain the general social homeostasis. Changes in the method of caring for and discharging of patients in one department of government are likely to affect the responsibilities and findings of others. In order to determine whether there has been a deterioration in general security as a result of ill-conceived or ill-judged and excessive outside placement of those treated in our psychiatric centers, I have requested that one of our social science research groups undertake appropriate studies. Further, our department should report periodically-perhaps every three to five years-as to the antisocial behavior of those discharged from care to determine our effectiveness in either modifying or controlling such behavior through the treatment methods being used. In the forthcoming year, the department will have available its first written five-year projection in regard to the transitions foreseen in the care of the mentally ill, the retarded, and the alcoholic within this state. It is expected that young adults will be the most rapidly growing segment of the state's population during this period. While there are positive aspects to this increase in giving to the state a larger work force of those younger and better educated, this same group is known to be afflicted and to first present symptoms of the major functional psychoses and other disorders. Against the rise in morbidity occurring in this group we may predict a lessened demand for hospital care of the elderly. We would expect, then, to encounter a greater demand upon the mental health services in the immediate future to care for this group, perhaps in the front-line services operated locally. The department expects that the usage of inpatient beds for the mentally ill will continue to diminish at a rate of 8 to 10% annually, dropping 20,000 beds within the five-year period. The projected annual decline in the inpatient population will be about 2,200. A redeployment of institutional staff to outpatient services has taken place already, amounting to some 2,500 positions valued at approximately $29 million for personal services alone. The department plans to redistribute staff from rundown, older institutions to new facilities and to enrich existing staffs to improve their functioning to standards acceptable to the accreditation organizations. We plan to try to achieve a 0.72 clinical staff-patient ratio (a modified Wyatt-Stickney ratio) over the next two Vol. 53, No. 7, September 1977
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years. We believe that a 0.9 clinical staff-patient ratio is the goal toward which the New York State system should move in the future. It is not commonly known that of the institutionalized mentally ill 65% of those discharged return to their own homes and families, while the remainder are placed in a variety of settings. We hope to provide alternatives to long-term hospitalization and also to rehabilitate those discharged from facilities in the community through family care, hostel programs, a surrogate landlord program, and a home-care program. Of these, the department's first priority is establishing the surrogate landlord program in which seed monies provided to voluntary groups through grants for rental and subleasing of apartments to former patients will allow the successful transition of these former patients to community living. Such monies would more effectively prevent existing delays in the establishment of community placement programs because of delay in obtaining Supplemental Security Income and other funds for support of patients after they are placed. These funds should be made available to nonnrofit groups which organize residential placement programs for the purpose of paying rent and other necessities for former patients on a temporary basis. Legislation may be required to facilitate this request. Our second priority is the request for hostels. In the area of mental retardation we expect a reduction in the residential census of state-operated mental retardation facilities over the next several years and an increase in the numbers of retarded people who are served in the community. It is estimated that by 1977 the population of the residential centers will be reduced from the 1975 figure of 20,076 to 17,600. The number of people being served on a nonresidential basis will increase from 7,300 to approximately 22,000 during the same period. Overcrowding will be eliminated by the continued occupancy of new facilities and accelerated community placements, and, if necessary, through less desirable expansion of mental retardation units into certifiable space as it becomes available in psychiatric centers. From the vast changes predicted regarding the diminution of institutional care will emerge-and has emerged-pressure to consolidate and phase out certain facilities. Such reductions of facilities have the potential for greatly reducing costs now administered by the state department. The support services approximate some 30% of the budget of every major institution. Those savings might be duplicated through a greater provision of funds for
Bull. N.Y. Acad. Med.
