HUMAN SERVICES RESTRUCTURING TASK FORCE

Institutions and Facilities Subcommittee
MINUTES

November 6, 1997 - Fifth Meeting of Six

MEMBERS PRESENT

Representative Joe Kremer and Representative Teresa Garman also attended the meeting.

MEETING IN BRIEF

Minutes prepared by Nicole Haatvedt, Legal Editor
Organizational staffing by John Pollak, Committee Services Administrator

  1. Procedural Business.
  2. MHI Tour.
  3. Correctional Facility Tour.
  4. Presentations by MHI and Correctional Facility Staff.
  5. Presentations by Directors of Department of Corrections and Human Services.
  6. Presentations on Dual Diagnosis Mental Health and Corrections Sex Offender Treatment Programs.
  7. Next Meeting.
  8. Written Materials and Documents Filed With the Legislative Service Bureau.

SUBCOMMITTEE BUSINESS

1. Procedural Business.
Convening. The meeting convened in the administration building of the Mt. Pleasant Treatment Center at 10:15 a.m. with a welcome from Chairperson Houser, Representative Heaton, and Superintendent David Scurr.
Overview. Mt. Pleasant Treatment Center consists of a state Mental Health Institute (MHI) and a medium security correctional facility with specialized programs for substance abuse and sex offenders. The meeting included a tour of the campus and facilities, a presentation on the history and operation of the MHI and the correctional facility, presentations by the directors of the Departments of Human Services and Corrections, and an overview of the dual diagnosis mental health and substance abuse treatment programs.
Luncheon and Presentations. The meeting continued with a working lunch in the administration building of the Treatment Center. A brief video of the MHI was presented to the Subcommittee, followed by presentations by Superintendent Scurr, MHI Clinical Director Dr. James Brooks, IRTC Director Kollin Alfred, Director of Department of Corrections Walter "Kip" Kautzky, Director of Department of Human Services Charles Palmer, Dual Diagnosis Staff Psychologist Sara Beth Tandy, and Correctional Counselors Paul May and Jeff Crane.
Adjournment. The meeting was adjourned from the Mt. Pleasant Treatment Center at 4:20 p.m.
2. MHI Tour.
The MHI has a 20-bed Center for Psychiatric Care. The center is an adult psychiatric unit serving 15 counties in southeast Iowa. Six of the beds in the unit are designated for a dual diagnosis pilot project which combines substance abuse and psychiatric treatment. In addition, there is a 60-bed Iowa Residential Treatment Center (IRTC). The IRTC is a substance abuse treatment program serving adults throughout the state. The tour included a gymnasium and a building area which is not currently in use for programs but is used primarily for ancillary services. The facilities include classrooms, a computer room used to train staff in the development of a paperless record system and for other instruction, and an Iowa Communications Network (ICN) connection. A vocational rehabilitation program serving Henry County and the institutions on the campus is also located on the campus.
3. Correctional Facility Tour.
The correctional facility is housed in buildings originally constructed for use by the MHI. These buildings have been secured and converted to use as a medium security prison. The designed capacity of the facility is for 528 inmates; however, the facility operates with approximately 900-1,000 inmates. The facility has specialized programs for substance abuse and sex offenders. The tour included a building used by a private business employing inmates in the manufacturing and processing of steel for parts. The facilities also include the Iowa Corrections Training Academy.
4. Presentations by MHI and Correctional Facility Staff.
Superintendent Scurr. Superintendent Scurr gave a brief overview of the history and current operation of the MHI. The MHI was established in 1861. In 1946 there were over 1,500 patients at the MHI. Until the mid-1950s patients were essentially warehoused with no hope of returning to the community. At that time medications were developed which improved treatment to more of a therapeutic environment, and many patients were placed back into the community. In 1976 one of the MHI buildings was converted for prison use. In 1983 the prison and MHI switched buildings to expand space for the prison. In 1992 the Iowa Corrections Training Academy was established. DHS restructuring in 1991 decreased the MHI bed capacity from 112 to 20 beds and the staff was cut by 105 employees. Currently the number of staff at the MHI is 87.48 (some employees are shared with the correctional facility). Inmates perform some housekeeping and maintenance tasks.
