Editor’s note: Heartland Health Monitor partner KHI News Service conducted a months-long investigation into what led federal officials to deem Osawatomie State Hospital as a facility too dangerous for Medicare patients and whether officials can rebuild the hospital for a successful future. This is the fifth and final story of the series.
Kansas officials say Osawatomie State Hospital has made significant improvements since federal inspectors deemed it unsafe in December 2015, but mental health providers say the state needs to examine its entire system to avoid a future crisis.
Federal officials cut payments to the hospital after the rape of an employee by a patient revealed safety hazards, but the problem had been a long time coming. Short staffing, low funding and the closure of other psychiatric units all gradually increased the pressure on OSH until inspectors determined patients and staff were in danger.
The hospital is losing about $1 million per month in funding from Medicare and other federal programs, but state officials say they are close to applying to restart payments. After that, OSH must pass two federal inspections to regain certification.
Tim Keck, interim secretary of the Kansas Department for Aging and Disability Services, declined to give a date when the hospital will reapply because some renovations to improve patient safety on one unit aren’t yet complete.
Keck didn’t rule out attempting to recertify other units so the state could be paid for treating Medicare patients, but OSH will seek to recertify only one unit in the short term. Units that don’t serve Medicare patients won’t have to be renovated.
Earlier this year, Keck said the department wanted to collect proposals for a public-private partnership to run OSH, but Kansas legislators approved a bill that requires their permission in order for privatization to happen.
Recertification is the department’s first priority at this point, KDADS spokeswoman Angela de Rocha said. If KDADS officials decide to pursue privatization, they would have to wait until at least January, when the Legislature will return for its 2017 session.
New treatment stems violence
While inspectors found multiple problems in the year before decertification, the most significant was the inability to protect staff and patients from violence. John Worley, the current OSH superintendent, said the hospital has reduced the risk of violence by adopting new processes to detect early warnings signs of patient agitation and handle the situation.
Employees also are receiving in-depth training about how to respond if a patient becomes aggressive without warning, he said.
KDADS hired Kathy Bolmer, who runs Tennessee-based KB Behavioral Healthcare Consultants, to assist with identifying and resolving problems at OSH.
Bolmer said she has worked with OSH administrators to reduce the odds of violence by improving treatment options so patients have less time to become bored or frustrated. The hospital also is hiring more employees so that someone can check on patients every 15 minutes, she said.
“There’s more happening on an individual basis,” she said.
The goal isn’t just to fix the problems that federal inspectors found but to build a “solid” treatment program, Worley said. That includes improving patient care from the beginning, providing sufficient staff outside the normal work week and making sure each patient has an in-depth discharge plan to continue receiving care after leaving the hospital, he said.
“We really have focused much more on care needs,” he said. “I think we’ve turned the corner on some of the processes.”
Employees have been enthusiastic about learning better ways to do their jobs, Bolmer said, but she acknowledged that major changes take time. Keck likened the process to “hardwiring.”
“It’s not like CPR training,” he said. “It’s more to the core of the way business is done.”
Medical care also has improved since the hospital clinic recently reopened, Keck said, and medical doctors are on call at all times. Inspectors found in late 2014 that one patient had died and another lost a toe when overworked nurses didn’t provide all needed medical care.
“I believe if we had a survey (inspection) today, the care we provide would more than surpass the standards,” he said.
Progress on staffing, budget
Staffing levels have improved, Keck said, and the hospital had a roughly 21 percent vacancy rate for all staff in mid-July, down from about 35 percent in February. Part of the difference comes from increased hiring and reduced turnover, but the department also eliminated some open janitorial and support positions that weren’t needed after Rainbow Mental Health Facility closed, he said.
“Things are quite a bit better from a staffing standpoint,” he said.
Having no staff vacancies probably isn’t feasible, but the hospital can shoot for the roughly 17 percent vacancy rate that is typical for the Kansas Department of Corrections, Keck said.
The employee turnover rate also improved, from 72 percent in 2015 to 19 percent as of early June 2016. Keck credited the Legislature for appropriating an additional $2 million to address vacancies by raising staff pay.
While many parts of state government endured cuts in a difficult financial year, the Legislature showed some willingness to invest in state hospitals. The budget for the fiscal year that started July 1 has allowed OSH to raise pay 10 percent for registered nurses and 12 percent for mental health technicians.
“Those two pay increases have been a really big help,” Keck said. “We need to be able to compete with other hospitals in that area.”
For a time, staff at OSH turned over often because of “forced” overtime, including double shifts that employees said they were told to work against their wishes. The hospital hasn’t eliminated forced overtime but has made progress in reducing it, Keck said.
“We need to give (employees) a life back,” he said.
Rebecca Proctor, executive director of the Kansas Organization of State Employees, said she isn’t certain how conditions are for staff at the hospital now, because some of the employees who used to report on the situation at OSH no longer work there. Still, she thinks the state needs to continue increasing pay to lure new employees so those working at the hospitals won’t have to put in excessive overtime.
“In many situations, if the pay is reasonable for the job, people are willing to stick it out,” she said.
Keck said the department also is looking into whether it needs to continue raising staff pay to be competitive with other health care jobs in the area.
“It’s probably going to take some salesmanship to the Legislature,” he said.