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front-line services, through either local counties or local assistance contracts with voluntary agencies. Many people are dissatisfied with the present funding of local assistance under the unified services section of the mental hygiene law. Few counties (two, with three more now applying) have enlisted in this partnership arrangement with the state in the several years since the law was enacted. Clearly, the current legislation relating to unified services is such that few counties have accepted the desirability of the program of comprehensive delivery under that scheme. The reluctance appears to rest on 1) the fixed mandate without privilege of withdrawal which leaves them uncertain from a fiscal standpoint, 2) the failure of the formula to absorb inflationary costs, as well as 3) the uncertain authority of the local governments vis-a-vis our regional and facility directors. To maintain front-line services which prevent institutionalization, there can be no denial of the need for legislation that more certainly will support the development of local mental health services, will define clearly the local authority, will assure prepayment of funding, and will work through the state-county relation. This has been done successfully elsewhere. The department has commenced to develop legislation on this subject to be submitted this year; this legislation might alleviate many of the current problems inherent in providing and supporting the local mental health and retardation services in the counties. A thorough study must be undertaken to bring about far-reaching changes in the mental health and finance laws to provide the necessary flexibility in the usage of monies allocated to the state Department of Mental Hygiene. This would allow the vast transitional process now under way in our delivery system to proceed with ease and efficiency to the benefit of those for whom we care and of those who care. As has happened in the past, in times of great agony and distress in the United States once again the visions, strengths, and energies inherent in those who worked for and established this country have reemerged.
Vol. 53, No. 7, September 1977
THE FUTURE SHAPE OF THE MENTAL HEALTH SERVICES IN THE STATE OF NEW YORK* LAWRENCE C. KOLB, M.D. Commissioner Department of Mental Hygiene State of New York Albany, N.Y.
T HE bicentennial year is an appropriate time for comparing earlier times with the present. In terms of knowledge, education, affluence, and health, the contrast is great. There has been substantial progress. But we should not use this bicentennial year merely as a period of reflection. It also should be a time to reassess our performance and to readjust our goals. Thoughtful reconsideration of objectives now is especially necessary because of the bleak fiscal prospects of the New York State government and its agencies. We no longer can afford to measure the quality of government services solely by the amount of money spent on those services. No longer is it possible to attempt to solve difficult sociomedical problems by pouring new tax monies into enthusiastically conceived but untested and unevaluated programs. The future shape of the delivery of services in the areas of mental health, mental retardation, and alcoholism must be foreseen today. These services must be erected upon the solid and tested structures which have so dramatically alleviated the suffering and improved the lives of those who have come for aid during the recent past. To sharpen our focus, let us quickly review the great change that has occurred in New York State alone in the care of persons suffering from severe mental illness or retardation. Between 1965 and 1975 the inpatient population at state psychiatric centers has decreased from nearly 85,000 to 35,000, a reduction of nearly 60% (see Figure 1). The population of these facilities reached a peak of 93,000 in 1955 and decreased by at least 9% annually in the 10-year period * Presented at a combined meeting of the Section on Psychiatry of the New York Academy of Medicine and the Council of Area II District Branches and the New York County District Branch of the American Psychiatric Association held at the Academy January 22, 1976. Address for reprint requests: Commissioner, Department of Mental Hygiene, 44 Holland Avenue, Albany, N.Y. 12229
Bull. N.Y. Acad. Med.
MENTAL HEALTH SERVICES IN NEW YORK
629
Thousands
80-
~~~~~State Psychiatric 40
State
I
woman
~~~~~~Developmental
...fante~_rs
-0
1965
'70
'75
Fig. 1. Resident population of New York State psychiatric centers and developmental centers, 1965-1975. (Vertical axis indicates number of patients.)
from 1955 to 1965. The resident population of state developmental centers reached an all-time high of 27,500 in 1966 and 1967 and then declined to 20,000 in 1975, a drop of 27%. The number of individuals served in state inpatient or residential programs decreased for both psychiatric and developmental centers, but the number served by the outpatient programs of these facilities increased markedly in the 10-year period from 1965 to 1975 (Figure 2). For the psychiatric centers, the number of outpatients actually exceeded the number of inpatients in 1975. The number of community clients utilizing state developmental centers is rapidly approaching the number in residential care.
Admissions to state psychiatric centers had increased throughout the department's history, but reached a peak in 1968, decreased sharply until 1972, and has risen slightly since then (Figure 3). Discharges tend to follow admissions fairly closely. Readmissions increased considerably from 1966 to 1971 and have changed relatively little since then. First Vol. 53, No. 7, September 1977
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Thousands
Non - inpatient
Centers
Centers
Fig. 2. Number of outpatients (shaded area) and inpatients (white area) served by New York State psychiatric centers and developmental centers in 1965 and 1975.
