Sweeping mental-health improvement plan coming to Iowa Statehouse

Iowa leaders are poised to propose an ambitious plan to strengthen mental-health services throughout the state.

The plan includes six new “access centers,” which would offer short-term help for Iowans who are having mental crises but who are not ill enough to need a bed in crowded psychiatric hospital units.

The plan also would more than double the number of "assertive community treatment" teams. Iowa now has 10 such programs, which closely monitor people with chronic mental illness and encourage the patients to stay on their treatment plans so they don’t spiral into crises.

The state proposal also would launch a single, 24-hour “crisis line,” which Iowans could call to talk to an expert about mental-health issues and to obtain referrals for treatment.

Critics have long complained that Iowa’s mental-health system is disorganized, under-financed and woefully short of psychiatrists, therapists and other professionals. Jerry Foxhoven, director of Iowa’s Department of Human Services, said the new plan can’t immediately fix all the problems, but he called it “an incredible step forward.”

Foxhoven outlined the plan Thursday afternoon during a Des Moines meeting of county supervisors from throughout the state. Foxhoven said the details would be included in a legislative bill that should be unveiled within the next week or so.

Foxhoven told several dozen county supervisors that Gov. Kim Reynolds enthusiastically supports the plan, which is based on a December report from an advisory panel that looked at Iowa’s mental-health system.

Foxhoven said Reynolds sees the 18-page report as “a roadmap for where we need to go.” He said he asked her which of its recommendations she wanted him to implement. “She said, ‘I want to implement the recommendations of this report. I don’t us want to piecemeal this. I want to move it forward and do what they recommend.’”

Iowa’s mental-health system is mainly financed by county property taxes and state and federal Medicaid money. In 2014, Iowa launched a regional mental-health system, in which the state’s 99 counties formed 14 regional agencies to coordinate much of the property-tax spending.

Foxhoven told supervisors Thursday that the new proposal would add to the services those regional agencies are required to provide. Much of the start-up money would have to come from the regions’ budgets, he said, but he promised many of the services would qualify for substantial state and federal money from the Medicaid program.

“We’ve already got that roadmap,” he said. “…The next thing we need to do is start the trip and to move forward. And we will do that, but we need to gas up the car.”

Foxhoven said the plan would not require much initial money from the state budget, which is already stretched. But he said the new services would be financed by the Medicaid program once they’re launched. He vowed the state would require such payments from the private companies now managing Iowa's Medicaid program.

Reynolds' spokeswoman, Brenna Smith, confirmed Friday afternoon that the governor supports the ideas in the pending proposal. "Gov. Reynolds clearly stated during her Condition of the State address last month the need for additional mental health reform this legislative session, and has been working with legislators to address her concerns," Smith wrote in an email to the Register. "The governor believes no parent, child, friend or neighbor should suffer in silence when it comes to mental health, and will continue to push for these needed reforms until this bill lands on her desk for a signature."

A recent Des Moines Register/Mediacom Iowa Poll found that 64 percent of Iowans are dissatisfied with how state leaders have handled the mental-health system.

Much of the critics’ attention has focused on the chronic shortage of open psychiatric hospital beds. But Foxhoven reiterated his contention that the main problem is a shortage of less-intensive treatment options. Many of the state’s psychiatric hospital beds are filled with people who could be treated in other programs if they were available, he said.

Peggy Huppert, executive director of the Iowa chapter of the National Alliance on Mental Illness, agrees with Foxhoven on that point. Huppert served on the 22-person committee that wrote the report on which the reform legislation will be based.

Huppert likens Iowa’s mental-health system to a plumbing system plagued with clogs. “We have people stuck in hospital beds, people stuck in emergency rooms with nowhere to go – and people who don’t get any treatment at all,” she said in an interview Friday.

Huppert said the six new “access centers” would offer a key way to ease some of those clogs. Each center would have about 15 beds. The centers might not have psychiatrists, but they would have medical professionals, such as nurse practitioners, with authority to prescribe medication.

Huppert said the new centers need to be spread around Iowa. “We wanted to have them so no Iowans would be more than 90 minutes from one,” she said.

The new plan would also designate “intensive residential service homes,” which would serve a total of up to 120 people who require 24-hour supervision because of serious mental illness.

Huppert expressed confidence that the state Medicaid program would pay for new services, as Foxhoven promised. She noted that Foxhoven's department recently approved rules allowing Medicaid payment for crisis centers. Although that process took longer than it should have, and was too late to save a successful crisis program in Centerville, the new rules should pave the way for some of the services spelled out in the new proposal, Huppert said.

Marion County Sheriff Jason Sandholdt also served on the committee that wrote the December report. Sheriffs’ departments routinely handle Iowans going through mental crises. Deputies bring people to emergency rooms for treatment, and often have to transport them hundreds of miles when nearby psychiatric hospitals are full.

Sandholdt said Friday that he’s enthusiastic about the new proposal. “I hope we won’t be sitting with a person in the local ER for two or three days while we try to find them an open bed,” he said. The routine strains sheriffs’ departments, he said, “and not only that – it’s terrible patient care.”

Sandholdt’s county no longer has an inpatient psychiatric unit, since the Oskaloosa hospital closed its unit last year. It was the eighth such closure in Iowa in a decade.

Sandholdt's deputies often have to drive mental-health patients as far away as Sioux City or Cherokee, which are more than 200 miles from Marion County.

The sheriff said there will be challenges in implementing the proposed reforms – including attracting mental-health professionals to the new programs. But he said the changes should save money overall, if officials from various parts of society work together.

Leaders of all stripes appear to recognize that, he said. “Instead of all of us complaining in our little silos, we’re seeing we can come together and do something about this,” he said. “It’s my opinion that in the past, we focused on fixing little pieces of the puzzle, but not the whole puzzle.”

Some county supervisors who heard Foxhoven's presentation Thursday expressed some skepticism.

Dawn Smith, a Cedar County supervisor, said her eastern Iowa mental-health region already struggles to find enough qualified employees for the programs it's trying to run. She's unsure how new programs would find staff.

She also said the regional authorities won't want to start new programs only to see them fold for lack of steady money from the state. "I think it's a gamble on our part," Smith said.

Bill Peterson, executive director of the Iowa State Association of Counties, said no one disputes that Iowa's mental-health system needs improvement. But he said many county supervisors will be skeptical of state promises of future support for new programs. "I think we've been down this road several times before," he said.

For example, he noted the state's longtime cap on property tax levies for mental health, and the concerns the Legislature won't live up to promises that it will "backfill" other property taxes that local government lost due to a 2013 state-ordered tax cut.

Huppert noted the increased public conversation and concern about mental health over the past few years. Families have been talking more openly about their struggles with the system, and politicians have been listening, she said.

When she was appointed last year to the committee considering the issue, she didn’t fear their recommendations would be put on a shelf. “I had a feeling this was going to have wings,” she said Friday.