It was not complete deliverance. Weighing just 20 pounds when she adopted him, his head the size of a 9-month-old’s, he would always be small. He was finally walking by age 3, a good athlete by elementary school. But there were learning disabilities. And by 10 or 11, signs of depression, then bipolar disorder. In young adulthood, the diagnosis was schizophrenia.
He twice landed in state psychiatric hospitals, where he received excellent care but also languished much longer than necessary, Alonge said. Both times, doctors deemed him ready to leave after several months of treatment. And both times, despite Alonge’s dogged efforts, he could not leave until months later.
The state of Virginia simply had no place else to put him.
“It was easier getting him out of Romania,” said Alonge, a 56-year-old lawyer whose son is 23. “It really was.”
The problem is a common and highly expensive one for the commonwealth. A shortage of group homes and other community-based housing for the mentally ill keeps many patients hospitalized far longer than needed — at significant state expense and possibly in violation of the Americans with Disabilities Act, according to a report that will be presented to legislators Thursday.
It costs $214,000 a year, on average, to keep a patient in a state psychiatric hospital, compared with $44,000 a year for community-based housing, according to the report, prepared by the inspector general’s office for the Department of Behavioral Health and Developmental Services.
With at least 70 “discharge-ready” patients stuck in state hospitals, the report says, Virginia is spending about $12 million a year on unnecessary psychiatric hospitalizations.
“[S]cores of individuals remained in the Commonwealth’s behavioral health facilities for an average of almost eight months after they had been determined by clinicians to be discharge-ready,” the report says.
The cost is not merely financial. Many patients deteriorate mentally during the long, frustrating waits to be discharged, experts said.
“They’re told, ‘You’re ready to go. You have done well . . . but there is no place for you to go,’ ” Alonge said. “So you can kind of give up hope. . . . My son said to me, ‘Don’t let me die in here.’ ”
Prospect of real savings
Inspector General G. Douglas Bevelacqua spent six months reviewing the state’s eight psychiatric hospitals that serve adults. During that time, an average of 13 percent of patients were clinically ready to be discharged but unable to leave.
The state puts those patients on what it calls an “extraordinary barriers list,” meaning it is very difficult to place them outside the hospital. Bevelacqua said that about half the time, “extraordinary” is a misnomer.
Over the study period, from July through December, an average of 165 people were on the list. Nearly half were difficult to place because of their age or status in the criminal justice system. Some were elderly and had related medical needs, but nursing homes did not feel equipped to handle their psychiatric issues. Others had been institutionalized by the criminal justice system — judged not guilty of crimes by reason of insanity, in some cases — and could not be released without a court order.
But for just over half of those on the list, the only barrier was a lack of beds in the community.
“For some people on the [barriers list,] there are, indeed, complex medical and legal issues that are involved with their discharge,” Bevelacqua said. “But there are also a good number of people — perhaps as many as half — for whom the only barrier to discharge is the sum of money necessary for them to return to the community, which is a fairly modest sum compared to what it costs for them to remain in the hospital.”
The state had an average of 87 discharge-ready patients during the period of the study. Based on the report’s cost estimates, the state could save almost $15 million annually by moving them out.
Those financial benefits would not be realized immediately, Bevelacqua conceded, which might explain why a state with a reputation for government efficiency has not moved more aggressively away from institutional care. The savings would not be achieved until enough patients had been relocated that whole hospital units could be shut down.
Even without the financial incentive, Bevelacqua said, the state needs to create more community-based housing to stay in line with the ADA, which requires that patients be housed in the least-restrictive setting possible. The state reached a $2 billion settlement with the U.S. Justice Department this month over its failure to move enough people with intellectual disabilities out of institutions. The agreement would close four of the state’s five training centers for people with intellectual disabilities, moving most of the residents into community-based housing.
The office of Gov. Robert F. McDonnell (R) referred questions about the inspector general’s findings to Behavioral Health and Developmental Services Department. Spokeswoman Meghan Wedd McGuire said the agency has been working on a strategic plan to reduce hospitalizations, one that includes expanding community housing.
“Virginia has been working for years to build community options for those with behavioral health disorders,” she said.
She added that the emphasis has not been on creating group homes but on placing people in independent apartments, where case managers and others provide medical and other support. Statewide, Virginia has 23 group homes for the mentally ill, serving about 300 people.
Until more group homes are developed, the waiting period will remain months long for such people as Alonge’s son, whose name is being withheld to protect his privacy. And the costs will remain high at state hospitals, which do not simply turn such patients out.
“Somebody who has schizophrenia . . . may pick up a television and throw it through a window, go outside without clothes,” said Cindy Kemp, executive director of the Arlington Community Services Board. “We could discharge those people, but it’s unconscionable to do that. . . . To place them in a shelter or to give them a room in a rooming house without trained professionals there to support them is setting them up for failure.”
Alonge’s son, who has held jobs stocking supermarket shelves and taking tickets at a movie theater, had his first stay at the Northern Virginia Mental Health Institute in 2008. He was there 14 months.
“About half that time, he was waiting for placement,” Alonge said. “He was discharge-ready, and there just wasn’t any place for him to go.”
When a community bed opened up, it was in a dormlike group home for 35 in Chesterfield, 21
2 hours away from his family’s home in Arlington. He lived there successfully for two years, during which time his mother took him home on weekends.
But his mental health started deteriorating in the spring of 2011. Alonge was unable to take him home some weekends because, as an only child, she had to take care of her ailing father. That upset him, as did his grandfather’s eventual death. He also was deeply shaken by the rare earthquake that struck in August.
He had to be hospitalized again in September. By February, he was deemed ready to go. He did not get the chance until June.
Going downhill while waiting
About two weeks ago, Alonge’s son got a spot in the only group home in Northern Virginia that provides the level of supervision he requires. The bed in the four-man house opened up only because one person living there died. Another patient had first dibs on the room, but that man’s condition had deteriorated while he awaited release and he no longer qualified for the placement, Alonge said.
Her son’s own mental health went downhill while he was waiting for discharge. Initially, he’d been cleared to live in a home with 24-hour staff, but staff that went to sleep at night. By the time an opening arose, doctors decided that he needed the added supervision of a facility with 24-hour “awake staff.”
He found that in the Arlington group home, a modest-looking rancher on a suburban street with wild rabbits and a picnic table in its large backyard. There, he is enjoying art and pet therapy, learning to do his own laundry, and make dinner for the whole house. The hope is that he and other residents will be able to stay healthy and learn the skills they need to live more independently, moving on someday to their own apartments — and opening up a slot for someone else stuck in the hospital.
“He has his own room, and they have different activities,” Alonge said. “He’s really happy to be there.”