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Justice Dept. slams mental health system

Last modified: 4/12/2011 12:00:00 AM
The U.S. Department of Justice has issued a scathing critique of New Hampshire's mental health system, accusing the state of violating the Americans with Disabilities Act by unnecessarily institutionalizing mental health patients instead of providing support in the community.

"The State acknowledges, and we agree, that its mental health system is 'broken,' 'failing,' and that it is in 'crisis,' " wrote U.S. Assistant Attorney General Thomas Perez.

The Department of Justice will try to negotiate a voluntary compliance agreement with the state. If negotiations are unsuccessful, Perez wrote, "the United States may then need to take appropriate action, including initiating a lawsuit, to obtain redress" for the ADA violations.

Advocates for people with mental illness say the report is no surprise - internal studies in New Hampshire have found similar problems, and the state has already created a 10-year plan to improve the mental health system. But the timing of this investigation could have an added impact as the state Legislature crafts a budget for fiscal years 2012 and 2013, which could include additional cuts to community mental health services.

Ry Perry, director of the Department of Health and Human Services Office of Client and Legal Services, said the department anticipates releasing a joint response with the state attorney general's office today.

"We are still reviewing the document and analyzing it and trying to understand its implications," Perry said.

The 28-page report from Perez to state Attorney General Michael Delaney is dated Thursday, and Health and Human Services officials said they received it Friday.

The investigation into the state's mental health system began in November 2010. U.S. Department of Justice officials did not return calls yesterday, and there is no indication of what sparked the investigation, which was done with the cooperation of state officials.

 Support system lacking

The central finding of the investigation is that New Hampshire lacks an adequate community support system for people with mental illness. As a result, individuals are institutionalized in more expensive and more restrictive settings, including New Hampshire Hospital in Concord and Glencliff Home, a nursing home for people with mental illness in Benton.

"In spite of a challenging fiscal environment, the State has continued to fund costly institutional care at (New Hampshire Hospital) and Glencliff, even though less expensive and more therapeutic alternatives could be developed in community settings," the report states.

Federal law requires the state to provide care in a setting that lets people remain as integrated as possible in the wider community - a standard that New Hampshire repeatedly fails to meet, according to the report. "Reliance on unnecessary and expensive institutional care both violates the civil rights of people with disabilities and incurs unnecessary expense," the report states.

The investigation found that the state's capacity for community care has declined in recent years. The number of inpatient psychiatric beds in community hospitals has dropped from 814 beds in 1990 to 496 in 2008. In the last five years, the state lost 39 beds in residential group homes. State spending on community behavioral health was reduced by $1 million during the 2009-10 legislative session.

The report points to a lack of community treatment teams, which provide services like psychiatry, nursing and vocational training in the community; and a lack of employment opportunities for people with mental illness. In its own reports, the state acknowledged that it is getting harder for people to access critical mental health services in the community.

The lack of community-based services has led people into institutions. Between 2000 and 2010, admissions to New Hampshire Hospital increased by 104 percent. "People in the community . . . are now often forced to seek services in the (New Hampshire Hospital) institution simply because community resources are deficient," Perez writes.

Patients also remain in institutions for too long because of a lack of services in the community, according to the report. State officials told the Department of Justice that almost a third of patients remain at New Hampshire Hospital longer than necessary because there is nowhere to send patients for follow-up treatment.

"At both (New Hampshire Hospital) and Glencliff, individuals with more complex physical and/or mental health conditions typically must remain institutionalized longer than necessary simply because more intensive protections, services, and supports are not sufficiently available in the State's community mental health system," the report says.

Patients have also been readmitted to New Hampshire Hospital at a rate that is 33 percent higher than the national average because of a lack of support services in the community.

The state has acknowledged that people with mental health issues are ending up in the state prison and county jails. Others end up in homeless shelters.

The Glencliff nursing home is meant to house older people for a longer period of time than New Hampshire Hospital. There, the report says there is virtually no attempt made to move people back into the community, unless a patient specifically asks to be moved.

"We find it troubling that in recent years, far more individuals housed at Glencliff have died each year than have been placed into community settings," the report states.

In addition to presenting quality of life issues for people who are unnecessarily segregated from society, the trend toward institutionalization also has cost implications for the state. Housing a person in New Hampshire Hospital costs $287,000 a year, compared with $124,000 at Glencliff and roughly $44,000 in the community.

 Implementing the 10-year plan

In 2008, the state created a 10-year plan for the mental health system, which addressed many of these issues. Recommendations included increasing supported community housing, increasing the number of community residential beds and increasing the number of community mental health beds for people with short-term crises, substance abuse problems or histories of violence. But many of the recommendations have not been implemented, and the state told the Department of Justice that it has been hampered by budget cuts and fiscal restraints.

The Department of Justice is asking the state to take a dozen remedial measures, including implementing parts of the 10-year plan, to provide more supports in the community for mental health patients. The Department is recommending that the state add residential alternatives to New Hampshire Hospital as well as affordable and stable community housing. It is instructing the state to add more vocational services and more support teams and create an overall system that lets more people move into the communities.

Meanwhile, the New Hampshire House recently passed a budget that would cut community-based services for about 7,000 mental health patients. The Department of Health and Human Services has warned that this will increase the risk of hospitalization for these individuals.

The Senate Finance Committee heard testimony from the state's Bureau of Behavioral Health yesterday, but committee members gave little indication of what they will do. Committee Chairman Chuck Morse, a Salem Republican, and several other Finance Committee members could not be reached last night to talk about the implications of the Department of Justice investigation on the budgeting process.

Colin Manning, spokesman for Gov. John Lynch, said the state had already identified areas of the mental health system that need improvement, which is why the state developed the 10-year plan.

"Unfortunately, we just experienced one of the worst recessions since the Great Depression and we haven't been able to move as quickly as we liked," Manning said.

Manning said the governor has moved forward with closing sections of the state hospital to redirect resources to community-based services. Lynch has raised concerns about the House's cuts to mental health funding, and Manning said Lynch will continue to work with the Senate on a budget "that continues to fulfill our responsibilities as a state."

Roland Lamy, executive director of the New Hampshire Community Behavioral Health Association, the umbrella group for the state's community mental health centers, said the investigation "shouldn't be a shock to anybody." Lamy pointed to the 10-year plan, which the association worked on with the state's Bureau of Behavioral Health.

"Collectively, everyone knows we lack a system that allows us to move patients effectively into the most appropriate setting of care," Lamy said. The state has not invested enough money in mental health care, so organizations have had to provide fewer services, Lamy said.

Association President Jay Couture said she hopes the investigation will make the Legislature think twice about further cutting the mental health system.

"I would hope . . . that it provides them with the information to recognize that these are critical necessary services," Couture said. "This validates that the state has areas of weakness that they need to address for this population, not areas of excess where they need to cut funding."


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