CEDAR RAPIDS — Robert Livingston on Jan. 30 in Cedar Rapids and Richard Huffman on Dec. 18 in Dubuque acted out violently after earlier telling authorities they were having a mental crisis and needed to go to a hospital for help.
Livingston, 47, shot and killed his estranged wife and mother-in-law in a spray of bullets from his AR-15 rifle and then shot himself in the head.
Huffman, 45, is back in jail, charged with first-degree arson and accused of lighting a convenience store gas pump on fire just like he did in Iowa City in 1998 — at which time he became a rarity in Iowa, a criminal defendant found not guilty by reason of insanity.
Neither of the acts of violence happened in a vacuum. Rather, they come at a time when Iowa is reshaping its mental health delivery system.
As part of the task, public officials and mental health providers, in newly established regions across the state, are meeting to determine what treatment services for mental health and disabilities they need to provide. Funding support from the Iowa Legislature and the governor’s office remains a question.
Dr. Alan Whitters, director of behavioral services at Mercy Medical Center in Cedar Rapids, and Kent Jackson, administrative director of behavior services at St. Luke’s Hospital in Cedar Rapids, have been on the front lines of mental health treatment for years. The two now are at the table to help design a mental health delivery system in the nine-county East Central Region that stretches from Dubuque through Cedar Rapids to Iowa City. And they say the same thing: The state and region’s mental health delivery systems are in need of help.
“The hope with mental health reform in Iowa is it will make things better,” Jackson said. “It’s possible to make things worse.”
He said a lot can happen in a week for individuals with severe mental illness who go without adequate help.
“You can get real sick real quick.” Jackson said. “ … We need more beds at every (mental health treatment) level in this state. As we talk about safety, that’s where the real push needs to be. Yes, I’m pushing.”
Whitters put it this way: “The system is broken.”
Mental health system
Jackson and Whitters said the discussion about mental health services in the East Central Region must be seen in the context of the abrupt shutdown in September of the Abbe Center for Community Care in Linn County. The facility served as a vital resource for hospital psychiatric wards looking for a safe residential placement for tougher cases, they said.
As it moved to close, the Abbe Center hustled to find community placements for 70 or so residents — a move driven, in large part, by money. Medicaid will not fund treatment at facilities with more than 16 beds, and counties did not want to pick up the additional costs.
“It would be nice to say, yeah, everything is hunky dory,” Whitters said. “But patients were not well-served by the closing of Abbe Center.”
St. Luke’s Hospital has the largest inpatient hospital psychiatric ward in the state with 74 beds, consisting of a 32-bed adult unit, a 24-bed child and adolescent unit and an 18-bed unit for older adults. The University of Iowa Hospitals and Clinics is second largest. Mercy Medical Center in Cedar Rapids has a 20-bed unit.
Jackson said St. Luke’s psychiatric units admit 3,000 to 3,500 patients a year with an average length of stay for the adult and child/adolescent units of six days and the older adult unit, nine days.
He said much of the time the units are full, fed by more than 60 of Iowa’s 99 counties in the past year. Hospital psychiatric units track “diversions,” which are those who inquire about admission, often on the phone, but are directed elsewhere because of lack of room. St. Luke’s averages about 230 diversions a month, but in January the number was 295, Jackson said.
Most seeking admission to a psychiatric unit come to a hospital emergency room, and Jackson said some emergency rooms in Iowa end up boarding psychiatric patients as they wait for a placement in a psychiatric unit. On average, St. Luke’s makes a decision about a psychiatric admission within two and a half hours, he said. Two out of three seeking admission are admitted, and the others are released with a treatment plan, he said.
Mercy Medical Center, where police took Livingston at his request a day and a half before he killed his wife, mother-in-law and himself, declined to discuss the specifics of how often its psychiatric unit is full of patients or how long patients stay in the unit.
However, St. Luke’s Jackson and Mercy’s Whitters said hospital psychiatric wards face pressure in two directions — serving those who seek admission when the units are full and finding an acceptable placement for those in the units who are ready to be discharged.
Some of the last residents at the Abbe Center went to residential care facilities in Iowa City and Delhi, both operated by Abbe Inc. affiliates with lower-cost, non-union employees rather than the higher-cost, unionized work force that worked at the larger Linn County facility. Additional homes in residential neighborhoods also opened for three to five clients each in the Cedar Rapids area.
Levels of care
Whitters and Jackson said a crucial need that the Abbe Center provided was residential beds for a higher level of mental health care.
The pair said a small number of psychiatric patients can be violent and difficult to handle in a hospital, not to mention in the community. Increasingly, the state’s mental health institutes don’t have room or are less willing to take those clients, they said.
Mechelle Dhondt, director of mental health and developmental disability services in Linn County, is working with Whitters, Jackson and other representatives of counties in the East Central Region. She said there are some funding realities that they probably will have to face.
For instance, Dhondt said Iowa may be interested in providing funding support statewide for just 50 of the more intensive, longer-term residential care beds known as subacute beds.
Dhondt said the focus of the regional board is on subacute beds and the short-term crisis stabilization beds. One idea, she said, is to have a small number of crisis beds near hospitals in Cedar Rapids, Iowa City and Dubuque.
In fact, a pilot project for one crisis client at a time has been operating for about two months in a Cedar Rapids home where three other longer-term mental health clients live, Dhondt said.
Foundation 2’s crisis program in Cedar Rapids is operating the experimental program. Barb Gay, the agency’s executive director, said the hope is for more crisis beds in the future.
“One bed is better than zero,” said Gay, who also sits on the East Central Region board.
Foundation 2 staffs a 24-hour crisis hotline and also operates a mobile crisis team in Linn County, which law enforcement officers can access to get assistance.
“We are big proponents of the program and would be happy to expand it,” Gay said.
Unlike Jackson and Whitters, Dhondt doesn’t think the closing of the Abbe Center was that big a blow to community mental health. Dhondt said her survey at the time showed an ample number of residential care facility beds in the region to handle those who were leaving the Abbe Center.
Closing Abbe did not increase the risk level in the community, she said.
“Any time you say anything like that, it makes people think there’s all these dangerous people lurking around our community,” she said. “And that’s really not the case. … There’s been so much rhetoric — and I really mean rhetoric.”
In the long term, Whitters said the move to deinstitutionalize the treatment of mental illness dates to the mid-1950s. The closing of the Abbe Center is a move in that direction.
But the result has become something of a re-institutionalization, he said, because now those with mental illness end up in jails and prisons.
Despite that, Whitters sometimes thinks that the latest move in Iowa is in the right direction and might work. But he said he has not seen a funding commitment to support it.
“I have yet to see any improvement. In fact, things seem to be getting worse,” he said.
Jackson said less accessibility to the state’s mental health institutes and the closing of the Abbe Center have complicated life for the hospital psychiatric ward.
“I can say that I have staff who routinely are looking at stuff like that,” he said of violence in the community. “They’re not assigned to do it, but they do it. We keep a pretty close eye on who is in the news for what.”
Jackson said St. Luke’s keeps psychiatric patients even when reimbursement has run out until it has established a discharge plan that is “humane and safe.”
“Having said that, we do not have the best options to choose from a lot of times,” he said. “So I feel we’re put in a situation sometimes where we have to take more risks than we’d like.”
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