Some new (and old) ways to fix the mental health system in Illinois

The mental health system in this country is badly broken.1 Over the past 60 years we failed to invest in community mental health services while we have eliminated most state hospital beds. The numbers are remarkable. The United States had 560,000 state-operated psychiatric beds in 1955 and now has 45,000.2 The number of state-operated beds in Illinois has declined from 33,000 to 1,200 during this same period. Among the many negative outcomes of our failed deinstitutionalization policy have been excessive, expensive, and unproductive use of emergency departments. Over seven million emergency department visits are made by people with mental illnesses each year and more than one in eight is uninsured.3 Another result has been the criminalization of people with mental illnesses. Here again the numbers are remarkable. There are 8,000 people with serious mental illnesses in state prisons and 3,000 in the Cook County Jail.4

But there is some good news for people with mental illnesses and their families and communities: (1) the Affordable Care Act provides a substantial new source of funding for mental health services in Illinois; (2) the Community Mental Health Act provides an underutilized source of funding for mental health services in Illinois; and (3) there are some innovative new models for delivering mental health services in Illinois.

I. The Affordable Care Act Will Provide Health Care Funding for More than One Million New People in Illinois

The Affordable Care Act (ACA)5 will dramatically increase the number of people with mental illnesses in Illinois who will have funding for mental health services. That is largely because of Illinois’ decision to expand Medicaid under the ACA.6 The Medicaid expansion provisions extend Medicaid coverage to those with incomes up to 138% of the poverty level from the previous limit of 100% of the poverty level.7 This expansion will add 672,000 people to the number of people eligible for Medicaid in Illinois.8 Another 724,000 persons will be eligible under the ACA health insurance exchange in Illinois.9 Of these newly eligible Illinoisans, 85,000 have a serious mental illness,10 190,000 have serious psychological distress11 and 210,000 have a substance use disorder.12

Among the ways that Illinois will benefit from the ACA is its substantial, positive effect on reducing the number of persons with mental illnesses in the criminal justice system. Currently fewer than 10% of the people entering the criminal justice system were enrolled in Medicaid, Medicare or had private insurance prior to their arrest.13 There are elevated rates of substance abuse14 and mental illness15 in this population. For persons with mental illnesses, the lack of insurance or Medicaid coverage usually means that their illnesses have not been treated. In states like Illinois which have chosen to expand Medicaid under the ACA, the vast majority of the people in the criminal justice system will either be covered by Medicaid or be eligible for subsidized health insurance.16 The Illinois Department of Corrections and county jails will be able to connect those persons with mental illnesses to mental health services promptly upon discharge.17 This should reduce recidivism in this population.18

The ACA will also help Illinois to expand other efforts to divert persons with mental illnesses out of the criminal justice system. For example, in 2008, Illinois enacted the Mental Health Court Treatment Act19 and then in 2010, the Veterans and Servicemembers Court Treatment Act.20 These laws are designed to encourage criminal courts across Illinois to identify persons with mental illnesses who are charged with non-violent offenses and divert them to community treatment rather than imprisonment by using probation, supervision or other means. At least fifteen counties in Illinois now have some form of mental health court.21 The number of these courts and the number of participants can be increased now that many more of the eligible participants will have their treatment funded by Medicaid or private insurance.22

Other innovative diversion efforts, such as the acclaimed Bexar County (Texas) Jail Diversion Program,23 can also be more easily implemented in Illinois with the infusion of new Medicaid funding to cover the costs of behavioral health services provided through these programs.

Of course, the Affordable Care Act will not solve all of the problems with the mental health system. For example, Medicaid rates in Illinois remain insufficient to cover the cost of mental health services and our current state Medicaid plan will not pay for many evidence-based and cost-effective services such as supportive housing and supported employment. But we should see substantial improvements in mental health services across Illinois due to the ACA.

II. The Community Mental Health Act Provides an Opportunity for Increased Funding and Local Control of Mental Health Services

In 1967 Illinois enacted the Community Mental Health Act (“the Act”).24 The Act permits a local government unit to hold a referendum to authorize a small property tax (not to exceed 0.15%)25 to support mental health, developmental disabilities, and substance abuse services within the area served by that governmental entity. The entities permitted to levy such a tax include counties, cities, villages, townships, public health departments, and school districts.26 The Act requires the creation of a seven-member community mental health board27 to administer and distribute the funds generated by the property tax levy.28 This local control is designed to create a process for communities to identify their own priorities and to fill gaps in the behavioral health services funded by the state or other funding sources. Although many counties, cities and townships across Illinois have taken advantage of the Act,29 most areas of the state are not participating. The Association of Community Mental Health Authorities of Illinois was created in 1972.30 It is a useful source of information about how to create or improve a community mental health board. Communities across Illinois may wish to take advantage of this Act to improve mental health services.

