Demand high for forensic beds at Riverview in Maine
The Riverview Psychiatric Center in Augusta, Maine, last year became the Riverview Psychiatric Recovery Center, an indication of the state-run mental hospital’s commitment to regaining the Centers for Medicare and Medicaid Services (CMS) accreditation it lost in 2013 – and the $20 million in federal funding that went with it.
Gone are the correctional officers whose use of stun guns on patients contributed to deficiencies cited by federal inspectors who de-certified the hospital. Inspectors also found problems with patient care and a lack of staff training.
The 92-bed facility is slowly recovering from negative news reports about patients attacking mental health workers and nurses and patients being pepper sprayed.
But there have been setbacks. An independent overseer last fall found that Riverview violated a consent decree stemming from a 1989 class action lawsuit requiring the state to maintain a comprehensive mental health system meeting patient’s individualized needs. Superintendent Robert Jay Harper said there is progress in recruiting new staff and training existing staff in de-escalating techniques. Patients also now co-lead some treatment groups and participate on management, policy, and program improvement teams.
“There’s no policing functions on the units at all but we do have a Capitol Police office in the state lobby,” said Harper, a former patient advocate with the Disability Rights Center initially appointed acting superintendent last March and made permanent in November. “They can’t go into a unit on their own. They can only go if they’re called and only if the administration is willing to say that there was a criminal activity.”
Harper makes it clear: Riverview is a hospital and not a correctional institution. But the facility is also an assessment center to determine if people making their way through the court system meet competency standards and can be held criminally responsible for their actions.
“Usually we have two or three empty beds on the civil side and zero empty beds on the forensic side,” Harper said.
Average length of stay in Riverview’s Upper Saco unit for those found not criminally responsible for their actions is about 3 and a half years before being declared safe to go back to the community to live in group homes and apartments, Harper said.
“That’s one of the difficulties with CMS,” Harper added. “They’re saying that’s clearly not an acute hospital stay and we’re saying we agree with you on that but we have no control over that because it’s the court that tells us whether they leave and the criteria they’re looking at is not necessarily where a person is in their treatment. They’re looking at whether they’re safe to be back in society. That’s part of the problem with states that have to make the most of very limited resources. They combine multiple functions in a single facility.”
Another part of the problem is that Riverview’s open campus and therapeutic environment work for most patients but a small percentage need a far more structured place for treatment – like the 32-bed Intensive Mental Health Unit that opened in February 2014 at the Maine State Prison in Warren. The Warren unit takes men only and only those found guilty or those awaiting resolution of their case.
Some men ask to remain in Warren’s mental health unit but are not allowed to, said Kennebec County District Attorney Maeghan Maloney.
“What they do then is the patient communicates their desire to stay to the defense attorney, and the defense attorney asks for the case to be continued,” Maloney said. “Obviously, this causes problems because we don’t want cases to be dragging in the system.”
Women’s options for placement are Riverview or the county jail and sometimes Riverview doesn’t have room.
“We’ve had a couple of incidents where a judge has ordered a patient to be sent to Riverview and Riverview has had to refuse because they didn’t have enough bed space,” Maloney said. “In one particular instance, the judge was insistent that this female patient not go to jail because her mental health deteriorated in jail, but Riverview simply didn’t have a bed for her and could not take her.”
So the woman spent two days in jail before Riverview was able to provide a bed for her. “It was not what the judge found to be in the best interest of the person,” Maloney said.
The Kennebec County Jail, built in 1991, was designed for 131 inmates; the average daily population in 2014 hovered around 180. It was higher on a mid-January day when Sheriff Randall Liberty counted 192 inmates, of whom three – two men and one woman – had come from Riverview.
“There’s a lot of transitional folks with mental illness, with substance abuse issues, people recently arrested, they’re drunk. There’s a lot of banging. It’s very noisy, not a therapeutic environment,” Liberty said.
State Rep. Drew Gattine (D-Westbrook), House chair of the 13-member Joint Committee on Health and Human Services, said the Department of Health and Human Services and the Legislature need to conduct an analysis of the current mix of beds among Riverview’s four units.
“I don’t think putting labels on beds or people as civil or forensic tells the whole story of what‘s going on in that hospital,” Gattine said.
Gattine said he wouldn’t criticize Riverview staff and administration for incidents where violent patients were sent to jail “because I’m not there and I’m not seeing what’s happening.” But he added: “If that’s happening a lot that signifies a breakdown in the treatment modules. I don’t think that that should be happening in our psychiatric hospital. That should be a real rarity.”
Despite talk of the need to create a special small unit to handle mentally ill patients with aggressive behavior, there is no agreement on where the unit should be located. (Harper said he thought such a unit should be located elsewhere to separate roles. Maloney said a unit would be preferable on the Riverview campus to be accessible to its trained team). No legislative sponsor had come forward to introduce any bill by mid-January and no proposal emerged in Gov. Paul LePage’s proposed biennial budget for 2016-2017.
The budget adds 12 new acuity specialists to the staff. Harper said acuity specialists will work one-on-one with patients. “They’re trained specifically to deal with acute patients in an aggressive environment and they usually work on the most acute units,” he said. Desirable job candidates will have several months experience in direct patient care and advance training in management of aggressive behaviors.
Riverview has about 350 employees and started 2015 with 20 direct care vacancies. The hospital is building new relationships with nearby nursing schools and just started an internship program with the University of Maine in Augusta’s Mental Health and Human Services program. Riverview also added training in motivational interviewing and nonviolent communication to help staff learn to de-escalate tension and make patients feel more secure.
Riverview recently won a support services consultation grant to help its psychology internship program receive American Psychological Association accreditation and increase from two to four its doctoral candidate interns getting their hours of supervision in for clinical practice. “It will be a nice stream for us for recruiting purposes,” Harper said.
Jenna Mehnert, executive director of the Maine chapter of the National Alliance on Mental Illness, said Riverview needs to increase its clinical staff and increase salaries as well.
“You know what happens is they train people and then they leave,” Mehnert said. “Staff morale there is really low right now. Between the not great press they’ve had and between vacancies and staff out on injuries, it’s not a place where the staff feels things are going great.”
Harper disagreed, adding the hospital’s primary challenges now remain the areas controlled by the courts.
“People are excited about changes and feeling empowered to make a difference,” he said. “Getting the internship grant helped a lot so we’re on the right road now.”