Community Mental Health Agency Success

[Sushirolls]

Some one posted a question, is there anything to improve CMH agencies, in context of my disparaging them and advocating for state hospitals. I don't believe there is anything we can do to improve them. We've had 60+ years to tinker with the concept.

• Liberal declarations of SSD, getting people minimal income... Money still gets blown on drugs, nicotine, or pets.
• People get housing then they complain about it and present to ED often with "group home itis" or disdain for their place for XYZ reason, for those not in group homes.
• ACT teams can only handle a small fraction of people, and even then they are only so effective.
• There is no $ in the game for the CMH patient population, so its not greatly valued, which translates to high no show rates - unless on a controlled substance - then show rates are higher.
• Staff turn over due to personnel quality, low pay, and myriad of other reasons impacting solvency of these agencies. I've seen a for profit mental health maybe do a bit better than average ones, but that isn't even the solution.

The best I've seen are 3 groups. The older schizophrenic who is just tired, plain tired of being admitted over and over to the hospital - still believes nothing is wrong, and no insight into delusions - but willing to take medications because of the recognition that it keeps from going back to the hospital/jail. Second group are those who truly fell on hard times, got enrolled in medicaid, experience the painful bureaucracy and are pushing hard to improve their money/employment to get out of the land of medicaid. Third group are those with ample family support. But the people with ample family support will do well, whether they go to CMH agencies or a Big Box shop. They get their loved ones to appointments, they insure medication compliance, etc. The best intervention we have - is family [que in Republican talking points here]. Our country is barreling in the other direction, dissolution of the traditional family concept, and it of all things is likely the best intervention for SMI. Go figure.

So in defeat, not from a joyous angle of 'look, I have a new shiny idea to solve the worlds problems' I believe a reversion back to large state based Long Term Psychiatric Hospitals is needed.

Have CMH agencies lived up to their vision, the mandates since the 1960s and reduction/closures of state hospitals? Have we made things better? Not just on paper from an angle of civil rights, and the historic abuses of the state hospitals (i.e. non mental health patients sent there for political reasons) but big picture SMI populations? You walk the streets of Portland, Seattle, etc are we doing better? See the news of some tragedy and bits come out from the reporting over ensuing days, nope, not a monster evil person as they title click bait, just another SMI person who was likely off meds and committed act XYZ. Are we really doing better with the CMH concept? I don't believe we are.

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[comp1]

I'm pretty sure the vast majority of psychiatrists who do primary inpatient work would agree that we need to return to much greater use of long term state psychiatric hospitals. Getting everyone else on board seems more challenging. Haven't seen much fraud, waste and abuse related to pets, however...

 

[WisNeuro]

I'm pretty sure the vast majority of psychiatrists who do primary inpatient work would agree that we need to return to much greater use of long term state psychiatric hospitals. Getting everyone else on board seems more challenging.

Generally, I reject the simplistic binary notion that we either have the CMHCs of today, or the long-term institutions of the pre-60s. That notion is just a political talking point for simple minds. There are parts of CMHCs which have enjoyed success, and there are situations in which long term hospitalization is more beneficial. It's not an either/or issue.

 

[Sushirolls]

Okay, so shine some light on the gray.
What are the successes of the CMH you've seen?

I'm pretty sure the vast majority of psychiatrists who do primary inpatient work would agree that we need to return to much greater use of long term state psychiatric hospitals. Getting everyone else on board seems more challenging. Haven't seen much fraud, waste and abuse related to pets, however...

The pet comment is related to people getting a $1000/month SSD check. But pet food costs $50/month, and the vet bills are more than a $1000 for the year. Patients prioritizing a pet over everything else that is more essential, rent, food, their own medicine, their own transportation, the phone bill, whatever.

 

[comp1]

Sure, it's all a bit subtler, but honestly...only a bit. To be blunt, we have very, very few state psychiatric beds per capita relative to the 60's. That...needs to go dramatically up, potentially up to where it was in the 60's. Of course what happens in the state psychiatric beds should be different than in the 60's, we do have some improved therapies, but we need those beds expressly for long term custodial care. I'm concerned that not viewing the situation as at least mostly a dichotomy has lead us to where we are now where we have a sprinkling of extremely rare long term custodial beds, but with the majority of patients with serious refractory mental illness doing a revolving door of acute care or correctional stints.

 

[SmallBird]

It is interesting and sort of tragic that New Hampshire claims they are going to solve 'ER boarding' because a judge ordered them to end the practice... which seems like a crazy thing for a judge to do as its not like patients were being boarded because everyone thought that was the best thing to do. Luckily they are going to add some beds but they also claim to have strategies to improve community based services as if nobody thought of that before. It is a losing battle trying to provide services for a theoretical group of patients that we don't have and ignore the patients who we do have, many of home need a contained environment long term.

 

[Sushirolls]

It's not just NH doing the judge mandated "fix this" order. There are other states doing the same ridiculous charade. One government entity fining another government entity due to a different government entity creating the mess.

 

[When is graduation again?]

I think your premise is too black and white. There are problems with CMHs, but the vision of enabling patients to live independent lives outside of hospitals should not be disregarded. I have a number of patients who cycled in and out of hospitals and jails before getting onto my ACT team and now are doing great. Even patients I initially believed should have been committed to state hospitals have managed to avoid hospitalization. The only patients I have that cycle in and out of institutional settings are heavy drug users and even then it's less than 10% of my patient panel.

If the following problems were addressed, then CMHs would be more viable.
1) The quality of CMH psychiatrists/providers tends to be awful because the pay is not worth the increased stress and risk.
2) The turnover rate is waaayyyy too high because organization's tend to get social workers straight out of training and pay them very little in exchange for supervision until they get fully licensed. It's rare to find a person who actually wants to be there.
3) Medicaid needs to pay more to incentive non-CMHs to see some of these patients to ease the burden on CMHs and to enable higher pay for CMH staff to reduce turnover.
4) CMHs should be required to actually abide by high fidelity models and stop bastardizing ACT/PACT models, which causes a substandard level of care.

