Patient care unsure after bureau closes Move to affect service for over 500 clients of mental health unit; Patients to be referred; But health workers fear sudden changes may worsen illnesses


By June 30, the Carroll County Health Department will eliminate its mental health bureau and the services it provides for more than 500 mentally ill, mostly low-income county residents.

Beyond that, little is certain.

Plans call for patients to be referred to private treatment providers over the next few months and for all 40 mental health bureau employees to be laid off. But the pending shutdown has created more questions than answers.

Unsure about specifics, staff members are struggling to explain the changes to anxious patients. And Health Department administrators who are overseeing the closure acknowledge that they don't have answers for every question.

Will private providers accept new patients at lower insurance reimbursement rates? Are equivalent services available in the private sector? How will the most seriously ill patients cope with the changes?

"It becomes very difficult to predict how it's all going to get phased in," said Howard Held, director of the bureau.

"I'm confident that it will work out, but I'm sure things will come up over the next three or four months that I will have to handle on a situation-by-situation basis," said Held, who is to become chief of the Health Department's addictions services division.

Many of those facing layoffs -- Health Department therapists, social workers and nurses who provide direct care -- say the elimination of services is poorly planned.

"It's hard for staff to understand exactly how it's going to work and assist the client with a sense of competence," said a psychiatric nurse who asked not to be named. "For every question that we have an answer to, there's 10 that we can't answer."

A 37-year-old woman who has been treated for schizophrenia for seven years through the mental health bureau is worried.

"It's hard to start over again," said the woman, who asked that her name not be revealed. "I'm afraid for myself and others like me falling through the cracks of getting helped."

Privatization trend

The closure comes at a time when publicly funded mental health services in Maryland are moving toward privatization.

The state Mental Hygiene Administration is creating a "Specialty Mental Health System," which will manage all public mental health funds for Medicaid patients and people with severe psychiatric disabilities.

By July 1, the system will be overseen by Maryland Health Partners, a partnership between Green Spring Health Services Inc. of Columbia and CMG Health Care of Owings Mills.

The state is requiring each county to establish "core service agencies" to coordinate local mental health services. Carroll's core agency is expected to be in place by July.

Carroll health officials have prepared a list of private providers for patients receiving mental health services, said the acting county health officer, Larry L. Leitch. The list has been submitted to the Mental Hygiene Administration for approval, he said.

"Some of these patients are very frail and it sometimes takes very little change to upset them," Leitch said. "Patients will have to work with their advocates to try to minimize the anxiety and disruption as much as possible."

Guidance may be lacking

The plan is for Health Department therapists to work with clients, linking them with other treatment providers. The theory is good, say some department employees who asked not to be named, but as the staff dwindles from layoffs and workers leaving for other jobs, patients won't have much guidance.

Mental health staffers predict that the anxiety and uncertainty may exacerbate the illnesses of some patients to the point where they have to be hospitalized.

"For people who have depended on this system through many crises, it's not sufficient to hand them a list [of providers] and think it's going to be handled," said one mental health counselor. "A lot of people won't know how to approach the new providers."

Mental health employees are critical of how county health administrators have addressed the closing and say employees, patients and private providers should have become involved earlier to smooth the transition.

Eric, a 28-year-old schizophrenic who asked that his last name be withheld, has received treatment through the county for six years. The medication Clozaril, which he's taken for two years, allows him to manage his illness effectively and he's able to hold a part-time job.

The bureau's closing means that Eric will have to find another counselor and a psychiatrist to prescribe his medication. But he's more worried about other patients who aren't as self-reliant.

"I'm afraid there are some people who do need a lot more support than I do who will, for a time, be left to blow out in the wind -- if not in reality, in their own minds," he said.

Linking patients, treatment


One of the biggest potential problems, according to Held and mental health therapists, will be linking patients who receive an array of department services with treatment in the private sector. For example, the employees in the department's community outreach division take patients to therapy appointments, help find community placements for patients released from Springfield Hospital Center and monitor patients' medication.

"You're not going to find very many agencies out there where therapists leave the office and drive people around," the Health Department social worker said. "As far as working with the severely and persistently mentally ill, the public mental health center is the only place that has provided that kind of service."

The Health Department psychiatric nurse said she's worried about the handling of patient prescriptions as layoffs begin over the next few months.

"Physician coverage is a big question mark in my mind," the nurse said. "The psychiatrists are the only ones that can write the prescriptions."

Held defended the phasing out of services, saying that it's happening statewide. Most departments in Maryland have privatized their mental health divisions or are planning to end services by June 30.

"I think we're one of the only health departments getting out of the business that has put so much planning into it," Held said.

Of the patients served by mental health bureau services, about 60 percent have Medicaid, Medicare or a combination of public and private insurance.

About 25 percent fall into a gray area, health officials say. These patients may work but don't have health benefits and don't meet the income criteria to be insured under the Medicaid program. They either pay nothing for their treatment or a minimal amount, such as $5 a session. A small number of mental health bureau clients pay for their treatment themselves.

'Hopefully, no one gets lost'

Health Department officials plan to begin referring clients to private providers within the next two weeks and hope that most clients will be linked with another provider well before the June 30 termination of services.

Leitch said four therapists will stay with the department until then to work with the remaining patients, before Maryland Health Partners takes over state mental health services.

"Hopefully, no one gets lost during this process, and those who wish to continue with treatment will find themselves another counselor," Held said.

"It's a monumental task, and when you throw in the emotional content of patients and staff undergoing changes, it's quite a challenge."

Pub Date: 2/09/97

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