In 2012 a similar program was established for neighborhoods within Chicago.31 The Community Expanded Mental Health Services Act32 now permits neighborhoods to tax themselves at a rate of .025% to .044% to support mental health services.33 This law operates very much like the Act described earlier. Thus far, only one neighborhood has chosen to pursue this funding strategy. Others may wish to do so.

III. Innovative Mental Health Services in Illinois

Psychiatric boarding is the practice of detaining someone in an emergency department for an extended time due to the unavailability of in-patient psychiatric beds or unavailability of a mental health professional to evaluate the patient. Boarding of psychiatric patients in emergency rooms was found unlawful by the Supreme Court of Washington State.34 While this decision was based on Washington State law, the problem exists here in Illinois as well. Unlike, patients with non-psychiatric conditions, psychiatric patients typically do not receive any treatment while they are in the emergency department. Also, they must be under surveillance by a security guard or other hospital personnel which is an expensive proposition for the hospital. So, the Illinois Psychiatric Society created a task force to look for solutions to the issue. In fact, the Task Force found that Illinois has some innovative models for reducing the prevalence of psychiatric boarding and improving the care of persons with serious mental illnesses. The following summarizes some of these innovations identified by the ISP Task Force.

Living Rooms

The Living Room concept has been implemented in a variety of ways.35 Some include crisis beds while others do not. The more common model is a comfortable living room where persons in mental health crisis can come and receive immediate treatment. Some Living Rooms are located near emergency rooms so people in crisis can easily be referred to them. They are staffed by peer crisis counselors and usually a clinician (APN/PA). Persons in crisis either walk in or are referred there from an emergency room. The peer crisis counselors sit and talk with the person to try and work through the present problem. The clinician can prescribe medications if the crisis is a result of the person running out of their medications or if medications would help.

Most Living Rooms are open for limited hours and limited days per week. This is due to the cost involved. For example, Peoria started a Living Room with an FQHC with a federal grant. It was used to deflect patients from the hospital or the police department. The Living Room stabilized the patient and connected the patient with medical and psychiatric help. The Living Room was staffed with nurses 24/7. The grant ran out after one year and it was too expensive to maintain so it closed. Now, the State has funded a crisis facility in Peoria with a Living Room, a detox center, emergency services and acute crisis beds for stabilization. The beds have just been started. Patients are actively treated. Other examples of Living Rooms in Illinois include:

a. Robert Young Hospital: They are going to build a Living Room into the ED.

b. MacNeal Hospital: This hospital is opening a Living Room kitty-corner from the Hospital’s ER.

c. Turning Point: independent site in Skokie, Illinois

d. Association for Individual Development: independent site in Aurora, Illinois.

Telepsychiatry/Telemental Health into Emergency Rooms

Many small and rural hospitals do not have a psychiatrist on staff or even nearby. Thus, when a psychiatric patient presents in an emergency room at such a hospital, the only thing the ER can do is start calling other hospitals to see if they have any open in-patient beds even though the patient may not actually need to be hospitalized. By having equipment set up to do telepsychiatry/telemental health, the patient can actually be treated in the ER and the patient may not even need to be hospitalized. One example of a company offering these services is Insight Telepsychiatry which operates a national call center.36 Insight Telepsychiatry works with specific ERs. It makes sure psychiatrists are licensed for the state in which the ER is located and has credentialed the psychiatrist at the particular hospital that has contracted with Insight. The psychiatrist is on call and does psychiatric evaluations as needed. Telepsychiatry is being used in Critical Access Hospitals as well. This is a growing area.

Another way telepsychiatry is being used is where a hospital with in-patient and outpatient psychiatric services provides telepsychiatry services to other hospitals in its hospital network. For example, Advocate Christ Hospital is acting as a telepsychiatry hub providing telepsychiatry services to three other Advocate hospitals.