I managed to make it about 15 months on my ACT team, but the stress and lack of support eventually got to me. I'm transitioning to private practice now. If Medicaid paid more, I'd still try to see some of these patients, but the pay is so abysmal that it's no where near worth it.

 

[splik]

The community mental health act was never fully funded, most of the proposed clinics were never built while 90% of hospital beds were closed, and the idea was transformed into a neoliberal project for rolling back funding rather than transferring funds from hospitals to the community. In other countries where they have robust community mental health services, there is no need for long term hospitals for non-forensic patients.

Every so often there is a call to "bring back the asylums". I am strongly against this. Most patients warehoused in asylums did not need to be, there were many abuses that occurred, these were total institutions, the process of institutionalization was harmful for patients, and our patient population today is different from the past. What we need is more robust high quality community health services that are able to provide more intensive services to patients who need them. We also need more regular inpatient psych beds, longer length of stays, and community based facilities (e.g. board and cares, psych SNFs, mental health rehab centers) that provide residential care to psychiatric patients who do not do well in the community. These services allow for greater freedom, rehabilitation, and are less costly than state hospitalization.

 

[comp1]

If you want to call them Mental Health Rehab Centers, that's fine with me. It would be a start. There are literally only 1400 Mental Health Rehab Center beds in all of California. I'm not sure how exactly a MHRC, with a longer length of stay, would function practically different from a state mental hospital bed, but it's fine with me as long as we have more long term custodial care facilities (we can call them anything we like). Remember, very few of these refractory and very seriously mentally ill patients have any sort of specific tie to a particular community.

 

[erg923]

State Hospitals before the 70s were generally run by physicians almost entirety (superintendents with provided housing on site?) and had terrible outcomes for almost any quality of life or "recovery" metric we would value today. They were costly and would be even more so today. I don't understand any kind of mentality that would advocate a return to this era?

Perceived "moral decay" and/or breakdown of the traditional nuclear family is reasonable to talk about here but that is not something that has occurred recently. That has been talked about for several generations now.

 

[comp1]

I guess long term custodial mental health was more costly compared to just letting people die on the street with their rights on. I'm not at all sure it is actually more costly than prison. In terms of recovery metrics, we are doing better globally within mental health, but I'm not seeing much improvement in a community health model for the people that should actually be in long term custodial care. There are certain patients, obviously a minority, who may demonstrate slightly improved functionality in the right setting, but will NOT "recover" to a level of functioning appropriate for the community ever and for which that model's underlying assumption is inappropriate and often actively harmful.

 

[Merovinge]

I guess long term custodial mental health was more costly compared to just letting people die on the street with their rights on. I'm not at all sure it is actually more costly than prison. In terms of recovery metrics, we are doing better globally within mental health, but I'm not seeing much improvement in a community health model for the people that should actually be in long term custodial care. There are certain patients, obviously a minority, who may demonstrate slightly improved functionality in the right setting, but will NOT "recover" to a level of functioning appropriate for the community ever and for which that model's underlying assumption is inappropriate and often actively harmful.

Yeah I hear Splik and the models from some European places that have family's adopt these severely ill/low functioning folks and have great success with it. But I also contrast that with the reality of the USA and there is absolutely no way that eudemonia is happening here. There is clearly a need for a small minority to have long-term care in a humane manner that is not served by the IP-SNF-ED-IP marry-go-round with maybe an occasional jail stint thrown in.

 

[allantois]

It is interesting and sort of tragic that New Hampshire claims they are going to solve 'ER boarding' because a judge ordered them to end the practice... which seems like a crazy thing for a judge to do as its not like patients were being boarded because everyone thought that was the best thing to do. Luckily they are going to add some beds but they also claim to have strategies to improve community based services as if nobody thought of that before. It is a losing battle trying to provide services for a theoretical group of patients that we don't have and ignore the patients who we do have, many of home need a contained environment long term.

lawyers love to think they are smarter than others

 

[bashir]

I think a lot of the disagreement here comes from how people are using terms differently. Maybe there is some genuine disagreement about whether there is a role for long term custodial care in a locked setting (what people think of when they say state hospital beds). I believe there is a role for this in the U.S., sadly, due in part to the pathologically individualistic society that we live in. I fervently believe that it is possible for it to be done well even though it has historically been done so poorly. But it should be a relatively small role. And these long-term hospitals should be oriented towards rehabilitation, because you never know who can surprise us and make a surprisingly robust recovery and someday be ready for a less restrictive environment. So perhaps "custodial care" isn't quite the right term. Do they need to be funded by the states? I would argue no, that the legacy of the federal government abdicating responsibility for the care of the most seriously ill in a game of hot potato with state governments was never ok and it's past time we demand the repeal of the IMD exclusion so that Medicaid can cover the costs of care in whatever environment is most appropriate. I think this would resolve a lot of perverse incentive problems including the old "put em on a bus to somewhere far away and they won't be our problem anymore" trick.

This begs the question, do longer term hospitals actually need to be separate from acute care hospitals in a world where they're all funded by Medicaid? Probably not, honestly. Why not have a longer term ward for people needing longer term stabilization? Kind of like subacute, but for months or in some relatively rare cases years. I think it's hard to envision people getting longer term care in acute care hospitals that currently have a "treat em and street em" in 3-4 days model of care. And it's also hard (for me at least) to visualize the kind of serious recovery and rehabilitation-oriented environment that would be necessary for this to be effective, based on my experience with acute care hospitals in my area, where little effort is spent on even the most basic things like encouraging patients to get out of their rooms and attend groups that might be therapeutic for them.

As for the CMHCs, some do great work despite the difficult circumstances. On the whole though the system is so underfunded that we as a society should be ashamed of ourselves. I don't think psychiatrists should feel obligated to martyr ourselves by agreeing to be indentured servants at underfunded and often mismanaged CMHCs. I am grateful to those psychiatrists who feel compelled to do that and I was one of them for a time, until I couldn't handle being routinely disrespected by the management anymore and fled to academia. I do believe that psychiatrists have a moral obligation to advocate for better systems of care (inpatient, outpatient, and everything in between) and basic needs like affordable housing for those with serious mental illness. I don't find it morally acceptable to hang a shingle and see exclusively worried well in a cash practice without making any attempt to advocate for the sickest of the sick, turning a blind eye to their suffering.