MHI Per Diem Costs. Dennis Nellor, finance director at the treatment center, addressed a question from the Subcommittee regarding per diem costs. Per diem costs reached a peak in 1994 and dropped until 1997 due primarily to downsizing at the MHI. The 1998 per diem cost estimates include estimates with and without the dual diagnosis pilot project figured in. Without dual diagnosis, the per diem is estimated at $332 for psychiatric treatment and $130 for substance abuse treatment. Including dual diagnosis in the estimates, the per diem is estimated at $293 for psychiatric treatment, $113 for substance abuse treatment, and $251 for dual diagnosis treatment. The variance is attributed to shared services among the different treatment programs and the lower costs of substance abuse treatment.
Dr. Brooks, Clinical Director and Staff Psychiatrist at the MHI. The Center for Psychiatric Care is a 20-bed adult psychiatric unit. Six of those beds are designated for dual diagnosis patients. The center is an acute care facility and the approximate maximum stay is 30 days. Sixty percent of the patients admitted to the facility are committed in some manner and 40 percent are voluntary admissions. There is coordination between IRTC and the Center for Psychiatric Care for after-care services and other shared services. The center follows a "personal enrichment program" approach to personalize treatment programs for patients. Classes in living skills, money management, codependency, and family planning and a sexual abuse survivors' group are among the offerings of the program. The center is able to emphasize family involvement in treatment because of the regional treatment area. The center interacts with the community, including the Iowa Mental Health Coalition, an organization which includes past patients at the MHI, and the residential care facilities in the area.
Mr. Alfred, Director of the Iowa Residential Treatment Center. The IRTC serves all 99 counties in the state. It is a 60-bed residential chemical dependency treatment program for adults. Persons who have psychiatric problems or are on psychotropic drugs are excluded from treatment at the center. Persons are served regardless of their ability to pay for services. The center is licensed by the Department of Public Health in substance abuse treatment and has special programs for operating while intoxicated (OWI) and youthful offenders. Individuals are admitted to the center by means of civil commitment, court-ordered treatment, and voluntary admission. The IRTC has an intensive outpatient program as well. Persons admitted to the center are assessed for various problems, including sex offenses and gambling. A GED program is offered, with 90 percent of the participants completing the program. The IRTC is involved with the community through OWI and youthful offender programs, a Speakers Bureau which makes presentations on chemical dependency, a Batterers Education Program, and a practicum training site for substance abuse counselors. In response to questions from the members of the Subcommittee, Mr. Alfred explained that there is increased usage and dependency on methamphetamine and that treatment for dependency on that drug is different. Approximately 90 percent of the persons treated at IRTC are methamphetamine abusers. Mr. Alfred opined that it is necessary to educate the public about how easily the drug is made, how readily available the drug is, and the longer withdrawal period involved with the drug (seven to 13 days).
5. Presentations by Directors of Departments of Corrections and Human Services.
Mr. Kautzky and Mr. Palmer related recent discussions between the departments as to possibilities for corrections use of buildings and other resources administered by DHS.
Mr. Kautzky, Director of the Department of Corrections. Mr. Kautzky addressed the recent federal court ruling requiring the department to address special needs inmates. He stated that it is important to identify what is meant by "special needs" inmates and, once such inmates are identified, the levels of physical and mental health requirements of those inmates need to be evaluated. "Special needs" inmates generally encompass three groups: medically limited inmates, behaviorally disordered inmates, and mentally disabled inmates. One of the possibilities under review is to establish a 100-bed correctional unit for women with special needs at Mt. Pleasant. The Mitchellville facility is currently housing over 400 inmates, with a designed capacity of 150, and expansion at Mitchellville is limited due to utility and other area concerns. Mr. Kautzky suggested that the proximity of the University of Iowa Hospitals and Clinics to Mt. Pleasant is an important factor in this decision. Transportation costs to and from the University Hospitals for medical treatment for inmates is currently a big expense. The facility at Oakdale is also overcrowded and backlogged. An additional 100-bed unit is proposed at Oakdale, along with an expansion at Ft. Madison, with the most difficult cases being housed at Ft. Madison. He also stated that DHS should think about prerelease involvement with inmates for substance abuse, family management, anger management, job placement, and other issues.
