Arizona State Hospital patients need more staff, specialized care, report says
Deficiencies in Arizona's mental health system, increasingly complex patient needs and staffing shortfalls are challenging leaders at the Arizona State Hospital, a new report says.
The 390-bed state hospital, known as ASH, is the last resort and highest level of care for patients in Arizona with serious mental illnesses. Critics who have been calling for independent oversight of ASH say conditions, staffing levels and transparency at the facility have become a problem. The hospital operates on a "recovery-based" philosophy. The aim is for patients to get stabilized and eventually return to living in the community, but some critics say that's not always happening.
The statutorily required report is technically a clinical improvement and human resource plan. It was submitted by ASH chief executive officer Mike Sheldon, is 103 pages and was made public this month.
Some of its key points:
Nearly 10%, or 11 patients out of 116 patients discharged from the civil side of the hospital over a four-year period, were readmitted after medically decompensating in a supervised group home. Those outcomes may have been avoided with "more robust community resources."
The number of high-risk patients has increased. Those with physician's orders for "close observation status" due to a risk of harm to themselves or others jumped from an average of 16 patients per day in July 2022 to 23 per day in June 2023.
The hospital is not equipped to provide numerous evidence-based treatments considered standard care for acute psychiatric patients, including electroconvulsive therapy, transcranial magnetic stimulation and vagus nerve stimulation.
Nearly 90% of patients housed on the civil side and 72% of patients in the forensic side of the hospital have a primary diagnosis of schizophrenia or another psychotic disorder,
Nearly one-third of all patients on the civil side of the hospital have either a neurocognitive or neurodevelopmental disorder and in some cases, both.
Arizona has the fewest number of state-operated psychiatric beds reserved for individuals under a civil commitment order, per capita, in the U.S.
ASH is permitted to staff 729 full-time employee positions, but as of June 30 only 629 of them were filled. The hospital relies on staff working voluntary overtime shifts and on contract registered nurses and behavioral health technicians to make up the difference.
ASH needs to add 117 full-time employee positions at an added cost of $10 million just to meet the community standard of care.
Gov. Katie Hobbs: Reflects 'years of disinvestment' in mental health care
The report "clearly shows that we have work to do to improve access to mental and behavioral health care at every level after years of disinvestment in the system," a written statement from Arizona Gov. Katie Hobbs' office says.
"The Governor, ADHS, and ASH leadership take the state’s stewardship of ASH extremely seriously, and hope the report will serve as a starting point to meaningful change in the coming legislative session."
The report is "remarkably transparent" and illustrates "big, giant gaps" in Arizona's system of mental health care that limit the hospital’s ability to readily discharge civil patients to less-restrictive settings, said Will Humble, a former state health director who is now executive director of the Arizona Public Health Association.
Several areas of the report articulate how Arizona's mental health system is in need of repair, including "outpatient (mental health) providers often losing contact with patients" and providers who "too often" send patients to ASH "out of a sense of desperation," due to a lack of resources, among other factors.
The hospital's civil and forensic units have a combined 259 beds and to house a patient costs about $256,000 per patient per year, according to state estimates from June. A separate, 131-bed Arizona Community Protection and Treatment Center on the 93-acre ASH campus, for patients who have committed sexually violent offenses and are deemed unsafe to return to the community, costs about $100,000 per patient per year.
Gaps in the mental health continuum of care result in people with mental illness ending up in jails, prisons and living on the street, said Holly Gieszl, a Phoenix attorney who represents several patients at ASH.
"I 100% believe the justice system has become a part of the continuum of care," Gieszl said.
Part of the problem, according to Humble, lies in the fact that ASH is a division of the Arizona Department of Health Services, while the state's public system of behavioral health care (including mental health) since 2016 has fallen to a different agency, the Arizona Health Care Cost Containment System, which is Arizona's Medicaid program.
"If AHCCCS had also been responsible for ASH, they would have seen the consequences of a lack of a step-down facility," Humble said. "It would bring more urgency to solving that problem because they are responsible for it. But when you are not responsible for a problem, it's less likely you are going to care about fixing it."
The report lays out several scenarios, with budget estimates, about how to improve services at ASH, including increasing the bed capacity; adding more clinical staff; building a step-down community reintegration unit; and building a facility for patients with diagnoses that require more specialized care, including those with disabilities such as dementia and autism.
The state should solicit an independent third-party consultant to conduct an analysis of the behavioral health continuum of care in Arizona that includes quantifying unmet treatment needs, the report recommends.
Losing $25 million for behavioral health facilities was 'absolutely tragic,' former legislator says
Humble said it's unfortunate that $25 million, designated in last year's state budget to build one or more secure residential behavioral health facilities in Arizona, is not in this year's budget. The money could have significantly improved the continuum of care for psychiatric patients who are chronically resistant to treatment, he said.
The $25 million was a one-year appropriation that lapsed because of a lack of legislative action, Hobbs spokesperson Christian Slater wrote in an email.
Secure residential behavioral health facilities "do not help to resolve the larger issue of community reintegration after successful treatment at ASH," Slater added, noting that "secure" means a locked facility that individuals are not permitted to leave.
But former state legislator Nancy Barto, who was active in getting legislation passed to improve the state's mental health system and advocated for more secure residential beds, disagrees. She told The Arizona Republic this week that the loss of the $25 million for secure facilities is "absolutely tragic" for people with serious mental illness.
"We have had a need for more secure facilities that can help in continuum of care for the mentally ill for a long time," Barto said. "We need a lower level than a hospital for a number of reasons. There's no place in between an unlocked group home and ASH."
Unlike hospitals or inpatient facilities, the ASH report says group homes and behavioral health residential facilities in Arizona are not required to have a registered nurse physically present at all times.
"Instead these facilities tend to be monitored by a behavioral health technician or equivalent and a rotating staff of clinical professionals provide services to residents per their treatment plan," the report says.
Some patients, upon being released from ASH, need a place as a transition where they can't walk away from treatment, Barto explained. Some also need careful monitoring to make sure they are taking their medications, she said.
"There's something called anosognosia, where you don't know that you are mentally ill," Barto said. "If you can't help them by keeping them in a safe place where they can get the treatment that they need and there's no place at ASH, where do they go? They go to the jail. They go to the streets … So now we are spending the same good money over and over and over again."
It's critical to recognize that ASH is only one of hundreds of interdependent entities providing critical services in the state’s psychiatric system of care, Sheldon wrote in his introduction to the report, and "any perception that the hospital is not functioning optimally is indicative of a larger set of systemic deficiencies within that care continuum."
Reach health care reporter Stephanie Innes at Stephanie.Innes@gannett.com or at 602-444-8369. Follow her on X, formerly known as Twitter @stephanieinnes.
This article originally appeared on Arizona Republic: Report: The Arizona State Hospital lacking staff, treatment options
