Fifteen years ago, when there was talk yet again that St. Elizabeths Hospital might be turned over to the District of Columbia, plenty of mental health care professionals found the whole idea appalling.
"Transferring the hospital to the District would be like dumping a load on a man who already has his hands tied behind his back," warned one hospital psychiatrist. He said the venerable, federally run mental institution, whose patients have included poet Ezra Pound and, currently, presidential assailant John Hinckley, might never recover from such a perilous shift in administration.
Today, with "St. E's" officially set to change hands Thursday, there is less resistance to a District government takeover -- but no less anxiety about how the transfer will affect the sprawling, 132-year-old facility and the city it serves.
District officials, working from a "shotgun divorce" blueprint that has existed for more than a year, say they are ready to assume control of the hospital and its 1,470 patients. The transfer will end the old, adversarial relationship between two mental health care systems -- one federal and in-patient, one local and outpatient -- and enable the city to consolidate its programs and services under a single authority, the newly created Commission on Mental Health Services.
The commission will have an annual operating budget of about $157 million and a staff of about 4,000, including about 3,000 federal hospital employes who will become District employes when the transfer is completed.
There are skeptics, however, particularly among those familiar with the District's track record on mental health care, who fear that the city is courting disaster. For years, they say, D.C. dumped many of its mentally ill and indigent residents at St. Elizabeths instead of treating them in the community. And when court decrees and the push for deinstitutionalization in the 1970s trimmed the hospital's patient roster, the city's shortcomings became all the more apparent: More mentally ill homeless persons filled the streets.
"It's absolutely no secret to anybody that the District's mental health system is one of the poorest in the country, even though the city is spending more on mental health care than anyone else," said Robert A. Washington, who officially becomes the city's new mental health commissioner this week.
Washington, who already has moved the commission's headquarters to the hospital, speaks of the "great crisis of confidence" in the District's handling of mental health and other community care issues. The city, he says, now has the chance, and the challenge, to prove it can do better.
But to do that, according to community workers and other mental health advocates, the District government will first have to address some glaring problems.
The District has a critical shortage of housing options for former mental patients and mentally ill homeless persons. City officials say they will need 47 new group homes, roughly 1,750 beds, during the next four years to accommodate the increasing caseload. Church groups and shelter providers say the city will need twice that to house what they estimate are 2,000 to 3,000 mentally disturbed homeless persons.
The new commission does not have the full staff of psychiatrists, psychologists, social workers, nurses and other support employes it needs to provide treatment and services after the patient is released, such as personal and financial management. Officials are rushing to fill an estimated 600 vacancies, though nurses and adequately trained case managers are already in short supply throughout the region.
Crisis beds are frequently full. The city's revamped Emergency Psychiatric Response Division gets good marks for increasing its emergency outreach efforts, but shelter managers say they are still expected to house violent or potentially violent people until space in a more appropriate facility opens up.
Community centers and city-contracted residential facilities, which will shoulder the brunt of mental health care, are erratic in the delivery of essential services. Mental health care advocates complain that the staff is often ill-trained and not good at recognizing the symptoms of mental disturbance, and that the centers do not have good day care programs, are not open nights and weekends and frequently subject clients to long delays in getting the medication they need to control psychotic behavior.
The District faces an attitude problem among veteran employes, many of whom have become comfortable with the old, less aggressive mental health care system. Even Washington, who has replaced directors at three community centers, predicted "massive staff resistance" as the clinics begin expanding their hours or start tracking down recalcitrant outpatients -- who used to be dropped from the rolls if they missed appointments.
On paper, where most of the consolidation plan exists at the moment, the concept looks good. The commission is gearing up to reduce the hospital's patient load to about 800 gradually over the next four years while shifting the majority of the hospital's staff and financial resources to four community-based centers, with improved mental health care services for adults and expanded programs for emotionally disturbed children and youth.
As envisioned by Washington, the new commission will expand staff and programs at the local mental health care centers, improve outreach services in the community, provide better follow-up care for former patients and, at long last, establish youth residential facilities in the District so that troubled youngsters do not have to be sent out of town.