Sorry for rambling. This thread felt like an invitation to air my righteous indignation which I have to do from time to time. Stepping off of my soapbox now.

 

[clausewitz2]

I think a lot of the disagreement here comes from how people are using terms differently. Maybe there is some genuine disagreement about whether there is a role for long term custodial care in a locked setting (what people think of when they say state hospital beds). I believe there is a role for this in the U.S., sadly, due in part to the pathologically individualistic society that we live in. I fervently believe that it is possible for it to be done well even though it has historically been done so poorly. But it should be a relatively small role. And these long-term hospitals should be oriented towards rehabilitation, because you never know who can surprise us and make a surprisingly robust recovery and someday be ready for a less restrictive environment. So perhaps "custodial care" isn't quite the right term. Do they need to be funded by the states? I would argue no, that the legacy of the federal government abdicating responsibility for the care of the most seriously ill in a game of hot potato with state governments was never ok and it's past time we demand the repeal of the IMD exclusion so that Medicaid can cover the costs of care in whatever environment is most appropriate. I think this would resolve a lot of perverse incentive problems including the old "put em on a bus to somewhere far away and they won't be our problem anymore" trick.

This begs the question, do longer term hospitals actually need to be separate from acute care hospitals in a world where they're all funded by Medicaid? Probably not, honestly. Why not have a longer term ward for people needing longer term stabilization? Kind of like subacute, but for months or in some relatively rare cases years. I think it's hard to envision people getting longer term care in acute care hospitals that currently have a "treat em and street em" in 3-4 days model of care. And it's also hard (for me at least) to visualize the kind of serious recovery and rehabilitation-oriented environment that would be necessary for this to be effective, based on my experience with acute care hospitals in my area, where little effort is spent on even the most basic things like encouraging patients to get out of their rooms and attend groups that might be therapeutic for them.

As for the CMHCs, some do great work despite the difficult circumstances. On the whole though the system is so underfunded that we as a society should be ashamed of ourselves. I don't think psychiatrists should feel obligated to martyr ourselves by agreeing to be indentured servants at underfunded and often mismanaged CMHCs. I am grateful to those psychiatrists who feel compelled to do that and I was one of them for a time, until I couldn't handle being routinely disrespected by the management anymore and fled to academia. I do believe that psychiatrists have a moral obligation to advocate for better systems of care (inpatient, outpatient, and everything in between) and basic needs like affordable housing for those with serious mental illness. I don't find it morally acceptable to hang a shingle and see exclusively worried well in a cash practice without making any attempt to advocate for the sickest of the sick, turning a blind eye to their suffering.

Sorry for rambling. This thread felt like an invitation to air my righteous indignation which I have to do from time to time. Stepping off of my soapbox now.

Doesn't have to be either or. I am mostly. Private practice but part time am in a specialty service in a CMHC and soon will be stepping into a role as medical director/advisor to a program aimed at supporting a specific local refugee population that had tremendous amounts of actual no-fooling trauma and somatic idioms of distress. It matters less that the work that feels more like a mitzvah is paid less because I can do just fine financially off the back of part-time private practice work.

If every private practice psychiatrist out there was also doing part time work in the public sector, we'd be sitting pretty. Bit like the requirement for British physicians to work a certain amount on the NHS in addition to private work if they opt to do that.

 

[TheRightMedication]

Doesn't have to be either or. I am mostly. Private practice but part time am in a specialty service in a CMHC and soon will be stepping into a role as medical director/advisor to a program aimed at supporting a specific local refugee population that had tremendous amounts of actual no-fooling trauma and somatic idioms of distress. It matters less that the work that feels more like a mitzvah is paid less because I can do just fine financially off the back of part-time private practice work.

If every private practice psychiatrist out there was also doing part time work in the public sector, we'd be sitting pretty. Bit like the requirement for British physicians to work a certain amount on the NHS in addition to private work if they opt to do that.

Or, rather than mandate it, you can increase medicaid reimbursement. If medicaid paid enough to support the staff I would need to stay in compliance with medicaid requirements, then I'd take medicaid.

 

[bashir]

Sushirolls, I reread your original post and I'm genuinely so confused. You say there is nothing to be done to improve CMHCs and then list things that can be solved with money. Are you proposing we should just stop even trying to provide outpatient care to people with serious mental illness because grossly underfunding the system hasn't worked? What?

 

[futureapppsy2]

A huge issue with state hospitals (and similar facilities for people with developmental disabilities) is that they had a pretty horrific track record for abuse and neglect--people chained in piles of human waste, people physically beaten, people left to seize without care, people being deliberately and knowingly overmedicated to essentially make them comatose, etc. Watch content on Willowbrook if you want to see some of the documentation on this. A huge issue with CMHCs is that they are severely unfunded, so they can't provide adequate care and massively burn out providers employed there. So, the answer is that we need good oversight and good funding for both of these, but we can't get that, because no one in the government is really willing to fund the amounts needed to provide adequate care. Also, the Olmstead Supreme Court decision limits the degree to which people can be institutionalized long-term, so there's that--and honestly, for a lot of fairly recent history, disabled child were often institutionalized more or less their entire lives, and who knows what society missed out because of that? There are a subset of people who can't function in the community essentially at all and would benefit from long-term institutionalization, but there are many more who can do quite well with services like ACT when they are adequately funded.

 

[smalltownpsych]

My own experience with CMHC was less about underfunding and more about too many social workers and LPCs and not enough psychologists. At least from ensuring a higher level of service clinically. I personally left immediately after getting my license because the social worker in charge would only pay me 50k and so I went and got a job as a clinical director for 80k. One of the LPCs that worked with me at the CMHC also interviewed at this same company and they didn’t hire him as they didn’t think he was good enough to be a therapist at their facility and he was pretty representative of the general skill set of therapists working there.

