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Rusk State Hospital faces budget, other challenges in serving Texans

New Directions

There are eight state hospitals in Texas that provide mental health services. One, the Rusk State Hospital (RSH), earned a perfect score of "100" on its three-year survey from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) in 2001.

An independent, nonprofit organization, JCAHO evaluates and accredits nearly 18,000 health care organizations and programs nationwide. While RSH officials say the hospital had received high scores from JCAHO in previous years, this was its first 100 rating. In fact, RSHis the only Texas Department of Mental Health and Mental Retardation (TDMHMR) facility to ever receive a 100 on a JCAHOsurvey.

Prisoners to patients
RSH's 920-acre tract in Cherokee County originally was home to a state prison. In 1878, a three-story penitentiary opened. The building now serves as RSH's administration building. When the prison closed in 1917, the Texas Legislature appropriated funds to convert it to a mental hospital. RSH admitted its first patient in 1919. The campus now includes two dozen buildings including several patient units as well as a canteen, chapel, recreation center and laundry center.

Now under the umbrella of TDMHMR, RSH treats patients with mental illness and mental retardation from 29 East Texas and Gulf Coast counties. Admissions may be voluntary or involuntary, according to the provisions of the Texas Mental Health Code.

Part of the admissions process is screening patients. TDMHMR designates individuals, called Mental Health Authorities (MHAs), to coordinate services for mentally ill residents in different areas of the state. Patients seeking admission to RSH first must be screened by the MHA for that area. To be admitted, individuals must be age 18 or older, be mentally ill and require in-patient psychiatric hospitalization. Patients can be involuntarily committed by the court or can request voluntary admission if they are considered legally competent.

RSH patients are treated in one of the property's five units. Upon admission, patients first go to the Angelina Unit, the primary admitting unit for general adult psychiatric services. Physicians assess and stabilize patients and transfer those needing longer-term care to the Sabine North, Sabine South or Neches units. The San Jacinto unit provides services for patients aged 65 years and older.

A senior physician, program director and unit nurse administrator head each treatment program. Treatment teams work with patients, family members and community agencies to plan psychiatric services tailored to meet each patient's needs.

The average length of stay for patients in the Angelina Unit can range from seven to 14 days, while patients in other units might stay from 30 to 90 days.

Fewer patients
With 937 employees, RSH is the second-largest employer in Rusk after the Texas Department of Criminal Justice. The hospital cares for an average of 346 patients a day and in fiscal 2001 admitted 1,969 patients, with 1,914 patients discharged. By comparison, Big Spring State Hospital, a 187-bed psychiatric hospital that serves El Paso, Lubbock, Amarillo and surrounding areas, cared for an average of 203 patients a day in fiscal 2001, up from 201 patients a day in fiscal 2000. Big Spring State Hospital's admissions of 1,328 total patients in fiscal 2001 was up slightly from 1,075 patients admitted in fiscal 2000.

Terrell State Hospital, which has 310 beds and serves patients in a 22-county area around Dallas, had 3,062 admissions in fiscal 2000 with an average daily census of 347 patients.

RSH's patient count has declined as the state's funding for bed capacity has decreased. For fiscal 2002, RSH will receive funding for 347 beds, down from 369 beds in fiscal 2001. Funding for bed capacity is determined by bed use during the past year and the budget, says Joe Rozelle, the hospital's director of community relations. The hospital's declining population follows a state and national trend. The typical state-hospital patient population has fallen from around 3,800 in the late 1950s to about 370 in the mid-1990s, according to the Texas Comptroller's 1996 Texas Performance Review (TPR).

In fiscal 1986, TDMHMR's eight hospitals had a combined daily census of 4,004 patients. By 1995, the average had fallen to 2,677 patients, according to the TPR report. The trend in falling hospital populations stems from an increased emphasis on treating patients with mental illness or mental retardation within the community and from improved medications that allow patients to function outside of a hospital setting.

"We first want to try to treat people in the community if at all possible," Rozelle says. "The folks that come here have pretty much received all the treatment they can receive. If their illness is such that they can't benefit [from outpatient treatment], they need to come to the hospital."

Tightening the budget belt
RSH's fiscal 2002 budget of $33.2 million is up slightly from its 2001 budget of $30 million. Hospital officials attribute the increase to pay raises for state employees mandated by the Texas Legislature in 2001. They say they face budget tightening in 2002 and may need to make some cuts depending on the needs of the TDMHMR system but are not considering cutting employees.

