Travis County's mental health system is cracking under growing patient load
In early December 2009, the voices started again. Reginald Demps, 47, had heard them off and on for years. This time, he told his mother, Willie Jean Fisher, the voices were telling him to kill. "He said, 'Mama, I'm hearing voices telling me to kill, and I don't want to kill.' He got the Bible; we read it and prayed. And he said he was all right." Fisher's son had suffered from symptoms of schizophrenia for a long time, since some time after he began classes at Austin Community College in the 1980s. One time, she said, he came home saying people in the streets had told him that she was talking bad about him. Another time, more recently, she caught Demps placing all of his clothes in a pile in the backyard. He grabbed a gas can and said, "I'm going to barbecue tonight," Fisher recently recalled. "I called the police and said, 'Send a mental health [officer].'"
As December wore on, it was clear to Fisher that Demps was in trouble: He wasn't eating, and he was staying in his bedroom in her Northeast Austin home nearly round-the-clock. He had been prescribed Seroquel, which is used to treat schizophrenia and bipolar disorder, but at this point she wasn't sure if he was still regularly taking his medication. On Dec. 14, 2009, she said, Demps told her he wanted to go to the Austin State Hospital; his older brother, Michael, drove him to Psychiatric Emergency Services, a facility on the eastern edge of Downtown run by Austin Travis County Integral Care (the county's mental health authority). When they arrived, the brothers were told there were no local psychiatric beds available, Fisher says. That night, Demps complained to his mother that he could not sleep, so she went to the store, bought him Advil PM, and gave him two pills to take; he took them and finally fell asleep.
On Dec. 15, 2009, Fisher didn't see her son until she got home that evening. He seemed fine, she said, and, tired, she went off to bed. But he wasn't okay. Well after she was asleep – sometime around midnight – Demps called the police on himself, reporting that he was suicidal. Austin Police and EMS both responded to the call, and Demps was transported to the emergency department at St. David's Medical Center. According to a police report, Demps was seen at the emergency room just after midnight; he remained there for just more than four hours before he was discharged with a cab voucher for a ride to Psychiatric Emergency Services for a "consult." He was "seen there and released due to he was not a danger to himself or anyone else," police reported. (According to the Austin Police Department report, Demps was taken to the hospital for an "intentional overdose (suicide attempt)." But Fisher, a nurse, said she was told there were no drugs found in his system; she later counted the pills in the Advil PM bottle, but aside from the two she'd previously dispensed, none were missing.) Mere hours later, just after 1pm on Dec. 16, 2009, employees at the Radisson Hotel in North Central Austin found Demps dead in a hotel stairwell: He'd fashioned a noose from his sweater and hanged himself from a door hinge.
'Never Enough Beds'
Unfortunately, Demps' story isn't unique: Travis County has the highest suicide rate in Texas. According to APD stats alone, 93 people killed themselves in Austin in 2009. Local statistics also show the supply of behavioral health professionals working in Travis County has declined over the last decade, despite an increasing need for services. Meanwhile, the number of individuals presenting at local hospital emergency rooms in the throes of a mental health crisis has also spiked dramatically – up 84% from 2006 to 2007. The increase is in step with a growing national trend. "It's really horrible," says Dr. David Mendelson, a Dallas ER doctor who conducted a survey regarding treatment of psychiatric patients in hospital ERs for the American College of Emergency Physicians. "People sit in the ERs a long time, they take a lot of resources, and they are high-risk patients." At the heart of the problem is the fact that mental health services have never been woven into the comprehensive health care structure. And in Austin the degree to which mental health services are fractured from the overall fabric of health care is high, especially for individuals in crisis. That is in part because, unlike Texas' other major urban centers, Austin has few inpatient beds for the mentally ill and has no psychiatric ER, or a so-called "crisis stabilization unit," connected to any of the city's seven major hospital emergency departments. As a result, Austin has long overrelied on beds at the Austin State Hospital – which serves 38 Central Texas counties – to provide short-term inpatient stabilization services, mainly for the poor or uninsured. "We are unique for all urban areas in Texas," says Dr. Jim Van Norman, director of medical and clinical services for Integral Care. "We are the only urban area without psych beds [in a hospital]. That is a real shortcoming in the community, and it has been a disappointment for a number of years."
