2008 Brought New Psych Resources on Arkansas Medical News Inc.

2008 Brought New Psych Resources

By: JENNIFER BOULDEN

Projects at UAMS, State Hospital and Around Ark. Enhance Mental Healthcare

For once, the past year has brought great improvements for the Arkansas mental health community. Although there is still a profound need for more psychiatric services and providers to serve the state's population, a spate of new facilities and resources in the state indicate that Arkansas is on the right track to breaching the gap in mental healthcare.

Among those advances in psychiatric services are the new Psychiatric Research Institute at the University of Arkansas for Medical Sciences (UAMS), the much-needed $32 million replacement State Hospital, a broad and collaborative psychiatric partnership with UAMS and the Northwest Arkansas (NWA) medical community, a joint inpatient venture by Western Arkansas Counseling and Guidance Center in Fort Smith and Booneville Community Hospital, and expanded community resources around the state from the National Alliance for the Mentally Ill (NAMI).

David Williams, the retired director of Ozark Guidance in Fayetteville who remains an active advocate of the mental health community, said he thinks the recent activity shows that Arkansas is trying to live up to its constitutional mandate to have adequate and equitable mental health services statewide.

"The state's various stakeholders, including legislators, providers, and family members, have really been working since early 2000 to make sure adequate and equitable services are available statewide, with a particular emphasis on acute care beds, hospital and residential," he said. "We're starting to see great improvement."

The PRI-de of UAMS

At the heart—or possibly, the head—of Arkansas' mental health resources is the new 110,000-square-foot Psychiatric Research Institute (PRI), UAMS' sixth Center of Excellence, which provides inpatient care, outpatient care, education and research in one facility. The institute's outpatient program officially begins Dec. 8, and the inpatient program will launch Feb. 3.

PRI Director and Chair of UAMS' Department of Psychiatry G. Richard Smith, MD, said that physicians and hospitals around the state will benefit from the specialized inpatient units and specialized outpatient services PRI will offer.

"Our programs will fill niches that are usually hard to fill," Smith said, explaining that a primary emphasis is on providing tertiary psychiatric care heretofore scarce in the state. "We have the advantage of having 70 or so psychiatrists and various programs affiliated with the department, with the State Hospital, Children's Hospital or the Central Arkansas Veterans Healthcare System or in our own department. Plus, we have psychologists and other experts that we can bring in for consultations to be able to get the right diagnosis, the right treatment and the best outcome for patients."

PRI's 40 inpatient beds fall into four 10-bed subunits:
Acute adult unit- Serving tertiary referral patients and UAMS' patient base.
Children's unit- Serving young children ages 2 to 12, primarily those that are in DHS custody who need diagnosis and treatment planning, a highly specialized, age-appropriate assessment new to the state. The average stay will be about 10 days to three weeks.
Medically involved unit- Serving patients that have serious psychiatric illness and serious medical illnesses at the same time, a currently underserved population. The physicians and the nurses will be trained for medical care as well as psychiatric care.
Geriatric psych unit- Serving UAMS' Institute on Aging and UAMS patients who have dementia and psychiatric issues associated uniquely with the elderly.

Additionally, the institute will house the state's first residential program for eating disorders, the Dierks Research Laboratories, UAMS' Center for Addiction Research and a Brain Imaging Research Center. Smith said a 3-tesla functional magnetic resonance imaging (fMRI) machine—only the second in the state, the other also owned by UAMS—is being installed, allowing researchers and students to observe the brain in action.

"With fMRI, we'll be able to determine the brain at work, see which neural networks and circuits are affected by which diseases and which medications," Smith said, adding that innovative clinical treatments such as the newly FDA-approved trans-cranial magnetic stimulation (TMS) will be available, as well as inpatient and outpatient electro-convulsive therapy (ECT) for people with refractory depression or who aren't responding to other treatments.

"To be able to train our students, residents, fellows in this environment is really the state-of-the-art for all of medical care: doing leading-edge clinical care, teaching, education and research all in one facility," he explained.

The State Hospital, Reborn

In May, officials unveiled the 130-bed replacement State Hospital, conveniently adjacent to the UAMS campus in Little Rock. The new facility for the mentally ill replaced an outdated 1964 building. The updated facility features 152,000 square feet of welcoming and patient-friendly space, including 90 beds for adults and 40 for juveniles.