Mental health hospitals and treatment centers nationwide are feeling the effects of state budget crunches, says Jennifer Bright, senior director of policy for health care reform for the National Mental Health Association.

"The entire public mental health system is under-funded, whether you're talking about community-based care or institutions," Bright says.

In addition to decreased budgets, an increased number of private psychiatric hospital closures has put even more pressure on state mental hospitals, says Kim McPherson, public policy specialist for the Mental Health Association in Texas.

Outside expenses
RSH officials say that outside medical costs, or the costs for treating a patient needing medical attention outside the hospital's area of expertise, are rising as well. From September 2001 to January 2002, RSH's outside medical costs reached $572,000, and officials project that those costs could reach $1.5 million for fiscal 2002.

RSH mainly employs mental health physicians and nurses, so if patients need surgery or other medical treatment, they are sent to other facilities.

"We take on a tremendous burden with medical expenses," says Dr. Rudy Rodriguez, the hospital's clinical director. "Our psychiatric patients that come here are very ill. Greater than 50 percent have serious medical conditions."

To help limit excessive outside medical costs, which cannot be predicted and can affect the hospital's budget, RSH officials have developed a list of medical conditions that cannot be treated at the hospital. Hospital officials try to screen patients before they are admitted to see if they might be better suited for other hospitals.

In fiscal 2002 about 86 percent of RSH's funding came from state general revenue funds, and 14 percent came from insurance collections. In fiscal 2001, RSH earned $26.6 million in Medicaid Disproportionate Share reimbursements, which was returned to the state's General Revenue Fund, providing a $1.5 million profit for the state. A hospital receives Medicaid Disproportionate Share reimbursements if the percentages of Medicaid and indigent patients served in an inpatient setting are disproportionately higher than at other hospitals around the state.

Recruiting and retaining employees also remains a challenge for RSH officials, who say the hospital sometimes competes for prospective workers with the neighboring Texas Department of Criminal Justice, which employs more than 1,000 people in Rusk.

Banner year
RSH officials cite several achievements for 2001. After providing smoking cessation classes for both employees and patients for several months, the hospital banned smoking for both patients and employees in September 2001.

RSH also successfully passed an audit by the State Fire Marshal's Office, and hospital officials met quarterly with the area's designated MHAs to discuss problems and issues.

RSH launched an Improvement of Care Environment (ICE) program, which included rehabilitating the Sabine and Neches patient care buildings with fresh paint in bright red and burnt orange. Hospital officials worked with representatives from Rusk's Main Street program, which rehabilitates historic buildings in downtown Rusk, on the painting and design of the buildings. Improvements included new hedges, groundcover and sprinkler systems. Funded primarily by TDMHMR, the ICE project included a little more than $200,000 in new furniture, repairs and paint.

Also in 2001, RSH officials began consolidating the Human Resources Department, formerly housed in two separate buildings, into one building. New carpet was installed, and sheetrock was replaced. The $250,000 project also calls for new exterior paint and landscaping and should be completed in spring 2002.

The ICE program has helped give the hospital, which has buildings dating from the 1930s, a much-needed update, say hospital officials.

"The exterior painting completed on the Neches and Sabine treatment units along with the renovations being made to Building 611 that will become our Human Resources building have and will greatly enhance the appearance of our hospital," says Mike Crysup, RSH's director of auxiliary services. "We are very proud of the continuing improvements that we are making to RSH."

The JCAHO rating and face-lift of some of the hospital's older buildings buoy RSH officials as they face a challenging year.

Among the challenges faced by RSH in 2002 was the resignation in January 2002 of the hospital's former superintendent and chief executive officer (CEO), Diane Faucher. In February, Mike Crysup, a 25-year veteran of RSH, was named interim CEO while officials with TDMHMR searched for a new CEO. In April, TDMHMR officials named Ted Debbs superintendent and CEO effective May 1.

Debbs was formerly project manager for Creative Socio-Medics and the executive director of the Jim Taliaferro Community Mental Health Center in Lawton, Okla. He also served as the director of mental health services for the Denton County MHMR Center. Hospital officials say top issues for 2002 include maintaining a balanced budget, managing rising outside medical costs and recruiting and retaining staff.

"Maintaining our integrity as far as the budget is concerned, that is a challenge," says Crysup. "The biggest challenge in front of most of us for the next couple of years is to try to maintain a facility that received a 100 on its last Joint Commission survey."

Karen Hudgins