 

[bashir]

My own experience with CMHC was less about underfunding and more about too many social workers and LPCs and not enough psychologists. At least from ensuring a higher level of service clinically. I personally left immediately after getting my license because the social worker in charge would only pay me 50k and so I went and got a job as a clinical director for 80k. One of the LPCs that worked with me at the CMHC also interviewed at this same company and they didn’t hire him as they didn’t think he was good enough to be a therapist at their facility and he was pretty representative of the general skill set of therapists working there.

As a general rule I think of the problem you describe as being a pretty direct result of underfunding. When you run a CMHC and can't afford psychologists or psychiatrists, you get less highly trained clinicians, whether you're talking therapists or "prescribers" (I hate this term).

 

[smalltownpsych]

As a general rule I think of the problem you describe as being a pretty direct result of underfunding. When you run a CMHC and can't afford psychologists or psychiatrists, you get less highly trained clinicians, whether you're talking therapists or "prescribers" (I hate this term).

I actually think that it is reflective of public policy more than money and that funding is often used to justify shortsighted poor planning and allocation of resources in many areas of government.

 

[comp1]

Not a lawyer, but I don't think Olmstead applies to many of the people we're talking about (and regardless, it's a vastly different Supreme Court since 1999). The plaintiffs were all developmentally disabled and had been found appropriate for community levels of placement, in addition to having the capability of specifically asking for it. I'm not sure inpatient psychiatrists would be arguing for community levels of placement for patients on their 20th inpatient admission in a year if they had relatively easy access to custodial care. I also don't see a lot of benefit to attaching long term custodial settings to acute care hospitals. They should be serving mostly different roles and have fairly different patient populations where one is likely to show significant response to medication or other therapeutic interventions and the other is not. I'm not at all convinced that every patient benefits from a recovery oriented mindset where recovery is so narrowly defined as eventually living in the community. Goals should always be tailored to the actual reality of the specific patient and not some sort of universal idea of what a patient should be able to achieve.

 

[Sushirolls]

Sushirolls, I reread your original post and I'm genuinely so confused. You say there is nothing to be done to improve CMHCs and then list things that can be solved with money. Are you proposing we should just stop even trying to provide outpatient care to people with serious mental illness because grossly underfunding the system hasn't worked? What?

I'm not seeing the confusion in my post. Sorry if that's how its presenting.

I am a pessimist, and believe even money wouldn't make enough improvements in the CMH system. You could possibly double or even tripple the budgets to raise salaries, hire staff, etc and I believe currently it would improve things in arbitrary quality units, 10-20%.

 

[comp1]

I'm not seeing the confusion in my post. Sorry if that's how its presenting.

I am a pessimist, and believe even money wouldn't make enough improvements in the CMH system. You could possibly double or even tripple the budgets to raise salaries, hire staff, etc and I believe currently it would improve things in arbitrary quality units, 10-20%.

Well yeah, you're not going to see much improvement with just more money because CMH is the wrong setting for a fairly large number of patients they serve.

 

[FlowRate]

The thing I found most frustrating about the otherwise very good CMHC I worked at as part of residency was that patients who didn't engage in services within X amount of time (and it was pretty short, I want to say 3 or 6 months) were removed from the CHMC's lists and would have to reapply if they were to need services in the future. There was a waitlist for getting in and somewhat stringent requirements for getting in. So it often led to a delay in the patient being able to get CMHC care. I sorta get the rationale but it always seemed weird to me when there were a few patients who legitimately cold have benefitted from once a year getting services through the CMHC for a few months. Or who would have benefitted from the motivation to engage post hospitalization but had to wait too long and lost interest/ability to do so.

 

[smalltownpsych]

The thing I found most frustrating about the otherwise very good CMHC I worked at as part of residency was that patients who didn't engage in services within X amount of time (and it was pretty short, I want to say 3 or 6 months) were removed from the CHMC's lists and would have to reapply if they were to need services in the future. There was a waitlist for getting in and somewhat stringent requirements for getting in. So it often led to a delay in the patient being able to get CMHC care. I sorta get the rationale but it always seemed weird to me when there were a few patients who legitimately cold have benefitted from once a year getting services through the CMHC for a few months. Or who would have benefitted from the motivation to engage post hospitalization but had to wait too long and lost interest/ability to do so.

This is a great example of the type of flawed design dynamic that I also see in these systems and the answer to critiques is always “funding” and nothing ever really changes which is why I tend to push against that narrative.

I am actually currently working with patients who have severe mental illness and parents with relatively unlimited resources and so I don’t have funding as an excuse anymore and I still can’t always help. Fortunately, the bar is pretty low to do better than the community system so that helps justify our monthly fees. We charge 3200 a month which is probably a lot less than a CMHC system expends for their “free“ care, but very few can afford to go outside that system and even the people who can don’t often have the option of the type of long term ongoing support that we provide.

 

[annoyedpsychiatrist]

I think your premise is too black and white. There are problems with CMHs, but the vision of enabling patients to live independent lives outside of hospitals should not be disregarded. I have a number of patients who cycled in and out of hospitals and jails before getting onto my ACT team and now are doing great. Even patients I initially believed should have been committed to state hospitals have managed to avoid hospitalization. The only patients I have that cycle in and out of institutional settings are heavy drug users and even then it's less than 10% of my patient panel.

If the following problems were addressed, then CMHs would be more viable.
1) The quality of CMH psychiatrists/providers tends to be awful because the pay is not worth the increased stress and risk.
2) The turnover rate is waaayyyy too high because organization's tend to get social workers straight out of training and pay them very little in exchange for supervision until they get fully licensed. It's rare to find a person who actually wants to be there.
3) Medicaid needs to pay more to incentive non-CMHs to see some of these patients to ease the burden on CMHs and to enable higher pay for CMH staff to reduce turnover.
4) CMHs should be required to actually abide by high fidelity models and stop bastardizing ACT/PACT models, which causes a substandard level of care.