Mr. Palmer, Director of Department of Human Services. Mr. Palmer emphasized that the Department of Corrections and the Department of Human Services must prioritize the critical needs of the Department of Corrections. The process of utilizing DHS facilities and resources must be a phasing-in process. The question of whether DHS can continue its current functions at the MHIs and other facilities in the state and add from corrections must be addressed. Superintendent Scurr interjected that he believes the Mt. Pleasant MHI could handle the proposed 100-bed women's program in addition to the current programs and with the addition of an ongoing program in place of the dual diagnosis pilot project. In response to a question from the Subcommittee, Mr. Scurr estimated that about 38 new staff members would be necessary for an added women's program.
Mr. Kautzky and Mr. Palmer addressed several questions from the Subcommittee. Mr. Kautzky stated that higher risk inmates would not be sent to a program at an MHI. That decision would be made on the basis of the behavioral stability of the individual inmate.
"State Papers" Program. The discussion touched upon the Indigent Patient Care Program at the University Hospitals, often referred to as the State Papers Program. Mr. Kautzky also stated that utilization of space at the University Hospitals for certain special needs inmates is an issue which needs to be approached cautiously. Questions arose regarding the possibility of using local clinics and hospitals for inmate medical care and directing moneys from the indigent patient care program to such clinics and hospitals instead of incurring transportation costs. Members of the Subcommittee inquired into the costs attributed to inmate medical treatment paid by the indigent patient care program. The Legislative Fiscal Bureau will provide those figures to the Subcommittee.
Sexual Predator Program. Mr. Palmer raised the issue of placement of sex offenders who are likely to reoffend but have completed their sentence. He stated that such persons cannot be treated by the Department of Corrections because they have served their time. He suggests a joint program which would provide treatment by the Department of Human Services and securing of the perimeter of the facilities by the Department of Corrections. Such a program would require some sort of civil commitment which is not currently provided for by state law.
Mr. Palmer stated that expansion of DHS services may be needed in the future for psychogeriatric treatment, a continuum of services at the Independence campus, and treatment for high-functioning individuals with a tendency for sexual violations at the Woodward campus.
Chairperson Houser requested that a chart be prepared addressing the available resources of DHS and the Department of Corrections needs for services and facilities.
6. Presentations on Dual Diagnosis Mental Health and Sex Offender Treatment Programs.
Dr. Tandy, Psychologist with the Dual Diagnosis Program. Dr. Tandy provided an overview of the Mt. Pleasant dual diagnosis program. In general, "dual diagnosis" means the simultaneous occurrence of both a substance abuse disorder and mental illness. Dual issues are not new; however, the recognition of the need for intensive, comprehensive treatment has just come to focus in the last 10 years. Historically, dual issues have been treated sequentially due to differing treatment philosophies between psychiatry and addiction models. This is an extremely difficult population to work with in which violence, abuse, and repeated treatment stays are the norm. When the need for comprehensive treatment became evident, parallel treatment programs were often used without communication between the two. Dual diagnosis treatment focuses on intensive, comprehensive, integrated treatment. Such treatment improves patient outcome and reduces recurrence. Recidivism with this population is hard to tally. Research suggests that recidivism may not be a good mark of success due to the basic chronic nature of brain diseases, but rather the length of time between treatment stays would be more appropriate.
