As soon as she saw the truck, Desiree Larranaga knew something terrible had happened.
The white Ford belonging to her friend Anthony Vigil was parked in the dirt past the end of Jaguar Drive, just outside Santa Fe city limits. It all added up too predictably: Vigil, 36, had argued with his girlfriend Theresa Diaz just days before and said that he wanted to kill himself. Diaz managed to keep the keys to the gun safe away from him, but called 911 after he started to cut his throat with a knife. Vigil was evaluated at Christus St. Vincent Regional Medical Center, but was released within approximately two hours.
A few days later, on Feb. 10, Larranaga went looking for Vigil after he failed to show up for work. His truck was parked just a few hundred feet from the pipeline bridge where Vigil had told Diaz he would hang himself. Two parking tickets tucked under the truck's windshield wipers fluttered in the breeze.
Afraid to look in the arroyo, Larranaga summoned law enforcement. Vigil, an orthopedic medical technician, youth baseball and basketball coach, and father to three kids, had hung himself from a chain-link fence along the bridge.
"He was not even admitted for a psychiatric evaluation or anything," Vigil's mother Veronica says of her son's experience at the hospital just days before his suicide. "They should have done that. They should have kept him for 24 or 48 hours, and they didn't do that. They let him out in less than two hours…If they would have admitted him and evaluated him it might have saved him."
Vigil's family members are not the only Santa Feans left questioning CSV policies after a loved one was denied access to the inpatient psychiatric unit (IPU). Increasingly, patients experiencing a mental health crisis are simply denied access to the IPU. Instead, they are often treated in the emergency department (ED) with a one-time dose of medication and then discharged, transported to Santa Fe County Adult Detention Facility or simply ejected back on the street after their needs are deemed noncritical. The costliness of inpatient psychiatric care, combined with a lack of sufficient coverage by Medicaid and Medicare, creates a major disincentive for CSV to take these patients on, as well as a skewed set of criteria with which to screen patients for admission.
Jenny Montoya, who spoke to SFR on condition that her real name not be used, escorted a close friend to the emergency department at CSV in January when he stopped taking his medication and was refusing to eat. Hospital staff told Montoya that her friend, who suffers from schizophrenia, was not going to be admitted. But when Montoya revealed that she knew some of the hospital's major funders, the staff changed its tune.
"The [emergency department] doctor and [emergency department] nurse agreed that he needed to be admitted to the psych ward, but the social worker that came on [duty] was like, 'No, I'm not doing it,'" Montoya says.
Montoya's connections were enough to get her friend admitted to the IPU—but only for 24 hours. When he returned for a follow-up outpatient appointment, he left without treatment after being told he needed to pay $200. A couple of months later, paramedics transported him to the ED again after he gave himself life-threatening injuries during a psychotic episode. This time he was admitted immediately because of his extensive injuries, Montoya believes.
Kat Jackson, who also spoke under a pseudonym, has been to the ED at CSV on several occasions as a result of her bipolar disorder. Each time, she was treated with the antipsychotic Haldol and released shortly thereafter, instead of being admitted into the IPU. Haldol is a treatment sometimes used on schizophrenic patients that temporarily suppresses the "feel good" neurotransmitter dopamine.
"They gave me [Haldol] and kind of checked on me to see how I was responding to the medication and eventually let me go…If they wanted to get somebody stabilized, they would admit them, or they would ship them to the state hospital [in Las Vegas]," Jackson says.
CSV serves the behavioral health needs of people living in seven counties in northern New Mexico, approximately 238,164 of whom suffer from mental illness, according to an April 2010 study commissioned by CSV. According to the study, by AE Consulting, 4,763 of those people are classified as suffering from serious mental illness, defined as "persons who often need psychiatric services provided through the hospital and the publicly-funded behavioral health system," though that's a low estimate, in the opinion of some members of the National Alliance on Mental Illness' Santa Fe chapter.
The study also found that CSV's 11-bed IPU is usually less than half occupied, with an average occupancy of 4%uFFFD patients. Yet according to the NAMI Santa Fe newsletter and Santa Fe County Sheriff's Office staff, CSV often claims the IPU is full when prospective patients are turned away.
"We had a meeting with the hospital and they were saying [the IPU] is underutilized," Deborah Tang, executive director of St. Elizabeth Shelter, says. "It's like, 'What do you mean it's underutilized? You're turning people away all the time!'"
Joe Hay is a case worker at St. Elizabeth Shelter who works with ED "frequent flyers"—patients who have a mental health diagnosis, a substance abuse problem or both, and seek repeated treatment at the emergency department. He tells SFR that, to be admitted to the IPU, patients need to be a clear threat to public safety or completely willing to get assistance, not a description often applied to those in the midst of a mental health crisis.