I managed to make it about 15 months on my ACT team, but the stress and lack of support eventually got to me. I'm transitioning to private practice now. If Medicaid paid more, I'd still try to see some of these patients, but the pay is so abysmal that it's no where near worth it.

this. Only positive is correct me if im wrong but a lot of them qualify for sovereign immunity. Worked at largest CMH in state (first or second largest I forget) for a year. Every day I came home anxious, worried, and feeling defeated. 20 patients a day on an ancient EMR. Ancillary staff didnt give a ****. My nurse would disappear on me to go take smoke breaks and then get mad when i would ask her to room a patient. Was told to supervise 3 midlevels and that escalated to 5. I complained and was labeled malignant by one of the big bosses and was told to adjust my attitude. I thanked him and promptly left soon after. Same person called me a month ago (after a year had passed) and tried to get me to come back and help them fix things but there is no "fix" because the people running it dont get it, where the money goes is quite fishy, and they cant keep staff that want to be there because they paid garbage so they max out patient schedules with an emphasis on numbers over quality.

For CMH to succeed they would need more funding and better direction and also more power given to providers. A patient threatened my life at one point and went to attack me, and they tried to force me to see the same patient a few months later saying I had to and I just kept refusing. Ridiculous.

 

[smalltownpsych]

this. Only positive is correct me if im wrong but a lot of them qualify for sovereign immunity. Worked at largest CMH in state (first or second largest I forget) for a year. Every day I came home anxious, worried, and feeling defeated. 20 patients a day on an ancient EMR. Ancillary staff didnt give a ****. My nurse would disappear on me to go take smoke breaks and then get mad when i would ask her to room a patient. Was told to supervise 3 midlevels and that escalated to 5. I complained and was labeled malignant by one of the big bosses and was told to adjust my attitude. I thanked him and promptly left soon after. Same person called me a month ago (after a year had passed) and tried to get me to come back and help them fix things but there is no "fix" because the people running it dont get it, where the money goes is quite fishy, and they cant keep staff that want to be there because they paid garbage so they max out patient schedules with an emphasis on numbers over quality.

For CMH to succeed they would need more funding and better direction and also more power given to providers. A patient threatened my life at one point and went to attack me, and they tried to force me to see the same patient a few months later saying I had to and I just kept refusing. Ridiculous.

One thing I have seen is that clinical decision making in mental health is often made by non-clinical people. When I have worked in more purely medical settings, this was much less the case. Hard to imagine an admin telling a surgeon what they needed to treat or not but they seem to think they can tell us what we should do, how often, how long, and who to treat. I refuse to work in a setting where my care is dictated by someone who is not qualified and have left two prior positions for precisely that reason.

 

[allantois]

One thing I have seen is that clinical decision making in mental health is often made by non-clinical people. When I have worked in more purely medical settings, this was much less the case. Hard to imagine an admin telling a surgeon what they needed to treat or not but they seem to think they can tell us what we should do, how often, how long, and who to treat. I refuse to work in a setting where my care is dictated by someone who is not qualified and have left two prior positions for precisely that reason.

I would argue that at least in my part of the country mental health agencies are usually headed by clinical people, most commonly social workers/mental health counselors

 

[Mad Jack]

State hospitals were far more humane than the public realizes, at least in many local cases. The state hospital near where I trained had a bowling alley, movie theater, sports facilities, dances, over a hundred acres of grounds and gardens, numerous other facilities and events, and jobs that could be worked to build a sense of skill and competence. It generally did well by the clients there. With changes to laws and funding, it has been reduced to a large inpatient-only environment with few amenities and little to offer, aside from a locked unit on which to linger. Those that would have been hospitalized there before often cycle between homelessness, substance use, inpatient units, and legal issues, with minimal quality of life. At least under the old system they would have been fed, housed, and have had enriching activities to engage in. Now they just suffer, all for the idea that being destitute and in the community is better than the old way

 

[comp1]

Institutional settings can absolutely be humane. The whole idea that the goal for everyone MUST be community living is not only setting us up for horrible failure, but also for a heck of a lot of suffering.

 

[Merovinge]

State hospitals were far more humane than the public realizes, at least in many local cases. The state hospital near where I trained had a bowling alley, movie theater, sports facilities, dances, over a hundred acres of grounds and gardens, numerous other facilities and events, and jobs that could be worked to build a sense of skill and competence. It generally did well by the clients there. With changes to laws and funding, it has been reduced to a large inpatient-only environment with few amenities and little to offer, aside from a locked unit on which to linger. Those that would have been hospitalized there before often cycle between homelessness, substance use, inpatient units, and legal issues, with minimal quality of life. At least under the old system they would have been fed, housed, and have had enriching activities to engage in. Now they just suffer, all for the idea that being destitute and in the community is better than the old way

I toured one in marked structure decline since the changes over the past 50+ years and holy heck I couldn't believe how nice it looked. Many of the building were vacant but it was like a small rural town like you describe with great outdoor rec areas/options (this was in a part of the state/country where land is essentially worthless). I was actually taken aback by how much nicer it was than probably many towns in the 1950s or so.

 

[Evidence Based]

I work in a community mental health system with an academic affiliation, and while some of the comments on this thread ring true I think very few of my patients (like maybe 5) would benefit from long term institutionalization over community care (and I work in a specialty psychosis clinic). I have a lot of patients doing really well, and I find the work to be quite rewarding. I don't think I could do it full time or without teaching, research, etc., but quality care in the community for people a lot of means is certainly not impossible.

Of course we should be pushing for a much better model that would truly support recovery (Trieste! https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.0167)

 

[FlowRate]

I've seen some state hospital models that are like the opposite of the integrated senior living - assisted living - SNF - locked dementia unit facilities. Step down care with increased freedom as patients succeed in each level. Seems intuitively compelling.

