By Albert Samaha
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To an outsider, Peter Fazio may have seemed a logical candidate for a discharge from the Manhattan Psychiatric Center to a community mental health center. Though he had been a patient at the Ward's Island facility since 1988, he seemed well-adjusted and even had a job working in the library.
But, underneath, Fazio was terrified of leaving the safe and familiar surroundings of the psychiatric hospital. In a 1997 treatment plan,doctors noted that Fazio grew agitated whenever discharge planning was discussed. "I will hurt myself," Fazio said. A hospital clinician, aware that Fazio's psychiatric history included several suicide attempts, underlined a note on his treatment plan: "Alert: He is a serious risk."
Even so, it became clear to Fazio by last summer that his release was imminent. Days after being escorted to interviews at community mental health facilities, Fazio took a razor to his throat, wrists, and stomach, and killed himself.
Some staff members believe that Fazio's suicide was a direct consequence of a "discharge at all cost" mentality that has been forced on MPC by its bosses in the Pataki administration. An internal review of the incident stopped short of endorsing this view, but did determine that the "active discharge role of this hospital has not been adequately communicated." The hospital has already followed orders to release hundreds of patients. Some 200 more are expected to be discharged in the coming year. As a result, say clinical staffers at MPC, many patients are being released prematurely. And some could end up on the streets, where they may pose a risk to themselves and others.
Though psychiatric hospitals are being downsized all over the state, the cuts are most dramatic at MPC. The facility, which has traditionally treated patients referred for long-term care by Manhattan hospitals, had over 900 residents just three years ago. During the 10 months ending February 4, 1999, the number of inpatients at MPC fell from 653 to 485 almost a 25 percent drop. (Nearly a third of the patients discharged from the state's 18 adult psychiatric hospitals during this period were leaving MPC.) And the exodus isn't over yet: the New York State Office of Mental Health has urged MPC to further reduce its population to a target of 250 people by fiscal year 200001.
"MPC is and will continue to downsize its patient population and wards," MPC director Horace Belton wrote in February 1998, a few months before his retirement. "We have been mandated . . . to do so."
Downsizing itself is nothing new. For years, advocates have been arguing that the state should close many of its underutilized psychiatric hospitals and dedicate the savings to community mental health programs, which are generally believed to provide a better environment for most people with mental illnesses. To a great extent, this has already happened. In 1995, the year Pataki took office, the number of inpatients at state psychiatric hospitals was roughly 9000. Today, there are fewer than 5300 patients in the system. In two years, OMH estimates, there will be only 3700 to 4700 inpatients statewide.
With many of the upstate psychiatric hospitals already near bottom several with barely a hundred residents the state has put intense pressure on MPC to bring down its patient population. Last March, OMH sent a team down from Albany to help MPC figure out how it could reach its target census. In May, the hospital set aside 14 staff members to start the Office of Discharge Planning, a body responsible for doing "whatever needs doing to move approximately 350 patients to an appropriate discharge."
The result, according to interviews with half a dozen current and former clinical staff at the hospital, as well as patient advocates, has been a concerted push to discharge patients. "Teams were walking through the wards, pointing to patients and saying, 'He can be discharged,' " one hospital clinician who wished to remain anonymous told the Voice.
In one instance, according to a senior MPC official, the hospital's current director, Eileen Consilvio, asked about a patient, " 'Why is she still here? She's not getting better. We ought to discharge her.' The medical staff didn't agree." Not long afterward, the same patient attacked a doctor on one of the wards. Neither MPC nor Consilvio returned calls for comment, though Consilvio issued a denial through an OMH spokesperson, Roger Klingman.
In another case, all of the patients on one physician's ward were transferred to other wards after he refused to sign off on a discharge that was being pushed by hospital administrators.
OMH denies that it is forcing patients out before they are ready. "If there was any pressure at all, it was to do appropriate discharges," says OMH's Klingman. "It really hinges in each individual case on a physician's decision. Without that determination, the person is not going to be discharged."
Nevertheless, at least one senior medical official recently quit because he felt patient care was taking a backseat to cost cutting. "I felt I could not be effective and maintain patient standards," said the official, who took advantage of a retirement package in December, along with about 40 other staff members. "I felt I was beating my head against the wall with no results."
