What makes Sammy run?

Huge and helpless, schizophrenic and hypertensive, Sammy Allen has fallen between the administrative cracks of a local mental health system that can't seem to get its ACT together

Hospitality House, a 65-bed licensed nursing and residential care facility located in Mount Pleasant, about 135 miles east of Dallas, is one such place. When contacted, Kristi Graves, a social worker at the facility, said that Hospitality House is now, for the most part, focused on rehabilitating people to reenter mainstream society rather than providing a place for a person to live out his life while being cared for. Graves added that Dallas County MHMR has to refer an individual to Hospitality House and must pick up a significant portion of the bill, which she estimated to be about $200 a day.

Allen has been under court-ordered outpatient treatment countless times, but the tool to enforce compliance is the threat of being sent to a state hospital--in reality more of an economic problem for the state than a disincentive to someone such as Allen. According to a 1996 report by the Performance Review Division of the state Comptroller's office, which analyzes cost-cutting measures in government agencies, the average daily cost to provide what is loosely called "supported housing" (housing in the community with an attending case manager) for a Texas consumer is $22, compared to $185 a day at a state hospital.

The report goes on to state that the mentally ill "historically have been served in state institutions. Such views, however, have changed significantly in the last several decades. Services that integrate consumers into their communities have proven to be not only effective, but also cost-efficient."

Of Allen's 46 stays in state mental hospitals since 1971, most were for only two to three months. Some lasted only two weeks. Consumers like Allen now spend most of their time living in low-cost motels, in boarding homes, in shelters, and in apartment complexes, where case managers visit periodically to check up on the consumer's status.

According to Sharon Killen, systems manager for DMHMR Adult Mental Health, people are discharged into Dallas County from state hospitals approximately 1,000 times a year; DMHMR's Liaison Services coordinates the outpatient care for these persons. From September 1, 1996, through March 31, 1997, the time period for which the most recent data is available, DMHMR served 12,009 consumers on an outpatient basis. Of that number, 1,367 received intensive case management, meaning that rather than the consumer just coming into a local clinic for medication, a case manager regularly monitored the person in the community.

"Every day I get asked or get a phone call saying, 'Hey, can you provide services for this consumer?' And I have to say, 'I'm sorry, I can't, I don't have the manpower,'" says Jesse Valdez, coordinator of DMHMR's ACT team.

In essence, ACT teams serve as mental health clinics on wheels, offering intensive outpatient services to what DMHMR terms "level III consumers": people who haven't cooperated in taking their medication; people who have moved through the mental health system's revolving doors (psychiatric emergency rooms, psychiatric intensive care units, jails, state hospitals, shelters, and boarding homes); people like Sammy Allen.

Originally conceived in Wisconsin in the late 1960s, ACT teams were developed as a way to monitor patients discharged from psychiatric hospitals, intervening before a patient got to the point where he or she had to be readmitted. The local ACT team has been a part of Dallas County MHMR since 1994, but wasn't officially mandated by Texas MHMR until 1995. Its purpose is to deal with people who weren't being helped by standard case management. The team consists of a registered nurse, a master clinician, five case managers, two community integration specialists (all full-time), and a half-time psychiatrist.

The clinician performs some counseling, initiates commitment procedures for consumers, and develops treatment plans. The case managers work in the field to develop close relationships with consumers and provide one-stop mental health care: crisis intervention, support with medication, and assistance with housing, basically seeing to it that the consumers are functioning well. The community integration specialists perform the more hands-on tasks, such as teaching consumers to prepare meals or do laundry.

The ACT team's goal is to provide an average of two hours per week to each of the 60 consumers on its rolls. Tony DeFreece, an ACT case manager and "point man" for Sammy Allen, had a caseload of 12 consumers: three in boarding homes, two in jail, one on the streets, and one about to be evicted from his apartment; the other five live with family or in apartments. (DeFreece has since left ACT.)

"We're about the only other option there is," notes ACT psychiatrist Logan. "If we can't do it with Sammy, there's nothing in Dallas County that can."

On March 20 of this year, after a more-than-40-day stay at Terrell State Hospital, Allen was released on a 30-day furlough to ACT. Later that same day, he sits on a couch at the DMHMR Westmoreland clinic, surrounded by several white garbage bags filled with his possessions, a wheelchair by his side. His body odor is overpowering. He rants, loudly and steadily.

Logan meets briefly with Allen, explaining his medications. He mentions that Allen will have to come by the clinic for Haldol injections every two weeks. Sammy says he'll walk away right now if a needle comes near him. Logan hands him a brown paper bag containing four pill bottles, one each of Klonopin (anti-anxiety), Cogentin (to prevent side effects from the Haldol), Procardia (for high blood pressure), and Dyazide (a diuretic).

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