Smith said the construction of the State Hospital, funded greatly by UAMS, was a key part of the university's larger campus expansion plan, which besides PRI and the State Hospital also included a new University Hospital, new residential hall and parking deck and a new central energy plant.

The need for a new State Hospital and other mental health facilities became more urgent when a U.S. District Court judge issued a ruling on the death of an inmate who died in jail while awaiting a bed at the State Hospital.

In the ruling, Judge G. Thomas Eisele wrote, "Our county and city jails should not become our mental hospitals by default. The solution lies with the political branches of our state government—the executive and legislative branches, and particularly the General Assembly, which has the power to bring before it all the interested parties: Mental health experts, law enforcement, financial and budget experts."

The Northwesterly Way

The PRI will soon have a sister institute in Northwest Arkansas (NWA) that Smith said is being called the Psychiatric Research Institute-Northwest (PRI-NW), an area-wide mental health collaboration located on the campus of Northwest Health System in Springdale.

In August, Arkansas Gov. Mike Beebe approved the release of more than $1 million in state funds that will finance a new inpatient mental health unit in Northwest Arkansas. Start-up funds for the inpatient center combine the $1 million from the governor's office with more than $1 million from the 2005 and 2007 Arkansas General Assemblies. The program will begin its outpatient program around the end of the year, with the inpatient portion slated for March.

The Care Foundation, Inc., is coordinating the inpatient adult psychiatric care unit with a coalition of mental health providers from Ozark Guidance, Northwest Health System, Washington Regional Medical Center, Mercy Health System of Northwest Arkansas and the University of Arkansas for Medical Sciences (UAMS).

"This is a great day for the people of Northwest Arkansas because having access to inpatient mental health services is very important to this region's present and future quality of life," said Beebe in Springdale at the Aug. 13 announcement of the additional funds availability. "And it's a proud day for me as governor to see these various entities coming together in a spirit of cooperation and shared responsibility to make this new inpatient mental health program a reality."

Jan Lightner, a program administrator for the Foundation, said the foundation served as a convening body to bring the disparate and competing entities together on the project.

She said a former administrator of Northwest Health System, Tom O'Neal, had written a compelling letter to the editor of a local newspaper detailing the severe shortage of psych beds in the area and the profound burden it placed on existing resources.

"We're always interested in what people are talking about in the community," she said. "There was a general concern about the number of people who needed acute mental healthcare and were either inappropriately put in the hospitals (many need one-on-one care that exceeds the hospital's staffing availability) or in the jails."

Lightner said the foundation set out to see whether the local hospitals and mental health providers, none of whom had the resources to solve the problem single-handedly, might be willing to put aside their own competitive agendas and collaborate on a solution for the greater area. The interest was unanimous, and the foundation recruited O'Neal to helm the multi-year project.

The result is a comprehensive inpatient and outpatient program, supported by each stakeholder.

Northwest Hospital is providing two floors (renovation reimbursed with state funds) for a 29-bed adult inpatient unit. Following the hospitalist model, PRI will provide psychiatrists and oversight of the inpatients, will establish outpatient services in cooperation with Ozark Guidance, and will use the program to train new physicians through the UAMS-NW campus. Ozark Guidance is the fiscal intermediary for the state funds and provides screening, consultative and outpatient services. Washington Regional Medical Center and Mercy Health System of Northwest Arkansas have committed up to $65,000 a year to offset the costs of caring for the program's indigent patients' non-psychiatric care. The Care Foundation has contributed additional funds for start-up costs.

"It's a pretty amazing model because it brings together the university, the for-profit hospitals and the not-for-profit community providers as well as the foundation," said Laura Tyler, administrator of PRI and UAMS' point person for the NWA psych program. "It's a unique model, and would not have been possible if there had not been strong support from the community as well as demand that the psychiatric needs of the community be addressed."

New Thinking, New Partnerships

There is evidence that Northwest Arkansas' or similar models may become popular solutions to the mental healthcare shortage in the state's rural areas.

Booneville Community Hospital (BCH) is entering into a unique behavioral health partnership with Western Arkansas Counseling and Guidance Center (WACGC) of nearby Fort Smith on its campus. Dzaidi Daud, CEO of the hospital, told Medical News of Arkansas in September that the partnership was the first of its kind between a small community hospital and a private mental health group, and one the Governor has talked about replicating around the state.

