The second study, due Dec. 1, calls for the health department to use $200,000 in general funding from its five psychiatric hospitals, including $78,000 from Spring Grove, to produce an "analysis of short- and long-term population and placement trends to determine potential demand for state-run psychiatric hospital capacity," with community-based alternatives to state placement considered as well.

The study also requires the health department to determine "best practices for facility operations, including building size and configuration," as well as "appropriate site locations based on future demand."

In-patient vs. out in community

The requirements speak to long-developing societal changes and more recent policy changes that have reshaped the landscape for psychiatric care in Maryland, according to Brian Hepburn, executive director of the Maryland Hygiene Administration, an agency within DHMH responsible for delivering mental health services.

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At a societal level, there are more community-based alternatives for psychiatric care, and more drug options for patients, than ever before. At the same time, there has been a shift in the understanding of care for those who remain in state institutions, Hepburn said.

"The idea of the older hospital was really one of having somebody go away for a prolonged period of time and having a calming, rural environment," Hepburn said. "Now, the idea of a hospital is to get a person stabilized and out to the community as fast as possible."

Over the years, these changes have contributed to a dramatic decrease in the number of psychiatric patients in state institutions, a number that peaked in the 1950s, when Spring Grove's population was close to 3,000, compared to its population of less than 500 patients today. But, they aren't the only — or even the greatest — cause of that reduction recently, Hepburn said.

Since 2002, that decrease has been driven by policy changes to, and increased enforcement of, the specific care requirements for uninsured psychiatric patients under the federal Emergency Medical Treatment and Active Labor Act (EMTALA), Hepburn said.

Until 2002, uninsured psychiatric patients who showed up at the emergency rooms of local general hospitals needing in-patient care were often sent directly to state institutions once they were stabilized. Now, those hospitals are required under EMTALA to not only stabilize such patients, but also work to provide or find them with a bed in an acute general psychiatric unit or private institution, Hepburn said.

In the last few years, enforcement of those requirements has also been ramped up, putting hospitals that don't comply in jeopardy of losing future Medicare claims payments, Hepburn said.

"As a result, hospitals now have to take individuals regardless of their ability to pay," Hepburn said, and the impact on state institutions has been profound.

"As of last year, there was hardly anybody going from an emergency room to a state (psychiatric) hospital because they were uninsured," Hepburn said. "At this point, the majority of individuals who are going into our state hospitals are either being referred from the courts or they are going from detention centers."

Felony offenders are all sent to the maximum security Clifton T. Perkins Hospital Center in Jessup. Misdemeanor offenders are sent around the state.

The two studies combined will provide a massive amount of information directly relevant to the discussion of Spring Grove's future, officials said — a positive step in the eyes of many, including Baltimore County Executive Kevin Kamenetz.

"The county executive is a big believer that you can't do anything intelligently unless you do a good amount of planning and study on the front end," said Don Mohler, Kamenetz's chief of staff.

"We've got to be innovative, we've got to consolidate where possible, and we've got to be efficient, and I think that's what the state is looking to do here."