Fig. 3. Admission and discharge of patients, New York State psychiatric centers, 1965-1975. Bull. N.Y. Acad. Med.
631
MENTAL HEALTH SERVICES IN NEW YORK
1965
'70
'75
Fig. 4. Admissions and discharge of patients, New York State developmental centers, 1965-1975.
admissions dropped substantially after 1968. Both first admissions and readmissions increased slightly in fiscal year 1975 (possibly reflecting the difficulties in the general economy). Deaths have decreased steadily since 1968. This lower death rate resulted only in part from the decreased admissions of the elderly since that date; the decrease in deaths is much greater than could be attributed to the drop in geriatric admissions or in the total inpatient population. Admissions to state developmental centers have been reduced by 77% during the past decade (Figure 4). This reduction is attributable both to the development of community programs and to administrative decisions relating to criteria for admissions. The number of discharge patients decreased from 1969 until 1972, but has risen in the past three years. Deaths of developmental center residents have decreased by 42% since 1968, far exceeding the 27% decrease in the over-all resident population. Both state and local facilities provided a wide range of inpatient and outpatient services during 1975 (Figure 5). The staffs of locally operated facilities served more than 4.6 million outpatient visits and state staffs served another one million, either at clinics or in clients' homes. Local day-care and rehabilitation units received more than 3.4 million visits and Vol. 53, No. 7, September 1977
L. C. KOLB
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Outpatienl Visits 197E
Millions2O
16
12
8
4
4
0
6
l
Inpatient Days 1975 Fig. 5. Inpatient and outpatient services provided by state and local facilities, 1975, given in number of outpatient visits and number of inpatient days. Thousamds 60
45
30
15
0
Mentally Ill
Mentally
Alcoholic
Retarded
Fig. 6. Number of inpatient admissions to state (shaded area) and local (white area) facilities serving the mentally ill, the mentally retarded, and alcoholics, 1975. Bull. N.Y. Acad. Med.
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under 16
65 & over
all ages 16 - 64
1966
'70
'75
Fig. 7. Median length of stay at state psychiatric centers by age group, 1966-1975.
comparable state facilities received more than 500,000 visits. More than 20 million inpatient or residential days were spent in state facilities and another two million in local facilities, largely psychiatric units of general hospitals. While the number of inpatient days in state facilities was 10 times the number in local facilities, there were many more inpatient admissions to local facilities which serve the mentally ill and alcoholics than to state facilities (Figure 6). There has been a marked downward trend in the length of stay for those admitted to the state psychiatric centers in each major age group (Figure 7). The median stay for admitted patients has dropped from 75 days in 1966 to 36 days in 1975. Before 1955 the median stay was eight months. The largest group, age 16 to 64, accounted for the bulk of admissions. The younger and older groups, while showing longer median stays than this group, also tended to decrease their length of stay during the 10-year period. The data demonstrate how much has been accomplished in recent years in the care of those with psychotic disorders and the profoundly retarded. Vol. 53, No. 7, September 1977
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That accomplishment is attributable to new and highly effective psychopharmaceuticals, the great increase in psychiatrists and mental health specialists, the better education of physicians at large in the detection and early treatment of psychiatric disabilities, and major changes in public attitudes toward the mentally ill-bringing them to earlier care and providing support so as to restore social functioning on their return to their communities. Governor Hugh Carey indicated in his inaugural address that he intended to make matters relating to physical and mental health the first priorities of his administration. The same message was given to me by Dr. Kevin Cahill, the governor's special assistant for health affairs, prior to my appointment as commissioner of the Department of Mental Hygiene of the State of New York. To date the statements made by the governor and Dr. Cahill have proven more than rhetorical. On the several occasions during the first month of my tenure when it appeared that the acting director of the budget was moving in directions other than indicated by the governor's message, the governor responded promptly and saved our departmental operations from what would have been a virtual freeze. From the standpoint of the budgeting process, the governor also has proved his interest in physical and mental health affairs during the past year through his actions to amend the deleterious conditions which have existed at our largest institutions-Willowbrook Developmental Center and Pilgrim Psychiatric Center. Health affairs have been reorganized at the state level to insure greater effectiveness in the working relations between the various departments involved in the delivery of health services, the development of manpower, and research. A newly established New York State Health Planning Commission, under the chairmanship of Dr. Cahill, meets regularly with various commissioners. Under Dr. Cahill's leadership the commission has gotten action on problems that in the past often became inextricably mired in lower level interdepartmental committees. I have observed seemingly insurmountable logjams rapidly dissolved. For example, a proposal to develop a joint program between the Department of Mental Hygiene and the Division for Youth, which also required the collaboration of the criminal justice system, in regard to the care of violently aggressive adolescents, was about to flounder. It took just three meetings within a single month to bring the several groups together and iron out the differences after it became evident Bull. N.Y. Acad. Med.