The resulting overuse of Austin State Hospital further complicates the already stretched system by taking up space needed for mentally ill jail inmates who've been found incompetent to stand trial and need to be stabilized before their cases can proceed. As of mid-April, there were 50 inmates waiting for transfer, one of whom had been there since Jan. 19, said Travis County Sheriff's Office Sgt. Kitty Hicks, who supervises the TCSO's Crisis Intervention Team. In sum, says Hicks, "There are never enough beds."
There are competing ideas about how to best tackle the systemic problem. Some say investing first in crisis stabilization beds is what is most needed; others argue the current fiscal climate calls for more investment in wrap-around services, like supportive housing and employment programs; still others contend that it isn't an either/or choice and that both avenues must intersect to keep people healthy while keeping costs under control.
Ultimately, the question Fisher wants answered is why her son's life ended in suicide. In starker terms, local mental health professionals want to know how to prevent even more deaths like that of Demps.
Better Than Before
Even in crisis, things are better than they used to be. Only a decade ago, the APD and TCSO were just starting to train officers to understand mental illness and to respond to mental health-related calls. Now APD and TCSO each have dedicated Crisis Intervention Teams, co-located at Austin State Hospital, and dozens of certified mental health officers on the streets. And officers no longer have to drive long distances to find an available treatment bed at one of the state hospitals when ASH is full, as they did in far worse times. As Van Norman tells it: "Five years ago, when [Hurricane] Katrina hit, law enforcement said, 'We're not traveling out of the county anymore.' So we had to think, where would somebody go if they were picked up by law enforcement?"
The question at the time, recalled Judge Guy Herman, who considers all applications for mental health commitments in Travis County, was "what is the best place of the available options: [hospital emergency rooms], the jail, the street, or in the back of a police officer's car?" The answer: The local ERs. "But we've got to put that in context," says Herman. "The best would be if there were beds in the private hospitals or in the public hospital, which is what happens in other communities."
The designation of local ERs as appropriate "mental health facilities" for people in crisis has been helpful, but it is not a long-term solution. The fact that there are no beds for psych patients within any of the local hospitals – including University Medical Center Brackenridge, owned by the health care district, Central Health* – means that patients in crisis are often parked in local ERs until doctors can either stabilize and discharge them or work with Integral Care to secure a bed at ASH or one of two private facilities. "It would be best for the patients if [their care] didn't involve the emergency department, but the reality right now is that they need to," says Dr. Christopher Ziebell, medical director of Brackenridge's emergency department. But bringing patients to the ER can actually be beneficial, says Dr. Steve Berkowitz, chief medical officer for St. David's HealthCare, because regardless of the reason they're brought in, all patients should be "medically cleared." Still, he added, "it's not a situation we wish we had."
Apart from ASH, there are just 23 in-patient beds available in Austin. By comparison, Houston and Dallas each have hundreds of local psychiatric beds at their disposal. While Austin lags behind the rest of the state, here too the local situation has actually improved over the last decade: Before the creation in 2004 of the local hospital district, now called Central Health, there were actually no local beds outside of ASH available for patients in crisis. Now, with local and state funding, some $7 million has been put to making those 23 beds available. But again, "here is where the frustration is," says Berkowitz. "There really are not enough psychiatric beds ... to take care of the patients we have in the ERs."
No Business Model
Despite the obvious need, neither Seton nor St. David's is particularly interested in getting into the psychiatric care business. First of all, said Ziebell, Medicaid won't cover the costs of running those beds. And unlike Dallas or Houston, which have had tax-financed hospital districts for a number of years, Austin's relatively new district is only taxing at roughly 6 cents per $100 property valuation. So it isn't surprising that if Dallas is taxing at 30 cents per $100, for example, that the county would have five times more capacity, Ziebell said. Putting it more precisely, he said, "The business model is not there for building it."
