Budget cuts, caseloads cause problems for mental health providers
Some people who need help are having more trouble getting it when it comes to mental health — and a series of setbacks for the Spartanburg Area Mental Health Center has left counselors with billowing caseloads.
A drastically cut budget paired with an influx in people seeking help has pushed the mental health center to find ways to provide adequate services for clients, while other agencies are stepping in to fill the gaps.
Most counselors at the Spartanburg Area Mental Health Center are taking on 100 to 150 clients suffering from mental health issues — almost double the state’s suggested limit for appropriate caseloads.
Records obtained through a Freedom of Information Act request show that the mental health center accepted 2,348 new clients in fiscal 2014, an amount that’s nearly tripled from previous years, officials say. Meanwhile, the staff size in recent years has been considerably reduced.
The mental health center is a division of the S.C. Department of Mental Health that serves Spartanburg, Cherokee and Union counties.
Assistant Director Elizabeth Boaze said the division’s operating budget from the state was reduced by nearly 40 percent around 2007 after the agency had already gone into a deficit when a new facility was built in 2001 off Dewey Street in Spartanburg. In addition, health care coverage changes had made Medicaid a smaller revenue source for the agency, Boaze said.
Positions went unfilled to cut expenses, resulting in a smaller staff of clinical, medical and support personnel to handle caseloads, she said.
The budget has since allowed for the filling of vacant positions and even the creation of some new positions, but salary offerings are not appealing to those seeking employment in the field, she said. Records show there are 21 current openings for nurses, counselors and specialists.
A nurse practitioner III is offered $47,000 and senior psychiatrist are offered $133,304 to $154,354. Salaries start at $30,582 for human service specialists and $37,213 for human service coordinators.
“Our master counselors with experience are a lot more difficult to find than finding someone to work the counter at McDonald’s.”
“Our master counselors with experience are a lot more difficult to find than finding someone to work the counter at McDonald’s,” she said. “There’s just not a lot of people out there.”
In the interim, Boaze explained that the mental health center is finding stop-gaps to fill patient needs.
Last week, the agency installed equipment to have on-call doctors from Charleston video conference patients to diagnose them and respond to their questions and concerns remotely. The video conference-style appointment for mental and medical patients has become more common practice industry-wide, she said.
“It’s harder to find qualified applicants, and we have higher caseloads than we would like,” Boaze said. “We’re trying to do something about it, but it’s not an easy fix.”
The mental health center has four full-time doctors and eight contractual doctors who work less than 30 hours per week, records show.
Out of the 5,176 cases handled in fiscal 2014, the conditions of clients served range from anxiety and depression to a variety of schizoaffective disorders. Those who may be suicidal or homicidal are prioritized when scheduling appointments, while those exhibiting more mild symptoms wait longer to see a counselor or physician, Boaze said.
Persons with a greater risk of suicide may be seen once or twice per week, she said. Those who are stabilized and taking medication may be seen once every three months or longer.
“We ask ourselves who can we see today and who can wait for an appointment.”
“We ask ourselves who can we see today and who can wait for an appointment,” she said.
Boaze also said when she came to the mental health center decades ago, the agency opened its doors to nearly everyone with a mental health concern. The parameters were later tightened to accept only those who were schizophrenic and suicidal, and now the criteria has re-broadened to include those with depressive and anxiety disorders.
Caseload totals vary from program to program across the state. Mental health centers are not required to have a caseload limit, though statewide goals include striving for a maximum caseload of 80 adult outpatient clients per clinician, said Tracy LaPointe, the S.C. Department of Mental Health’s public information director.
On Monday, a panel of experts talked about the challenges the mental health community is dealing with to help those who need services. The experts said soaring medication costs, a dearth of providers and climbing need are the leading causes of an unhealthy merry-go-round that has those in need of mental health and substance abuse counseling cycling between the Spartanburg County jail and area emergency rooms.
The panel discussion was part of an ongoing series hosted by the Spartanburg Village Network.
During the discussion, Heather Witt, the senior director of community investment with the United Way of the Piedmont, said about 72,000 people in Spartanburg County are in need of behavioral health services, but only one out of six people in need have access to services.
Boaze estimated that about 200 of the 750-inmate average population at the Spartanburg County jail could need mental health services.
Community health partners and nonprofits are scrambling to fill the void left by massive state budget cuts at the Department of Mental Health, and the shuttering of the PACE Center, which served 400 to 500 mental health patients annually, and the Raymond C. Eubanks Detoxification Center.
United Way of the Piedmont brought together a 22-member taskforce working to address this problem in Spartanburg. They began their work about 18 months ago, and the first step was a community needs assessment.
“We noticed it from the perspective of a funder when the PACE Center closed. When that center closed, those people had nowhere to go. At that time, the Department of Mental Health was only seeing people in crisis,” Witt said.
Boaze and Witt both said the county is playing catch up since the state restored some of the funding back to the Department of Mental Health.
“We never got out of debt,” Boaze said. “We’ve been trying to work our way out of a deficit.”
The correlation between mental health and substance abuse has led the Spartanburg Alcohol and Drug Abuse Commission to step into the gap of mental health services.
In the next few weeks, SADAC will begin offering one-on-one counseling services to people with substance abuse issues and those who are at risk of developing a problem. In the past, the agency’s commitment to walk-in assessments left it hamstringed to provide individual treatment.
“It really left their hands tied,” said Sue O’Brien, who took over as SADAC’s executive director in March.
To fix that, SADAC is set to hire four new clinical employees who will handle walk-in assessments and case management for clients. This will allow therapists the time to provide individual treatment.
Since she arrived, O’Brien estimated about eight people each week were being turned away for individual counseling on a range of issues related to their substance abuse problems — including grief, depression and anxiety. In most cases, those clients were referred to private providers or the Department of Mental Health.
“That just didn’t make any sense because we have the therapists, and they have those therapeutic relationships,” she said.
Additionally, many of SADAC’s clients find it difficult or impossible to get services through the overburdened Department of Mental Health, which has had to direct substantial resources to the treatment of the persistently and severely mentally ill.
“The type of clients who are really underserved are not those with persistent, severe mental illnesses, it’s those with depression, anxiety, etc.,” O’Brien said.
In August, O’Brien received County Council’s permission to hire four new clinical employees who will be dedicated to walk-in assessment and case management for SADAC’s clients. The approval was immediately followed by an edict from the S.C. Department of Alcohol and Other Drug Abuse Services permitting the mental health treatment of patients who do not have substance abuse problems, but are at risk of developing them. Those risk factors can include legal or school trouble, family relations with substance abuse problems, and other factors.
“Just about anyone could meet one of those,” O’Brien said.
Bob Toomey, director of the state’s Department of Alcohol and Other Drug Abuse Services, said the move is part of a broader strategy to enable complete care of families that provide the building blocks of a healthy community. Spartanburg County is leading the way on the initiative, and implementation of the Alcohol and Other Drug Abuse Services department’s family treatment goals were aided by the countywide Community Needs Assessment.
“That’s exactly the right way to do it, expand quality and then expand access,” Toomey said. “I think Spartanburg is really stepping up.”
Substance abuse does not exist in a vacuum, so there has been a relationship between the Department of Alcohol and Other Drug Abuse Services and mental health service providers for decades, Toomey said. Many patients have co-occurring disorders, dual diagnoses, or engage in self-medication.
“These services are part of a larger fabric of community support, weaving themselves together in a way that leads to a resolution and not just a silo,” Toomey said.