The handwriting is on the wall, or so it would seem for Knoxville's Lakeshore Mental Health Institute—even though the state's plan to shut down the 125-year-old facility still has to pass muster with Tennessee Gov. Bill Haslam and the General Assembly.
The reasons for the hospital's pending closure point to the checkered history of mental health care in the United States, as well as to the lack of political will to fund a huge facility with a small, though needy, clientele in tough economic times. That doesn't make the resulting questions—most notably, what to do with the hospital's most troubled residents—any easier to answer.
Tennessee Commissioner of Mental Health Doug Varney proposed closing Lakeshore at a state budget hearing in mid-November. His plan would see the hospital closed by June 30 of 2012, although that timetable is subject change, given that the Assembly may not vote on the issue before July.
With the facility no longer in operation, he says, the state will be able to devote Lakeshore's not-inconsiderable yearly budget to funding more private community health resources, from alcohol and drug detox to mental health crisis units to in-patient residential facilities.
Varney frames the decision as a matter of principle, rather than of dollars and cents. "This is not about money," he says. "It's really about patient care. If we reinvest this money, we can serve more people, serve them better, and serve them closer to home. It's more ethical."
But not everyone is eager to embrace change. A pair of recent community forums saw attendance by a host of concerned—and in some cases outraged—citizens, Lakeshore employees, and family members of patients who questioned the wisdom of the move, its ramifications for public safety, and the well-being of staff and residents alike.
Knox County Commissioner Jeff Ownby, who has family working for Lakeshore, proclaimed that he would "kick and scream to the end." Varney did not attend either forum; one of the employees in attendance said that he had not even toured the Lakeshore facility.
Meanwhile, the notion that the plan is driven solely, or nearly so, by concern for the welfare of patients would seem to strain credulity. "First and foremost, this is a fiscal move," observes one prominent local mental health professional. "Will it ultimately result in better treatment for patients? The answer is that some cases, that will probably be true. In other cases, it will not."
He acknowledges, however, that the closing of Lakeshore is "probably inevitable given what's happening across the country."
According to Ben Harrington, executive director of the Mental Health Association of Tennessee, the trend away from state-run mental health facilities toward reintegration and community-based care—or deinstitutionalization—began in the '60s with the Community Mental Health Act, which provided more federal dollars for local mental health resources.
Whether the act was ultimately successful is a debatable; many believe that the resulting deinstitutionalization—especially in the 1980s, when conservative fiscal policy led to a significant reduction in federal monies for social welfare—has contributed to social ills such as the expansion of the nation's homeless population.
But Harrington says that this time, there's reason to believe the defunding of a state facility will yield tangible benefits for community-based programs. "In years past, we saw buildings close, and we heard the pledge to reinvest over and over," he says. "That pledge wasn't always met. And that's led to some skepticism about the closing of Lakeshore today.
"But I have a whole lot more comfort about the plan today than I did a few weeks ago. I've met with Commissioner Varney and the governor, and they've voiced their intent to reinvest those dollars in East Tennessee. And as more and more details are brought to bear, and we've had more understanding of the plan, it's making me more comfortable."
"We're not happy with the closing," Harrington adds, "but we're happy with the prospect of reinvesting that money, which is what we've been asking for for years."
One of five state hospitals—others are located in Bolivar, Nashville, Memphis, and Chattanooga—Lakeshore at its peak housed well over 2,000 patients on any given day. Now that number has dwindled to around 90; the annual patient count is between 2,200 and 2,400.
It costs somewhere around $26 million annually to operate the facility, Varney says, with $20 million of that coming from the state's general fund, and the rest coming from third-party payments. As local pundit George Korda put it in a recent televised discussion, it's a difficult sell, "justifying a facility of that size and scope for 100 patients."
But the question remains as to how to provide for the hospital's neediest denizens, patients whose problems are too severe to allow for reintegration into the community at large and less stringent levels of care. Korda also predicted that, "you're going to see more people in that [Knox County] jail."
According to Varney, 90 percent of Lakeshore patients stay at the hospital for 10 days or less, meaning that only a relatively small percentage would need long-term hospitalization in another facility. In that regard, Harrington says about 50 current residents have been at Lakeshore for a year or more.
Varney says the most serious cases would be moved to the state's Nashville facility, while the less problematic long-term patients would likely be placed at private mental health institutions such as Peninsula in Knoxville, Woodridge in Johnson City, and Ridgeview in Oak Ridge. "No one who poses any kind of danger will be placed out in the community," he says.
"The unfortunate truth is that many of these patients simply ended up in Lakeshore because they're indigent. Too many end up there just because they're poor."
The plans for the reinvestment of Lakeshore dollars into community mental health resources are still a work in progress, Varney says. But he says that around $6 million should be allocated to contract for more services with the three aforementioned private facilities. Additionally, substantial amounts will go toward residential living at other existing facilities, toward crisis units and drug detoxification services, and toward so-called "safety net" services for indigents.
"It has been an issue in the past—what to do with those folks with complex medical and mental health needs, who require more supportive environments," Harrington admits. "We have other residential facilities, but maybe not equipped for those complex needs. I think what the department is wanting to do is look at how to advance the facilities we have, and that's exciting. That means they're taking an opportunity to transform the system."
Harrington says he's further assured by the fact that the state is doing a "patient-by-patient analysis of what the needs are, and where people might be placed. I'm comforted by that effort to work with every patient."
"Are these the only steps that need to be taken? Probably not, but it's still early in the process. So we have to continue to verbalize our concerns and help the department flesh out its plans. That's our job as advocates, to watch and see that those dollars are reinvested in mental health services in East Tennessee.
Still other questions remain, such as what will happen to the roughly 370 employees currently staffing Lakeshore. Varney has admitted that the issue is "challenging"; answers are still in short supply.
The Lakeshore property is another matter for consideration. Forty acres of the land is state controlled, says Harrington, and money from its sale will be allocated to the state mental health trust fund.
"It would be nice to see the city step forward and buy the rest of the land, and see that those dollars are reinvested in East Tennessee," he suggests.