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that both the governor and Dr. Cahill were insistent on joint departmental effort. Two other advisory bodies recently were established in relation to the New York State Health Planning Commission. One is a Health Planning Advisory Council, made up of various leaders in the health field, including some who would be classified as consumers. The other is the New York State Health Research Council, which was established by recent legislation. The Health Planning Advisory Committee might be called a "think tank"; it provides the offices of the governor with guidance on such highly controversial social issues as legislation regarding marijuana and narcotics. The state Health Research Council functions much as do similar councils which operate under the federal government and the City of New York. Within the New York State Department of Mental Hygiene, spurred on by my own thoughts on the proper constituents of living systems and assisted by a management-analysis report of ongoing operations and the recommendations of Dr. Cahill's task-force reports to the governor, we have reorganized to meet the needs of our mental health system of the future. The state department, I am convinced, must be continually concerned with all persons and elements contributing to the service-delivery systems, whether public, voluntary, or private. It must recognize and sustain the efforts of each of these sectors, aid them, and, finally, evaluate the services rendered. It must transcend-far more than it has in recent years-its preoccupation with the work carried on by its own operating facilities. The primary goal of the new administration of the department will be the social rehabilitation of all its patients and clients. All treatment programs will be directed toward the achievement by each patient and client of effective functioning in a dignified position in the family and community; this will be done by providing each with the maximum opportunity to develop his or her talents and social attributes as recognized by those groups. To these means, the department, at my direction, has established an Office of Social Rehabilitation in connection with the office of the commissioner and his first deputy commissioner. That office offers the commissioner and each regional and local director advice and technical assistance on the means to most effectively aid in socialization, housing, and vocational and avocational rehabilitation. That office seeks to maintain an Vol. 53, No. 7, September 1977
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active input from all related community organizations through an established council. It advises on appropriate budgeting for alternative methods of care and rehabilitation to prevent reinstitutionalization by preparing people for a successful return to community living. It is developing recommendations relating to foster-family care, halfway-house and hostel care, day care, intermediate health care, and habilitation. The recommendations concern themselves with the number of such units needed for each population area, the appropriate density of placements, and the education of community groups to support and accept the clients and patients. The Office of Social Rehabilitation also is concerned with assuring the availability of necessary medical, pediatric, and psychiatric support services; the development of care and rehabilitation centers in the community, as well as the existence of necessary communication, transportation, and evaluation procedures to assure the humane treatment of all those incapable of returning to the community-now approximately 25% of those discharged from the facilities of the Department of Mental Hygiene. This newly stated departmental goal is far from being centered solely upon the correction of psychopathology. It recognizes the deficiency and impairment in social functioning which derives from experiental deprivation. But it does not deny the social impairments which accrue as the result of inhibitions derived from psychopathological processes. Beyond this major goal, the department is seeking the maximum assistance to all those admitted to mental health, mental retardation, and alcoholism facilities operated both locally and by the state. Local facilities now generally provide initial diagnostic, emergency, crisis-intervention, and short-term care. Yet, in certain rural and suburban areas, state facilities continue to offer these early forms of intervention as well as necessary long-term care and habilitation. The department reaffirms its traditional charge to care for those who remain so severely impaired by brain damage or personality disturbance that they are incapable of independent existence outside its facilities and require continuous care. It shall, however, press vigorously for the placement of all who are capable of living in alternative treatment sites outside of institutions. Changes also are underway within the departmental divisions The care of the young and adolescent has received insufficient attention in the past. A new, separate Office of Children and Youth has been established and charged with the development of preventive programs, the over-all proBull. N.Y. Acad. Med.
