Mental Health Institutions necessary part of care continuum, advocates say

Part 2 in a series on Iowa's treatment issues. Read Part 1.

CEDAR RAPIDS — Kara Bradley spent most of the past 10 years in mental health institutions in Iowa, Texas and Oklahoma.

She needed intensive treatment and supervision to control impulses to harm herself, often by swallowing objects such as pens and toothbrushes. Therapy, medication and strategies for staying busy have quelled those urges and made it possible for Bradley, 25, to live in a Marion house with three others and 24-hour staffing.

'What really turned my life around was a letter from my cousin,' Bradley said. 'She said, 'This is pathetic. You're better than this.''

Although getting out of the Independence Mental Health Institute was a major milestone, Bradley knows there were times in her life she needed acute inpatient care that is difficult to find outside Iowa's four institutes. Gov. Terry Branstad plans to close two of those facilities this summer, shifting patients to institutes in Independence and Cherokee or to private programs.

Mental health advocates in Iowa understand the financial burden of running the facilities in Mount Pleasant and Clarinda, both of which date to the 1800s. And they agree helping people with mental illness live in the community, rather than in large institutions, is more humane and cheaper.

A 1999 U.S. Supreme Court case reinforced the belief that people with mental illness have a right to live in residential environments with fewer restrictions.

But some lawmakers, advocates and families say Branstad acted too soon, without a plan for community services. They fear Iowa's most severely ill patients — some of whom are violent — won't get the care they need with fewer institutions.

And while the federal Affordable Care and Patient Protection Act (ACA) has created budget surpluses now, mental health agencies want consistent funding.

'People don't realize how much time it takes to establish those services,' said Nancy Hale, executive director of the Iowa chapter of the National Alliance on Mental Illness.

NEW FUNDING SOURCE

For years, Iowa families dealing with mental illness have been seeking a greater breadth of services. Needs include rural inpatient beds, residential programs with 24-hour staffing, day programs and work opportunities, respite care and specialized children's services.

But even with all this demand, suppliers are not lining up. Most families don't have the money to pay for mental health services on their own.

And for the approximately one-quarter of Iowans on Medicaid, the federal reimbursement rate is so low that many providers have decided it's not worth their time.

But under the ACA, the federal government pays for mental health services for all low-income Americans, not just those with a documented disability. That freed up money counties previously were spending on psychiatrists, therapists medications and vocational services for people not on Medicaid.

Iowa's 15 mental health regions — charged with providing mental health care for Iowa adults — have a combined fund balances of $100 million because of the new health care law.

'The onset of the Affordable Care Act and Medicaid has become a resource for moving folks into residential communities and opened the doors to a lot of opportunities,' said Ryanne Wood, chief executive officer of the region that serves the southeastern Iowa counties of Washington, Henry, Jefferson, Keokuk, Lee, Louisa and Van Buren.

The southeast Iowa region is developing a five-bed crisis stabilization transitional living program in Burlington to provide a short-term inpatient option that doesn't require hospitalization.

The East Central Region — which includes Linn, Johnson, Benton, Bremer, Buchanan, Delaware, Dubuque, Iowa and Jones counties — just signed a $950,000 contract with a Philadelphia-based not-for-profit to provide a residential support program for 25 mentally ill adults.

Resources for Human Development, which oversees 175 programs in 14 states, would help transition Eastern Iowans from mental health institutions and other congregant housing into apartments where services would be tailored to individual needs, said Stacy Olsen, its director of national business development and social innovation.

'We need to find a system that works for them,' Olsen said.

The not-for-profit's employees visited the Mental Health Institute at Independence, where they met with five or six adults from the region receiving treatment and talked with their counselors, Olsen said. The organization thinks it could help all but one of those people find residential care in the community.

not for everyone

Advocates worry about what may happen to severely-ill patients or those prone to violence.

'Twenty-five percent of our beds are occupied by people who have nowhere to go,' Rep. David Heaton, R-Mount Pleasant and chairman of the Health and Human Services Appropriations Subcommittee, said of Iowa's four institutes.

About 90 percent of the patients at Iowa's mental health institutes are committed involuntarily, which means a court determines they are a danger to themselves or others. Employees at the Independence facility were injured by patients nearly 70 times in 2013, with half of those injuries considered assaults, The Gazette reported last year.

In some cases, mentally ill people with violent tendencies bounce back and forth between Iowa's prisons and mental health institutions.

Thirty Iowa hospitals offer inpatient psychiatric beds, but they are scarce and concentrated in urban areas.

Bradley, of Marion, has never been violent, but her bipolar disorder has been difficult to treat.

It started when she was 15 and confessed she'd been plotting to take a gun to school and shoot bullies. Her adoptive parents, Tammy and Scott, couldn't believe quiet, gentle Kara had been having these thoughts.

'Kara was really good at hiding things,' Tammy Bradley said.

While living in an institution in Tulsa, Okla., Kara Bradley picked up the habit of swallowing foreign objects when she felt the need to harm herself, her mother said. That tendency made her hard to place once she turned 21.

The family tried residential living with 24-hour care in Des Moines, but one day Bradley tried to run out onto Interstate 35.

Police saved Bradley's life and eventually took her to a Des Moines hospital for care.

'I was really starting to give up,' Tammy Bradley said. 'I didn't think we would be able to get our Kara back.'

Bradley's swallowing of objects didn't get better until she went to the Independence Mental Health Institute. There, staff knew how to deal with the issues without granting attention that might encourage the habit, Tammy Bradley said.

In 2013, Bradley moved to the Abbe Center for Community Care Inc., 1860 County Home Rd., in Marion.

When that center closed in September 2013, she moved into a house in Marion. The house is one of 16 shared housing sites staffed by the Penn Center, an Abbe Center affiliate.

Medicaid pays for the services, while the client or region pays the rent, explained Mechelle Dhondt, chief executive officer for the East Central Region.

Bradley prepares meals and does chores. She recently started a job sorting clothes at Goodwill, which she can reach by bus.

'I'm learning new things and trying new foods,' she said. 'It's a blessing.'

That may not always be the case. Although the mental health regions have cash reserves now, they don't have a consistent funding stream. In past years, counties' mental health budgets were about one-third federal, one-third state and one-third local from property taxes, Dhondt said.

Citing the cash on hand for several regions, Branstad recommended no new funding this year. Lawmakers, including Heaton, are trying to figure out which regions need money so they can help just those regions.