Edwards must emulate Jindal mental health care move

It turns out that former Gov. Bobby Jindal had it right. Now if only Louisiana’s current Gov. John Bel Edwards would follow through.

Recently, the U.S. Department of Justice gigged the state for excessive institutionalization of mentally ill individuals. A letter to Edwards noted that Louisiana maintained too few options to treat such individuals in the community rather than in hospitals or nursing homes. Moreover, the document noted that unless the state came to some kind of agreement that began expanding community placements at the expense of institutionalization, the federal government would pursue legal action.

The problem begins with Louisiana having too many nursing home beds. Historically, public policy has favored nursing home interests, to the absurd point now that the state pays tens of millions of dollars annually to maintain empty beds in private facilities. This has given the state one of the highest per capita number of beds in the country, ranking fourth highest among the states (2014 data) and thereby diverts dollars that could go to home- and community-based programs.

As research has demonstrated, if you build them, they will get filled – colloquially known as “Roemer’s Law,” although not postulated by the former governor. Hence, the fewer beds available, the less likely the tendency to warehouse patients occurs. Note, however, that a certain minimum must exist to treat adequately acute patients as opposed to their long-term care, which some argue states do not meet that capacity currently to do so, although others assert that when conceptually understanding that service and beds are separate, collaborative care models can provide enough adequate service without a dramatic increase in hospital beds.

Comparatively, Louisiana ranks decently on that measure. In terms of total beds for acute psychiatric patients, according to somewhat dated but likely not largely changed data it ranks 23^rd in number of private beds and, using more recent data, 19^th in number of state beds per capita for this purpose. However, in 2010 it lagged the nation in rate of admissions among adults with a diagnosis of any mental illness, at 1.1 percent.

The DOJ letter reveals why. With insufficient attention paid to evaluating patients’ conditions, knowledge of options, and existence of community supports with an eye towards their discharge, patients get backlogged in institutions. The institutional bias keeps them first in acute care situations too long, then puts them in institutional settings too often – assuming that the mentally ill get to a hospital rather than incarcerated, which also would drive down the proportion of diagnoses admitted. The problem is not in a paucity of beds, but in practices and policies that encourage over-bedding and makes Roemer’s Law a self-fulfilling prophecy.

All of this was secondarily on Jindal’s mind when in 2012 he ordered the closure of Southeast Louisiana Hospital, one of the state’s psychiatric facilities and the main reason why the state number of beds shrunk from 903 in 2010 to 616 this year. Then, cost considerations figured as the primary reason, with less expensive provision available outside of government, but the Jindal Administration also noted that the state should move away from the institutionalization model and wanted to work more in community settings in partnership with private providers.

Naturally, special interests wedded to the government-provision model got all upset with the move, predicting dire consequences from it. Just as naturally, none of that came true. Today, the St. Tammany Parish government owns the site and has redeveloped it, featuring a private provider of both inpatient and outpatient psychiatric treatment, lauded by Edwards.

That’s a commitment that Edwards must continue. While that does not necessarily mean closing either of the two remaining state psychiatric hospitals, it does mean wiping out the institutional policy bias in mental health care. It seems unlikely that the state can avoid federal government legal action against it unless it does so.