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Proposed bill could help keep mentally ill out of hospitals while receiving assisted outpatient treatment

Daily News - 12/4/2016

A Louisville lawmaker is, for the fourth time, attempting to address mental health care in Kentucky with proposed legislation that would help keep the state's mentally ill out of hospitals by establishing court-ordered outpatient mental health treatment.

"We have not really dealt with mental health in Kentucky," said Rep. Tom Burch, D-Louisville. "I have a compassion for that. If I do anything in my life, I hope that I will be able to pass this legislation. I don't care who gets credit for the bill, I just want the bill to pass."

Burch is referring to his bill, BR 87, filed Nov. 23, that would allow a mentally ill person who is already involuntarily hospitalized to be discharged from the hospital if the person agrees to court-ordered outpatient mental health treatment. The second part of the bill addresses mentally ill people who have been involuntarily committed to a hospital twice within a 12-month period, creating a new method for these people who meet certain criteria to access court-ordered outpatient treatment without having to be committed again.

The hope behind the proposed legislation is that once the people who are served by court-ordered outpatient mental health treatment have had a longer period of stabilization, they will be more likely to be fully compliant in their mental health care and better able to recover in their own homes and communities without repeat hospitalizations.

"I support anything to try to assist those with mental illness," Warren County Attorney Amy Milliken said. In some cases, "they don't recognize that they have a mental illness until it's too late. We've seen families try to help them and try to support them. The families are truly powerless to get them the treatment they need because we can only hold them so long."

Milliken's office oversees involuntary commitment court proceedings. In most cases, people are involuntarily committed for 72 hours and once they are medicated and deemed stable, they are released from the hospital. What sometimes happens is because they have been stable for such a short period of time, they will decide to stop taking the medication that stabilized them and will return to the mental state that landed them in involuntary hospitalization.

The second portion of the proposed legislation referred to as "Tim's Law" is named for a man who was repeatedly hospitalized due to schizophrenia.

"It's named for a man, Tim Morton, from Lexington who had a serious mental illness and had a condition called anosognosia," said Dr. Sheila Schuster, a licensed psychologist and executive director of the Kentucky Mental Health Coalition, which supports the proposed legislation. "That means you are so ill you don't recognize that you have an illness. He had both physical illnesses and mental illnesses. His mom, trying to keep him alive, could not talk him into taking his medication.

"The only thing she could do was take out a mental inquest warrant to Eastern State Hospital and they would admit him for a 72-hour hold and get him on his medications. He would do that for a while then he would quit taking them. ... He was hospitalized 37 times over a 15-year period. He passed away from physical illnesses that were never treated."

People like Morton with serious mental illness such as schizophrenia die, on average, 25 years before their peers who do not have serious mental illnesses. They often have other illnesses, but because of their mental illness don't know that they are sick and need treatment.

"What we're trying to do is get people treatment without having to go through the mental inquest warrant and have people hospitalized," Schuster said. "So we're focusing on a very narrow group of people ? people who have a serious mental illness, people who have been involuntarily committed at least twice in the previous 12 months and people that have symptoms of anosognosia."

Milliken is familiar with a similar story in Bowling Green in which a severely mentally ill person committed suicide after the person's family tried to save that person through several involuntary hospitalizations.

"We tried and tried to help," she said.

The proposed bill, as it is currently written, would:

?require that an attorney be present for a patient-agreed order and allow a peer support specialist to be present;

?require the court to appoint an outpatient provider agency recognized by the Cabinet for Health and Family Services to assemble a multi-disciplinary team to develop a treatment plan, monitor treatment adherence and report to the court;

?require that crisis services are available 24 hours a day;

?provide that failure to abide by the order may result in rehospitalization provided that the criteria are met, procedures are initiated via affidavit by the multi-disciplinary team and mental health examinations take place at community mental health centers;

?permit additional orders with due process;

?require that patient-agreed order services are covered by Medicaid and require that courts report such orders to the Kentucky Commission on Services and Supports for Individuals with Mental Illness, Alcohol and Other Drug Abuse Disorders, and Dual Diagnoses.