Program Statistics. The dual diagnosis pilot project was established at the MHI in 1995. It utilizes six beds on the 20-bed psychiatric unit. The program has treated 103 total clients since fall 1995, 17 of which have returned (16 percent recidivism). The average length of stay since 1995 is 38 days, but for fiscal year 1997 the average length was 36 days. Fifty-six percent of the admissions to the program are through civil commitment, 32 percent are voluntary, and 12 percent are by district court order. The program serves a 15-county area in southeast Iowa and persons outside the area if there is room, but generally there is no room. The treatment is a four-part process. The first two parts, acute psychiatric stabilization and the treatment process, are accomplished at the MHI. The second two parts, prolonged stabilization and rehabilitation, take place outside the MHI and are addressed through after-care planning.
Future Plans. It is hoped that the program will be expanded to serve all 99 counties. There is currently a problem with committal issues. Involuntary commitments are the hardest to put through the process. Currently, mental health commitment through Iowa Code chapter 229, rather than substance abuse commitment, is the most inclusive to dual needs. Funding is difficult to pinpoint because each funding stream points to another funding stream for payment. Mr. Palmer interjected that this is something that is being worked on for new managed care contracts.
County Views. Kelly Yeggy, a local central point of coordination coordinator (CPC) from Washington County, stated that due to legislation in recent years the mental health budget is essentially frozen. Counties pay 80 percent of the capped rate for MHI mental health treatment. The substance abuse budget is not frozen, as these services are payable from general county revenues. For substance abuse services at an MHI, counties pay 25 percent of the capped rate. She also stated that outpatient services are paid for substance abuse treatment but not for mental health treatment. Ms. Yeggy opined that something needs to be changed in this area, especially when dual diagnosis cases are involved. Harold Templeman, DHS Division Administrator, stated that new capped rates are being worked out and that this is probably something that needs to be addressed by the Legislature. John Easter, Iowa State Association of Counties (ISAC), discussed the need for county participation in the rate-setting recommendation.
Dual Diagnosis Costs. Dr. Prasad Mikkilineni, a psychiatrist providing treatment services to the MHI, stated that a dual diagnosis unit is more cost-effective with 20 to 24 patients than eight to 10 patients. The issue of providing a funding stream for dual diagnosis treatment at private hospitals was raised by Chairperson Houser. In response to a question from Ms. Schmidt regarding problems with limited lengths of stay for such treatment, Ms. Tandy stated that sometimes patients were pushed out too soon and that, if the managed care contractor agrees on a funding stream, she foresees more problems. Dr. Mikkilineni stated that, currently, state-paid care can only continue for patients at the MHI if the patient is suicidal, otherwise the county pays for continued care. It was also noted by members of the Subcommittee that children and adolescents with dual diagnosis problems are not currently being treated by the dual diagnosis program and that something should be done in this area.
Mr. May and Mr. Crane, Corrections Counselors with the Sex Offender Program. Mr. May stated that the sex offender treatment program is typically completed by an offender immediately preceding release and usually takes about 10 to 12 months to complete. The offenders are given psychological pretests and posttests. There is a probationary period for participants in the program followed by coursework and counseling. Offenders complete many of the work assignments on their own. Mr. May stated that only 5 percent of the offenders who complete the program reoffend, compared to 95 percent of offenders who do not complete the program. Mr. Crane and Mr. May emphasized that the caseload for caseworkers in the program is tremendous, averaging 75 offenders at one time. In response to a question from Representative Heaton, Mr. May stated that follow-up treatment occurs only if it is court-ordered or if it occurs through the parole program.
7. Next Meeting.
The next meeting of the Subcommittee is scheduled for Thursday, December 11, at the Farm Bureau Corporate Headquarters in West Des Moines.
8. Written Materials and Documents Filed With the Legislative Service Bureau.

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