‘There’s a lot of anxiety:’ Mental health system braces for more cuts

Heather Gates, executive director of the mental health agency Community Health Resources, speaking press conference about the budget last June.

Arielle Levin Becker / CTMirror.org

Heather Gates, executive director of the mental health agency Community Health Resources, speaking at a 2015 press conference about the state budget.

State funding cuts led Heather Gates’ Windsor-based agency to eliminate one of its most intensive programs for people with serious mental illness, one intended to help them stay out of the emergency room, out of prison and off the streets after long-term hospitalizations.

Roberta Cook’s North Haven-based agency, BH Care, expects to serve about 400 fewer people this year than last – a drop of more than 10 percent – after staff reductions.

And Catholic Charities recently closed a Meriden outpatient mental health facility that served children and adults.

They’re all bracing for more cuts.

“What’s challenging in this environment is you never know what’s the end of it all,” Gates said. “I am just very fearful of what is next.”

This fiscal year began with $55 million in cuts to the Department of Mental Health and Addiction Services and big questions about how they would be felt in a system that many say is already stretched to capacity. So far, many involved in the system say the impact has been mixed: Some agencies have been able to absorb reductions, while others have reduced hours, closed programs or laid off staff.

But like Gates, many see the cuts they’ve already faced as just a start.

“We’re sure that another round will be coming very soon,” said Marcia DuFore, executive director of the North Central Regional Mental Health Board in Newington.

To be sure, no new cuts have been announced. DMHAS spokeswoman Mary Kate Mason said the agency is not working on additional cuts for this fiscal year. Although Gov. Dannel P. Malloy’s administration has told the department to come up with $14 million in savings beyond the $55 million already cut, Mason said the department does not anticipate passing on the new cut to service providers.

And many involved in mental health care have praised the department for trying to minimize the impact of cuts on the system.

But there’s already a $1.27 billion deficit projected for the next fiscal year. And there are multiple signs additional spending reductions could be needed to keep this year’s budget balanced.

“DMHAS is trying to be as thoughtful as possible and trying to impact client care as little as possible, but this stuff is starting to be felt,” said Margaret Watt, executive director of the Southwest Regional Mental Health Board in Norwalk.

One hospital in her region has a 100-person waiting list for outpatient behavioral health services, she said. A community health center told her it was getting 25 new calls each day looking for behavioral health services. “The demand may be increasing. The services are shrinking,” Watt said.

Others say that beyond any specific cuts, there’s a greater sense of worry about what’s to come.

“There’s a lot of anxiety,” DuFore said. Many service providers tell her they’re spending a lot of time dealing with housing concerns, because clients are feeling particularly vulnerable and worried they could become homeless and not have help available.

‘We tried to be really strategic’

Mason, the DMHAS spokeswoman, said officials tried to implement the cuts without affecting the highest-intensity inpatient beds. Instead, the department first cut money for new programs and caseload growth before chipping away at existing programs.

“We tried to be really strategic in what we were doing,” she said.

The cuts include:

  • $17 million from 76 department layoffs, elimination of vacant positions, staff retirements and attrition.
  • A $1.5 million cut – 9 percent – to community support programs that provide care management and teach people with mental illness skills for living independently, such as cooking, budgeting, self-care and safety. In addition, the department reorganized the services and how they are funded. In some cases, people will receive less intensive support than they were getting – something that worries Gates and other providers.
  • $1.3 million from employment services that help people find jobs and offer coaching to help them stay employed. The program serves 4,000 people per year; Mason said the 200 clients losing slots will be moved to other services.
  • Eliminating the Gatekeeper Program, which trained people who interact with seniors to notice signs of problems, and dispatched social workers if needed.
  • A $4.4 million cut in grant funding for services including outpatient treatment, intensive outpatient programs, partial hospitalization, residential detox, methadone maintenance, outpatient services at community health centers, ambulatory detox, and acute inpatient mental health services. Service providers can bill clients’ insurance or Medicaid.
  • Closing a state-run transitional residence program in Bridgeport for people who were homeless, and closing a Norwalk transitional residence program for people returning to the community from prison or psychiatric hospitals. Together they served approximately 82 people per year.
  • Reducing hours for mobile crisis programs, which had clinicians who could go out in person and try to de-escalate a situation. Shifts with the highest demand are still staffed, but during other hours, callers reach a live person who can triage the call, but no one will go out. (DuFore said she worries that could lead to more mental health crisis calls going to police.)
  • Reducing services under the military support program, which provided free behavioral health services for veterans. The program was originally slated to be eliminated, but now it still offers triage, referrals and care management. It no longer pays for counseling, which would instead be funded by clients’ insurance.

“We’ve done everything we can to try and not have a tremendous impact on the service system,” Mason said. “I think, thus far, the service system seems stable.”

