Friday, March 25, 2005 | 2:54 a.m.
WEEKEND EDITION
March 26 - 27, 2005
2005 could be the year that mental health care takes a front seat in Nevada's legislative process after years of riding in the baggage department.
It has taken a crisis -- overcrowded Clark County emergency rooms caused by a shortage of psychiatric beds -- to awaken lawmakers to the dire straits mental health care finds itself in Nevada.
The Legislature is debating a wide range of funding and policy options that could greatly increase access individuals with schizophrenia, bipolar disorders and other mental illnesses have to acute-care beds, medication, counseling and housing.
Lawmakers are being asked to:
Approve funding for emergency psychiatric beds for Las Vegas between now and May 2006 when a state psychiatric hospital is to open at Oakey and Jones boulevards.
Increase the number of beds planned at the hospital from 150 to 190.
Establish triage centers that will give mentally ill clients immediate access to medication and case assessments.
Approve funding for a proposed state-run mental health clinic in downtown Las Vegas.
Increase the Mental Health Court's budget in Clark County for nonviolent criminal offenders.
Provide more housing to enable mentally ill individuals to achieve stability in their lives and become productive citizens.
Give mentally ill individuals a stronger voice in their own treatment and in the setting of state policy.
It's not as though lawmakers have completely tuned out the mentally ill up to now.
Gov. Kenny Guinn, who proposed about $102 million in new mental health spending for the coming biennium, inherited a sparse budget in that area when he took office in 1999. Lawmakers, at his request, have approved budget increases that have averaged 15 percent annually over the past six years.
"It has been a very high priority of mine and very needed," Guinn said. "Very little about mental illness was addressed before 1999, so we've really had to pay attention to it."
In 2003 lawmakers approved $32.2 million to build the psychiatric hospital that Guinn advocated. Lawmakers also formed a commission, which developed a plan so that the state could implement federal recommendations to make it easier for the severely mentally ill to live, work and participate in their communities.
Guinn's proposed budget for the next biennium includes $45 million to relieve the emergency room overcrowding. He wants to spend $11.3 million to add 40 beds to the 150 already planned for the psychiatric hospital.
He also wants to continue funding for the 28-bed emergency psychiatric annex added last year to the Desert Regional Center at 1391 S. Jones Blvd. to help with the emergency room crisis.
"It's better to take care of mental health issues before they become so disruptive that it becomes more expensive to make progress," Guinn said.
Playing catch-up
Mental health care in Nevada has been a game of catch-up since 1992. That's when a recession forced service cuts so deep that four of the five mental health clinics in Southern Nevada were closed.
Southern Nevada is back to four state-run clinics that provide case management, medication and outpatient crisis counseling. The fifth clinic has been proposed for downtown and needs legislative approval.
Funding, though, has not kept pace with Southern Nevada's rapid growth.
The state ranked 37th by spending $57.31 per resident for mental health services in 2001, according to the latest Health and Human Services Department figures. No. 1 was New York, which spent $175.97 per person, more than triple Nevada's spending.
"New York has a more aggressive group of people involved in this work," said Rosetta Johnson, past president of Nevada's National Alliance for the Mentally Ill chapter. "The people in Nevada are very conservative and have been unwilling to spend the money required to help people with mental illness."
The results are overcrowed emergency rooms because there are not enough psychiatric beds in Las Vegas.
People often wind up in emergency rooms because Nevada law allows those who display violent tendencies and are suspected of being mentally ill to be held involuntarily for up to 72 hours.
Bed shortage
Nevada has 4.5 psychiatric beds per 100,000 residents, far below the national average of 33 beds per 100,000, said Carlos Brandenburg, Mental Health and Developmental Services administrator. Even with the proposed additional beds, Nevada would still have only about 10 per 100,000 residents.
It hasn't helped that privately run hospitals in Southern Nevada have also eliminated 134 psychiatric beds over the past two years, Assemblywoman Sheila Leslie, D-Reno, said.