A person who meets the criteria in the proposed bill could be court ordered to receive assisted outpatient treatment up to 360 days.

"I think this would assist in getting those with mental illness the help they need," Milliken said of the overall bill. "I think it would greatly assist the families in getting that loved one the assistance they need when they may not always understand that they need it."

The portion of the bill that would provide for compliance monitoring is a key component to successful recovery, she said.

"Right now we will get them stabilized. They are released from Western State (Hospital) because they are stabilized. When they get out and they don't like how the medication makes them feel, if they stop taking it, they are right back to where they were," Milliken said. "It can take the family weeks or months to know about it. In that time they can be (crime) victims. They can hurt someone else or worse they can commit suicide."

Dr. Louis Mudd, a Bowling Green psychiatrist who has provided medical help to the mentally ill for 25 years, said the bill could be very beneficial to the small segment of mentally ill patients who are experiencing the extremes of their illness to the point that their entire well being is jeopardized.

"People definitely have problems because they don't comply with their medicines," he said. "Medicines themselves can cause problems, too. I wouldn't want to try to force everybody to take medicines. It's only the rare cases.

"I have encountered this several times myself. I have seen disastrous consequences from people who don't understand their psychiatric illness or their medical illness that puts them in more harm then they understand. I think it would help the low percentage that are in that position where they really do need help but they just can't recognize it because of their mental illness. The criteria to protect patients' rights is so specific when it comes to being hospitalized against your will, and there are a great many people who don't meet that criteria and fall through the cracks. You can't get them the help they need because they are not eminently in need."

The proposed law is an attempt to help those people fully understand the seriousness of their illness, he said.

"I think it's an effort. It's a step in the right direction as long as you protect their rights. The legal representation and a peer that works with them are both excellent ideas to protect that right," Mudd said.

Some form of assisted outpatient treatment has been adopted in 46 other states, Schuster said.

Studies from other states have shown that this approach decreases the number of hospitalizations, Mudd said.

"What we're doing now clearly is not working for some people," Schuster said. "Why would anyone think it's a good idea to be hospitalized and rehospitalized over and over and over again? We're trying to break that cycle by getting people engaged in treatment while they're still out in the community.

"We want people treated in the community and not in the hospital. It's much more effective, cheaper and efficient if you can get people treated in the community."

If the patient is Medicaid-eligible, that's how the services will be paid for. If he or she is not Medicaid-eligible, there are limited funds available through the state department of behavioral health.

Schuster and Burch ultimately think the legislation, if passed, could save the state money over the long term because outpatient treatment is cheaper than in patient treatment. Also, it is not uncommon for the extremely mentally ill to land in the criminal court system, which costs taxpayers more money in court and incarceration costs than outpatient mental health treatment does, Schuster said.

"Incarcerating people is not working. If they fall through the cracks, they end up homeless or perhaps attempting suicide or successfully committing suicide. The outcomes are not good if we can't get treatment to them," Schuster said. "When people are not able to exercise any rational thinking and to make decisions for themselves, then sometimes society has to step in and provide protection for the person from themselves or for the rest of society.

"In this case, our hope is that if we can get people engaged with the black robe effect, knowing that a judge is going to be watching ... that they go and they get far enough along in the treatment process that they will feel better and they will be able to take control of their lives. That's really what recovery is all about that you can live in the community and have a life and make decisions about yourself just like everybody else does."

Burch lost a mentally ill cousin to illness that wasn't properly treated. Like Morton, his cousin had schizophrenia.

"When we found him, he had his pills sitting on the table with half a bottle of vodka," Burch said. Burch's cousin died of liver failure.

"Tim (Morton) should have never been committed (37) times," Burch said. "He should have been committed for a longer period of time and acclimated to his medication. That's the purpose of this bill is to maintain them, make sure they are not a danger to themselves or somebody else.

"My theory is there is no added expense. My goal is to pass Tim's Law. That's only the beginning. We've got to do more in mental health. We've go to do a lot more. "

- Follow Assistant City Editor Deborah Highland on Twitter @BGDNCrimebeat or visit bgdailynews.com.