Do We Know What We've Been Doing? Do We Know What We Are Trying To Do?

by

JOHN F. MAGOOLAGHAN, D.P.A.

I have read with great interest the article "Deinsti- tutionalization: Noble Solution of Tragic Failure" by Barbara Baer in the February, 1981, A.M.H.A. News- letter. Miss Baer has done an excellent job of defining the problem; however, I fear that she has oversimplified and has not offered any suggested solution.

I view the problem in a different manner. I see six basic groups of patients or clients in the mental health system, as fol tows:~

A. OUTPATIENTS:

1. Those who, because of their own strengths or their strong support systems, can be reasonably expected to be able to maintain themselves in the community with the amount of psychiatric and other social services now available to them.

2. Others who might be able to move into group 1 if more psychiatric and supportive services were avail- able. These, without the additional help to achieve group 1 will probably deteriorate to group 3.

3. Those who will need some amount of hospitali- zation or re-hospitalization. Some will be group 2 individuals who have dropped back because the additional services they need to remain in the community are not forthcoming. Others will be "deinstitutionalized" former long-stay patients whose abilities to survive and live in the community have been destroyed by a debilitating disease called "insti- tutionalization" which, if not "treated" in the early stages of onset, can become "irreversible."*

B. INPATIENTS:

1. Those short term admissions (or readmissions) who, based on the acute services currently available to them, can reasonably be expected to rejoin groups A-1 and A-2, above, in the near future.

2. Those requiring inpatient services for a longer time or in greater quantity and diversity. Some will advance into groups A-1 or A-2 after a period of time (possibly via group B-l). Others will decline into group B-3.

* For purposes oJ this paper, "'irreversible'" is defined as the conditiou o[ those who have completely lost the ability to make the small decisqons o[ cveryday living; those who are so a[raid o[ community living that they would not venture out o[ their rooms; and those who have been institutionalized so long that the institution has become their real "'home" and "'community."

3. Those whose "institutionalization" has become "irreversible."* These are very unlikely to be able to achieve A-2 status even if present inpatient services were materially improved. At best, they might become revolving door clients in the A-3 category.

The B-3 and A-3 groups are very important and proper understanding of their needs is the key to future planning. For the most part (and this is certainly not a universal statement) they include large non- recurring populations from the "pre-medication" and "pre-community-psychiatry" past. Often they constitute a very large proportion of the total census of the i r institution. These institutions are trying - - thru expenditure of professional and financial resources - - to maintain accredited status in the face of rising standards in order to maintain present levels of revenue from Federal and other third-party sources. Ms. Baer is correct in pointing out that these efforts to maintain "accredited" status have eaten up any savings which might otherwise have gone into new community services as was expected when "deinstitutionalization" began. She is also correct in stating that many long term patients in the B-3 group could go into community services such as adult homes, congregate living homes, or nursing homes, if these existed.

IVHAT CAN IVE DO?:

At present, the system seems to be working reason- ably well for those individuals who fall into groups A-1 and B-1.

The B-2 and A-2 groups are the all important "swing" groups; these are the individuals most likely to achieve improved outcomes if the inputs of resources could be increased appropriately. It is fairly obvious that many B-2s could move up to A-2 or even A-1 status directly or by way of B-1 if additional help were available. Where can we find the additional resources needed ? Many of these needed resources would become available if we stopped wasting them by mistreating so many of the B-3 and A-3 clients!

What would happen if we, in effect, set up a B-4 group by converting some of our state psychiatric hospital buildings to long term care facilities aimed exclusively at servicing two groups? These groups would consist of (1) those belonging to a long-term non-recurring population in group B-3 who have become "irreversibly institutionalized," and (2) those

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in group A-3 to whom the institution has become "home and community," and to whom the outside community has become a strange and fearful place.

Clearly, the A-2 and B-2 groups are the ones who would benefit most from additional services now. These groups are already being sustained to an extent; their needs seem to be for additional professional clinical help. It is exactly this kind of professional clinical help which would be freed up from the institutions if the B-4 group was established.

At the present time many beds in state psychiatric hospitals are occupied by persons who should be in the B-4 group. Many chairs in the waiting rooms of our scarce community services are taken up by indi- viduals who, if given the choice, would be more comfortable in the B-4 environment. Many state hospitals, serving large populations who belong in this group, have been and are spending more and more money to improve pro/essional and para-pro/essional psychiatric services in order to remain eligible for the continued flow of Federal and third party dollars. This is where many of the dollars which "deinstitutional- ization was to have saved" have gone. If we change some of these psychiatric hospitals to long term care facilities for these non-recurring clients, wouldn't we be able to free up professional staff of exactly the kind needed to increase services to the A-2, A-3, B-2 and some B-3 groups who need increased services and for whom such marginal increases are most likely to result in the biggest payoff in results achieved and lives improved ?

CONCLUDING COMMENTS:

Obviously, the foregoing is not presented as a total answer; nor is it presented as a large part of the answer. Rather, it is a means of making a substantial first move toward future solutions.

It should not be expected that the transferred pro- fessional and para-professional services would equal

the total marginal needs of the "swing" groups. Most likely it would not, particularly at first. However, it would have some impact and might possibly have a multiplier effect by helping some individuals eventually to sustain themselves longer at home, thus releasing some help to others in need.

Also, the fact that the B-4 population should be non-recurring is important. Any future planning must anticipate a gradual shrinking of this aged, institution- alized group with concurrent releasing of resources to be used to increase community services. The gradual reduction of this population could be paired up with the foreseeable retirements among long term institution employees to avoid unnecessary strains on the hospital communities as a whole.

For this concept to be feasible, it is absolutely necessary that Federal support now provided to these B-4 candidates while they are currently in the A-3 and B-3 groups should not be reduced because they are discharged from psychiatric hospitals and voluntarily admitted to long term care services in the same or similar locations. Likewise, buildings which would have been acceptable as safe and appropriate if they continued to be "psychiatric" must automatically continue to be appropriate if changed to "long term care."

SUMMARY:

Pursuit of the word "hospital" and of the continu- ation and maximization of Federal dollars has led to a distortion in our distribution of skilled resources. If these resources can be redeployed in a manner more nearly matching how the needs are distributed, the entire system can be made more productive. This redeployment, once started, might develop a leverage effect over succeeding years. Certainly, we would be trying to do things more in the way various groups of patients seem to want and that alone should increase the effectiveness of the entire system.

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