Making Effective Use of State-Operated Psychiatric Beds
• Illinois, like all other states, has dramatically reduced the number of state-operated beds over the past sixty years. That number peaked at approximately 33,000 in the 1950’s. At present we have fewer than 1,200 beds located in the seven remaining state hospitals: Read, Madden, Elgin, McFarland, Chester, Alton and Choate. Unfortunately, the state has repeatedly and consistently closed state hospitals without increasing and maintaining the community services needed by persons with serious mental illnesses.
• The population in state hospitals falls into three legal categories:
• Approximately 400 persons found not guilty by reason of insanity (NGRI) and committed pursuant to 730 ILCS 5/5-2-4. The commitment and release of NGRIs is usually controlled by a criminal court. NGRIs typically are confined for many years. A substantial percentage of the NGRIs currently confined in state facilities could be safely treated in the community.
• Approximately 340 person found unfit to stand trial on criminal charges (UST) and committed pursuant to 725 ILCS 5/104-17, et seq. The commitment and release of USTs is controlled by the court before which their criminal charges are pending. USTs are typically confined for many months and sometimes for years. A substantial percentage of USTs currently confined in state hospitals could be safely treated in the community.
• Approximately 400 “civil” patients who are either voluntarily admitted or involuntarily committed under the Mental Health and Developmental Disabilities Code. 405 ILCS 5/1-100, et seq. DHS has almost complete discretion over the admission and discharge of civil patients. Their confinement typically lasts days or weeks.
• It is important to note that while the total capacity of state hospitals has declined by more than 95% since the 1950’s, only the number of beds devoted to civil patients has been reduced. The other two categories–NGRIs and USTs (together referred to as “forensic patients”)–have grown.
• Illinois is not using its existing inpatient capacity efficiently.
• There are forensic patients waiting in county jails for a bed in a DHS facility because DHS does not have any additional forensic capacity at Elgin and other forensic facilities. These patients have a right under Illinois law and the United States Constitution to be transferred promptly to a mental hospital for treatment. Additionally, their continued presence in county jails imposes substantial and unfair financial burdens on counties across the state.
• There are two other legal categories of persons who could be placed in state hospitals but are placed there very rarely:
• persons with serious mental illnesses who are serving prison sentences and may be transferred from DOC to DHS pursuant to 730 ILCS 5/3-8-5
• persons found guilty but mentally ill (GBMI) under 730 ILCS 5/5-2-6
• Almost all of the civil patients housed in state hospitals lack any third-party payment source such as Medicaid, Medicare or private insurance. Federal Medicaid law severely restricts reimbursement to state hospitals. Persons with an entitlement to third party payment are almost all diverted to private hospitals even when these hospitals are unable to meet their needs. This is one reason why Illinois’ decision to expand Medicaid under the Affordable Care Act has reduced the need for civil beds.
• Although persons with serious mental illnesses frequently have serious co-occurring non-psychiatric medical conditions, DHS has dramatically reduced the ability of its remaining state-operated mental health facilities to treat these conditions. Thus, state hospitals frequently deny or delay admission to persons with non-psychiatric medical conditions who would otherwise be admitted.
• The seven remaining state psychiatric hospitals discourage or prevent persons from being admitted directly to these facilities. They are diverted to emergency departments operated by private hospitals.
• Many private hospitals do not have inpatient psychiatric care. These hospitals often have substantial difficulty finding a hospital which is able and willing to accept patients for transfer. These patients often are detained in emergency rooms or other non-psychiatric unit for extended periods. This practice is frequently referred to as “psychiatric boarding” and is not conducive to good mental health care.
• Although there are proven or promising crisis intervention programs which could divert many people from emergency rooms and inpatient care, Illinois has not adequately funded such programs.
• One of the reasons that there are so many persons with mental illnesses in the criminal justice system is the lack of alternatives available to police and other emergency responders.
• There are many Medicaid recipients with serious and difficult to treat mental health conditions who are not being adequately cared for by private hospitals. Because of funding restrictions, these persons are discharged before they are ready to return to the community or without an adequate community treatment plan. It is not uncommon for these persons to be repeatedly re-admitted to private hospitals due to these failures. Some of these Medicaid recipients are admitted to state psychiatric hospitals which provide care without requiring the managed care organization to reimburse DHS for the cost of this care.
• It is unlikely that Illinois can afford or will choose to increase its state-operated inpatient capacity.
• If Illinois chooses to spend more money on mental health services, that money should be spend on community care or on increasing the quality of state-operated inpatient care, not on increasing the state-operated inpatient capacity.
• Illinois should not further reduce its state-operated inpatient capacity in the absence of a comprehensive and fully-funded plan for increased community services.
• Because state psychiatric beds are scarce, Illinois must insure that those beds are used for the people who would pose the greatest risk of harm to themselves or others if not hospitalized.
• No state hospital bed should be used for someone who could be safely treated in the community.
1. The availability or absence of third-party funding, such as Medicaid, should not determine whether someone is placed in the appropriate public or private facility. DHS should work with the Department of Healthcare and Family Services (DHFS) to insure that Medicaid patients who cannot be adequately treated by private hospitals and the community mental health system are cared for in state hospitals
2. DHS should insure that it is reimbursed for the cost of caring for any person covered by a third-party payer, specifically including Medicaid managed care organizations.
3. DHS should discontinue its practice of refusing admission to state hospitals on the basis of co-occurring non-psychiatric medical conditions unless those conditions are so serious that the state hospital cannot provide the necessary care.
4. DHS, DHFS, the Department of Corrections, county jails and local law enforcement should work cooperatively to create crisis diversion systems which will reduce the need for civil admissions and reduce the number of forensic admissions.
5. DHS should insure that forensic patients who need inpatient care are admitted to a state hospital within a week of a finding of unfitness to stand trial or insanity.
6. DHS should work with the criminal justice system to create a comprehensive plan to treat USTs in the community whenever possible. That plan must include an adequately and reliably funded community care system for USTs and for removing unfit misdemeanants from the criminal justice system.
7. Because of some of the provisions in the NGRI statute, clinical practices in state hospitals and a lack of understanding of this population by judges, lawyers, clinicians and administrators, NGRIs are often confined in state hospitals when they could safely be treated in the community. DHS should take the lead in removing obstacles to release and in creating and adequately and reliably funded community care system for NGRIs. Alternatively, if Illinois lacks the political will to make this happen, it should give serious consideration to abolishing the insanity defense in order to free state hospital beds for civil patients, many of whom are more in need of inpatient care.
8. If, and only if, the above changes make available beds which are not needed for civil patients, DOC should contract with DHS to have those persons found GBMI or who could otherwise be transferred under 730 ILCS 5/3-8-5 treated in state hospitals at DOC expense.