Critics of the discharge plan charge the Pataki administration isn't concerned with patient care, but simply wants to reduce staff and save money. They point out the governor's recent budget failed once again to propose any new money to expand community mental health facilities, even though state statistics show that there is an unmet need of approximately 14,000 beds.
The pressure to release patients is occurring despite the fact that a growing percentage of MPC's patients have criminal, and sometimes violent, backgrounds. In 1993, of the 740 patients admitted to the hospital, only 7 percent came from correctional facilities like Rikers, Sing Sing, and Attica; in 1997, these patients accounted for 70 percent of the hospital's 134 new admissions. Today, virtually all of the new patients entering MPC have criminal backgrounds.
Up until a few years ago, all but a handful of MPC's admissions were referrals from Bellevue, Metropolitan, Harlem Hospital Center, and other acute hospitals in Manhattan. But in 1996, staff say, these "receiving hospitals" were directed by the state to divert any patient who required extended care to Rockland Psychiatric Center in Rockland County. (Critics of this move believe the governor has steered patients away from the city as a way of preserving jobs for his upstate supporters.) The following year, under a separate state policy, MPC began receiving more and more patients from correctional facilities.
Some of these patients can pose a threat to the community if they are discharged prematurely, particularly if they stop taking their medication or if they revert to using drugs and alcohol. Such relapses aren't uncommon, according to doctors and advocates, because community treatment programs are often understaffed and cannot legally force patients to take their medication or even return to the facility each night.
"As we get to the more severe patients, with drug addictions and criminal histories, we can expect a larger percentage of trouble after discharge," a former MPC physician told the Voice.
But not every physician at MPC is as worried that the pressure to release patients will result in dangerous people walking the streets. "You get brownie points if you get patients out," says one physician still working at MPC. "But only a physician can sign an order to discharge patients. Many of the patients can respond just as well in a supervised community setting."
The key, experts say, is to gradually move patients to independence and release and to make sure that patients continue to receive adequate care and supervision outside of the hospital. Patients can be completely lost if they are placed in a community residence that doesn't suit their specific needs or if there is no one to help ease their transition to independent living. This may be even more important at MPC, where many of those being discharged have been living in the hospital for years.
The Manhattan State Citizens Group, among other patient advocate groups, believes that MPC is in such a hurry to place patients in community beds when they become available that hospital officials are making important placement decisions without proper input from patients' families.
A case in point: Dorothy Goode's son, Michael, was released from MPC in December after receiving treatment in the hospital for more than 13 years. Despite the fact that she supports Michael financially and keeps a close eye on his progress, the 80-year-old woman learned of her son's discharge not from the hospital, but from the supervised residence that was accepting her son.
Goode says that the hospital also neglected to arrange for her son to get his government entitlements ahead of time. She says that the officials at the supervised program actually told Michael that he needed to go to the Social Security Administration office himself to apply for SSI. While navigating the bureaucratic maze can be a dizzying task for any New Yorker, Goode felt that it would be nearly impossible for someone who hasn't lived an independent life for more than a decade. Ultimately, she went down to the government office on her son's behalf.
"They're in a hurry to get the patients out. Once they find somewhere that will take them, they just rush them out," Goode says. "If I wasn't alive, I don't know what would happen."
Even for patients who remain at the hospital, the atmosphere is increasingly grim. In recent years, MPC has begun to look more and more like a prison. Officials have built fences, tightened security, and greatly restricted the number of patients allowed to walk around the grounds.
On a recent afternoon, the MPC's recreation and rehabilitation facilities looked like a ghost town. Staff say this is because the rehab center which includes a library, a bowling alley, a theater, a cafeteria, and pool tables is located in a separate building from the patient wards, and only a small number of patients have access to these facilities.
Shortly after Peter Fazio committed suicide, a patient at MPC composed an emotional letter to MPC administrators that eventually circulated throughout the hospital. She wrote: "All you have been concerned with is downsizing the hospital as quickly as possible and you forget that you are dealing with human lives and feelings. You can not all of a sudden force patients you have kept here for so many years to leave. Forget your stupid deadlines and let time be spent on these patients to prepare them so they don't all of a sudden feel abandoned. Because the hospital is locked down now 95 percent of us never go further then Casa Verde [a fenced-in recreation area], and yet you are discharging people left and right who haven't spent a day on their own in years.