This paper presents a long-overdue plan and proposal to the office of mental health to close state psychiatric centres and to discharge all remaining patients to the community. From long-term care and extended service units to admissions and adult, children, and adolescent services provided by inpatient treatment wards, this is a call for the complete and final discontinuation of state-level care and treatment centres in the United States. There is no question society has arrived at a crossroads in the future of mental health treatment. More than ever, the need for complete access to and the integration of mental health care is clear, and consumers and practitioners alike acknowledge that the mental health system currently does not address gaps in mental health care and treatment. Instead, the system is still informed by the era of institutionalisation and does not facilitate access to services at the local level where the potential need for connectivity and person-centred care is most abundant. This recommendation challenges the ongoing deferral of full community access to and integration of mental health care in the United States and aims to disrupt the current increasingly insidious Neo-institutionalisation, indicating that access to mental health treatment is the country’s first priority in addressing mental health crises for consumers who have historically fallen through the cracks of the system.
Without question, the future of full integration and access to mental health services resides in the community. To fully integrate services and consumers into the network of already available mental health programmes, remaining patients in long-term state psychiatric centres must be discharged and released from the eternal holding pattern to ultimately integrate and help consumers gain access to community resources, and most importantly, to allow them to live amongst other people outside the gates of the institution. Therefore, phase one of the ward closure team manual for community access will target the release, discharge and re-integration of patients into the community. Later phases will target the establishment of reliable systems of care in which chronic and high-risk patients will have reliable access to services and programmes that will benefit this group in leu of hospitalisation.
Phase one theoretically begins in local state governments and municipalities that govern the regulation of mental health treatment. In New York, this would be the office of mental health. The commissioner must ultimately approve this document and other similar research related to the mass-organised discharge of patients in psychiatric centres. Thus, the office of mental health must approve funding for ward closure teams to infiltrate state psychiatric hospital systems at all levels that impact discharge planning and community re-integration. In theory, each freestanding unit in all state hospitals will work side-by-side with its assigned ward closure teams. Social workers, psychiatrists and all inpatient staff charged with the successful discharge of its patients must partner with the ward closure teams until the final discharge from the hospital in which the final patient re-enters the community.
The crux of phase one is the funding needed to staff the ward closure teams across New York State. Each team will serve as an interdisciplinary reflection of the treatment gaps identified at each hospital’s locale. This means that prior to each ward closure team beginning its work in a unit, the hospital will send a memorandum of requirements to the office of mental health, which will inform the makeup and composition of the teams assigned to each hospital and community. Thus, needs related to transportation and rural concerns will be managed by ward closure teams specialising in the needs of rural communities and their mental health systems. More urban-based communities with complex spatial and access issues will be staffed with workers adept at handling the mental health concerns of patients in urban settings.
The planning involved for both the ward closure teams and the existent treatment teams in the units surpasses the assessment of the composition of the community. Indeed, ward closure teams will be required to have a full understanding of local existing services in the community and will work side-by-side with treatment teams in the units to identify issues foreseen prior to each discharge. Hence, issues of adherence will be measured against connectivity issues in the communities’ existing health care networks. Other issues, such as medical co-morbidities, will necessitate ward closure teams to acquire a full understanding of existing health networks that serve clients with complex medical and psychiatric issues and other complex case management services, which freestanding clinics do not traditionally provide. Thus, diagnostic and public policy stakeholders of health and medicine and public policy stakeholders of health, medicine and chronicity will be counterbalanced with ACT teams and other mobile units, such as care managers, which go into the community, complete home visits and supply case management services to users dependent on the system of care, i.e. the certification and re-certification of benefits to continue services without interruption.
To achieve the desired goal, the next major step of phase one will occur just after the assignment of ward closure teams to respective communities and psychiatric centres. At this point, the teams will infiltrate and gain access to inpatient services and begin working side-by-side with hospital staff to identify concerns prior to discharge. This will be a process in which patients will work with both the ward closure teams and their treatment teams in the community so that post-discharge services can be matched with the needs identified by both long-term clinicians and the new closure teams to achieve the primary goal, which is complete access and the integration of patients into the community and the end of institutionalisation.
