Nowhere to Land

Crisis care for the mentally ill crumbles under the weight of not enough money, too much beauracracy

Tim Ramey is an unfortunate 26-year-old soul whose mother loves him dearly even though four years ago he almost raped and killed her. Mentally ill, he will always need structure, medication and guidance. Because of his problems he won't be able to get that living with his parents.

"I want to take care of Tim, but I am deathly afraid of him," Dale Ramey says sadly about her son.

For the most part, his life is a not unusual pattern of partial victories followed by devastating defeats. His latest crash and burn commenced on July 30 when he was transported to the NeuroPsychiatric Center from Eva's Personal Care Home after he took a razor blade and made superficial cuts on his arms, threatened to kill a caregiver at the home and then said he was going to kill himself. His ACT (Assertive Community Treatment) team, a sort of roving unit of troubleshooters working for the Mental Health Mental Retardation Authority, hustled him to the emergency facility in the Ben Taub Loop. Things were being handled and would get better soon.

Tim Ramey is okay now -- at least for the next 90 days.
Deron Neblett
Tim Ramey is okay now -- at least for the next 90 days.
Tim Ramey is okay now -- at least for the next 90 days.
Deron Neblett
Tim Ramey is okay now -- at least for the next 90 days.
Tim Ramey is okay now -- at least for the next 90 days.
Deron Neblett
Tim Ramey is okay now -- at least for the next 90 days.

Except that's not the way it went. At least not according to Dale and Tim Ramey.

Tim's father, Bobby, got a call around 1 p.m. from Eva's that his son was being taken to the psychiatric center. Bobby immediately called NPC to get his son's status and to give authorization for treatment. In the next two hours, Bobby made three attempts to work with the center's staff. All failed. They refused to acknowledge his guardianship. He was told he would have to come to the medical center facility from their Spring Branch home and show them legal proof. He kept being told someone would talk to him about it further, but no one came to the phone.

Tim finally called his father himself from the psychiatric center around 3 p.m. and told Bobby he was going to have to come down to the medical center. But Bobby had to be at work by 3:30 p.m., and Dale was out of town on business. Bobby told his son he was just going to have to wait for Dale.

By 6 p.m. Dale got back and spoke with the center's staff, which had gone through a shift change, meaning she was starting all over again. Dale learned her son had been sitting in the waiting room since his arrival about five hours before. She was told he had received no treatment, no medication and had not been seen by a doctor because consent papers had not been signed. Dale wanted to know why the ACT team hadn't handled the paperwork for Tim's admission since it has the authority to do so. She was told her son had just been dumped off at the door. Both Tim and the ACT team say this was not true; that the ACT team representative talked to the center staff and was assured an evaluation would begin shortly.

Dale told NPC staffers they already had her son's information in the center's own computers; past NPC administrators had assured her anytime Tim came in, they would have all the information they needed. Within 15 minutes NPC faxed her the consent forms. Five minutes later she faxed back signed forms and guardianship proof.

The next call came around 8:30 p.m. when another NPC staffer said Tim was about to be discharged, without medication, without a treatment plan. Dale pleaded with them to keep him overnight, and they finally agreed.

Half an hour later she got another call. Nope, Tim couldn't stay without a mental health warrant. The doctor on duty refused to keep him there without one. The warrant would have to come from the owner or acting house manager of Eva's Place, firsthand witnesses to Tim's outburst. Dale asked if her husband could file it after he got off work around 12:30 a.m. since Tim had told him he was going to commit suicide over the telephone. No.

Around 11 p.m., an ACT team member talked to NPC and was told the mental health warrant was not needed, that NPC had dropped the ball on the admissions process, a special waiver was being granted and Tim could stay the rest of the night, Dale says.

Which he did, sleeping in a waiting-room recliner.

Tim Ramey has no clout, no leverage, no way to wheel and deal. Toss someone like him into a stressed-out, understaffed facility like NPC, too many of whose personnel clutch to rules and regulations like a life jacket, and sometimes things go very wrong.

Of course, this was not the way things were supposed to be.


MHMRA, the agency authorized by Texas to allocate state mental health services money in Harris County, opened the $5 million NeuroPsychiatric Center last October, far later than planned. Designed as an emergency center replacing the downtown Crisis Center, it was to relieve the load of people who'd been going to the adjacent Ben Taub emergency room.

Equipped to handle about 800 patients a month in so-called 23-hour care and to provide 39 beds for overnight stays of three to five days, NPC was overwhelmed from the start.

Instead of 800 patients, it averaged 1,200 to 1,300 people a month, MHMRA Executive Director Steven Schnee says. Instead of the equivalent of ten full-time psychiatrists, they started with six and a half. Resources stretched, the center became known for long waits before evaluation and treatment, a situation it has yet to correct, although Schnee says they've improved. "We have reorganized the staffing patterns."

