Some of these folks are very sick, so when you’re trying to get someone back in the community, some services aren’t available or folks aren’t willing to take that risk with a very sick person.
MHI Cherokee: a portal between the past and future of mental health care
This 10-part series, a collaborative effort of the newspapers of Rust Publishing, NWIA, examines the myriad issues surrounding the mental health care crisis in Iowa. Reporters and editors from the Spencer Daily Reporter, Storm Lake Pilot-Tribune and Dickinson County News have contributed to the report.
Established state institutions also feel the impact as mental health care undergoes another period of transition in Iowa.
The number of state inpatient psychiatric beds ranks last in the nation per capita and state administration actions have drawn increased criticism — particularly after closures of half the state's mental health institutes in July, 2015.
PHILOSOPHY OF CARE
A transition to community-based care — in outpatient settings as often as possible — is now recommended and preferred by most patients and providers.
But with outpatient providers closing doors and emergency room visits on the upswing, some argue that the beds like those provided at Cherokee’s MHI are still desperately needed.
Priorities in mental health care, particularly for children, were touted at the top of Gov. Kim Reynold's agenda as she signed a bill into law in May, establishing a children's mental health care system, requiring core services and having a response sufficient to address the backlog for children.
Area leaders, like Seasons Center CEO Kim Scorza, don 't see state revenue to go with the state's new requirements to address mental health care.
Legislative cost estimates suggest the new mental health policies will come with a price tag of $10.1 million over the next two years, with most of it funded by mental health regions.
Those regions raise revenue through property taxes, currently limited by a levy cap. Democrats unsuccessfully lobbied to raise that levy cap to keep pace with the cost of the new state requirements.
Bill HF2456, signed into law in March 2018, required the development of six access centers, community treatment teams, sub-acute services and intensive residential service homes.
"This legislation is an important step in the right direction for Iowans with mental illness," said Jerry Foxhoven, director of the Iowa Department of Human Services, after its passage.
DHS documents indicate the access centers would be set up by the end of 2019 and would act as a stopgap between the need for inpatient psychiatric care and outpatient care.
With an almost intimidating architecture dubbed a "linear Kirkbride" design, MHI is, in some respects, a living relic from the turn of the 20th century.
Designed under the philosophy of Dr. Thomas Kirkbride, the architecture's deliberate design was used to construct hospitals largely in Eastern and Midwestern states over a period of about 75 years starting in 1851.
Kirkbride's resolutions on mental hospitals embodied 19th century humanitarian "moral treatment" philosophies to give the mentally ill a place of safety, or "asylum."
The philosophy emphasized the healing natures of a pastoral lifestyle, requiring hospitals to be built in rural settings no closer than two miles to a town.
A Kirkbride hospital was also designed to be inherently paternalistic. The superintendent lived on the second floor in the central, domed administrative building. Patients were admitted to the farthest wards and moved closer to the "father figure" as their minds were "restored to sanity."
Thousands of patients were brought in on railroads from other facilities shortly after the facility's opening in 1902. The facility's census peaked in 1945 at 1,729 patients, declining into the '70s as the hospital changed its focus from a custodial to active treatment model that sought to release patients as soon as they started to improve.
The last person to be buried in the cemetery on MHI's campus died in 1962, as mental health care movements attempted to stop the "warehousing" of the mentally ill, with the advent of more effective medications.
Total restraint and seclusion was targeted for reduction in 1999 after a workgroup was established to research and develop methods of care that would make it unnecessary. In 1999, seclusion and restraint hours totaled 12,165. By 2001, total hours had been reduced to 3,438.
The formidable, red MHI building in Cherokee has far fewer patients annually compared to any of its peaks over the last 117 years. But, administrators say the need is still great.
Staffed with 170 employees — about half of whom are clinical — MHI is one of the largest employers in town.
With 36 beds, 12 of which are designated for children, MHI’s liaison Diane Knaack says the facility is completely full all the time, processing roughly 400 admissions per year. The average length of a patient's stay is 69 days for adults and 20 for children. That annual admissions number is down from 552 in 2015, when the average stay was 34 days for adults and nine days for children.
The length of stay is up from the last four to five years. Superintendent Cory Turner connects the population increase to the difficulty of finding placements outside of MHI's red walls of Sioux Falls granite.
