Abbe Center’s closing leaves gap in mental health services

The Gazette Editorial Board

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“The Abbe Center is the best thing that has happened to Colin in his year of mental madness.”

So wrote Dianne Williams of rural Chickasaw County in an email message about her 22-year-old son's experience at the Abbe Center for Community Care in Marion. Now, after five months of treatment there, Colin Williams, along with about 75 others at the residential care facility, must move on. The Abbe Center is closing its doors on Sept. 30.

For Colin and his mother, a Gulf War veteran, it's yet another traumatic challenge they face after “the incident that changed our lives forever,” she told The Gazette Editorial Board during an interview.

Dianne and Colin's story provides a window into the state of mental health care services that Iowans should understand and lawmakers could better address.

On June 16, 2012, Colin, then a resident at a group care home in New Hampton, exploded into angry, threatening behavior, Dianne said. She rushed him to the hospital's ER but to no avail. Colin's anger escalated. He ran off, eventually wandered into a garage and attacked four men.

A few hours later, after a court committal, he was sent to a facility in Sioux City. After three days, he was returned to the New Hampton group home but, as Dianne had feared, his behavior didn't improve. Colin came back home but exhibited terror, hearing voices, seeing things not there, she said. He tried to jump out his bedroom window several times. Sheriff's deputies intervened again.

THE PATH TO ABBE

From there, Colin, who has been diagnosed with schizophrenia, spent time at hospitals and care facilities in Waterloo, Mason City and Iowa City. His medications were frequently changed, and Dianne's access to him was often restricted, she said. Eventually, he was placed at the Mental Health Institute in Independence. After a few months, MHI staff recommended Colin be placed at Abbe Center.

At first, Dianne said, she was hesitant to have Colin leave MHI. As it turned out, “Abbe is the best place in the state,” she told us. “Eye contact and shaking hands and allowing physical contact never happened before Colin went to Abbe. ... The doctor changed his plan and drugs, and within two weeks, there was a big difference. Abbe has been wonderful. They've given him back his life.”

But now, as the Abbe Center's closing nears, the search is on for another residential facility that can provide the intense level of care for the mentally ill that Abbe offers as part of its services. Abbe officials, as well Colin's local county central coordinator of services and the state Department of Inspections and Appeals, all can help with relocation. As of last week, his placement was not yet finalized.

“Dianne can't go much longer without a plan and this fear of the unknown,” said Jane Caroway, an educator who had Colin as a student for four years and advocates for those with mental illness. “There's a lot of love in his family, but it's not safe for him to be at home.” And they fear that without adequate, long-term residential care and treatment, Colin could wind up being among the homeless or commit a crime that puts him into Iowa's prison system - already overtaxed with inmates who have varying levels of mental illness.

ABBE'S DOWNSIZING

Abbe's closing will cap years of downsizing before funding cuts at the local, state and federal level accelerated two years ago, when Linn County faced a $5.4 million deficit in its mental health and developmental disabilities budget. Referrals to Abbe have since dropped sharply, as has revenue. According to Abbe President Dan Strellner, Medicaid rules that pay for residential care don't cover facilities larger than 16 beds. And a national movement following the Supreme Court's 1999 Olmstead Decision affirming rights of people with disabilities to live in community settings has led to shifting many patients from large institutions - many of them, as in Iowa, the original “county homes” and state mental health institutes - into more community-based homes and smaller centers.

Abbe's official capacity for residential beds for people with mental illness (RCF/PMI) is 64, one of four large facilities remaining in Iowa.

Strellner and Dr. Al Whitters, chief of psychiatry at Mercy Medical Center, Cedar Rapids, who works with Abbe clients, say they understand Linn County's budget cuts that impacted the non-profit Abbe Center. They worry, however, that the full continuum of care for the mentally ill faces a serious gap, especially for the people “least able to defend themselves or who are a danger to themselves or others.”

HOSPITALS FULL

They note that hospital units in Cedar Rapids and Iowa City have nearly 170 beds for psychiatric patients that are “always full” - more beds than the rest of the state combined. Yet, after Abbe closes, the new nine-county region that has been created under the state's redesign of mental health services will have only nine RCF/PMI beds that provide the “subacute” care for patients released from the hospital units. At Abbe alone, there are about 25 patients who require such care.

Statewide, the DIA lists 13 RCF/PMI facilities with a total capacity of 312 beds - counting Abbe. The actual statewide need? That number is hard to come by.

REDESIGN'S ROLE

The state redesign is in its second year. Strellner and Whitters agree with its intent to provide level services throughout the state “but there's a lot of work to do yet. Some of it has been implemented without fully understanding the consequences,” Strellner told us.

Steve Miller and Mark Smith of Linn County NAMI (National Alliance for the Mentally Ill) have similar concerns and believe Abbe's closing leaves a hole in vital services.

Part of the unknown, Strellner and Whitters said, is how well the redesign works with the new Iowa Health and Wellness coverage for low-income Iowans and the evolving federal Affordable Care Act.

Rick Shults, state administrator of the mental health division of the Iowa Department of Human Services, told us the redesign did not envision an impact on the number of RCF/PMI facilities and beds. However, the redesign is based on the Olmstead Decision principles and “because of this, we will all be working together to expand the availability of effective services that will allow people to live and work successfully in more communty-integrated settings. The more the integrated settings grow and prove successful, there may be an impact on larger facilities.”

As we've written before, a statewide redesign was needed. Inconsistent access and delivery of services in parts of Iowa needed to be shored up. An adequate number of smaller residential facilities with high-level care may eventually fill the need as larger ones close.

TRANSITION FUNDING

But full implementation will take several more years. In the meantime, the “evening out” process doesn't appear to be serving some people - such as those who are better served in an RCF/PMI facility. That's why we were disappointed when Gov. Branstad earlier this year vetoed $13 million in supplemental funding that legislators had approved for transitional assistance as the redesign unfolds.

We urge the governor and legislators to address this situation early in the 2014 session. The state's financial situation certainly is strong enough to provide more transitional funding. Iowans with needs similar to Colin's - the most at risk - can't afford to wait much longer.

Comments: editorial@thegazette.com or (319) 398-8262

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Iowa's mental health and disability development services system redesign: http://www.dhs.state.ia.us/Partners/MHDSRedesign.html

Abbe Center for Community Care

http://www.abbe.org/

NAMI Linn County

http://tinyurl.com/mj29v7u

Iowa Department of Inspections and Appeals, Health Services Division

http://dia.iowa.gov/page11.html