Berkowitz agrees: "Like any business, we can't be all things in all situations." Another factor is that neither St. David's nor Brackenridge has any psychiatrists on staff. If a psychiatric consult is needed at Brackenrdige, says Ziebell, it can take up to 36 hours to get a doctor to the hospital. "The majority of psychiatrists no longer have hospital privileges, or they associate with a state hospital or an institution where all of the patients are psychiatric," says Berkowitz. "That is the number one problem we have."
Integral Care's Van Norman isn't particularly impressed with either of these arguments. Both hospitals have MRI machines and ultrasound and X-ray equipment, and they keep specialists – like orthopedists, for example – on contract, so duplication of services doesn't seem to upset the hospitals' business models. Yet, he notes, none of them keeps a psychiatrist under contract or provides any room for psych patients. When asked about the lack of psychiatrists on staff, Van Norman says, hospital representatives have told him, "We're okay." He says he doesn't understand that: "You wouldn't decide you're not going to have an orthopedic specialist and say, 'Well, we'll just muddle through with these broken legs.'"
Nonetheless, more and more psych patients are arriving at Austin ERs in need of intervention. And without psychiatrists on staff, pressure falls on ER doctors to diagnose and treat patients without the aid of specialists. At St. David's, says Berkowitz, doctors first do a "medical evaluation" of every patient, including patients who come to the ER with mental health issues as their primary complaint. Beyond that, he said, "there is no protocol, because it's a judgment." In more severe cases, the hospital can legally hold a patient until a psychiatric bed is available. If that standard is not met, however, what happens next is entirely up to the attending doctor.
Sometimes that means patients are discharged when they aren't really out of crisis. Indeed, says TCSO's Hicks, "There are a lot of people released, and we'll go and pick them up again two hours later. It does get frustrating." And, law enforcement officials say, there are cases where patients commit suicide not long after being released from the ER – as demonstrated in December 2009 when Reginald Demps took his life.
The Final Hours
Some time after Demps arrived at St. David's ER, just after midnight on Dec. 16, 2009, his mother was awakened by the telephone. St. David's was calling to say that her son had been brought there by police and EMS. She was relieved that he had found help. She couldn't get over to the hospital that night because her car wasn't working. The caller didn't give her any indication that her son would soon be released, nor did the caller ask if she could be called upon to take him home and care for him. She was available to do so – she'd done so in the past, and with her nursing background felt confident in her abilities. When Fisher woke up the next morning and Demps wasn't home, she became worried. She borrowed a car and set out with son Michael to look for him. They went to St. David's. There, she said, someone in the ER told her that Demps would be at the Austin Lakes Hospital, in the St. David's Pavilion on 32nd Street. Demps was not there. They called the ER again: Fisher said a man on the phone told her only that St. David's wasn't a "psychiatric hospital."
"They didn't tell me nothing" about her son being discharged to Integral Care's Psychiatric Emergency Services, she said, and when she pressed for more information, she says, she was told he was an adult and that they were not obligated to release to her any further patient information. It wasn't until later that she learned from the police that her son Reggie had died.
So far, Fisher hasn't had any success piecing together Demps' last hours. When the Chronicle asked for information about Demps, both St. David's and Integral Care declined to comment, citing privacy concerns – but from what is known (primarily from information in the APD report on his death), it does seem possible that Demps fell through one of the cracks in the current crisis services system.
Demps was taken to St. David's ER for a possible suicide attempt and was there for roughly four hours. He would have been medically assessed and at some point a decision would have been made regarding whether he was a danger to himself or others. Had Demps been seen as a danger, the ER physician could have started the process to have him committed and held him at the ER until a bed became available at one of the psych facilities. But according to written answers provided to the Chronicle by St. David's officials, doctors might also decide to send a patient to the Integral Care Psychiatric Emergency Services facility, "a more appropriate psychiatric service provider" if the "patient is seen as a threat to him or herself or others."