 

[comp1]

Yeah, I think step down as opposed to step up is very reasonable, as long as there is an understanding that not every patient should be expected to eventually discharge from custodial care or even significantly step down levels of care. Budgeting should assume that most people at this level of care will remain roughly the same functionally barring some sort of massive advancement in medicine. And definitely, the vast majority of people, even those with severe psychotic illnesses, who are regularly being seen in any sort of outpatient care would not be appropriate for long term custodial care. We're not talking about patients who are even intermittently coming to outpatient appointments. We're talking about people who get all or almost all of their care from the correctional system or acute inpatient care units and have for most of their adult lives. It actually requires a pretty firm grasp on reality and a relatively high level of functionality to engage with an ACT team or, even higher, make it to an actual scheduled outpatient appointment.

 

[smalltownpsych]

I would argue that at least in my part of the country mental health agencies are usually headed by clinical people, most commonly social workers/mental health counselors

I’m not sure if having a midlevel in charge is really that much better than another administrator.

 

[Coupd'Cat]

I think your premise is too black and white. There are problems with CMHs, but the vision of enabling patients to live independent lives outside of hospitals should not be disregarded. I have a number of patients who cycled in and out of hospitals and jails before getting onto my ACT team and now are doing great. Even patients I initially believed should have been committed to state hospitals have managed to avoid hospitalization. The only patients I have that cycle in and out of institutional settings are heavy drug users and even then it's less than 10% of my patient panel.

If the following problems were addressed, then CMHs would be more viable.
1) The quality of CMH psychiatrists/providers tends to be awful because the pay is not worth the increased stress and risk.
2) The turnover rate is waaayyyy too high because organization's tend to get social workers straight out of training and pay them very little in exchange for supervision until they get fully licensed. It's rare to find a person who actually wants to be there.
3) Medicaid needs to pay more to incentive non-CMHs to see some of these patients to ease the burden on CMHs and to enable higher pay for CMH staff to reduce turnover.
4) CMHs should be required to actually abide by high fidelity models and stop bastardizing ACT/PACT models, which causes a substandard level of care.

I managed to make it about 15 months on my ACT team, but the stress and lack of support eventually got to me. I'm transitioning to private practice now. If Medicaid paid more, I'd still try to see some of these patients, but the pay is so abysmal that it's no where near worth it.

Absolutely agree with #1-4, and I would also add that CMHs have historically been run by non-physicians up and down the admin chain because they couldn't hire enough psychiatrists in the first place, and so needed to learn how to do without. As a result, it is very frustrating to work in a hierarchical and toxic system that expects you to do as your told even when the people telling you have less clinical experience than a pile of bricks. The prior CEO of our CMH praised a prior psychiatrist as a model employee because he "did what he was told" and ran up to a floor he didn't even work on to inject a patient q15 with various antipsychotics so he could be transported to another facility "I asked everyone else and no one was brave enough to do it!". They left to go make more money elsewhere and the new CEO is a genius who once announced that patient information shouldn't be shared in our /clinical/ meetings because that would be a HIPPA violation.

Anyway, I still have hope that there will be gradual change from the ground-up if there are more like-minded clinicians and psychiatrists joining CMHs, but who knows. I want to believe there's some change in how our country as a whole views what people with SMI "deserve" or what people who have been marginalized for generations "deserve" but the backlash is just as strong.

 

[annoyedpsychiatrist]

Absolutely agree with #1-4, and I would also add that CMHs have historically been run by non-physicians up and down the admin chain because they couldn't hire enough psychiatrists in the first place, and so needed to learn how to do without. As a result, it is very frustrating to work in a hierarchical and toxic system that expects you to do as your told even when the people telling you have less clinical experience than a pile of bricks. The prior CEO of our CMH praised a prior psychiatrist as a model employee because he "did what he was told" and ran up to a floor he didn't even work on to inject a patient q15 with various antipsychotics so he could be transported to another facility "I asked everyone else and no one was brave enough to do it!". They left to go make more money elsewhere and the new CEO is a genius who once announced that patient information shouldn't be shared in our /clinical/ meetings because that would be a HIPPA violation.

Anyway, I still have hope that there will be gradual change from the ground-up if there are more like-minded clinicians and psychiatrists joining CMHs, but who knows. I want to believe there's some change in how our country as a whole views what people with SMI "deserve" or what people who have been marginalized for generations "deserve" but the backlash is just as strong.

you know i put a lot of passion into my 12 months of working at a CMH. I instituted ideas like "hey maybe we should get EKGs for people on 4 antipsychotics, and start to reduce antipsychotic polypharmacy" "hey maybe that person who is actively abusing fentanyl shouldnt be getting xanax from here" "lets not give the person who was just arrested for meth, adderall" "lets not put an NP with no clinical experience (who just graduated and has never done anything with psych before) into a clinic by herself and then have me sign off on her notes". I remember she would keep trying to order adderall for patients because they had ADHD "they said they couldnt focus and were positive on ADHD screener!!".

When I left, a psychiatrist replaced my role and he was fired after he was having a f/u visit with a patient, and it was discovered the psychiatrist was in a hotel room in miami at the time, and a naked woman got out of the bed and walked past the camera. I wish I was making this up. Shortly after they lost the rest of their physicians and they are now down to a 84 year old medical director who originally started out in ob/gyn, and one NP. This is one of the largest CMHs in the state.

Its really sad, because I liked so many of my patients there but when I tried to make changes, improve quality by introducing standards of care based on evidence based medicine, advocate for a better EMR and not 22 patients a day, etc I was told I was malignant by one of the higher ups. The same higher up who called me a year later and tried to get me to come back.


Easy ways to attract physicians at CMHs

1. improve the pay
2. improve the EMR
3. Reduce patient load
4. Government steps in to reduce liability/more acknlowedgement that the people being treated are very sick people and that is taken more into account
5. more power given to physicians, less given to businessmen


The thing is THEY CAN AFFORD TO PAY PHYSICIANS MORE. These places are far from broke. My last place was always getting grants, all the freaking time. I know they werent hurting, and I was doing the work of 3 psychiatrists at times. But they dont care about quality, they want conveyor belt medicine and they dont care if they continuously rotate through providers or utilize undertrained providers.

sorry long winded rant of how broken the system is for CMH.

