Even though admissions to Maryland's state psychiatric hospitals are on the rise, a state committee is recommending closure of an Eastern Shore facility, and the elimination of 350 inpatient beds across the state.

Still in draft form, the panel's report is part of the state's efforts to reduce the populations of eight Maryland psychiatric hospitals. While the draft recommends closing the Upper Shore Community Mental Health Center in Chestertown and cutting beds elsewhere, it suggests allocating $57 million for services that would allow for the release of the extremely mentally ill from hospitals over the next five years.

Under the proposal, housing with 24-hour supervision, crisis intervention and mobile treatment could free patients from institutions. Savings achieved through the attrition of more than 600 hospital employees who would no longer be needed could help cover the cost of community care, though an additional $35 million from the state would be required.

If the plan is adopted, about 1,100 inpatient beds for the mentally ill would be left at state psychiatric hospitals.

Thirty years ago, before deinstitutionalization of psychiatric hospitals led to the development of community-based treatment programs for the mentally ill, these facilities served an average of 7,500 patients a day. Now, many of the turn-of-the-century hospital buildings stand vacant on sprawling campuses spanning hundreds of acres. Sale of this surplus land could create money for com- munity mental health services, according to the report.

A General Assembly budget committee requested the report a year ago from the Hospital Beds Needs Assessment Committee -- made up of mental health professionals and state health officials -- to determine how to shift more hospital patients into community programs.

By recommending that the 36-bed Upper Shore Community Mental Health Center be shut down in 2001, the committee avoided a more controversial decision to close one of the "big three" psychiatric hospitals in Central Maryland.

Patients at the Chestertown facility would move to the Eastern Shore Hospital Center in Cambridge, scheduled for completion in July 2000. The report calls for the vacated Upper Shore hospital to become a treatment center -- under the oversight of another state agency -- for individuals with substance abuse problems and mental illness.

Twice in the past 12 years, other commissions reporting to the state have called for closing one of the big three hospitals -- Crownsville Hospital Center outside Annapolis, Spring Grove Hospital Center in Catonsville and Springfield Hospital Center in Sykesville -- but state health officials have backed off in the face of strong public opposition.

"Given the political realities of hospital closure, I think this is the best we can do," said committee member Herb Cromwell, executive director of the Maryland Association of Psychiatric Support Services, which represents community-based providers serving the mentally ill.

He pointed out that while hospital admissions have decreased in the state's eastern and western regions, the big three hospitals are operating at or above capacity.

"There's still a lot of pressure on these beds for use," Cromwell said.

Hospital officials say the state's goal is ambitious, given the recent increase in admissions and the severity of mental illnesses among the patients now targeted for discharge. Some of these patients have been hospitalized for decades.

"The type of patients that we're wanting to place now really do require round-the-clock supervision," said Dr. Mark Pecevich, superintendent at Spring Grove. He still praised the multiyear structure of the proposal.

"It allows time to develop resources in the community we don't have right now," he said.

That is not enough to persuade the Maryland Chapter of the National Alliance for the Mentally Ill to endorse further emptying of state hospitals.

"How can the state even think about downsizing when there hasn't been a statewide needs assessment and admissions are up?" asked Brenda K. Hohman, executive director for the alliance and a committee member.

She said the recommendations in the draft report are based in part on a partial assessment that included state hospital patients but didn't evaluate jails or homeless shelters, where many of the state's mentally ill are inappropriately warehoused.

"We agree the physical facilities need to be smaller, more efficient campuses, and we support improved community services, but we question the wisdom of reducing the number of hospital beds," Hohman said.

The report to legislators calls for reducing the average daily population at state psychiatric hospitals -- now 1,350 -- by 350 over the next five years. The goal is for 70 patients to be discharged each year.

"These 350 long-term residents are those with the greatest number of behavioral, social, legal and somatic problems," the draft states. "In many cases they have not succeeded in community placements."

Mental health officials say some of the most common reasons these patients have returned to hospitals are failure to take medications, substance abuse and episodic violence.

By 2004, the report states, public psychiatric facilities will hospitalize between 1,030 and 1,142 patients a day statewide. Clifton T. Perkins Hospital Center will retain 214 beds for patients with criminal backgrounds, and 135 will be set aside for juvenile patients. The facilities in the eastern and western regions of the state would be allotted 80 beds each, and 640 beds would be reserved for the hospitals serving Central Maryland.

At those three facilities, the proposal recommends having about 200 beds at Spring Grove and Springfield and 172 beds at Crownsville -- an overall loss of about 270 beds for the hospitals.

Over the past decade, the Mental Hygiene Administration has reduced beds in the state psychiatric hospital system by more than half, from 2,800 to 1,350. But from 1997 to last year, admissions to the state's inpatient psychiatric hospitals increased 14 percent, a trend state health officials say they cannot explain.

The pattern is continuing, according to officials at the three Central Maryland hospitals, even with pressure to reduce beds and discharge patients quickly.

They say the new patients are younger -- generally ages 18 to 25 -- and sicker, typically suffering from schizophrenia, major depression or bipolar disorder. Many are transfers from private hospitals, where inpatient stays have been dramatically shortened because of managed care.

"We're down from six long-term wards to three, and the acuity level I'm seeing is amazing," said Spring Grove's Pecevich. "They are the sickest of the sick."

He said his 295-bed facility has been operating at 98 percent to 103 percent of capacity for several months.

The situation is the same at Crownsville, where 211 beds are frequently full and individuals with severe mental illnesses often wait in neighboring emergency rooms and detention centers for admission.

"The patients that we're sending out there are really marginally well, and they shouldn't have to go on a waiting list with 141 people for community beds in Prince George's County," said Superintendent Ronald R. J. Hendler, who has eliminated 39 beds at Crownsville over the past 18 months but said he won't be able to meet the state's directive to shut down another 21 by the end of the month.

"How do we lower the beds with a high demand for services and when the patients we have in the hospital are so difficult to discharge?" Hendler said.

"Something's got to give somewhere along the line."