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"Hospital without Walls"


February 8, 2001


"Hospital without Walls"

Could Become a Jail without Bars

By Daniel B. Newby

When relatively healthy people voluntarily seek mental health care, they go to the office of a psychiatrist, counselor, or social worker. When severely ill individuals who are a danger to themselves or others need care, they are admitted to a hospital for the mentally ill.

Organizations like the National Alliance for the Mentally Ill (NAMI) and the Disability Law Center (DLC) are concerned that in Utah there is no intermediate setting for people who are mentally ill and in need of treatment, but not so crippled by their conditions that they need to be hospitalized. The DLC points out that Utah has only one already overcrowded facility for inpatient commitment, and the Utah Division of Mental Health (DMH) estimates that it costs $300-500 per day to treat each hospitalized patient.

Enter PACT — a Program of Assertive Community Treatment. Proponents of PACT, which has been adopted in many states, call it a "hospital without walls." A PACT team can assess whether a person is in need of its services, make a diagnosis, form a treatment plan, and prescribe and administer medication, all in the comfortable setting of the patient's own home. Think of it as the home health care of mental illness. And the cost? Only $50 per patient per day. The Legislative Executive Appropriation Committee will shortly consider the DMH's proposed budget, which includes enough money (when federal matching funds are included) to develop four PACT teams.

Why would anyone object? Because the freedom of many Utahns could be at stake.

DMH estimates that nearly 150,000 Utahns suffer from serious mental illness—almost one out of every 15 Utahns. Many of these will be treated by private providers, but a huge target market still remains for PACT. PACT teams are small (each team serves a maximum of 120 patients) and designed to function with relatively high autonomy, which makes PACT very easy to scale upward in size. At $50 per day per patient PACT costs $18,250 per patient each year. That's no small sum if you're planning to treat 100,000 people, but adding a few teams each year would hardly show up on the state budget radar.

DMH has been circulating and promoting a set of standards used by NAMI to encourage the development of PACT and are used by PACT teams around the nation. Based on these PACT standards, admission criteria include "significant functional impairments" such as "inability to be consistently employed at a self-sustaining level or inability to consistently carry out the homemaker role (e.g. household meal preparation, washing clothes, budgeting, or child-care tasks and responsibilities)." Lack of good personal hygiene, not obtaining medical care, and not meeting one's nutritional needs are other indicators that a person might need PACT's services. If one in 15 people are in need of care, a lot of bad housekeepers could find themselves subject to involuntary psychiatric treatment, which can include the administration of psychotropic medication.

But who says PACT is involuntary? Well, PACT standards do not require that a patient's consent be obtained before he is admitted to the program. In fact, some other states refer to PACT as IOC — Involuntary Outpatient Commitment. These standards also state, "clients to be served [may be] individuals who... because of reasons related to their mental illness, resist or avoid involvement with mental services." However, the standards also stipulate that the program cannot violate state and federal law regarding patient's rights. In Utah, involuntary commitment is temporary, and a patient must, because of mental illness, be "likely to injure himself or others if not immediately restrained," to be committed.

Interestingly, in a June 8, 1999 memorandum, Robin Arnold-Williams, Executive Director of the Department of Human Services (DHS), recommended to Governor Leavitt that involuntary commitment statutes be loosened to include those who are "gravely disabled," and in "significant need of treatment." This memo coincidentally recommended the funding of four PACT teams beginning in FY 2001. Loosening the standard for involuntary commitment would allow PACT to treat patients presenting a marginal danger to themselves or others and would also open the door to involuntarily treat people who, like the bad housekeeper, merely differ from society's accepted norm.

This is a major, legitimate controversy that deserves to be debated by the legislature and reviewed by the governor, but instead it is beginning with a simple budget appropriation. Loosening commitment laws will require action by the legislature and governor, but the import of such a change may be lost if they are unaware of the new and powerful delivery mechanism PACT represents.

PACT coupled with relaxed involuntary commitment has the potential to obliterate vital individual rights. If our legislators approve PACT, it should contain stringent protections for the individuals impacted, including the right to a trial by jury prior to commitment. And until our elected representatives are prepared to examine the program, no funds should go to starting it.

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Daniel B. Newby wrote this article while he was employed as Director of Operations & Development for the Sutherland Institute, a Utah-based public policy research institute.

Permission to reprint this article in whole or in part is granted provided credit is given to the author and to the Sutherland Institute.

Disclaimer: Newby left the Sutherland Institute on January 28, 2003, and has conducted all his efforts since that time as a private citizen.  The Sutherland Institute has officially and publicly disavowed and distanced itself from Newby's political views, tone, and activities.  As a courtesy to the Sutherland Institute, we have posted their e-mail on the matter.


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