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Fishkind, president-elect of the American Association of Emergency Psychiatry, said he tries to stay focused on providing better care and doesn't let himself get angry. He wants to see Texans move to an understanding that sometimes you invest money to save money -- just like in a business.
He's one of the group that huddles up to decide whether NPC should go on drive-by status. He stresses that in each case this was just for a matter of hours and that they worked with other area hospitals to find places for these people. Most NPC patients are of the "23-hour care" variety, meaning that technically they are there for less than a day. Eight beds have been reopened on NPC's second floor, which houses patients for three to five days.
But most NPC patients who need hospitalization go to the University of Texas Harris County Psychiatric Center. MHMRA contracts with HCPC for 143 beds. Those institutions talk among themselves hourly when patients back up. As soon as HCPC discharges someone, NPC moves another patient over, opening a slot for someone new. Sometimes beds open up in Rusk, the state hospital, said Barbara Dawson, head administrator at NPC.
It's a gigantic game of human chess.
Based upon population, Harris County should have six or seven public emergency psychiatric facilities, not just the two it has with Ben Taub and NPC, Fishkind said. Some hospitals such as Methodist have staff to provide emergency psychiatric services, he said. And the Memorial system has a crisis response team that Fishkind describes as excellent.
Still, Schnee said, Memorial Hermann Southwest just closed its psych unit. In fact, more than 500 private psychiatric beds have closed in Harris County, Schnee said. With the vast number of uninsured patients in Texas, hospitals find psychiatric beds and psychiatric facilities unprofitable, so they close, Schnee said. "It's a business decision, not a question of whether or not the treatment is needed."
With job layoffs, people lose health care benefits. People used to dialing the 1-800 number on their insurance cards are now clients of the public health system, walk-ins with cell phones and no way to pay for life-sustaining medicines. And Harris County can't handle all this new popularity.
In fiscal 2003, there is no additional money for mental health services in the county, Schnee said. In five years, HCPC has not received any significant increase from the legislature, he said.
Commissioners Court has continued to generously fund local mental health needs, but its resources just don't match those of the state's.
Increased cooperation among the county mental health agencies will be crucial in coming months, Fishkind said.
And hospitalization isn't even the desired goal in most of these cases. Dawson is proud to say that of the more than 12,000 NPC patients in the last year, only a quarter of them had to be hospitalized. The goal is to see to patients' needs and put them in the least restrictive environment.
The Ben Taub psychiatry department has worked up one proposed program that holds promise, Fishkind said. "Partial hospitalization," as it is called, would bring patients into the hospital setting during the day for treatment but would allow them to sleep in their own homes at night. Again, this would take tremendous pressure off the system and make most patients a lot happier.
It also stretches mental health dollars to serve a lot more people.
HCPC, which is now attracting streams of walk-in patients, has already changed its way of doing business, spokeswoman Geri Konigsberg said. A month ago, HCPC began moving patients into a new discharge unit where they can watch television or movies and play games while waiting for relatives to pick them up after work. "It keeps them in a safe environment and frees up beds," Konigsberg said.
At MHMRA, Schnee said his agency is working hard to get more people on third-party or Medicaid coverage.
Whenever there are funding shortages, there are also questions about whether an agency is managing itself correctly. A 1997 investigation discovered MHMRA lost track of federal housing funds and spent little of the $5.4 million it had received from 1993 to 1996. This, when housing continues to be one of the crucial problems for the area's mentally ill.
Fishkind said a new chief financial officer and deputy executive director are trying to make the most of every bit of funding. He acknowledged that all mental health authorities are moving toward different models of operation and delivery and MHMRA will be no exception if it wants to survive.
Over time, there has been increased outcry that insurance companies cover mental health at a fraction of what is provided for in medical coverage. A congressional bill would broaden mental health insurance coverage -- a bill that the insurance lobby is fighting.
Even if it passes, of course, it won't help the uninsured, of which Harris County has far too many.
Mental health coverage in Texas will change, Konigsberg said, as more people demand improvements for their children. HCPC just signed a contract to provide services to kids in Head Start. That's kids from birth to five years old. As Konigsberg puts it, would you rather pay for prevention now or jail later?