At St. Elizabeths itself, according to Washington, there will be two hospitals, one for acute, short-term care and a long-term facility for the chronically mentally ill. And the commission, he said, is committed to changing any wards where "the m.o. is coffee, cigarettes, television and no programs."
The new commission will consist of three divisions: adult, children and youth, and forensics (or mentally ill offenders). Housing outpatients at community residential facilities will cost $50 to $70 a day, considerably less than the $225-a-day price tag at St. Elizabeths. Still, according to Washington, overall cost of community care will be about the same once other support services are factored in.
Margaret Wormley, who will direct the $60 million-a-year adult services division, said she plans a phased release or transfer of several hundred elderly, mentally retarded and mentally ill patients. She is looking to integrate most of them into the community in small group facilities, not nursing homes.
"The idea is not to have people go from one institutionalized setting to another," said Wormley, whose toughest task will be finding suitable housing for elderly outpatients. She said case managers and other transition staff members have undergone retraining in preparation for the transfer.
The $18.5 million-a-year forensics division, according to its director, psychiatrist Ray Patterson, will expand programs for the hospital's court-committed criminally insane and will provide mental health services for the city's correctional inmates and parolees. As always, he said, the challenge will be balancing treatment needs with the security of the community.
Mareasa Isaacs, who will direct the new children and youth division, said her mandate is to set up "a continuum" of mental health services up to age 18. St. Elizabeths' two 16-bed units for children and adolescents will be relocated, but probably to another area of the hospital. Also, three group facilities will be opened in the city, which now spends about $11 million a year to send youths to residential programs outside the District.
"A lot of the programs will be brand new, and we will probably be hiring 375 people," said Isaacs, whose budget will be about $18.9 million a year. "The system will focus on doing a lot of family work to help children return to their homes as quickly as possible."
The District, according to mental health advocates, is going to need all these resources and more to cope with newly released hospital patients and an estimated 15,000 chronically mentally ill people already in the community.
"It's a disaster, and for some reason, it's gotten worse," said Anne Baxter, who directs the Calvary Shelter for women in Northwest Washington. Her 28-bed facility got so many seriously disturbed residents this past summer that Baxter hired a two-hour-a-week psychiatrist, who put more than 15 of the women on medication.
"I anticipate seeing a lot more mentally ill patients here, and that's why I got the psychiatrist," Baxter said. She complained that the city does not provide the kind of lifetime help that some outpatients need and is too frequently leaving the care burden to shelters that "can't offer what these people need."
Robert Keisling, a St. Elizabeths psychiatrist who runs the city's 24-hour crisis unit, located on the grounds of D.C. General Hospital, said the District "obviously has a long way to go" before its new commission system is functioning smoothly.
His unit sees about 25 to 30 patients a day and has set up emergency response teams to visit shelters and private homes to help people "who are mentally ill and refusing to come in." He said the psychiatrist-outpatient ratio has doubled at community mental health centers during the past two years and now averages about one psychiatrist for every 150 clients.
"But a lot of changes have to take place if the whole thing is going to work," said Keisling, who sees aggressive case management and appropriate housing arrangements as necessary for the system's success.
Most patients spend two weeks in the hospital and return to their families. The challenge, Keisling said, will be to treat people before they get so ill that they need hospitalization and to find outpatient care for those who have no family support.
Charles Walker, 58, and Vernell Logan, 49, are St. Elizabeths patients awaiting release as part of the transfer plan. They say they were admitted to the hospital with alcohol abuse and related problems, and they credit the St. Elizabeths staff with helping them stay sober.
Logan, hospitalized since January, is scheduled for discharge next month and says she is "glad and nervous all at the same time" about getting out. She will be living in her own apartment under the city's Tenant Assistance Program and receiving public assistance. She hopes to continue mathematics and computer programming classes she started taking at the hospital.
Walker, a patient for the past year, has been attending Alcoholics Anonymous meetings at the hospital five nights a week. He has applied for Supplemental Security Income and expects to move into a group home soon, though no housing assignment has been made and no definite date set for his discharge.
Keisling said the community centers are being "beefed up" to handle the impending release of Logan, Walker and other patients. "If the city facilities do not do the job, there will be more homeless people . . . , but nobody is suggesting that we close down hospital wards and send people out the door before the programs are ready and there's a place for them to go."