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Mental health: It’s top-notch community services, not more beds, that we need

Knowing the number of beds – acute-care beds – without putting them into context with the number of people served in the rest of our mental health system simply doesn’t tell us anything other than the number of beds.

Whenever there is a discussion about the problems with our mental health system, the conversation veers off to a discussion about beds. A recent article in MinnPost, “Minnesota’s jails turn into storehouses for people with mental illness,” is no exception. The story reported on the number of people with mental illnesses in our jails and implied that there were two possible solutions: to build more inpatient hospital beds or build a new facility where police could drop off people to be assessed. These oft-suggested “solutions,” however, will not fix the problem.

Sue Abderholden

The article reported that Minnesota has the lowest number of beds per capita in the nation, implying that more people with mental illnesses end up in our jails. There are several problems with this statement and assumption.

The first problem is that there are simply no standards or studies that say how many beds a state should have per capita. Nor is this a good measure of our mental health system. Knowing the number of beds – acute-care beds – without putting them into context with the number of people served in the rest of our mental health system simply doesn’t tell us anything other than the number of beds.

A false comparison

The second problem is that a “bed” is not a “bed.”  If one is looking at the beds we used to have at the state hospitals back in the 1960s and ’70s when institutions were closing, these were largely non-acute-care beds – they were more residential, where people lived for long periods of time. Acute-care beds, which are those at community hospitals, provide intensive short-term treatment to stabilize a person. Most of the beds in Minnesota today are acute-care beds. So making comparisons to the number we had in 1970 or to the number of beds in other states (where some large institutions still exist) is a false comparison. We’re comparing apples to oranges. The number of residential beds was high back in 1960 because there was nothing else. There were barely any community services.

When trying to put forth a connection between the number of acute-care beds and people going into our jails, it’s important to recognize that most people coming into our jails today would not meet the admission criteria for hospitalization. They aren’t going to jail because there are no beds. They are going to jail for a myriad of other reasons — such as no insurance, lack of access to community care, unstable housing, few in-home supports, poverty and zero tolerance. So more beds won’t address the situation.

I would be the last person to say that our mental health system is working well. But I will say that we have made advances over the past couple of years in terms of developing and funding community-based services and supports that work. The problem is that we just don’t have enough of them.

People spend a majority of their lives in the community – not in a hospital bed – and our efforts must focus on increasing access and funding to these services and supports, which are far more inexpensive than a hospital bed. People are turned away from hospitals, sometimes because there isn’t an empty bed, but more often because they don’t meet the criteria – and the “step-down” level of care they need rarely exists.

What we need: community-based services

In in a recent meeting with psychiatrists and hospitals, no one was advocating for more beds. They said that it was a front-door and back-door issue, meaning that if we had more community-based services we could prevent people from needing hospitalization and we could help them leave more quickly. They called for more intensive services to help people transition out of the hospital or Anoka to prevent readmissions and to enable them to leave the hospital when they no longer need that level of care.

In terms of replicating the Florida model here, it is important to understand that Florida invests few dollars in their community mental health system. The Orlando Sentinel recently reported that Florida ranked 49th out of 50 states in funding for community mental health services. States that aren’t investing in community mental health often have to resort to using funding from their criminal justice system. We need to be very careful when looking at options in other states, and put their model into context.

Minnesota has many community services that are not available in other states. We don’t need to rely solely on police to respond to a mental health emergency – we have, in many parts of the state, mobile mental health crisis teams. These teams can assess the person, provide rapid access to psychiatry and provide stabilization services to those that need them. Minnesota has crisis homes for people who do not meet hospital level of care but are in crisis. There is even a mental health urgent care center in St. Paul that serves the East Metro communities. We have several psychiatric emergency rooms for people with mental illnesses so they don’t have to wait in rooms with loud noises and bright lights.

‘Then where will they go?’

There is no quick fix to the problems in our mental health system. Building more beds or a huge assessment facility will not address the core problem. I am reminded of the common phrase, “If you build it they will come.” Yes, people will use the beds and the assessment facility if we build them, but more importantly we must ask, “Then where will they go?”

Once assessed in such a facility, once treated in a hospital, we need community services available to support them when they are discharged.  If not, we start the entire cycle over again.

In the future, we need to measure the capacity of our entire community mental health system, including options to help people live in affordable safe housing. Let’s make sure they have a bed in their home, and services and supports to keep them well in the community.

Sue Abderholden, MPH, is the executive director of NAMI Minnesota.

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Comments (2)

  1. Submitted by Rachel Kahler on 07/15/2014 - 10:06 am.

    Yes

    We are still failing to build a SYSTEM. Most people with mental health problems don’t need a bed outside their home. They need the ability to either recover or cope. Some of the things they need include medication, counseling, financial help, and general welfare checkups. Beyond an official system, they need friends, family, and community to understand that mental illness shouldn’t be a stigma. The need for counseling or medication isn’t a weakness. Further, the official system (medical and counseling) and the non-official system (family, friends, and community) need to be able to work together better. It shouldn’t be so difficult to help someone with mental illness. The system should account for the fact that many people who suffer from mild to moderate mental illness have jobs that they can’t leave for treatment (lest they lose the job and end up in worse shape), so scheduling and location should be able to accommodate them. Similarly, for those that need friends/family/community to help, there should be accommodations that take into account that they can’t necessarily schedule their lives around when a clinic, pharmacy, or other facility is open. Cost isn’t the only barrier to getting mental health help; transportation, time, and other issues are also important.

  2. Submitted by Patrick Thibault on 07/16/2014 - 07:40 pm.

    Winds of politics

    Start by examining what happens to a mental health system when previous political administrations believed that making government small was their mission. Government is an equation, meaning services provided through legislative and executive rule.

    As a result of previous administrations the mental health system was changed, and destabilized. We are now trying to right the ship. Building recovery-based services with the client, where they choose to live, is a wonderful plan both for providers of services and the human beings who request them.

    But please do this in a judicious and thoughtful manner or we will fall backwards. Right now the system is like a sapling, trying to take hold. Let’s not uproot it before it’s had a chance to take hold.

    In the article it was said that there is a “front-end” and a “back-end” problem. I think the data needs to be looked at more closely. Why does someone from Minneapolis end up in Rochester? Or Duluth? No beds?

    How can someone who has lived in a residential program for over a year and end up in a hospital, not be accepted back to their home?

    How much of that type of data do we have to draw any reasonable conclusions?

    Let’s take a seat at the table and design a mental health system for the 21st century.

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