District officials worked for about a year putting together a plan for a comprehensive mental health system and the future of St. Elizabeths mental hospital after the city government takes over the federal facility in 1987.
They produced an impressive document and included all the right people in the process, and the pieces look like they all fit together -- on paper.
But the reality of dealing with hundreds of emotionally disturbed individuals in the community rather than in an institution will include problems that cannot be reduced to paper. These problems include keeping track of thousands of patients with emotional and behavioral problems and gaining community acceptance for the group houses where the city intends to house many of them.
City officials acknowledge that their plan is ambitious in trying to cut the size of the hospital in half, from 1,600 to 800 patients, and developing new residential placements for about 115 mental patients a year for six years.
Most of the new placements will be in supervised apartments in the city, with some having a case manager to look in on them and make sure they are following their plan of treatment, said Virginia C. Fleming, director of the D.C. Mental Health System Reorganization Office.
About two or three group homes will be started each year, most of them run by private citizens who will get their own homes licensed by the city and then will take in perhaps six or 10 emotionally disturbed individuals, Fleming said.
It is one thing to talk about cutting the hospital population in half and sending about 800 patients back into the community, either home or to some form of supervised living arrangement. Keeping track of them on a day-in, day-out basis so they can live as normal a life as possible is quite another.
First of all, by definition the people being transferred have emotional and behavioral problems that they cannot deal with by themselves. They have difficulties coping with day-to-day life.
A person's family may or may not be able to deal with this. It takes a special kind of love and patience to deal with a mate, a child, a parent who has recurring bouts with unfocused anxiety, unwarranted depressions, irrational responses to common events. It takes a special kind of caring and vigilance to watch for that first sign that a patient is regressing, that the treatment is not working as it should, health officials explained.
The city is planning to hire 50 more case managers by October 1987 to watch out for some 2,000 seriously ill patients receiving treatment in the community, a ratio of 40 patients per case manager. Will that be enough to discover problems early, particularly ones that may run in erratic cycles? Another 2,500 outpatients will not have case managers.
Group homes -- licensed as Community Residential Facilities (CRFs) -- have been accompanied by a wide range of problems in the past, from neighborhood opposition to questionable monitoring and inspection.
In addition, the city is planning a large increase in the number of group homes not only for former St. Elizabeths patients but also because the District has been under court order to close down Forest Haven, a city facility in Laurel, Md. that has housed hundreds of mentally retarded persons.
The city also is closing down Cedar Knoll, its minimum security facility for juvenile delinquents also in Laurel, and some of the inmates there are to go to group homes in the city. There already are hundreds of mentally ill persons in group homes throughout the city.
The city is starting to reach the saturation point on group homes it can locate in the District, according to Audrey Rowe, D.C. commissioner of social services. Rowe for years has participated in meetings in every ward with irate citizens who feel they already have too many group homes in their neighborhoods.
The city had 329 group homes with nearly 10,000 beds a few months ago, city officials said.
The group homes for the mentally ill will be run by "your neighbor, my neighbor . . . women who don't have any other jobs," Fleming said. They will get some training at St. Elizabeths before applying for a CRF license.
In a large institution such as St. Elizabeths there are enough staff members and family members visiting patients that if problems develop or if proper services are not provided, people will know and someone will bring it to the attention of authorities.
The situation at small group homes is different, particularly in cases where family members are not actively involved. With vulnerable residents, often confused and on drugs, the onus is on the city government to be active and aggressive in monitoring each facility to ensure that patients are getting the proper treatment and care.
The District's track record of inspecting and monitoring facilities in the city is not a good one. Until recently, its inspections at nursing homes were announced to the facility beforehand, giving the homes a chance to clean up for the inspectors. When inspectors have found serious violations nonetheless, they generally have required only that the facility develop a "plan of correction" that may or may not be followed.
Reporters seeking routine inspection records wait weeks and months for them, only to find files missing, empty and incomplete.
Fleming said the city knows a heavy extra load will be placed on the D.C. Department of Consumer and Regulatory Affairs, which licenses and inspects community residential facilities, and said that up to now DCRA has not been making "as many visits as one might like." The department has been asked to identify the added resources it will need, she said. A formal system of patient advocates also will play an important role in quality of care, Fleming said.
The District did not invite the task of dealing with large numbers of mental patients in the community. The courts have ordered deinstitutionalization for those who are determined capable of living in a less restrictive setting, and St. Elizabeths was turned over to the city at the insistence of the federal government.
But if the city is going to make community mental health programs work, if it is going to keep the patients from falling through the cracks and ending up on the streets, the city will have to keep close track not only of those needing care but of those doing the caring as well.