At least once a week, Kimberly Rowlands talks to someone contemplating suicide.
“It’s a big chunk of what I do,” she said.
Rowlands, 48, is what is called a mental health co-responder. When Olathe police respond to reports of someone threatening to kill himself or herself, she goes with them.
“I wouldn’t even guess how many times I’ve been called out,” she said. “I’m not on duty 24 hours a day, but when I’m working and a call comes in, I go out.”
Rowlands is on the front line of a problem that is growing nationally and in Kansas.
In the U.S., suicides have exceeded automobile deaths since 2009 to become the 10th leading cause of death. According to the Centers for Disease Control and Prevention, suicide accounted last year for more than 1.4 million years of life lost before age 85.
The number of Kansas suicides increased more than 31 percent between 2011 and 2012. According to the Kansas Department of Health and Environment’s recently released vital statistics report, coroner’s offices across the state reported a record-high 505 suicides last year.
There are significant regional differences in suicide rates. For the past decade or more, the rates typically have been highest in the states of the mountain west and lowest in the more heavily populated states of the northeast.
But with Kansas’ significant recent increase, it has moved into the rank of states with the highest rates. No one seems to know why, or whether the dramatic one-year increase was an aberration or the beginning of a disturbing trend.
Between 2011 and 2012, the state’s suicide rate went from 13.4 deaths per 100,000 population to 17.6 deaths per 100,000 population.
“The numbers are very troubling,” said Miranda Steele, spokesperson for the Kansas Department of Health and Environment. “We’ll be working with our partner agencies and with KDADS (Kansas Department for Aging and Disability Services) on seeing where we go next with our interventions.”
Funding an issue
Historically, much of the state’s response has been defined by its support for community mental health centers; the work of groups such as the Governor’s Mental Health Services Planning Council, and education campaigns.
“We’ve made a good start,” said Michael Garrett, chief executive at Horizons Mental Health Center in Hutchinson. “Every mental health center in the state puts on programs for educating the public about depression and how to recognize the signs that someone is contemplating suicide. We do training five or six times a year in Reno County.”
But the mental health centers’ initiatives, he said, have been squeezed by cuts in state spending.
Kansas Medicaid officials are preparing for a new phase of KanCare that will target services to the seriously mentally ill.
They will be using a “health home” model that appears to be producing good — though preliminary — results in other states and which will allow Kansas to draw additional federal aid dollars as part of the Affordable Care Act.
Among the goals of federal and state officials in using the model is to reduce emergency room visits and hospital readmissions among Medicaid enrollees.
The Kansas Medicaid program — which was rebranded as KanCare at the beginning of 2013 when virtually all 380,000 enrollees were moved into commercially run managed care plans — is scheduled to begin health home efforts on Jan. 1, 2014, and will direct them at about 36,000 of the state’s seriously mentally ill, though participation is voluntary.
A health home is not so much a place as it is a concept of care delivery built on close coordination among a patient’s various medical providers so that health crises can be prevented or minimized through better management of a person’s conditions.
The mentally ill are disproportionately likely to also suffer other chronic conditions.
“They (federal Medicaid officials) expect fewer emergency room visits, fewer readmissions to inpatient settings and, of course, they also want to see lower costs,” said Becky Ross, Medicaid initiatives director at the Kansas Department of Health and Environment, the state’s chief Medicaid agency. “There are some things they will require all states to measure and then we have some additional things we’ll be measuring.”
Kansas officials are in the process of developing a state Medicaid plan amendment, which Ross said they would formally submit to federal authorities in October after earlier submission of a draft document. And they plan to consult with federal mental health officials on the plan before Aug. 2, Ross said.
Work on the Kansas health home initiative began in April 2012, when a team of state officials began meeting about it. That quickly grew to include a “focus group” of about 70 people who work with the Medicaid program as providers or as association representatives.
And Tuesday, at least 200 people are expected for a forum in Topeka where Ross said state officials hope to collect additional information from potential health home providers so that finishing touches can be put to the state’s plan amendment. An earlier forum was held in April and Ross said Tuesday’s gathering would be the final one.
