Dell Medical School Team Unveils Plans to Reinvent Austin State Hospital

Rising from the ashes of the aging mental hospital

The future ASH campus, with the proposed new hospital at left

The campaign to transform the historic, haunted, and exhausted Austin State Hospital into a world-class center for brain health has turned another corner, with last month's delivery to the Texas Health and Human Services Commission of the "ASH Redesign" study led by UT's Dell Medical School. This tees up a push to obtain from this Legislature, already in progress, the $280 million-$330 million needed to build a new hospital on the ASH campus in North Central Austin.

That campus, opened as the state asylum in 1861 on what was then the outskirts of town, now serves a 38-county region for adult inpatient mental health care, and an even larger chunk of the state for children and adolescents. The parlous condition of the state's entire mental health system has been well-established for generations, and in ASH's case presents what the Dell Med-led team sees as a unique opportunity for more than cosmetic changes.

"It's sometimes harder to move a B-plus system to excellence than a D-minus system," said Dr. Steve Strakowski, the chair of Dell Med's psychiatry department, when presenting the ASH Redesign report to the community on Jan. 28. Since ASH – along with several of Texas' other state mental hospitals – "is way past its expiration date, and we have to get that done," Strakowski said, the redesign can serve as "a centerpiece for what the continuum of [mental health] care might look like in the future, that we can then pulse out through the service area."

The daily waiting list for beds at the state hospital hovers at around 100 people, largely being sent from jails throughout its 38-county service area.

The redesign team includes participation from throughout that continuum of care – HHSC as the system operator, plus local mental health authorities (Integral Care and Bluebonnet Trails), Central Health, other UT System and Dell Med experts, law enforcement and rural health care providers, and voices of patients, families, and caregivers. At the Jan. 28 forum at the medical school, co-presented by NAMI Austin, many attendees came from that latter group – current ASH residents and their advocates, and current and retired staffers. Their feedback evinced at least a little resistance or uncertainty about the grand plans for change, but nothing that would likely throw a wrench into the effort.

The original "Old Main" building at ASH – the third-oldest public building in the state – would, of course, stay (it's used for administration now), but many of the 38 buildings on the 80-acre campus, including those being used for full-time patient care now, are in bad enough shape to be flagged for replacement. The plan preferred by the Dell Med team would be to build a new 240-bed adults-only hospital on what is now the southwest corner of the campus, facing Lamar and closest to Central Market. (The renderings presented so far look very, very similar to the Dell Med buildings on the UT campus.) That would cost $283 million; other options include expanding to as many as 288 beds, or building a separate residential wing, which would bump the price tag over $300 million.

Currently, there are about 250 beds at ASH, including 30 for youth, and about 70 patients who live there full time, for which the facility is not designed. The daily waiting list for beds at ASH usually hovers at around 100 people, largely being sent from jails throughout the service area. The ASH Redesign as proposed would create more space for those people, but Strakowski, who came to Dell Med from Cincinnati, places a lot of emphasis on retooling the entire mental health system to make some of those admissions unnecessary. Currently, when people are sent from jail to ASH – as when to stabilize their condition so they're competent to stand trial – the space crunch leads to wait times that can be longer than the sentence for the original offense, at a cost to the state of about $75,000 a case. Meanwhile, several hundred beds in private mental health centers are available throughout the ASH region, but legislative fixes need to be made to make it feasible for those facilities to take these cases.

Overhauling the "46B" system, as it's known (in reference to the Texas Code of Criminal Procedure), is but one of the ways that a new ASH proper can anchor the campus' transformation into what its foremost Capitol champion, Austin Sen. Kirk Watson, calls "M.D. Anderson for the brain." Just as that UT health center in Houston anchors not only clinical care but cancer research, Watson – who sits on the powerful Senate Finance Committee from which that $300 million may come – and Strakowski both want ASH to provide the platform for a complete rethink of the underfunded and stigmatized post-institutional state mental health system.

"What brought me from Ohio was this opportunity," Strakowski told the audience at the NAMI forum. "Because we're not very big yet and don't have a lot of stuff, we can step in and convene, whether or not we run the hospital directly. We're developing new models of care here." So far, he can count on the support of the state, Watson notes: "I've been very proud of the Legislature's willingness to invest in brain health, as being just like any other form of health care."

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Austin State Hospital, ASH, Steve Strakowski, Dell Medical School, Dell Med, brain health, 46B, Kirk Watson

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