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grammatic administration of the ongoing children's facilities of the department (which heretofore operated under the Division of Mental Retardation), and the development and support of programs undertaken with two other state agencies: the Division for Youth and the Education Department. While we may be heartened by the falling death rates in our institutions, my surveys of health records or certain practices in the prescription of drugs and of the level of medical and surgical practice in certain of the institutions have provided convincing evidence of the need to strengthen our health services. Accordingly, we have established an Office of Health Services with major responsibility for the development of procedures for all aspects of the care of the physically ill within the departmental population. We foresee additional contracting for medical and surgical assistance and the updating of our diagnostic processing, particularly through the regionalization and use of automatic analytic techniques for laboratory testing. Some of these will operate under departmental auspices and others through outside contractors. In recognition of a number of pressing needs for change and modernization in the delivery of mental health services with the departmental facilities, in the past year I called upon many people within the state to serve on various task forces. The reports of these task forces are now available. The Task force on Alternative Methods of Care for the Aged and Chronically Ill reported that at the end of fiscal year 1975 46% of the patients in our state psychiatric centers were 65 years of age and over. Of this group, 78% had been residents in psychiatric centers for more than two years. Moreover, 40% of the geriatric patients had been institutionalized for 30 years or longer. About half were aged 65 to 74 years, more than one third were 74 to 84 years, and about one eighth were 85 years of age or older. From the viewpoint of physical condition and mental capabilities, neither the chronically mentally ill nor geriatric patients are homogeneous groups. A recent survey of hospital patients has shown that patients in psychiatric centers varied in functional capacity, from those able to pursue a fully independent life to those completely dependent on others; various intermediary levels of function were observed also. The task force has recommended the conversion of certain psychiatric centers to multipurpose use. Where the numbers and types of patients justify it and where an existing facility may be adapted to different uses Vol. 53, No. 7, September 1977
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without great expense, the facility may be subdivided into a variety of units, each providing a different level of care and, of necessity, staffed differently. The variations in staffing promise to be exceedingly important in these days of shortages of highly trained medical personnel. Therefore, the task force recommended a wider usage of new professional categories such as physicians' assistants and nurse-practitioners. In addition, the task force suggested, as a long-term program, the full exploration of new modes of management of chronically mentally ill and geriatric patients, with emphasis on programs which will enable patients to remain in their normal settings. Examination of the following possibilities was suggested: 1) The conversion of parts of community nursing homes or healthrelated facilities into units for subacute care of mentally ill persons as a substitute for mental hospital care. In this arrangement, the home would provide boarding care, while therapeutic staff might be supplied by a responsible mental-health agency directly by contract with the home or through staff sharing. 2) For the ambulatory, mentally disabled, elderly person with minor behavior problems, the potential should be sought for humane care in free-standing homes or as a part of a generic proprietary home for adults or home for the aged. To support this system clinically, the task force suggested that the development of related crisis-intervention centers which would respond immediately to the requests of caretakers in providing for the medical, psychiatric, and social needs of the patients be tried. Since two thirds of all admissions to state facilities are readmissions, it seemed obvious that an immediate assessment should be undertaken to determine the characteristics of the repeaters, the illness justifications for re-admission, and the clinical or social means necessary to reduce recidivism. In considering the serious problem of multiple admissions and ways of improving the care of patients caught in this recycling process, a task force under the chairmanship of Dr. Elizabeth Davis has advised in its report to the commissioner as follows (I report here only its most salient recommendation): "It is important to distinguish between recycling resulting from deficits in treatment and appropriate rehospitalization in the context of a treatment program." The task force recommended that state and local officials adopt a policy mandating review of the treatment program for multiple-admission inpaBuU. N.Y. Acad. Med.