Like many Kansans, Rick Cagan spent much of last weekend reading and listening to news reports about the gunman who killed 20 children and six adults at an elementary school in Newtown, Conn.
Cagan had a professional reason for learning what he could about the tragedy. He runs the National Alliance on Mental Illness-Kansas Chapter office in Topeka.
“It’s devastating,” he said. “It’s heartbreaking.”
According to initial news reports, the gunman, 20-year-old Adam Lanza, may have suffered from a personality disorder or had been diagnosed with Asperger’s, a form of autism. However, there is no indication that he had the kind of severe mental illness suffered by others responsible for mass shootings.
Jared Loughner, the man convicted of shooting former Arizona Congresswoman Gabrielle Giffords and killing six others, for instance, suffered from schizophrenia, a mental illness that causes disordered thinking and delusions.
And James Holmes, the man accused of shooting 12 people to death and wounding 58 others last summer at a movie theater in a Denver sought mental health treatment before the attack, according to multiple news reports.
Mass shootings nearly always rekindle debates about gun control and the adequacy of the nation’s mental health system. Commenting on the later, Cagan said many Kansans with mental illness are not getting the early treatment they need to avoid crises.
“More than 60 percent of the adults who have a serious mental illness are untreated,” he said, noting that in Kansas half the admissions to the state hospitals for the mentally ill involve people who’ve had no previous contact with their community’s mental health center.
In Kansas, state-hospital admissions are reserved for adults who are seriously mentally ill and have been deemed a danger to themselves or others.
“NAMI is always reluctant to jump in with some sort of comment when these kinds of incidents occur because there’s so much that we don’t know,” Cagan said, referring to the shootings. “But, still, blaming the individual only goes so far. At some point, we have to look at the overall well-being of our mental health system.”
Budget cuts in the mental health system
Kansas’ system, he said, hasn’t fared well in recent years.
“I don’t like saying this,” Cagan said, “but we’re just lucky this didn’t happen in Kansas.”
Amid national concerns that the seriously mentally ill are dying from preventable diseases, a leading Kansas healthcare philanthropy is about to make a down payment on a multi-year initiative aimed at integrating physical and mental health services for safety-net patients.
Within the next couple weeks, the Sunflower Foundation expects to open a competitive grant program that Chief Executive Billie Hall said likely would provide more than $1 million in funds to selected health providers focusing on integrated patient care. Foundation officials expect to award the grants by March.
“When we made the decision to get into this particular area,” Hall said, “we knew it would be a long horizon. We know we are in for five, maybe 10 years, depending on how things go in our state.”
The foundation’s board chose the initiative as a major priority about 18 months ago.
To date, Hall said, the foundation has spent about $50,000 sending some providers from different Kansas clinics to visit Cherokee Health Systems in Tennessee, which has 43 clinical sites in that state and a history of melding medical and mental health services.
Integration can mean having mental health and primary medical care agencies housed in the same building, said Melody Martin, a program officer with the foundation. But that is not the only way to do it, she said.
For instance, community health centers in Lawrence and Newton now have social workers or behavioral health specialists who work alongside the clinics’ medical teams.
At Heartland Community Health Center in Lawrence, behavioral health specialist Karin Denes-Collar technically is employed by Bert Nash Community Mental Health Center, which is located several blocks to the west of the clinic. But her office is at Heartland, where she consults daily with the medical staff about the conditions of various patients.
For example, she said, a patient with diabetes might also suffer depression in ways that could hinder the treatments for the underlying medical conditions. A homeless man with a chronic physical malady likely also struggles with a range of other problems that compound the illness. Assistance with those problems might best come from a social worker.
Reconnecting kinds of care
Area providers and national experts alike say that better coordination of care is essential to proper treatment for the mentally ill.
In an April 2009 paper, the National Council for Community Behavioral Healthcare said that persons with serious mental illness were dying 25 years earlier than the rest of the population largely because treatable conditions — such as diabetes and cardiovascular disease — had gone unmanaged.