 

[MacDonaldTriad]

My career is long enough to say that many of my mentors lamented about the community movement and the demise of state hospitals. I can also say that my perspective has evolved from believing this movement to be evil, to believing that it is complicated, and the truth is complicated. During my career, I have seen the state hospital system to continue to be cut back so far, you can’t access treatment unless you are a felon.

Those who believe enough in CMH to try and are leaders are gob smocked by their county’s boards of supervisions who blame them for not solving the homeless crises that is “clearly a mental health failure” (which it is not). They come back from meetings beaten up by boards saying that they are dumfounded as to what would make any group of politicians believe that a mental health director could be so omnipotent.

My two cents is that those who say that “we” (psychiatrists) are guilty of over stating the ability of the newly invented Chlorpromazine to empty out the state hospitals. I actually think that this relatively modern addition to our arrows in our quivers has been remarkable, but not a panacea. Our state hospitals began to be shut down at alarming rates, but many of the patients we steward are probably better off not committed to these hospitals. Unfortunately, many are not. We are still relatively new as compared to a few or couple of centuries of state hospital existence, depending on how you define state hospitals or compassionate care. It is of small wonder that government debate found it convenient to cut state hospital funding. Many say that CMH could have succeeded better if the funding were redirected in an equal ratio. Again, the truth is in the middle.

Some under our care need custodial care and historically, state hospitals were not nice places. None the less, many had better supports and vocational rehabilitation services than anyone does now, at least for the more severely ill. There are exceptions where modern vocational supports are doing well for patients with skills that are less challenged by their mental health pathology.

This always comes down to the endless argument about how to use limited resources for the greatest good of society. We can push and demand that any money not spent on the most severely and persistently mentally ill is cruel and this group should get priority. However, we could spend 100% of everything on the sickest of a large population and service only a percentage that is probably in the teens, or even the single digits if the court system is allowed to mandate/sentence into care systems having jail and prison overcrowding in mind.

Alternatively, we can offer services to moderate or even mildly ill populations at the expense of some of the most desperate. This proves the old adage that we have proven over and over. “Bad care is more expensive than good care”, but the rub is that no care will always be cheaper than either of these, at least cheaper for us. Admittedly, this does shove costs to the penal system which counterbalances my above reference to the court system.

Anyone who sees this as simple and has the answers and questions what our leaders were or are thinking need to give it a try before they learn differently.

 

[Merovinge]

My career is long enough to say that many of my mentors lamented about the community movement and the demise of state hospitals. I can also say that my perspective has evolved from believing this movement to be evil, to believing that it is complicated, and the truth is complicated. During my career, I have seen the state hospital system to continue to be cut back so far, you can’t access treatment unless you are a felon.

Those who believe enough in CMH to try and are leaders are gob smocked by their county’s boards of supervisions who blame them for not solving the homeless crises that is “clearly a mental health failure” (which it is not). They come back from meetings beaten up by boards saying that they are dumfounded as to what would make any group of politicians believe that a mental health director could be so omnipotent.

My two cents is that those who say that “we” (psychiatrists) are guilty of over stating the ability of the newly invented Chlorpromazine to empty out the state hospitals. I actually think that this relatively modern addition to our arrows in our quivers has been remarkable, but not a panacea. Our state hospitals began to be shut down at alarming rates, but many of the patients we steward are probably better off not committed to these hospitals. Unfortunately, many are not. We are still relatively new as compared to a few or couple of centuries of state hospital existence, depending on how you define state hospitals or compassionate care. It is of small wonder that government debate found it convenient to cut state hospital funding. Many say that CMH could have succeeded better if the funding were redirected in an equal ratio. Again, the truth is in the middle.

Some under our care need custodial care and historically, state hospitals were not nice places. None the less, many had better supports and vocational rehabilitation services than anyone does now, at least for the more severely ill. There are exceptions where modern vocational supports are doing well for patients with skills that are less challenged by their mental health pathology.

This always comes down to the endless argument about how to use limited resources for the greatest good of society. We can push and demand that any money not spent on the most severely and persistently mentally ill is cruel and this group should get priority. However, we could spend 100% of everything on the sickest of a large population and service only a percentage that is probably in the teens, or even the single digits if the court system is allowed to mandate/sentence into care systems having jail and prison overcrowding in mind.

Alternatively, we can offer services to moderate or even mildly ill populations at the expense of some of the most desperate. This proves the old adage that we have proven over and over. “Bad care is more expensive than good care”, but the rub is that no care will always be cheaper than either of these, at least cheaper for us. Admittedly, this does shove costs to the penal system which counterbalances my above reference to the court system.

Anyone who sees this as simple and has the answers and questions what our leaders were or are thinking need to give it a try before they learn differently.

The problem is exactly as you put it. When money becomes siloed off into budgets instead of largely fungible it creates all sorts of perverse incentives and moral hazard. If we can spend $100 to save the penal system $1000, people who depend on the budget of the $100 don't want to do it. It is still more complicated than this alone, but the very perverse economics is one of the largest barriers to actually seeing reform/improvement so I'm not even sure it's even a worthwhile problem to attempt to target when functioning in a system that will always be broken from an econ 101 perspective.

 

[Coupd'Cat]

you know i put a lot of passion into my 12 months of working at a CMH. I instituted ideas like "hey maybe we should get EKGs for people on 4 antipsychotics, and start to reduce antipsychotic polypharmacy" "hey maybe that person who is actively abusing fentanyl shouldnt be getting xanax from here" "lets not give the person who was just arrested for meth, adderall" "lets not put an NP with no clinical experience (who just graduated and has never done anything with psych before) into a clinic by herself and then have me sign off on her notes". I remember she would keep trying to order adderall for patients because they had ADHD "they said they couldnt focus and were positive on ADHD screener!!".

When I left, a psychiatrist replaced my role and he was fired after he was having a f/u visit with a patient, and it was discovered the psychiatrist was in a hotel room in miami at the time, and a naked woman got out of the bed and walked past the camera. I wish I was making this up. Shortly after they lost the rest of their physicians and they are now down to a 84 year old medical director who originally started out in ob/gyn, and one NP. This is one of the largest CMHs in the state.