Whether that was the conclusion the doctor made about Demps is unknown; according to APD, Demps was discharged just after 4:30am and sent in a cab to Psychiatric Emergency Services to be seen. While PES is equipped to handle walk-in patients in crisis, the services there are voluntary, and there is not necessarily a doctor at the facility in the middle of the night (Integral Care officials say a doctor is always on call). More importantly, however, according to written information provided to the Chronicle by Integral Care officials, patients discharged from local ERs and sent to PES are assumed to be out of crisis: "If an individual is discharged from the hospital, it means that a clinical assessment was done at the hospital prior to that, determining that they were not a harm to themselves or others," Integral Care officials wrote in an e-mail. That said, officials noted that anyone seeking services at PES, regardless of the hour, is "assessed, evaluated and cared for with the same urgency and attention."
Although there are clearly problems with the system – as Demps' case highlights – Hicks says she still feels for the hospitals. "Their main function is [physical] medicine," and yet they've been thrust unprepared into providing psychiatric care. Indeed, local officials say the designation of the ERs as appropriate mental health facilities was meant to be an interim solution, while local stakeholders worked together toward a more long-term plan. But that planning, which began in 2005, hasn't yet produced a permanent solution that would take the ERs out of the main loop of providing crisis mental health services. "It was allegedly to be an interim plan until we'd gotten a medical hospital-based model," says Judge Herman. "I don't have a problem with an interim solution. But an interim agreement cannot end up like Korea after 50 or 60 years, or like the Cuban embargo: It cannot become the de facto solution."
'Suffering in Misery'
To that end, what is the best long-term solution to meet the community's needs? "If all you do is build beds, then everyone has to wait to get service until they're in crisis," said Beth Peck, senior health care planner at Central Health. "I think what we've figured out is that we need a range of [services to address a range] of issues." Ziebell agrees that the paradigm should change to a model dedicated to keeping people well – in his view, local mental health stakeholders should alter their perspective and decide that "every admission to the psychiatric hospital is a failure in the system."
There's no doubt that building wrap-around services is a goal of all the local stakeholders: The city of Austin has committed money to funding respite care at two facilities, for example, while Travis County has invested in a Mobile Crisis Outreach Team, which responds directly to wherever people are when they go into crisis. Currently lacking, say Peck and others, are supportive housing and employment programs – the very kinds of infrastructure that help keep people healthy and out of crisis.
And, of course, there is Integral Care, which runs PES and also provides regular behavioral health services to thousands of clients each year. Integral Care's total budget for services in 2010 is just less than $46 million, with which it estimates it will serve 20,000 unduplicated clients. Of that, it has budgeted $8.3 million to serve nearly 7,000 people with mental health crisis services, accounting for just more than 18% of the total budget. Still, there is a long waiting list of people – 1,200 currently – in need of basic mental health services, the kind that people coming out of crisis require to remain stable.
Many of those waiting are considered less at risk for crisis, but unless they actually do end up in crisis, landing in a bed at ASH or somewhere else, they could wait indefinitely for service. These folks, Integral Care's Van Norman says, "suffer in silent misery, which is a real tragedy." And at times, they're "rattling around and showing up at PES, showing up at the [ERs]."
Of course, fixing the system requires money, and there's little to go around. The state hospital system recently avoided huge cuts that could have eliminated hundreds of beds locally, but Integral Care saw its 2010 budget for delivering crisis services cut by more than 6%.
Where does this leave patients in crisis – particularly the poor or uninsured? Somewhere in the mix, it seems, like Demps. Dealing with his death has been difficult for Fisher, primarily because she doesn't understand what led him to take his own life. He'd had struggles with drugs, which she believes were connected to his mental illness, and he'd had more than one run-in with the criminal justice system – for drugs and for assault. But he had been a client of Integral Care, she says, and when he was taking his medicine regularly, he was stable. She wants to know what happened in the early morning hours before his death: Why wasn't he put on a suicide watch at the hospital? Did he actually see anyone at PES, or did he leave the facility before he was evaluated, as he had the day before when he was told there were no local beds available? And why didn't anyone from the hospital call her to ask if she could bring him home? "I think what I hate most," she says, "is that I didn't get that chance."*Correction: The original version of this article reported that the city of Austin owns University Medical Center Brackenridge; ownership of the hospital was transferred to the county’s health district, Central Health, after the district’s creation in 2004.