"He has shown much interest and support in getting this program up and going," Daud, who has a background in mental health management, said. "It's a problem everywhere, where do we put mental health patients? They take up enormous staff time and resources, so this program may be a model for how we can address those needs on a community partnership basis."

Daud is working with Pete Kennemer, head of WACGC, to open a behavioral healthcare center in the recently vacated former Booneville Community Hospital building (the hospital's new facility is next door). It will have 25 psychiatric beds — 10 for acute care and 15 for residential crisis. The acute beds will be managed by BCH and the crisis beds will be run by WACGC.

"The initial plan was to bulldoze the old hospital," Daud said, "but we were approached by the Western Arkansas Counseling and Guidance Center about adapting the space for a 10-bed inpatient psychiatric unit. Now 10 psych beds is just a drop in the bucket, but the surveys we've conducted show that we have a dire need. There are only 24 beds in a 34-county region here. So the need is there, the funding is there, and the partnership between BCH and WACGC is one-of-a-kind, unique in a three-state area."

Tyler said that nationally more communities are turning to mental health partnerships. "I think we will see more of them especially as resources are scarce and people are seeing the benefit of working together to solve the problem in their area."

She said that among PRI's goals is to partner with the network of community mental health centers across the state, and also to find ways to enhance primary mental healthcare through UAMS' Area Health Education Centers (AHECs).

Williams, who was part of the planning of the NWA collaborative, said, "I think the model that we're trying to develop in Northwest Arkansas along with our colleagues at Western Arkansas Counseling and Guidance in Fort Smith is a good regional model. Creating an acute care network that's made up of several providers who are focused on making sure that the continuum of care is in place for people whether they have insurance, Medicare, Medicaid or need indigent care, whatever," Williams said.

He said that while he thought small communities around Arkansas individually would not have the resources to pull off such a collaboration, it could be possible to accomplish using larger geographic areas, such as the Department of Human Services' designated regions.

"I think this is a pretty good model for seeing what we can do in the four corners of the state in conjunction with Little Rock," Williams said.

The Case for Community-based Resources

Kim Arnold, executive director of the Arkansas chapter of the National Alliance for the Mentally Ill (NAMI) said that while there seems to be more activity toward enhancing mental health services, she still has concerns about what types of services are prioritized.

"I think that while many things are happening, we need to continue to work on making sure our plan is a plan that will help the whole state, and not just one area," she said. Are we focusing on mental health more? Yes, and that's good. Are we doing the right things? Only time will tell. I'm not sure that we are at this point."

Arnold said her concern is that too much focus is put on bed-based care, which she said is an important piece of mental healthcare, but should be the option of last resort. She said a greater emphasis on enhancing community-based services could prevent a great many psychiatric episodes from escalating to the point that residential care is necessary. While Arkansas needs to have psychiatric beds available for patients who need to be hospitalized, she would like to see fewer people needing hospitalizations in the first place.

"There's a definite place for bed-based care, but we also need more community-based services so that we can insure that we've done everything and that residential care really is the last resort, and that we don't have people who are just stuck there because there is no where else for them," Arnold opined.

She said NAMI Arkansas has been working to bring several classic NAMI educational programs and support groups back to all areas of the state, and is constantly looking for potential community leaders to train, people who have "been there" with mental illness as a patient or family member and are ready to give back to the community.

Physicians and healthcare providers and NAMI could be enormously helpful to each other, she said. "We have all kinds of educational materials, resources and support available free for physicians' patients, brochures they can put in their offices. If they would only tell their patients about us, direct them to our Web site, where they can empower themselves with information, we could help ease physicians' burden," Arnold explained.

"In return, if physicians and hospitals would help us out by recommending people who would make good support group facilitators or class leaders, we could together reach more people in communities around the state and help reduce the stigma and misinformation associated with mental illness."

Arnold said she applauds the recent efforts to embrace evidence-based care. "One good thing is that there is a more concerted effort and look to evidence-based practice. That shows that we recognize the need to utilize and put our resources into research-based practices that we know are effective and get results."

The important thing, she said, is that future mental health initiatives in the state embrace the inherent potential of the mentally ill with optimism.

"We tend to be too paternalistic towards the mentally ill; tend to say, 'Oh, they'll never get better. They'll never get help,'" Arnold said. "Well, it's possible, and we need to provide the support for that. Recovery happens."