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tients. It defined criteria for the retention of such persons in an appropriate 24-hour-care facility, e.g., a psychiatric inpatient facility, a nursing home, or a chronic-disease hospital. For the individual who is admitted for the third time in a period of 12 months, retention in an inpatient psychiatric facility or transfer to an appropriate 24-hour in-care facility should be required if any of the following criteria apply: 1) The patient is significantly dangerous to himself or others because of mental illness. 2) The patient shows no improvement in the psychiatric symptoms which necessitated admission nor is there improvement in the critical support systems (social network and care facilities) available. 3) The patient lacks basic self-care skills in one or more of the following four functional areas: a) Control of bowel and bladder and ability to manage other bodily functions such as eating, menstruation, etc. and personal hygiene such as dressing, bathing, and dental hygiene b) Ability to use the available resources to obtain transportation to critically needed aftercare services c) Awareness of and ability to use daily living tools such as eating utensils, grooming tools, money, and the telephone d) Social skills sufficiently stabilized to be able to utilize recommendations for postdischarge treatment 4) The patient is not sufficiently stable to be able to utilize recommendations for postdischarge treatment. 5) Before discharge a sufficiently available and accessible social and treatment network to support existence outside the institution must have been identified and linkage to this network established. 6) If, after a third discharge within 12 months, the social network refers a patient for readmission, the responsible hospital must readmit the patient or assume total responsibility for treatment pending review by the local treatment-review body. In order not to admit the patient to 24-hour care, the hospital must have and use resources for a) crisis intervention, b) continuity of care in the form of individual assignment of responsibility for coordinating treatment and follow-up, and c) provision or arrangement for needed medical or surgical care. From the standpoint of the public, violence in the streets and lenience toward the aggressively violent are now, and have been for some time, significant social issues. Highly critical evaluations of the effectiveness of Vol. 53, No. 7, September 1977
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so-called rehabilitation or treatment programs as practiced in some correctional systems have been published recently. Our specialty is accused of the incapacity to predict violent behavior and, thereby, of certifying individuals for inpatient care unnecessarily, while, from another quarter, we find outselves attacked for the release of aggressively violent people, thereby contributing to the insecurity in the streets. Past studies showed that previously hospitalized mental patients were less aggressive and less likely to commit felonious acts; yet, samples of the general population in several more recent reports suggest otherwise. The latter reports cannot be ignored; today we release at an earlier period more persons who are hospitalized than in the past, usually on drug therapy, and we cannot give assurance that continuance of treatment is certain. Dr. Hugh Butts headed a task force to address the problem of the management of the aggressively violent. That group made many recommendations, one of which was the establishment of an Office of Forensic Psychiatry in the department. Indeed, the present state administration charges us with the total care both of those who have been convicted and have then become psychotic as well as of those who have committed assault and have been released by reason of insanity or certified to the department as incapable of standing trial. It seems likely that we shall have to expand the departmental effort here. The department's position is that the two groups should be treated in a similar way. A significant change in the criminal law to judging commission of a crime without consideration of the mental state of the individual (a move I consider highly desirable) does not seem imminent. For the immediate future we are recommending the establishment of more forensic units throughout the state similar to the Hutchings Psychiatric Center at Syracuse for diagnostic and therapeutic attention to court-related patients not convicted of crimes. Also, the department looks forward to the establishment in five correctional facilities of diagnostic, evaluation, and treatment units (Clinton, Elmira, Auburn, Attica, and Bedford Hills). Of these two, the department's first priority is the development of the services at the correctional institutions; the second priority is for the new forensic units. I have long believed that a state department of mental hygiene should recognize its role as one of several governmental units concerned with maintaining an effective level of social homeostatis-a level which allows the vast majority of citizens in each community to realize their maximum Bull. N.Y. Acad. Med.