On Site Treatment in the Emergency Department

Like many other Chicago area hospital emergency rooms, due to the decrease in State Operated Facility beds, Advocate Illinois Masonic Medical Center used to have patients staying in the ER for four or five days. While they ended up admitting many uninsured patients, the sheer volume threatened the fiscal viability of the hospital’s psychiatric unit. So, the hospital had to put a plan together. They developed a 24/7 Crisis Team staffed by a masters level psychologist or Licensed Clinical Social Worker available to the ER. The ER also has four psychiatric beds that are monitored by round the clock security. A psychiatrist rounds one to two times per day, five to six days/week. Medications are prescribed and staff provides therapy, both Activity Therapy and focused interventions, towards crisis stabilization, often with in-patient staff assistance to make the level of care consistent with care in the in-patient unit. The patients are still under the ER doctor’s care but the crisis workers are helping the ER doctors with the psychiatric patients. ED physicians feel more comfortable discharging patients after they have been evaluated by a psychiatrist. In evaluating a psychiatric patient, the hospital has three goals:

a. Can the patient be discharged to a shelter or other community alternative such as Thresholds, Trilogy, or First Access?

b. With patients who have significant substance use comorbidities, can they be sent to a rehab program once their psychiatric status is stable?

c. For those patients to be transferred to a State Operated Facility, patients will be given medication while awaiting transfer, with the rounding psychiatrist titrating the dosage.

Another option to having permanent psychiatric beds in the ER is the use of a pod system in the ER. In this model, regular ER rooms include “garage” type doors that would be used to cover the oxygen and other potentially dangerous ER equipment so they would not be accessible, thereby creating an in-patient room. By having patients in a pod, one security guard can be used for four beds. The doors are kept open so the patients can be monitored. Lurie Children’s Hospital and Cadence Health are both using this option.

Treating Patients Outside the Emergency Department

Advocate Illinois Masonic realized that just adding the psychiatric beds in the ER was not sufficient to eliminate psychiatric boarding. Therefore, they created two additional programs designed to keep patients out of the ER.

1. First Access Program. This program is located in a wing of the outpatient clinic across the street from the Advocate Illinois Masonic hospital. When appropriate, patients are walked over from the ER to an intensive out-patient program. The patients go through the program for one or two weeks. The warm hand off and immediate access to treatment are what makes this a good solution to the psychiatric boarding issue. This program has decreased over-crowding in the ER substantially.

2. Medically Integrated Crisis Community Support System (MICCSS). A key problem in healthcare is that 5% of patients use 50% of healthcare resources. By keeping patients out of the ER, substantial savings can be achieved. The third program at Advocate Illinois Masonic, MICCSS, focuses on the patients that frequently use the ER. For example, one patient had 90 ER visits in one year. A team that includes a social worker, nurse and masters level psychologist, with a back-up psychiatrist, go to shelters to treat targeted patients. Medication is administered to the patient and therapy provided. This prevents the patients from coming to the ER. This is a grant funded program and some of the grant is being used for temporary housing as housing is often an issue for patients with severe mental illness. It also pays for the psychiatrist and the medications.

The IPS Task Force is continuing to research further solutions to the issue of boarding of psychiatric patients in emergency rooms and will be conducting a survey of emergency departments this year to gather more data on the issue. ■

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Meryl Camin Sosa, J.D., is the Executive Director of the Illinois Psychiatric Society. She can be contacted at the Illinois Psychiatry Society, 312-224-2600.

Mark J. Heyrman, J.D., is a Clinical Professor at the University of Chicago Law School. See <http://www.law.uchicago.edu/faculty/heyrman>. He can be contacted at 773-702-9611 or by e-mail at m-heyrman@uchicago.edu

1. See, e.g., American Psychosis, Torrey (Oxford University Press, 2014)

2. Torrey, et al., “No Room in the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals” (Treatment Advocacy Center, 2012).

3. Owens, et al., “Mental Health and Substance Abuse-Related Emergency Visits Among Adults” Agency for Healthcare Research and Quality (July, 2010); See also, “Increased Emergency Room Use by People with Mental Illnesses Contributes to Crowding and Delays,” Report of the Bazelon Center for Mental Health Law: <http://www.bazelon.org/LinkClick.aspx?fileticket=Epvwc7WBOHg%3D&tabid=386>.

4. “Mentally Ill Are Often Locked Up in Jails That Can’t Help” Nation Public Radio, (1/20/14): <http://www.npr.org/2014/01/20/263461940/mentally-ill-inmates-often-locked-up-in-jails-that-cant-help>: Cook County Sheriff, Office of Mental Health Policy and Advocacy: <http://www.cookcountysheriff.com/MentalHealth/MentalHealth_main.html>.