“The bottom line is that the mind and body are connected,” said Tim DeWeese, director of clinical services at the Johnson County Mental Health Center in Mission. “And so the more physically healthy you are, the more mentally healthy you are going to be and vice versa. I think it’s really just reconnecting the two things. I don’t know where we got off base.”
The Sunflower Foundation is building upon a pilot project started two years ago by a subsidiary of the Association of Community Mental Health Centers of Kansas in collaboration with the Kansas Association for the Medically Underserved (KAMU)
Providers from nearly a dozen communities, including Heartland in Lawrence, were part of the pilot, said Connie Hubbell, director of governmental affairs at KAMU. The participants collected data for about a year starting in early 2011.
Undertaken with little funding, Hubbell said the pilot yielded results that were encouraging nonetheless. For instance, data compiled on 81 patients indicated an 8 percent reduction in monthly expenses per patient.
“So we know it’s out there,” she said. “We know it can happen. The integrated model is cost effective, it does save money, and it’s much more appropriate for the patient.”
Integration in action
One of the biggest challenges, Hubbell said, is successfully melding the consultative atmosphere of mental health with the often-frenetic pace that goes with providing primary care in a safety-net clinic.
The financial toll of untreated mental illness in Kansas is $1.17 billion annually, according to new research released today by the Health Care Foundation of Greater Kansas City.
In the KC metro area, the cost is $624 million per year — about $287 million of which is also included in the statewide Kansas tally.
About one in 10 adults in Kansas and Kansas City has at least one of the serious mental illnesses considered in the research: major depression, anxiety disorder, schizophrenia and bipolar disorder, said Jessica Hembree, the foundation's policy officer. About 40 percent of those go untreated, she said.
The financial consequences of untreated mental illness is spread across the economy, according to the research, but the lion's share was shouldered by individuals and employers.
Hurting the bottom line
"We were surprised by how many of those costs are borne by individuals and by private employers," Hembree said. "I think it's a wake up call to the business community that the lack of funding for mental health is affecting the bottom line of businesses just as much as the pocketbooks of taxpayers. The costs are showing up in the places we don't want them to show up, which is job development and business creation."
The study reinforced what advocates have been telling the Legislature for a number of years, said Rick Cagan, executive director with Kansas Chapter of the National Alliance on Mental Illness.
"You can cut funding for mental health centers — and (legislators) have substantially over the last four or five years — but you can't make these people go away," Cagan said. "These are life-long chronic illnesses and they need treatment. They're going to show up as a cost on somebody's ledger."
Kansas spending for mental health services dropped by more than $14 million — or 16.4 percent — between fiscal years 2009 and 2012, according to a recent report by the national NAMI organization. Only six states made steeper cuts during that same period.
→ Continue reading and download full report at khi.org.
A new inspection report on the state mental hospital here has underscored the severity of what has been a major problem at the facility for months and years: Because of the poor working conditions, state officials are having a hard time keeping doctors, nurses and others on the job.
The Joint Commission, a national organization that accredits hospitals, found that the facility in the past five years lost more than two-thirds of its medical staff due to budget cuts, turnover related to poor working conditions and other factors.
Employees complain they have been forced to work overtime to the point they are mentally and physically exhausted. Many have left in frustration. And now, according to some at the hospital, state officials have difficulty getting nurses from temp agencies to take shifts at the hospital even for short spells.
Currently, the hospital has 790 employees. It’s authorized to have 886. The hospital’s 467 mentally ill patients are at the facility because they have been deemed a danger to themselves or others. The hospital complex includes three 30-bed psychiatric units, a 190-bed forensic unit and a 177-bed sexual predator treatment program. Of the 467 patients, 217 are in the sex predator program.
State officials acknowledge that the staff shortages, starting earlier this year, required some direct-care workers to sometimes work 12- and 16-hour shifts.
