In an era of budget cuts to state agencies, the number of Oklahomans in need of psychiatric crisis care services has surged and mental health providers say people are sicker than previous years.

From fiscal years 2015 to 2018, the number of Oklahomans who are need of crisis care centers across the state increased by 21 percent — from 8,049 people to 9,735, according to data provided by the Oklahoma Department of Mental Health and Substance Abuse Services.

Because resources are limited and service providers must treat the sickest people first, Oklahomans in need of mental health services are regularly turned away because they are not sick enough. As a result, people in need of services often don’t get care until they are in the midst of a crisis.

And providers say delaying mental health care has had another consequence: People coming into crisis centers seem sicker now than in previous years. The acuity levels are higher, and it takes patients longer to get better.

Mental health care providers consider the increase a manifestation of several issues, including a series of cuts to mental health services, higher drug use and stigma around mental illness.

“Definitely more people are showing up in crisis then ever before,” said Carrie Slatton-Hodges, deputy commissioner of treatment and recovery at ODMHSAS.

“We’ve seen that trend for the last few years continue to rise, and it has not stopped.”

Oklahoma is ranked among the highest in the nation for mental illnesses and substance use disorders, and an estimated 1-in-5 of Oklahomans has a mental illness, according to the U.S. Substance Abuse and Mental Health Services Administration.

Between fiscal years 2016 and 2017 ODMHSAS’ budget shrank by $23 million, which led to deep cuts to provider rates and therapy caps for mental health and addiction treatment services.

Cuts to psychotherapy services impacted more than 73,000 Oklahomans, according to data provided by ODMHSAS. The cuts also led to the loss of about $56 million in state billing and federal matching funds for community-based providers. At the same time, $5 million was cut from case management and other services.

To recover from years of cuts, the agency needs $28 million appropriated to its budget to recover, according to ODMHSAS.

About 10 years ago, the agency requested state funding for five additional crisis units with urgent cares attached. So far, ODMHSAS has been able to fund three. However, as funding has diminished from outpatient services, the demand for crisis care has grown. The state could now use three more facilities, Slatton-Hodges said.

“We’ve had major setbacks in our system over the last decade, but in particular the last five years or so,” she said.

“So opposed to being able to keep people in recovery or get them in recovery, they’re going into crisis and showing up at an acute level instead of just being able to maintain them at the community level.”

‘Last lifeline’

Thousands of Oklahomans in crisis walk through the doors of Family & Children’s Services CrisisCare Center each year. Last year, more than 4,300 people came to the facility.

“We get people who come through who are literally having the worst days of their lives and we’re their last lifeline,” said Chris Perry, associate chief program officer of the organization’s crisis services.

“You know, the work we do literally saves peoples’ lives every day.”

Perry has worked in mental health in Oklahoma for more than 20 years. He said the number of people seeking crisis services has steadily increased.

The facility is broken up into two sections: a psychiatric urgent care and a crisis stabilization unit. In the urgent care, patients are accepted regardless of whether they can pay. It is considered a monitoring unit.

Oklahoma law allows people to stay in one of the center’s 12 recliners for up to 23 hours and 59 minutes for monitoring before they must be released or transferred to a bed.

The chairs aim to help free up the limited number of psychiatric beds, which providers consider a precious resource. About 80 percent of people who are admitted to the facility’s urgent care are stabilized and do not go on to longer-term care, Perry said.

“So only about 20 percent have to move on, which is great because that’s a considerable amount of beds we’re saving for people that really need help,” he said.

The 24/7 crisis center houses a 16-bed crisis stabilization unit where patients, on average, stay for about six days. The goal is to help stabilize patients by providing monitoring, therapy and long-term treatment plans aimed to keep them from going back into crisis. The crisis center only accepts Medicaid.

Patients without pay sources are often transferred to the Tulsa Center for Behavioral Health, a 56-bed inpatient facility that is operated by the state. If that center is full, they may be transported to a bed in a different city.

There are 506 inpatient and crisis mental health beds in the Tulsa area, the vast majority of which are private, according to a recent report compiled by the Urban Institute. Of those beds, only 103 are available for public mental health clients. The report estimated based on its population, Tulsa should have about 490 public beds.

Perry said he believes the increase in Oklahomans seeking crisis care services is a sign of several underlying issues.

“There’s so many facets to it, you know, I think one of the easiest things to say is it’s a sign of society and how things continue to, and I hate to sound doom and gloom, the increased use of drugs, higher poverty rates, more violence, more abuse,” he said. “I think that all plays into it.”

At the same time, Oklahomans who have high acuity levels often don’t follow up with outpatient services, which can keep them out of crisis and is cheaper for the state.

“Because of their symptoms, they don’t keep schedules,” Perry said. “When they leave here and feel a little better they don’t feel like they need services. They won’t consistently take their medication.”

Perry said people in crisis who come into the facility often make quick turnarounds. He believes the stigma around mental health has affected when people seek mental health care and how it is funded.

“I just hate to tell people when they come through or give them the impression that everyone who comes through is violent, that everybody that comes through is really acute because that’s not the case,” he said. “Most people with severe mental illness are not that way.

“When you get to know individuals with severe mental illnesses and their stories, you have a real different outlook on it. That’s a challenge I think at the state level, getting funders to realize the prevalence that it can be your neighbor, it can be your family member.”

‘People are just waiting until they can’t anymore’

Joy Sloan is the CEO of Green Country Behavioral Health Services in Muskogee, which houses a 15-bed crisis center. She said over the last four or five years the center has typically been at capacity. At least half of those patients are from Tulsa County, where beds are often full and patients overflow into her facility.

Sloan, who has worked at the facility for about 27 years, has seen crisis care evolve over the decades, but one change sticks out to her: People seem sicker now.

“It’s weird,” she said. “The acuity level is so much more intense.”

Sloan’s facility ranks incoming patients on a four-point scale, with four being the highest level of acuity. Years ago, when a patient would come in and be placed as a one or two on that scale, staff would treat them. Years of state budget cuts have changed that. Sloan said can’t recall “how many people got turned away at the door because they weren’t sick enough.”

“Now we can only see levels three and four,” she said. “If you’re not that sick, we’ll say, ‘We’re sorry, get sicker and we’ll try to help you.’ It’s a ludicrous model. It makes people tougher to treat.”

By the time people finally enter Sloan’s facility, which receives the majority of its funding from ODMHSAS, they need intensive care.

“We are the safety net for the state,” Sloan said. “It would be ideal if funding were available so we could see people before they get sick.

“Our mental health system says, ‘No, let’s wait until you’re as sick as you can be.’ That’s backwards.”

And because people are sicker when they come in for treatment, it’s more difficult to keep them engaged in outpatient services, which can divert people from getting to the point of crisis.

“Every time they (patients) decompensate, they never get back to the level they were before,” Sloan said.

The organization recently launched a 24/7 Care As Needed (CAN) unit, which serves as a drop-in center for people with critical needs. Sloan said she’s working with local law enforcement in an effort to divert people with mental health and substance use issues from jail, and instead bring them there. The unit also aims to stabilize people and free up the facility’s crisis beds.

Sloan said the facility did not receive additional funds for the unit, but allocated funds from other areas.

ODMHSAS received an increase in state appropriations for fiscal year 2019, which included $5 million for Smart on Crime initiatives and $2 million toward restoring provider rates.

Slatton-Hodges said she hopes the additional funding will slow the growing rate of Oklahomans who need crisis care.

“I don’t see it being at a point where it will level out, yet,” she said. “But hopefully it will slow the growth somewhat.”

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