"Some of these folks are very sick, so when you're trying to get someone back in the community, some services aren't available or folks aren't willing to take that risk with a very sick person," he said.
Medicaid's turbulent privatization with managed care organizations has also played a role in the increased length of stay, Knaack conceded.
"It has slowed us down a little bit," she said, in the facility where 73 percent of patients are on Medicare or Medicaid. "It's getting better."
Patients who meet two of the following criteria are candidates for admission at MHI: suicidal intentions, the intention to harm others, need for psychotropic medication monitoring or need for 24-hour observation. The vast majority of referrals come from hospital emergency rooms.
"If we get a bed, we fill it," Knaack said.
Cuts of over $27 million in operating funds in 2010 removed approximately 20 beds from the facility.
"We may be the last call," for hospitals looking for a bed placement, said Turner.
The facility has survived the chopping block more than once over the last decade, thanks in part to its accreditation standards and adjoining Civil Commitment Unit for Sexual Offenders, which is housed and funded separately on the campus.
Turner staved off rumors of further reductions or closure, saying that MHI isn’t going anywhere.
But Iowa DHS's public information officer Matt Highland redirected the focus of conversation when asked whether MHI would consider expansions given the always-full status of the facility and complaints from health care providers about a lack of beds.
"I think one important thing to look at is a setting like this is for a very specific population," he said, "and is not meant to be long-term, but meant to get them back into the community."
The state is more focused on filling the gap between "mild depression and need of institutionalization," he said, with focuses on other step-down services and facilities.
MHI is slightly different from its private inpatient counterparts because of enhanced security and psychiatric rehabilitation classes. The classes are offered to patients for three to four hours per day to teach them how to manage their illness and symptoms.
"It's a living environment," Turner said, though a more secure one that has moved away from the old residential model that allowed patients to roam the acreage. Knaack says that model, which was in use when she started, was phased out in the 1980s with a movement toward deinstitutionalization.
Previous DHS spokespersons have said on the record that private providers can render some services at a quarter of the cost delivered by the state.
"There is a role for both public and community inpatient providers in Iowa," Highland said.
BEDS AND WORKFORCE
"Working with everybody in the community (law enforcement, professionals and family members) is where we're finding comprehensive service, as opposed to 'add more beds, add more beds,' because that’s not the solution," Highland continued.
The superintendent said MHI's beds are meant for seven to 10 day stints — slightly longer than three-day "crisis" beds being built, but still considered "very acute" patient needs.
"I view the state hospital system as a last resort to help them," Turner said.
Despite Iowa being ranked last among states for state inpatient psychiatric beds, Turner and Highland contend the availability of private inpatient beds should be sufficient for needs.
"When people talk about declining beds in state facilities, it doesn't acknowledge all the other beds out there," Highland said.
State rankings show Iowa at number 29 in terms of state and private beds available, at just over 20 per 100,000.
Health policy experts broadly recommend 40 to 60 inpatient beds per 100,000, though only two states meet that recommendation according to those numbers.
"It's kind of a misnomer, really," Turner said, calling claims of a lack of beds "shocking," because there's "so many beds available."
"People are saying we need beds. They're there. Just on a very basic level, they're there," he said.
Emergency room directors in Storm Lake, Spencer and Spirit Lake all insisted that bed placements are notoriously difficult to find in Iowa.
"Nobody would deny we need a larger, more robust workforce," Highland said, when challenged to answer concerns from providers and facilities struggling in the current environment. "That's something we’re working toward."
"We get to see people get better." Turner said. "It makes you know you're doing the right thing, even in administration, when you're saying, 'wow, we did something there to help this person.'"
Even with difficulties and challenges at the facility, he says those results are what keep them going.
- Mental health caseload takes a toll on hospital ERs (06/11/19)
- The people who care (06/04/19)
- New programs, static funding strain Iowa's mental health system (06/04/19)
- At the forefront of mental health (06/04/19)
- Responding to the mental health crisis in NW Iowa: Beating the stigma (05/29/19)
- Law enforcement challenged with limited resources (06/18/19)
- 'The biggest mental health facility in the state is the county jail' (06/18/19)
- The two Jeffs -- Part I: Criminal cases reveal hidden hurt (06/25/19)
- The two Jeffs -- Part II: Guilty plea leads to tragic end (06/25/19)