“Our primary challenge at Larned is staffing,” said Angela de Rocha, a spokeperson for the Kansas Department of Social and Rehabilitation Services, which oversees Larned and the other state hospitals.
Since July 1, 2011, according to state figures, the hospital has paid almost $1.4 million in overtime wages. It’s spent $135,000 on temp-agency nurses.
The staffing dilemma has created or contributed to other problems noted in the report from the Joint Commission.
The commission’s inspectors called the hospital’s high turnover rate “alarming,” and told state officials they must quickly correct 30 problems — most of which stemmed from the staffing issues — or potentially lose accreditation.
The inspection team visited Larned between March 5 and March 9. It found 14 problems serious enough that the state was given 45 days (until May 5) to correct them. It was given 60 days to correct the other 16 problems. After the 60 days, an unannounced return visit will come as inspectors check the state's remedies.
Among the findings outlined in the 37-page inspection report:
• The hospital has been without a medical director for three months. It also lacked a director of pharmacy. (Officials currently are in the process of hiring a new pharmacy director, de Rocha said. And a New York doctor who likes to hunt and seeks a rural setting has shown interest in the medical director's job. He might be coming to Larned for an interview within the next two or three weeks, according to SRS officials.)
→ More findings and the full report at khi.org.
State hospitals for the mentally ill and the developmentally disabled have not replaced many employees who’ve quit or accepted Gov. Sam Brownback’s invitation to take early retirement.
At the same time, the number of patients at the hospitals has remained flat or increased.
That means fewer workers caring for more patients.
The governor’s budget proposal for the coming fiscal year would allow for 2,298 full-time positions at the five state hospitals, or 311 fewer slots than there were in fiscal 2011 and about 100 fewer than the current fiscal year.
Democratic members of the House Appropriations Committee said this week that the reduced hospital workforce was causing problems.
“At Osawatomie State Hospital we have 55 fewer FTE’s (full-time equivalent employees) than we had in the fiscal 2011 budget and we’re running over (patient) capacity,” said Rep. Bill Feuerborn of Garnett, the committee’s ranking Democrat.
Feuerborn said 13 employees at Osawatomie took the administration’s offer of early retirement. Only three of those positions were refilled. The additional vacancies occurred from people quitting or otherwise leaving the hospital’s roster.
Feuerborn’s district includes Osawatomie State Hospital, the largest of the state’s three hospitals for the mentally ill.
The committee, dominated by Republicans, debated four of the five state hospitals’ budgets on Monday, approving all four in line with the governor’s spending recommendations.
“I’m hearing from several employees who are concerned about safety issues and mandatory overtime,” Feuerborn said. “They work eight hours and then they’re told they mandatorily have to work another eight hours. But they’re not paid overtime. They’re given comp time that they have to be given permission to use.”
Feuerborn told KHI News Service he thought the arrangement might be a violation of labor laws.
“These are people who are working under a lot of stress,” he said.
Officials at the Kansas Department of Social and Rehabilitation Services said it was legal to require employees to work double shifts.
Feuerborn also said the other state hospitals were not replacing employees who had been fired or quit.
“We have 58 fewer employees at Parsons State Hospital than we did two years ago,” Feuerborn said.
The hospitals are under the broad supervision of SRS, but the individual hospital superintendents manage each somewhat differently.
Parsons State Hospital, for example, has reported that its overtime costs increased 139 percent in the current fiscal year, which began July 1, 2011.
Budget documents provided to legislators also showed Kansas Neurological Institute in Topeka losing 16 full-time positions in the proposed budget for fiscal 2013.
KNI and Parsons State Hospital care for people with severe developmental disabilities.
“Across the board, about a hundred positions at the state hospitals have been lost” in the past year, said Rep. Jerry Henry, a Cummings Democrat.
Henry, echoing concerns he said he heard from hospital workers, said the facilities were “OK when nobody’s sick or on vacation, or there’s a holiday. But when somebody is sick or on vacation or there’s a holiday, we’re in trouble.”
→ Continue reading at khi.org.