"It requires a lot of cooperation [from the patient] in order for [the IPU admission] process to start, or very severe threats like criminal activity before they will keep a very long psych hold on somebody," Hay says. "Otherwise, they just get let out again…They need to say they want to get treatment, to agree to testing, to agree to an evaluation, to agree to stay in the psych ward or go to the Behavioral Health Institute [in Las Vegas] and without that cooperation…it needs to be very, very severe; otherwise, they get sent out again."
First Judicial Court Judge Michael Vigil (no relation to Anthony Vigil) presides over the region's Treatment Court program and gives a similar report on the care received by people he's referred to the ED.
"We have had people who we have sent to the emergency room from our Treatment Court program, which is a program that works with mentally ill defendants, and who seem to be in a psychotic state. And we will have them taken to St Vincent's, and they will usually give them some type of medication and release them back onto the street with very little follow-up," Judge Vigil says. "It's people who we feel need to be hospitalized until they're stabilized."
Unfortunately, the consequences for patients who don't surmount these hurdles and gain entrance to the IPU can be dire. Judge Vigil points out that Santa Fe is lucky an incident like the 2005 murders perpetrated by schizophrenic John Hyde in Albuquerque hasn't yet happened in Santa Fe. So far, the deadly events here that seemingly could have been prevented with more proactive hospital policies have mostly been suicides.
"We have had people who try to get treatment and end up killing themselves," Vigil says. "They're suicidal; [hospital staff] will talk to them for awhile; they won't admit them; and they'll end up taking their own life."
Anthony Vigil was discharged from the hospital despite exhibiting the most critical signs on the widely used Scale for Suicidal Ideation: the suicidal gesture or attempt that he made by trying to cut his throat and the specific plan to kill himself at the pipeline bridge. Under state statute, if a mental health patient has just attempted suicide or is judged by a psychologist or psychiatrist to "present a likelihood of serious harm to himself or others," he or she can be committed for evaluation without a court order.
Dr. Anjali Dasari, CSV's medical director for Behavioral Health Services, says CSV follows admission criteria that is standard across the behavioral health care industry and among insurance companies. Though she expects someone who was brought to the ED after a suicide attempt would need to be admitted, she says it would depend on the specific circumstances.
"If someone had attempted suicide that very day, I would think they are in crisis and they need help and they need to come in," Dasari says. "But it depends; the situation can vary from patient to patient, so I think, if I were to be the admitting psychiatrist, I would take a look at the whole picture and go from there."
There are degrees of suicidal intent, according to Mark Boschelli, the clinical director at Presbyterian Medical Services Santa Fe Community Guidance Center. In behavioral health care parlance, these are referred to as levels of "lethality."
"The majority of the time, there's people who do have suicidal ideation on a regular basis and quite often they are not hospitalized because their acuteness doesn't meet the threshold," Boschelli says. "Sometimes people are just struggling, and I guess they've been conditioned to say it's suicidal ideation, when in fact it's just that they're feeling sad."
Boschelli says some patients have been "conditioned" by learning that people will listen to them more closely when they say, "I'm going to kill myself, I'm going to hurt myself."
PMSCGC runs a program called the PACT (Program of Assertive Community Treatment) Team, which works specifically with the top 50 emergency room "frequent flyers" in an attempt to keep them out of the ED at CSV. The PACT Team receives some money from CSV as a treatment "scholarship" for patients not covered by Medicaid.
CSV Board Member and North Central Director of PMS Larry Martinez defends the ED's process of screening potential IPU patients, saying that people who complain of their family member not being admitted are often mistaken about the appropriateness of inpatient care under the circumstances.
"The hospital winds up getting a disproportionately large number of people going to the emergency department when many of the reasons for their going is due to a behavioral health issue," Martinez says. "Oftentimes the emergency department is not the appropriate place for someone who's addressing a behavioral health issue. It's where care is the most expensive, and the emergency room department can only go so far in responding to the behavioral health needs of the individuals."
In the fall of 2009, CSV considered closing its IPU altogether. The Santa Fe chapter of NAMI derailed that plan by organizing public meetings and laying out the consequences of northern New Mexico being left without such a facility.
But after committing to keeping the unit open, CSV commissioned what it terms a "utilization study," an as-yet-unreleased report created by health care consultant Howard Gershon. CSV has so far declined to release the report's findings or the changes to CSV services that may be made as a result.
But according to NAMI Santa Fe member Martha Cooke, the "Gershon study" focuses on the amount of money IPU loses annually and what can be done about it. Cooke, along with other NAMI Santa Fe members, has been present at closed meetings with the hospital when the report has been discussed.