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potential. Institutional care in a governmental facility has a dual social function: providing therapy and security for individuals and society. Some individuals must be confined somewhere to maintain the general social homeostasis. Changes in the method of caring for and discharging of patients in one department of government are likely to affect the responsibilities and findings of others. In order to determine whether there has been a deterioration in general security as a result of ill-conceived or ill-judged and excessive outside placement of those treated in our psychiatric centers, I have requested that one of our social science research groups undertake appropriate studies. Further, our department should report periodically-perhaps every three to five years-as to the antisocial behavior of those discharged from care to determine our effectiveness in either modifying or controlling such behavior through the treatment methods being used. In the forthcoming year, the department will have available its first written five-year projection in regard to the transitions foreseen in the care of the mentally ill, the retarded, and the alcoholic within this state. It is expected that young adults will be the most rapidly growing segment of the state's population during this period. While there are positive aspects to this increase in giving to the state a larger work force of those younger and better educated, this same group is known to be afflicted and to first present symptoms of the major functional psychoses and other disorders. Against the rise in morbidity occurring in this group we may predict a lessened demand for hospital care of the elderly. We would expect, then, to encounter a greater demand upon the mental health services in the immediate future to care for this group, perhaps in the front-line services operated locally. The department expects that the usage of inpatient beds for the mentally ill will continue to diminish at a rate of 8 to 10% annually, dropping 20,000 beds within the five-year period. The projected annual decline in the inpatient population will be about 2,200. A redeployment of institutional staff to outpatient services has taken place already, amounting to some 2,500 positions valued at approximately $29 million for personal services alone. The department plans to redistribute staff from rundown, older institutions to new facilities and to enrich existing staffs to improve their functioning to standards acceptable to the accreditation organizations. We plan to try to achieve a 0.72 clinical staff-patient ratio (a modified Wyatt-Stickney ratio) over the next two Vol. 53, No. 7, September 1977
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years. We believe that a 0.9 clinical staff-patient ratio is the goal toward which the New York State system should move in the future. It is not commonly known that of the institutionalized mentally ill 65% of those discharged return to their own homes and families, while the remainder are placed in a variety of settings. We hope to provide alternatives to long-term hospitalization and also to rehabilitate those discharged from facilities in the community through family care, hostel programs, a surrogate landlord program, and a home-care program. Of these, the department's first priority is establishing the surrogate landlord program in which seed monies provided to voluntary groups through grants for rental and subleasing of apartments to former patients will allow the successful transition of these former patients to community living. Such monies would more effectively prevent existing delays in the establishment of community placement programs because of delay in obtaining Supplemental Security Income and other funds for support of patients after they are placed. These funds should be made available to nonnrofit groups which organize residential placement programs for the purpose of paying rent and other necessities for former patients on a temporary basis. Legislation may be required to facilitate this request. Our second priority is the request for hostels. In the area of mental retardation we expect a reduction in the residential census of state-operated mental retardation facilities over the next several years and an increase in the numbers of retarded people who are served in the community. It is estimated that by 1977 the population of the residential centers will be reduced from the 1975 figure of 20,076 to 17,600. The number of people being served on a nonresidential basis will increase from 7,300 to approximately 22,000 during the same period. Overcrowding will be eliminated by the continued occupancy of new facilities and accelerated community placements, and, if necessary, through less desirable expansion of mental retardation units into certifiable space as it becomes available in psychiatric centers. From the vast changes predicted regarding the diminution of institutional care will emerge-and has emerged-pressure to consolidate and phase out certain facilities. Such reductions of facilities have the potential for greatly reducing costs now administered by the state department. The support services approximate some 30% of the budget of every major institution. Those savings might be duplicated through a greater provision of funds for
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front-line services, through either local counties or local assistance contracts with voluntary agencies. Many people are dissatisfied with the present funding of local assistance under the unified services section of the mental hygiene law. Few counties (two, with three more now applying) have enlisted in this partnership arrangement with the state in the several years since the law was enacted. Clearly, the current legislation relating to unified services is such that few counties have accepted the desirability of the program of comprehensive delivery under that scheme. The reluctance appears to rest on 1) the fixed mandate without privilege of withdrawal which leaves them uncertain from a fiscal standpoint, 2) the failure of the formula to absorb inflationary costs, as well as 3) the uncertain authority of the local governments vis-a-vis our regional and facility directors. To maintain front-line services which prevent institutionalization, there can be no denial of the need for legislation that more certainly will support the development of local mental health services, will define clearly the local authority, will assure prepayment of funding, and will work through the state-county relation. This has been done successfully elsewhere. The department has commenced to develop legislation on this subject to be submitted this year; this legislation might alleviate many of the current problems inherent in providing and supporting the local mental health and retardation services in the counties. A thorough study must be undertaken to bring about far-reaching changes in the mental health and finance laws to provide the necessary flexibility in the usage of monies allocated to the state Department of Mental Hygiene. This would allow the vast transitional process now under way in our delivery system to proceed with ease and efficiency to the benefit of those for whom we care and of those who care. As has happened in the past, in times of great agony and distress in the United States once again the visions, strengths, and energies inherent in those who worked for and established this country have reemerged.
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