And Mason said the department is not looking at additional cuts for this fiscal year.

But there are indications that more cuts to state spending will be needed to balance this year’s budget. Among other things, the budget relied on significant savings in personnel costs across agencies, but layoffs have progressed more slowly than anticipated. Nonpartisan analysts recently reported a $78 million deficit and have raised concerns about worse-than-expected tax receipts. And as written, the budget relies on about $190 million in unspecified savings from state agencies, about $60 million of which have yet to be assigned to any agencies or line items.

Health care and social services have historically borne a large share of midyear budget cuts.

And then there’s next year. Benjamin Barnes, Malloy’s budget director, has repeatedly warned of additional cuts in the budget year that begins July 1, 2017. In a recent memo to agency heads, he wrote that growing fixed costs and flat revenue growth mean “that cuts to agency spending will be necessary. As a result, we will not be able to provide all of the services and programs that many have come to expect.”

What does that mean for mental health services?

“While we are still several months from finalizing the governor’s budget proposal for the upcoming biennium, it can be stated unequivocally that the options included in that proposal will only be presented after a thorough and thoughtful review of the agency’s core services, utilization of those services, and external events that could impact the agency,” said Chris McClure, a spokesman for Malloy’s budget office.

A top ranking, but still strained

The Malloy administration has repeatedly pointed out that spending on mental health has increased since 2011.

Connecticut is considered to have among the nation’s top mental health systems. The advocacy group Mental Health America, for example, recently ranked Connecticut first in the country on a scorecard of measures that include prevalence of mental illness and access to care, although it doesn’t assess funding.

Even so, many who work in the system worry about its ability to handle the demand.

“The entire service system is so contracted that there’s no wiggle room anywhere,” said Janine Sullivan-Wiley, executive director of the Northwest Regional Mental Health Board in Waterbury.

Many agencies have already cut hours and staff to bare bones, she said. A Waterbury agency that served roughly 400 people closed in August. At one hospital in Northwest Connecticut, it takes roughly six weeks to get an appointment in the outpatient behavioral health program, she said.

The capacity problem is the result of “a perfect storm” – demand has been rising, while funding cuts have kept providers from expanding services, Sullivan-Wiley said.

“It’s financial suicide to expand in a climate like that,” she said. “If Gap lost $7 every time it sold a pair of jeans, its jeans department would shrink or move to the back of the store, and that’s where I think a lot of behavioral health services are.”

At Catholic Charities, part of the Archdiocese of Hartford, the behavioral health department loses a substantial amount of money, said Robin Hawley, the organization’s director of behavioral health. Over the years, they have tried to make up for dwindling state grant funds and low Medicaid reimbursement rates through fundraising and United Way contributions. But that money is also getting tighter.

The organization, which served about 7,500 clients at 10 sites in three counties last year, recently closed its Meriden site and consolidated two Hartford sites into one. It also cut a fulltime physician and support staff hours, and is anticipating reduced funding in the future.

“We’ve been shrinking all our expenses and everything else we can,” Hawley said. “At this point, we have nothing left to cut except for services.”

Cuts hit intensive services

Although Gates has dealt with cuts in the past, she said she was shocked when the department eliminated the most intensive residential program her agency, Community Health Resources, runs. It served 20 people with serious mental illness, with staff available seven days a week. They are now in other programs within the agency that provide substantially less service, Gates said.

“These are people who for the most part have had long-term hospitalizations, have serious and persistent mental illness so they’re living with a very serious illness and need a lot of support in the community just to manage day to day,” she said.

Mason acknowledged the cut will mean less intensive services for some clients, but said the department believes they will still be able to get the supports they need.

“The thinking was that people are still going to receive services. They’ll still have contact with staff. Staff will still be working with them to further develop their skills in the community, and I think that staff will still be available to assess them on an ongoing basis,” she said.

The department will evaluate whether the supports are adequate or whether they need other services, Mason said.

Another agency, United Services, based in Danielson, was able to absorb some of the cuts, serving clients in other programs or offsetting grant cuts with increased Medicaid payments and payments from private insurers.

But a cut to the agency’s case management program means approximately 100 fewer people will participate, President and CEO Diane L. Manning said. The program works with people with mental illness to help them become independent. Many clients have serious medical conditions as well. Some get out of the hospital with no place to go home to.

“If someone’s discharged from the hospital and they don’t have someone to help make sure that everything goes into place, the likelihood of them being readmitted is higher,” Manning said.

And Manning is worried about what future budget woes will bring. After years of work to try to keep people out of the hospital, emergency rooms and prisons, Manning worries progress will be set back.

“If I can’t ensure that somebody has a safe place to live, I can’t ensure that they’re going to take their medication,” she said. “I’m just really concerned that we’re going to see people lined up in emergency rooms again and people dying.”

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