The study reportedly finds that the hospital takes a $1 million loss annually on the IPU, Martinez—who has also seen the study—tells SFR. Another topic is the issue of the ED "frequent fliers," an issue brought up by CSV staff at Santa Fe County Indigent Hospital and Health Care Board meetings going back over a year. The partnership between CSV and the PACT Team appears to be an example of the direction CSV will be trying to move with its psychiatric care. If CSV offers funding to outside organizations that decrease dependence on the hospital's resources for the most serious cases of mental illness and addiction, it can tighten its profit margins.
Judge Vigil says the prospect of changes to the IPU based on a utilization study worries him.
"I hope they're not going to do even less…I think that's just fancy talk for less services," Judge Vigil says.
CSV's shift away from inpatient psychiatric care is part of a national sea change that has been underway since the 1950's, when antipsychotic drugs were developed.
After the introduction of Thorazine, an antipsychotic similar to Haldol, former President John F Kennedy authorized $3 billion in federal spending to create outpatient mental health clinics that would largely replace institutions. An estimated 400,000 mental patients were deinstitutionalized between 1960 and 1980. The basic philosophy of deinstitutionalization still has broad support today.
"People can actually be supported in their community and live a productive life like everybody else," Boschelli says. "So the stigma of mental illness and substance abuse is decreased proportionally."
Boschelli says that, at any one time, about 10 of the 50 PACT Team clients is "on the verge of a psychiatric hospitalization," but the majority of the time, they can be stabilized without admission to the ED.
Santa Fe Municipal Court Judge Ann Yalman, who deals with many mentally ill individuals through the city's Homeless Court program, says the PACT Team is effective but limited in scope because it only works with its established clients. Even for PACT Team clients, the program doesn't obviate the need for emergency psychiatric care for people in acute, potentially dangerous mental states.
The PACT Team's charge to assist individuals who would otherwise rack up the most hospital bills points to a major motivating factor behind the deinstitutionalization trend: money.
Behavioral health problems tend to be obstacles to steady employment, meaning many behavioral health patients are either completely uninsured, covered by Medicare or covered by Medicaid.
Medicare is a federally funded and administered health insurance for those over 65 or unable to work because disabilities. Medicare sets reimbursement limits for various services, aiming to cover about 80 percent of the cost, and sets a lifetime limit on inpatient psychiatric unit use of 190 days.
Medicaid is a federally funded but state-administered insurance for impoverished people who meet certain other criteria. Since about half of the PACT Team patients are Medicaid recipients, it's logical to assume that a sizeable proportion of those who seek emergency psychiatric services in Santa Fe are on Medicaid.
Before 2004, the state Human Services Department administered Medicaid payments to a slew of different behavioral health care providers, a system deemed confusing and difficult for patients to navigate. In 2004, the state Legislature created an interagency body that oversees a private company responsible for managing all Medicaid payments to behavioral health providers.
A company called ValueOptions New Mexico held this contract until July 2009. At that time, OptumHealth New Mexico, a subsidiary of the nation's largest insurer, United HealthCare, took over the contract. OptumHealth now determines how much to reimburse CSV for treatment of patients at the IPU, just as private insurers decide how much to pay CSV back when their customers receive services there.
Under its contract with the state, OptumHealth can keep as profit unspent money that it receives from the state each month which is designated for members' services.
A 2011 report to stakeholders issued by OptumHealth provides insight into the company's philosophy on inpatient care. The publication trumpets reduced IPU use in several other states where OptumHealth holds managed care contracts. In Washington, IPU use went, in less than a year, from 19.6 annual inpatient days per 1,000 patients to 12.1 annual inpatient days per 1,000, according to the report. In New York, the average length of stay at inpatient facilities went, in a two-year span, from 55 to 11 days under OptumHealth's watch.
But consolidating behavioral health services under one for-profit company tends to create "monetary incentives to withhold services and divert [funds] to administration and profit," according to a 2004 study of New Mexico's behavioral health care system published in the journal Psychiatric Services. In 2005 and 2006, the Legislative Finance Committee wrote, in audit reports to the state Behavioral Health Collaborative, that it was concerned about the practice of paying a managed health care company a set monthly rate in advance rather than reimbursing it for services after the fact—the same payment arrangement used with OptumHealth today. The LFC wrote that the practice "reduced [the state's] leverage to require the contractor to perform adequately."
