Former Commissioner, Texas Department of State Health Services
Associate Vice Chancellor, Population Health, UT System
This piece originally appeared in TribTalk, a publication of The Texas Tribune.
Texas’ mental health hospital system was designed and built a century ago and is ill suited to meet the needs of our state. Although these hospitals play an essential role in the mental health delivery system, many of them are functionally obsolete.
That’s why the Texas Legislature next session must make restructuring and replacing the state’s outdated mental health hospital structure a top priority.
The system was developed when Texas and health care were significantly different, a time when Texas was very rural and good treatment options for mental illness weren’t available. Large campuses of 60 to 90 acres, often in rural areas of the state, were built to house 3,000 patients each, and they included farms, baseball parks and cemeteries. Most patients sent to these facilities weren’t expected to recover.
Today, there’s hope for recovery. Hospitalizations for civil commitments are shorter, with the goal of returning people back to their communities, families and jobs. The large facilities now house just over 300 people each. Increasingly, those who require inpatient treatment are sicker, more difficult to treat and more likely to be admitted following a crime.
Unfortunately, our state mental health hospital system never adjusted to these changes. Buildings are old — most were built between the 1930s and 1970s. Many are abandoned, decaying and, frankly, a safety hazard. Buildings used for clinical care are in reasonable condition but poorly designed for modern care, with convoluted hallways with poor visibility from nursing stations. Higher-acuity patients require more caregivers, further crowding already limited common spaces.
And instead of single- or double-occupancy rooms, up to six patients may sleep in a single room. Imagine the challenge a patient with paranoid schizophrenia faces sleeping in a room with five strangers and only being able to retreat to an overcrowded common room. I believe these factors lead to the patient-on-patient and staff violence that’s too often seen in these facilities.
A recent Department of State Health Services study determined that five state hospitals — Rusk, Austin, San Antonio, Terrell and North Texas at Wichita Falls — were beyond repair and should be replaced. Furthermore, the buildings and facilities at the Big Spring, Kerrville and North Texas at Vernon state hospitals, as well as the Rio Grande State Center, El Paso Psychiatric Center and Waco Center for Youth, should be repaired and renovated, and the unused, decaying buildings on these campuses should be torn down, the report said.
The mental health hospital system also lacks the capacity to meet today’s needs, and the demand will only increase as Texas’ population grows. The state needs an estimated 570 additional inpatient beds today and about 600 more beds by 2024.
Replacing and repairing these hospitals will not be cheap. Replacing the large hospitals is estimated to cost about $180 million each, so replacing five hospitals, repairing the remaining hospitals and adding capacity will have a price tag close to $2 billion.
So how can Texas best address this urgent but expensive public policy issue?
Next session, the Legislature should fund the replacement of two hospitals. Solving the problem in one session is not realistic, but replacing two hospitals is. The likely candidates would be the Rusk, Terrell or San Antonio state hospitals.
Replacing and building new hospital capacity will take time, but we need additional capacity now. The state should buy currently unused inpatient capacity from hospitals across Texas. This capacity can be purchased in more urban communities, where most of the patients reside, allowing them to be cared for closer to their families and support structures. Our rural facilities are appropriate for long-term and forensic commitments, but allowing other patients to receive their care closer to their communities would facilitate recovery.
As Texas repairs and restructures its mental health inpatient system, stronger partnerships between our academic medical centers should also be fostered. And there are already good models to follow. The Harris County Psychiatric Center is managed by the University of Texas Health Science Center at Houston and provides learning and training opportunities for our next generation of mental health workers. In 2013, the UT Health Science Center at Tyler partnered with the state to convert a 30-bed ward to care for mental health patients. These partnerships work, bringing in updated technology and additional primary care tools and resources to improve overall care.
Finally, Texas must continue to improve the availability and quality of outpatient community services, which are effective and relieve the pressure on our state mental health hospitals. Without these services, more severely mentally ill patients end up in our jails, emergency rooms and hospitals.
By working together, elected officials, state agencies and higher education institutions can develop a 21st century behavioral health system for Texas that will be a model for the rest of the nation.
David Lakey, MD, is associate vice chancellor for population health at the UT System.