Needs beyond hospital walls
While people working in the mental health system welcome news of improvements at OSH, some see a need for broader investments in care for people with mental illnesses. OSH received some additional funding from the Legislature this year and will get an income boost if it regains Medicare certification, but other parts of the mental health system haven’t fared so well.
Gov. Sam Brownback’s office announced a 4 percent cut to most Medicaid providers in mid-May in an attempt to close a budget gap left by the Legislature. Medicaid is a significant source of payments for mental health providers, because people with severe mental illnesses are less likely to be employed and have private health insurance than the general population.
Reg Ayres, emergency services coordinator for the Elizabeth Layton Center, which provides mental health services in Miami and Franklin counties, said the center would like to offer additional services such as helping clients manage medications. Right now, resources just don’t allow for most people with mental health issues to receive those services, increasing the likelihood their illnesses will escalate, he said.
“I certainly feel that we could reduce the number of people going to the hospitals if we had more funding,” he said.
The state needs to put more money into the system to fund either more community services or additional hospital beds, said Bill Persinger, CEO of Valeo Behavioral Health Care in Topeka. People with severe mental illnesses will show up somewhere in the system, he said, and additional funds for community services can help prevent many people’s symptoms from escalating to the point that they need to go to the state hospitals.
Persinger likened it to deciding how high to build a levee in an area that is prone to floods: It may not be possible to stop all flooding, but investing more to build a higher levee will reduce spillover.
“The lower the levee, the higher the chances that people will have to go to the state hospital,” he said.
With the current pressure on community services, Persinger said the state likely will need more psychiatric hospital beds, though it isn’t clear how many. Kansas had more than 1,000 beds in the early 1990s but lowered that number to 340 in 1997. Private units also began closing not long afterward due to changes in insurance, further squeezing the system.
“We need more hospital beds than we have now, but we don’t need as many as we had in 1995,” Persinger said. “If funding (for community programs) continues to be a concern, I don’t know if 206 beds (at OSH) will do it.”
And while OSH does need to increase its staff, doing so won’t solve the systemwide workforce problem if those workers leave other mental health jobs in Kansas, said Kyle Kessler, executive director of the Association of Community Mental Health Centers of Kansas.
“By solving one problem, you could create another,” he said.
Committee studies system reform
Over the past two decades, Kansas has convened a number of committees and task forces dedicated to finding and fixing gaps in the mental health system that leave people without adequate care, or care for them only in hospitals — the most restrictive and expensive option.
Their core recommendations have changed relatively little over time: Kansas needs to build its community services, including treatment and supports like housing, and ensure quality treatment in state hospitals for people with the most severe needs.
The most recent group to evaluate the system, the Adult Continuum of Care Committee, raised similar concerns when it started meeting in summer 2015 Its members continue to work on identifying what services are in place for people with mental illnesses and what needs remain, such as improved early intervention and more peer support, said Wes Cole, a former OSH superintendent who serves on the committee.
Former OSH superintendents said they hope the process will lead to a long-term plan. Steve Ashcraft, who was superintendent of OSH from 2011 to 2013, said previous efforts to address just part of the system have been ineffective.
“Until there’s some sort of a strategic plan, you’re just kicking the can down the road,” he said.
That plan will have to involve substantial state investment, because mental health hospitals tend not to make much money, Ashcraft said.
“The private sector is not a solution for these kinds of patients, unless someone’s going to come forward with a lot more money,” he said. “Somebody’s going to have to incentivize them financially to take those patients.”
Other former superintendents agreed on the need for a plan but differed on the likelihood that the state would implement one in the near future.
Steve Feinstein, OSH superintendent from 1994 to 1998, said the state’s past efforts haven’t provided much reason for optimism. Kansas has responded to various “crisis” situations over time but never answered questions about the role of the state hospitals, the number of beds they should have and what kinds of services they should offer, he said.
“The story really hasn’t changed that much in all this time. There have been patches put on problems, crisis fixes,” he said. “I believe it’s a crisis, but I think it’s a long-standing crisis that’s just fluctuated just on the edge of the tipping point to where the system crashes.”
Cole said he sees progress, however, and is confident the committee is moving toward solutions.
“I think we’re on track,” he said. “We’ve got a problem. We’re Kansans. We’ll solve it.”
And for now, at least, elected officials seem to be listening. Rep. Will Carpenter, an El Dorado Republican and chair of the House Social Services Budget Committee, said exploring needs in the mental health system will be a top priority for the committee if he is re-elected and chairs it in the next legislative session.
Some legislators not often prone to agree seemed to share the view that the state should invest more in its hospitals. Rep. Dan Hawkins, a Wichita Republican and chair of the Health and Human Services Committee, and Rep. Jim Ward, a Wichita Democrat and minority member of the committee, agreed that state hospitals need more resources.
“I think Osawatomie’s still a viable institution, we just need to put some money into it to make it work,” Hawkins said.
Some of those who represent the area surrounding the state hospital called for even stronger involvement. Rep. Kevin Jones, a Wellsville Republican, and Sen. Molly Baumgardner, a Louisburg Republican, said the Legislature should demand a study of the hospital and how it could be improved.
It isn’t a matter only of interest to the people of Osawatomie, Baumgardner said.
“This is a responsibility, a constitutional responsibility, for us to provide suitable mental health care,” she said.
Megan Hart is a reporter for KHI News Service in Topeka, a partner in the Heartland Health Monitor team. You can reach her on Twitter @meganhartMC