5. The full name is the Patient Protection and Affordable Care Act, 124 Stat.119, P.L.11-148 (2010).

6. In National Federation of Independent Business v. Sebelius, 132 S. Ct. 2566, 183 L. Ed. 2d 450 (2012),the United States Supreme Court held that in order for the ACA to be constitutional, states must be allowed to chose whether or not to participate in the Medicaid expansion portion of the ACA. As of this writing, 27 states (including Illinois) and the District of Columbia have chosen to participate in Medicaid expansion.

7. 42 U.S.C. §1396a(a)(10)(A)(i)(VIII).

8. National Survey on Drug Use and Health, 2008-11; Miller, “Dashed Hopes; Broken Promises; More Despair; How the Lack of State Participation in Medicaid Expansion will Punish Americans with Mental Illness,” American Mental Health Counselors Association (February 2014),Table 1. <http://www.amhca.org/assets/content/AMHCA_DashedHopes_Report_2_21_14_final.pdf>.

9. Id.

10. Id.

11. Id., Table 2.

12. Id., Table 3.

13. Wang, et al., “Discharge Planning and Continuity in Health Care: Findings from the San Francisco County Jail” 98 Amer. J. of Public Health 2182 (2008); Coolsen & McDonnell, “Anticipating the Impact of Health Care Reform on the Criminal Justice System” 27 Court Manager 32 (Winter, 2012-13).

14. National Center on Addiction and Substance Abuse at Columbia University, “Behind Bars II: Substance Abuse and America’s Prison Population” (February, 2010).

15. Steadman, et al., “Estimates on the Prevalence of Adults with Serious Mental Illnesses in Jails” 60 Psychiatric Services 761 (June, 2009).

16. Coolsen & McDonnell, “State Courts and the Promise of the Affordable Care Act” Trends in State Courts, National Center for State Courts (December, 2014): <http://www.ncsc.org/sitecore/content/microsites/trends-2014/home/Monthly-Trends-Articles/State-Courts-and-the-Promise-of-the-ACA.aspx>.

17. Id.

18. Mancuso & Felver, “Providing Chemical Dependence Treatment to Low-income Adults Results in Significant Public Safety” Washington State Department of Social and Health Services Research and Data Analysis Division (2009).

19. Public Act 95-606 (eff. 6/1/08), codified at 730 ILCS 168/1, et seq.

20. Public Act 96-924 (eff. 6/14/10) codified at 730 ILCS 167/1, et seq.

21. The United States Substance Abuse and Mental Health Services Administration (SAMHSA’s) GAINS Center for Behavioral Helath and Justice Transformation: <http://gainscenter.samhsa.gov/grant_programs/adultmhtclist.asp?state=IL>.

22. Coolsen & McDonnell, “Anticipating the Impact of Health Care Reform on the Criminal Justice System,” 27 Court Manager 32, 34 (Winter, 2012-13).

23. The Center for Mental Health Services, Jail Diverson Program: <http://www.chcsbc.org/innovation/jail-diversion-program/>; “San Antonia Reduced Its Jail Population by Treating the Mentally Ill” Chicago Magazine online (August 20, 2014): <http://www.chicagomag.com/city-life/August-2014/San-Antonio-Reduced-Its-Jail-Population-By-Treating-the-Mentally-Ill/>

24. 405 ILCS 20/0.1, et seq.

25. 405 ILCS 20/4.

26. 405 ILCS 20/2.

27. These boards are often known as “708 boards’ because the original legislation authorizing their creation was in a statutory section numbered 708.

28.405 ILCS 20/3a

29. A partial list of participants is available at: <http://www.acmhai.org/membershiplist.htm>.

30. <http://www.acmhai.org/index.html>.

31. Public Act 96-1548 (effective 1/1/12).

32. 405 ILCS 22/1, et seq.,

33. 405 ILCS 22/15.

34. In the Matter of the Detention of: D.W. v. Department of Social and Health Services, 332 P.3d 423 (Wa. 2014).

35. See For Psychiatric Crises, Alternatives to ERs Have Their Advantages: <http://psychcentral.com/news/2014/01/15/helping-ers-better-care-for-people-in-crisis-or-with-a-mental-illness/64580.html>.

36. See <http://insighttelepsychiatry.com/>.