According to HSD spokeswoman Betina McCracken, Medicaid reimburses CSV approximately $485 per IPU patient per day, significantly less than the amount one privately insured patient was charged for a treatment she received there after a panic attack. That patient's attorney, Walt Schliemann, tells SFR that the woman's insurance was billed $3,394 for a hospital visit in which she was (perhaps incorrectly) diagnosed as bipolar after a 20-minute consultation and injected with Haldol.
Montoya, the woman who helped her schizophrenic friend gain admission to the hospital, says it appeared CSV was reluctant to admit him because he wasn't a private pay patient.
"When I pushed, I found out it was all about money…[the social worker] said he didn't meet the criteria, and I'm like, 'The criteria for what?' And it was the criteria with regard to insurance, and that potentially his family would have to pay [the rest of the cost]," Montoya says.
Dasari says CSV "provide[s] services for anybody in need of services." Under federal regulations, IPUs receiving Medicare money are not permitted to use different admission criteria for patients using different payment methods.
Santa Fe's behaviorial health services demonstrate the effect of the nationwide transition in mental health care that began in the 1950s, but has never been completed. Institutions were phased out, but community mental health centers never fully took their place.
Health care policy scholars have a word for what happened instead: transinstitionalization. The result is a landscape of stopgaps, temporary fixes and poorly funded programs unprepared to handle the mentally ill.
"The county detention center is the de facto psych unit," Cooke says.
When the Santa Fe County Sheriff's Office transports people in the midst of mental health crises to CSV, they are often deflected to the Santa Fe County Adult Detention Facility, even if the individuals are not facing charges, Sgt. William Pacheco tells SFR.
The jail has two psychiatrists, three therapists, and a mental health director, case worker, social worker and mental health administrative assistant on staff to deal with the influx of inmates with mental health issues. Facility psychiatrist Dr. Eli Fresquez says there is at least one inmate on suicide watch at any given time, and approximately 10 percent of the jail's population is suffering from mental health issues. About 35 percent of detention officer training is dedicated to behavioral health issues, such as recognition of mental illness signs and symptoms, issues with psychiatric medications, and mental illness crisis management.
"I think we are the largest mental health provider in the area," Fresquez says.
"Most of them are going [to the jail] because the hospital is not admitting them," Judge Vigil says. "It's not ideal; it's terrible, They shouldn't be in jail; they should be in a mental health facility. But nobody wants to pay for it so the taxpayer is being required to pay for it, through corrections."
Some of the mental health patients who are being held on criminal charges probably wouldn't be there if they had received adequate intervention for their mental health crises.
"People with bipolar disorder or paranoid schizophrenia are usually in a psychotic state or a manic-depressive state at the time of their commission of the crime," Judge Vigil says. "That does not excuse the crime because they still have a basic understanding that their actions are inappropriate; it's just their mental health is really causing them to do things they wouldn't normally do if they were properly medicated and in treatment."
In Homeless Court, Yalman sees the same faces over and over. These are the people who have slipped through the cracks between CSV, the PACT Team and other local mental health services.
"There's delays getting them into programs…in the meantime, they're having all these problems and the problems are with the law," Yalman says. "The resources are just not sufficient, and they're overburdened…the jails become sort of a repository for the mentally ill, which isn't what their purpose is."
St. Elizabeth's already tight budget is strained further by an unfunded service they provide for people who are discharged from CSV but are too sick to be on their own. Respite care, as it's known, serves many mental health patients—despite there being no actual health care workers or mental health professionals at the facility. In addition, respite guests tend to stay two or three months at the shelter, which is supposed to have a 30-day limit. CSV's revolving door is a familiar phenomenon to St. Elizabeth's staff.
"It's very difficult to get people into the behavioral health ward when people are in crisis, and to keep them there long enough so they can actually alleviate whatever the crisis is," Tang says.
One of the hardest things for George and Veronica Vigil to accept about their son's death is that they had no idea he went to CSV, or that anything out of the ordinary was happening with him, until they found out he was missing shortly before his body was discovered. Veronica spoke to her son approximately a week before his death, when he was riding the New Mexico Rail Runner Express back from Albuquerque after a shift at Presbyterian Hospital. He was his usual happy-go-lucky self, she says.
That's the scenario that people with mentally ill friends or family shudder to imagine: What would happen if they weren't there to advocate on behalf of the vulnerable patient? Santa Fe NAMI President Louise Drisdale says she had to learn how to get her mentally ill son the care he needs.
“When you’re in the depths of trauma in your family, all you want is somebody to help you fix it; and when you don’t know the right questions to ask, it’s really, really hard,” Drisdale says. “You depend on the people who should know what they’re doing…I believed the system would take care of [my son], but it doesn’t happen like that. If there isn’t somebody to advocate for them, that’s where they fall through the cracks.” SFR