"They've converted them into medical surgical beds because the insurance reimbursement rates are higher and because psychiatric units are expensive and difficult to run," said Leslie, Assembly Health and Human Services Committee chairwoman.
Leslie, also a coordinator of Washoe County's Mental Health Court, blamed the emergency room crisis on a "perfect storm."
"We have a grossly underfunded mental health budget combined with an exploding population," Leslie said. "This is the best example of pay now or pay later.
"What we've seen in Las Vegas emergency rooms in the last couple of years is the result of that. I sense my colleagues from Southern Nevada have an intense desire to address this issue."
Crammed emergency rooms aren't the only problem, though.
The mental health division's performance evaluations reveal that individuals must wait longer than they did in 2003 or 2004 to obtain medications, counseling and other outpatient services because of increased demand. The state services caseload in Southern Nevada climbed from 7,802 in January 2001 to 10,240 this January.
"Instead of seeing a doctor once every 30 days it may be once every 60 days," Brandenburg said. "A doctor can see only so many patients.
"The growth in Clark County has created a tremendous drain on our infrastructure. I don't have that problem in Washoe County or in rural Nevada."
Johnson, whose son is schizophrenic, would like the state to do a better job of early intervention when it comes to dealing with mental illness.
"We often don't get people treated before they become psychotic, before they become homeless, before they become a nuisance," Johnson of Reno said.
Guinn's budget
The governor's budget for Southern Nevada Adult Mental Health Services, which operates the valley's four clinics and will also run the hospital, calls for the full-time equivalent of 672 positions in fiscal 2006 and 787 in 2007, a sharp increase from the current 431.
Most new positions would be for the hospital, but the clinics would also get professional personnel to handle medication and outpatient psychiatric services.
Included would be 28 additional psychiatrists to help lower the patient-psychiatrist ratio from 700 to 1 to 345 to 1, which Brandenburg said is in line with national standards. The county would also get 99 more nurses, which the state hopes to lure by increasing salaries 14 percent.
"Recruiting is going to be a challenge," Brandenburg said, acknowledging the nursing shortage Las Vegas now faces. "I'm not going to lie to you. We're basically competing with the private sector and with other states."
Agency funding under Guinn's plan would climb from $59 million now to $74.6 million next year and $98.9 million in 2007.
Other than salaries, the sharpest proposed increases are for medications and transitional housing. Because of inflation, drug costs are expected to increase by 26 percent in 2006 and 40.7 percent in 2007.
"What has been proposed goes in the right direction," said Vic Davis, Southern Nevada's National Alliance for the Mentally Ill chapter president. "We're still so far behind after they cut the budget in half in 1992. But the additional acute hospital beds will take care of some of that."
Davis, who has three relatives with mental illnesses, is also enthused about proposed legislation that would establish 24-hour triage centers where mentally ill individuals could get medication and counseling without having to wait for weeks to get appointments at the clinics. These centers also would ease some of the emergency room overcrowding.
"If they have to wait two weeks to see a doctor at the clinic, you'll see them in the emergency rooms," Davis said.
"The biggest problem we have is when people stop taking their medications. The quicker they can get back on their medications the better off they will be."
Proposed legislation
Among the bills lawmakers are debating:
Assembly Bill 9, referred to the Assembly Judiciary Committee, would allow independent contractors who provide medical services for the Division of Mental Health and Developmental Services to be liable for no more than $50,000 in civil damages per case.
The only independent medical contractors who now have that limit are those for the Nevada Corrections Department.
Brandenburg said AB9's importance is that it would give his division a better chance of recruiting professionals to serve in rural communities.
Assembly Bill 37, referred to the Assembly Health and Human Services Committee, would transfer authority over mental health programs and facilities for children from the Division of Child and Family Services to the Division of Mental Health and Developmental Services.
The legislation also would require that once a child is admitted to a division facility for treatment, its administrator must immediately plan for the child's discharge. The child would have to be transferred to an "appropriate placement" no later than 48 hours after the administrator has determined that the child has stabilized and no longer needs treatment.
