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"They told the clinicians they had to enter their own data," Tamedy says. "But if you're seeing 15 patients a day, all day, you get behind in your documentation. Anybody who works for that agency will tell you, you can never stay caught up with everything."
Schnee acknowledges that MHMRA's staff is stretched too thin. Ideally, he says, clinical teams should handle 50 patients a month, a ratio that would require millions upon millions of dollars in additional state funding. MHMRA has let unlicensed employees go because they couldn't bill the government and insurance companies for services. Meanwhile, the agency can't recruit enough qualified clinicians. MHMRA is short five or six psychiatrists, and each clinic is short at least three LPHAs. The staff shortage has the greatest impact on the poor, Schnee acknowledges, who are losing their place in line for services to insured patients.
"It's not like we said, "Whoops, we're missing physicians, so we're not going to serve people,' " Schnee says. "We serve them, but we have to space them out more. There may be less time with the physician." Patients "may not be getting the attention we wish they could."
As a result, perhaps, patient complaints about surly and disrespectful staff are on the rise. Rose Childs, MHMRA's deputy director of the adult mental health division, says she hasn't heard of anyone being "really nasty," although she understands that not everybody is happy with the new system. "I'm not going to deny that," Childs says.
Unlike other state-funded health and human services, access to public mental health care is a matter of diagnosis and disability, not income. Local agencies like MHMRA are required to spend their state funds on a "priority population" -- children with life-threatening emotional or social disabilities; and adults with schizophrenia, major depression, bipolar disease or other disorders that require long-term care.
According to a 1999 study by the local Mental Health Needs Council, 160,000 Harris County residents have symptoms that qualify them for public mental health services. At least 55,000 of them go untreated, either because they can't afford private care, have no insurance, don't seek treatment because of the stigma, or the MHMRA system can't handle them. Many end up in the county jail or the state prisons, where they get at least some care. Others are in and out of state hospitals.
But an increasing number of Harris County residents are getting mental health care under the worst circumstances: in the emergency room. Because of staff shortages, MHMRA can handle only 270 to 300 appointments a week, which barely covers the number of patients discharged from Harris County Psychiatric Center. The agency is obliged by contract to see HCPC patients within five days of discharge, but that hasn't happened regularly in more than a year. In the last three months, four out of ten patients discharged from HCPC didn't get an appointment within five days, and nearly half of those didn't get one within two weeks.
"We don't have the data yet, but I believe a large percentage of our patients never make it to MHMRA's first appointment," says Dr. Roy Varner, HCPC's medical director. The longer a discharged patient has to wait to see an MHMRA physician, the greater the likelihood he'll stop taking his medication, Varner says. Invariably, the patient's symptoms return and he ends up seeking emergency treatment.
For years that meant a trip to Ben Taub Hospital, which is run by the county. That changed a year ago, when the crisis unit opened at the new NeuroPsychiatric Center. At the time, MHMRA anticipated the crisis unit would see 20 to 25 patients a day. More than 40 are coming into NPC daily, and a quarter of them are new to the MHMRA system. One in five cases is serious enough to merit hospitalization. The rest have to be stabilized and released within 24 hours. Sometimes they leave NPC with a prescription for antipsychotic medication. But rarely are they given an appointment for follow-up care.
"That's treating them and streeting them," says Kristi Huddleston.
Undoubtedly, NPC's crisis unit fulfills a significant need. Ben Taub, which also has a 20-bed psychiatric ward and an acute-care lockup, was so busy that it was on "drive-by" status, or filled to capacity, nine days a month. The crisis unit has eased that burden on the county hospital.
But NPC is also a source of considerable frustration, especially among patients and advocates who lobbied Commissioners Court in 1997 to build the $5 million center. NPC was proposed as a crisis unit, plus a 39-bed short-term hospital. The crisis unit opened last October, a year late. The second-floor hospital opened eight weeks ago, two years late. And as it happens, the second floor isn't a 39-bed hospital as planned, but a 16-bed "acute-care facility."
As an acute-care facility, NPC is not regulated by the Joint Commission on Accreditation of Healthcare Organizations, which sets staffing, record-keeping and procedural standards for hospitals. The lack of accreditation means NPC can get by with fewer employees, but it also limits how long most patients can stay before being transferred to a regular hospital. Barbara Dawson, NPC's administrator, says the acute-care facility was designed for patients who need three to five days in bed before they are stabilized. Beyond that, the patient is typically moved to HCPC, a state hospital or, if the patient has insurance, a private hospital.