To achieve this aim, the plan and each of its phases require not only community support and support from stakeholders regarding mental health and public policies but also the shared dream and goal of creating a society without walls or restrictive barriers for patients with chronic and long-term mental health conditions who are typically assessed and slated for long-term, ongoing, round-the-clock care that a state institution provides. Thus, the vision and scope of this proposed plan and the prospective teams charged with implementing the final solution and ending the era of Neo-institutionalisation is clear: full community access to and the integration of all community mental health programmes as well as the elimination of a level of care that is both dated and obsolete in the context of the full meaning of de-institutionalisation.
Mental health is a community and public health need, and after implementing the proposed plan, the fallacies and misnomers of the old system shall never again point towards institutionalising people and sending the ‘problem’ patients to long-term care units far from the community and its resources. Access to services must be provided, and new pathways must be engendered so that consumers can gain access to the many lines of care already provided by the systems of care in New York State and by all regulatory bodies with a vested interest in mental health treatment.
Neo-institutionalisation is complex and insidious, and it must end. Therefore, the focus of the ward closure operations manual is twofold. The first wave of operations targets state psychiatric centres based on a global assessment of outlying communities and on the express needs of the consumers being discharged. The second wave targets the overhaul of treatment silos and installations already in place in the community that need more integrated access for consumers. There is no question that the resources already exist in the community, and this document is a proposal regarding how to re-configure existing structures that provide mental health treatment to serve patients.
The success of the second wave depends on the elimination of freestanding treatment silos. This means that all treatment programmes that discriminate and choose to openly serve only subgroups or ‘high-functioning’ patients will be given a mandate by the office of mental health to broaden their scope of services, or they will be subject to a loss of licensing and funding. An example of a programme that only serves a small niche of ‘qualified’ patients includes outpatient settings that refuse to accept state-sponsored insurance for patients who are disabled and reliant on Medicaid and other service dollars. Conversely, treatment centres that offer services to all patients or that are cited for re-structuring and successfully re-configure their clinics, group practices and day treatment centres will be awarded funding to commit to on-site projects and community outreach projects to further extend services to the community.
The next segment of the phase is an ongoing community mental health surveillance and hygiene drill that continues throughout re-integration and that will expire after the final discharge from the locale’s state psychiatric centre. Under the assumption that the influx of new chronic patients will test the limits of the community’s local emergency rooms and community hospitals’ abilities to provide services and will largely increase the census of mental health treatment at health centres, this surveillance and hygiene study will bridge the existing gaps in each community during the critical phase of mass-organised discharges from state psychiatric centres. The study will be monitored and fed into a state-wide planning commission for full community access to and integration of mental health care. Next, a broader approach, including at the global level, can be implemented and used as a model for other state regulatory bodies interested in eliminating the dated level of care and the deferred recovery of patients.
The planning and hygiene study will ultimately be interpreted and measured against the re-structuring efforts already underway in the community. The gaps in care identified based on the hygiene and surveillance study will be seriously considered, and once verified, local community mental health care planners, managers and stakeholders will be charged with identifying solutions to the problems. Given the latitude required to make changes at the local level, it is the recommendation of this proposal that county community mental health departments and Single Point of Access (SPOA) committees spearhead the final structural adjustments to the mental health care system. Ultimately, the office of mental health will begin drafting new regulatory codes that promote and encourage the end of Neo-institutionalisation. Thus, codes will be established that discourage extended hospitalisations and ongoing treatment plans without an end. While not forbidden, these treatment pathways will generate red flags at community mental health offices and in Albany, and these programmes will be monitored for future compliance with integration and access practices.
This proposal is essentially a recommendation and call for regulators at the state and federal levels to revamp and to raise the bar to promote the best practices amongst practitioners and public health stakeholders of mental health care. Research suggests that the delivery of mental health treatment must go on without interruption from either hospitalisation or from falling into a gap in available treatment at the local level. Given that many community treatment settings are either inaccessible or do not target the provision of resources for patients to continue recovery on their own terms and in their own communities, it can be assumed that the next logical step in creating a culture equipped and prepared to address mental health care crises will require practitioners and law bodies to pay close attention to this recommendation with due diligence. The roll-out and the implementation of ward closures in the United States and anywhere that patients are in a psychiatric holding pattern without hope of accessing services in their communities is urgent.
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