Assembly Bill 40, already approved by the Health and Human Services Committee, would finance community triage centers from the time the legislation is approved through June 2006 to provide 24-hour medical assessments and short-term monitoring of mentally ill individuals and substance abusers.
It would provide $500,000 in state funds to establish a triage center in Clark County and $100,000 for one in Washoe County. The triage centers would be licensed and regulated by the state Board of Health.
Assembly Bill 41, also approved by the Health and Human Services Committee, would commit $1 million in state funds in both 2006 and 2007 to keep the Mental Health Court running in Clark County. The money would help pay for psychiatrists, counseling and housing for nonviolent offenders who are referred to the court.
Assemblyman William Horne, D-Las Vegas, the bill's sponsor, has said the court lowers jail and hospital costs by steering offenders toward treatment. The court opened in December 2003 through a $150,000 federal grant but will not be able to continue without state funding.
"This is an extremely important bill," Brandenburg said. "We have found that people who go to Mental Health Court stay out of hospitals and jails longer and stay in the community longer."
Assembly Bill 47, already approved by the Judiciary Committee, would require that when delinquent children are ordered to detention facilities they must undergo screening to determine whether they need mental health or substance abuse services.
Assembly Bill 175, already approved by the Health and Human Services Committee, would add $17.9 million to the mental health budget for the next biennium. The largest addition would be $5 million in both 2006 and 2007 to the state mental health division to finance temporary beds for acute psychiatric crisis patients if the division cannot provide that care.
Leslie, a lead sponsor of AB175, said this would make psychiatric beds available in Southern Nevada to bridge the gap between now and when the psychiatric hospital opens. She said she hopes the funding will be enough to finance up to 50 beds in each of the next two years.
Filling gaps
"We are trying to respond to the gaps in the governor's budget," Leslie said. "He has put a significant amount of new resources into the mental health budget, but there are still gaps such as for community housing. When you provide housing support for people, they can stabilize and become productive in the community."
AB175 would allocate $1.7 million to the mental health division over the next two years to house 90 individuals in community residential settings.
Clark, Washoe and Carson City counties would receive $1.9 million, $1.2 million and $200,000 respectively for mental health courts. Clark would get staff and supported living arrangements for 75 additional nonviolent criminal offenders.
The bill would also supplement AB40 by allocating $1.8 million over the next biennium for a mental health triage center in Southern Nevada and $1 million for one in Northern Nevada, with the stipulation that the money must be matched by local governments and hospitals.
"Even with the massive resources we're putting into mental health this year, is it enough? No." Leslie said. "But will it make a difference? Yes. It should reduce the backlog in hospital emergency rooms."
Assembly Bill 177, co-authored by Johnson and referred to the Health and Human Services Committee, would create a steering committee of professionals and clients as well as law enforcement officials who would be charged with making recommendations to the 2007 Legislature.
The committee would explore how the state could better coordinate funding and services by integrating existing mental health services from various government agencies.
"What we have to address is the fragmentation of services within the mental health system," Johnson said. "We often don't put our money into programs that are the most effective for people with the most serious problems."
The legislation has the support of Jackie Crawford, Nevada Corrections Department director who wrote in a letter to Leslie:
"We recognize the need for our department to participate in a full continuum of care for seriously mentally ill offenders who leave prison and return to local communities.
"More needs to be done to formalize the efforts to integrate mental health systems and services between state agencies and local programs and providers."
Senate Bill 21, already approved by the Senate Human Resources and Education Committee, would require that written treatment plans for individuals in mental health facilities could only be developed and modified with the individual's input.
Senate Bill 131, already approved by the Senate Government Affairs Committee, would add another person to the eight-member state Mental Health and Developmental Services Commission. That person would be a current or former recipient of state mental health services.
All of the commissioners, who establish mental health policies through the Nevada Human Resources Department, are appointed by the governor.
"You need to have consumers involved in any kind of policymaking decision," Brandenburg said. "This ensures that any policy is made with active participation from consumers."