Still, he told the MHMRA board at a trustees meeting July 25: "We don't provide the level of active treatment we all are seeking to provide."

There have been frequent staff turnovers among higher-ups. The first medical director quit, leaving the staff directionless and in chaos. They have just recently hired a new medical director, Dr. Avrim Fishkind, and Barbara Dawson, the former director of the Richmond State School, has been on board only three months as acting director of NPC. The director of nursing just started as well.

The second floor, which was to house those 39 beds, has never opened. In fact, at the July 25 board meeting, Schnee suggested it might be better not to ever open it as a hospital, instead licensing it as a "crisis stabilization" center. It would be "very similar in appearance" to a hospital, Schnee said, but wouldn't have to adhere to the higher standards of hospital accreditation and could thereby save money.

Gerald Womack, a member of the MHMRA board, was the only one at the meeting to challenge Schnee about the proposal to step down from hospital status. "I think the people of Harris County really have it in their heart that we would have a hospital," Womack said quietly.

But other board members may be swayed by the money message delivered by Schnee. State tax money isn't covering first-floor operational costs; the revenues coming in aren't doing that either.

On September 6, the second floor will finally open. But it won't have the promised 39 beds. It'll have 16. By cutting it to a max of 16 beds, the facility qualifies for "crisis stabilization unit" status. And they'll be able to bill for certain programs supported by federal funds, payments that wouldn't be allowed if they were a hospital, Schnee says.

Schnee insists this is no betrayal of the public trust. He is working with a limited amount of tax dollars. NPC has established there is a tremendous need for immediate crisis help. They may still open the remaining beds, he says, if that's in everyone's best interest.


Out of necessity, the courts have certain requirements to protect the rights of people in commitment procedures. But relatives of the mentally ill complain they must take off work, jeopardize their jobs and come in at all times of the night and day to fill out paperwork that is already on file with the county's mental health system.

Acting Director Barbara Dawson readily acknowledges that this hasn't been working as it should. Yes, the admittance process is redundant, lengthy and complicated. (Amazingly enough, it is still faster than the Ben Taub emergency room's, MHMRA people say, adding that police prefer to come to them so they can get out on the street faster.)

And people who come to NPC for help but have no third-party insurance, such as Medicaid or Medicare coverage, are sent on to the Harris County Psychiatric Center, where 143 state-funded beds are available. Whereupon they find themselves filling out the same paperwork they just completed, again.

All this has resulted in enough of an outcry that NPC has started meeting with the probate courts (which are in charge of mental health commitments) and the HCPC to come up with some way to streamline the process, thereby rescuing patients and NPC personnel from hours of paperwork and getting to treatment sooner.


Tim didn't last long at Eva's, getting himself ejected in short order for the second and final time. Dale Ramey became a wild woman, looking for a place to put him. She was able to get him into Bayou City Medical Center, but this was short-term. She appeared before the MHMRA board, begging for help. Schnee assured her they would try to do something, and Deputy Director Rose Childs began working on the case.

But promised return calls from Childs didn't come through as fast as Dale wanted. Dale grew more frantic and began contacting any legislator she could think of, any organization that's supposed to represent mental health consumer rights. She was told there's a place in Mount Pleasant with long-term care beds set aside for each county in the state. But Harris County's one bed was taken, and although one county can contract or "buy" a bed from another, Dale was told Harris County has no money for residential care of the mentally ill.

She was told Rusk was not an option. Schnee says they will send people to Rusk, but prefer to keep them closer by. Where was she supposed to put Tim?

Finally Rose Childs resurfaced with directions to what looks like the next best hope for Tim. He is now part of the Continuum Healthcare System Inc. It gives him residential housing on Southmore at night and vans him over for a day counseling program at the for-profit company's Texas Serenity Community Health Center facility on Airline in north Houston.

The facilities are good. Owner-founder Don Johnson, who has branches in eight Texas cities, says proudly: "We don't put our people into any facility I wouldn't spend the night in." That might be dismissed as so much self-promotion, except for the fact that his operation is accredited by the Joint Commission of Hospital Organizations, the highest level of accreditation. The kind of accreditation standards NPC is looking to avoid.

But this is transitional housing, probably 90 days tops. Then Tim is back out in the minefield of personal care homes.

Dale Ramey is desperate to see that change. Her crusade now is to draw attention to the lack of places for people like her son Tim. She wants a long-term residential option for the mentally ill in Harris County. She's even got a small group of people together to talk about this.

But as Johnson says, Texas is not so good at health care spending, ranking 49th among the states. "We're real good at building prisons, which handle people when they hit their lowest points, instead of empowering people" with mental health services, says Johnson.

Over the years Texas has drained money away from out-of-favor state institutions and then from community-based mental health centers, Johnson says. With no place to go, he says, these patients are often forced into hospital emergency rooms.

"They become what we call frequent flyers," Johnson says. "Flying in and out of the hospitals."

Frequent flyers with no place to land.

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