Its really sad, because I liked so many of my patients there but when I tried to make changes, improve quality by introducing standards of care based on evidence based medicine, advocate for a better EMR and not 22 patients a day, etc I was told I was malignant by one of the higher ups. The same higher up who called me a year later and tried to get me to come back.

This is what I think is incredible. Did the people who run these institutions wake up every day and decide they want to lead dangerous and malignant cesspools where standards of care go to die? Do they go to sleep at night congratulating themselves for another successful day of lying and threatening their staff into obedience? The thing that pisses me off the most is when they insult staff to my face and imply that direct staff paid half of what they are paid are untrained uneducated complainers. The latter have twice as much empathy and common sense than they ever will.

How is it that the same nonsense is in every CMH? Similar shenanigans as to your story - people sleeping up and down the building and impregnating other staff, breaking up marriages. I don't see how - what about this 60s-era asbestos funhouse is an aphrodisiac

The good old "I'm not malignant, you're malignant" playbook. Right next to the "these are problems everywhere that will never change I can't do anything about it, you're the idiot for asking"

Even the EKGs - When I asked, the response was "the doctors didn't want it a few years ago because then they would be more liable".

12 months is a respectable time. Honestly any amount of time is a respectable time. Hearing about the variety of CMHs out there, I think ours falls somewhere in the middle on the disaster scale. Psychiatrists are near fully staffed, no NPs. I respect most of the other psychiatrists. The pay for psychiatrists in our state CMHs is higher than the nearby academic centers. Reasonable patient census. Very little micromanaging (the bar is so low). Great case managers, thus high show rates. And there are individual GEMS of people who find some way to stay. The other plus is that manager turnover is just as high. I've managed to outlast two, and I have too much spite and pride to feel like they've won by driving me out of a job that I enjoy 80% of the time. But I also have too much pride to make a career here.

 

[TheRightMedication]

Is working at a CMH on a 1099 an option? That would free you from half of the shenanigans.

 

[Coupd'Cat]

Is working at a CMH on a 1099 an option? That would free you from half of the shenanigans.

I don't see how, besides having less skin in the game. Half our doctors are locums, same things still happen except they complain less than the staff psychiatrists who are more vested.

 

[Stagg737]

State hospitals were far more humane than the public realizes, at least in many local cases. The state hospital near where I trained had a bowling alley, movie theater, sports facilities, dances, over a hundred acres of grounds and gardens, numerous other facilities and events, and jobs that could be worked to build a sense of skill and competence. It generally did well by the clients there. With changes to laws and funding, it has been reduced to a large inpatient-only environment with few amenities and little to offer, aside from a locked unit on which to linger. Those that would have been hospitalized there before often cycle between homelessness, substance use, inpatient units, and legal issues, with minimal quality of life. At least under the old system they would have been fed, housed, and have had enriching activities to engage in. Now they just suffer, all for the idea that being destitute and in the community is better than the old way

I toured one in marked structure decline since the changes over the past 50+ years and holy heck I couldn't believe how nice it looked. Many of the building were vacant but it was like a small rural town like you describe with great outdoor rec areas/options (this was in a part of the state/country where land is essentially worthless). I was actually taken aback by how much nicer it was than probably many towns in the 1950s or so.

Back in early 70's my dad was a tech at a state-hospital-like institution and when I first described modern inpatient treatment to him while I was in med school he was shocked. He told me about patients getting day passes and going to the movies or out to lunch with the techs and how a lot of their patients weren't even on locked units. Even if we wanted to bring some of those places back, I doubt we could implement them in any way that resembles what it once was d/t the level of liability issues. Imagine having a hospital like that today where a patient was allowed to leave for lunch and then died, even if unintentionally. It would be a disaster.

I work in a community mental health system with an academic affiliation, and while some of the comments on this thread ring true I think very few of my patients (like maybe 5) would benefit from long term institutionalization over community care (and I work in a specialty psychosis clinic). I have a lot of patients doing really well, and I find the work to be quite rewarding. I don't think I could do it full time or without teaching, research, etc., but quality care in the community for people a lot of means is certainly not impossible.

Of course we should be pushing for a much better model that would truly support recovery (Trieste! https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.0167)

I'm sure there are plenty of places where this is true, but where I'm at having more beds like old institutions that MJ and Merovinge described would be a dream. I see ER patients almost daily who would benefit from a place where real long-term stabilization could take place. There are multiple counties with ACT or crisis or various other outreach teams where I'm at, but they're still woefully understaffed in compared to what is needed. I can't count how many patients I've seen in our ER over and over again with the same problem without an effective solution, and many of them are plugged into the local community programs. Even with long-term institutionalization though, the ultimate goal would still be for them to return to the community, but they could get there after a longer, therapeutic hospitalization instead of having 5 or 6 admissions over that many months where they're just bounced around various local hospitals or in and out of the state facility.

 

[annoyedpsychiatrist]

I don't see how, besides having less skin in the game. Half our doctors are locums, same things still happen except they complain less than the staff psychiatrists who are more vested.

yeah exactly, they will just leave when it gets too bad. Half the time they're there putting in "enough" effort, and when it becomes a hastle they peace out. The ekg response is great. I think thats the overarching theme "if we dont know theres a problem, we can pretend the problem doesnt exist". It is a shame really. I actually had less people asking for adderall in CMH setting than I do here, lol.

for me the silver lining has been that at least theres a lot of psych jobs out there and were valuable in the market. that gives us some power at least.

 

[Candidate2017]

CMHCs do extremely important work. They cure homelessness, criminality, poor choices, substance use, fatherless homes, medical issues such as scabies and obesity, borderline and antisocial personality disorders through good intentions, words, and pills. If something can't be cured, it just needs an infusion of more tax dollars.

 

[sloh]

lf something can't be cured, it just needs an infusion of more tax dollars.

Always looking for the (sarcastic) punchline to your posts