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Mr. TULLIS. The Psychiatric Association is made up of about half of members in public service.

Mr. PREYER. Thank you.

Mr. ROGERS. Mr. Nelsen.

Mr. NELSEN. I noted in one part of your testimony you said the State would be supervising itself. Yet your final recommendation suggested a sort of survey.

Mr. TULLIS. This group would be independent of the operation of the program itself.

Mr. NELSEN. I see. Thank you.

Mr. ROGERS. Dr. Roy.

Mr. Roy. I have no questions. I thank you for your statement.
Mr. ROGERS. Mr. Hastings.

Mr. HASTINGS. You mentioned at one point you have given "only a couple of examples of such occurrences." Those irregularities you state I have not been familiar with them before. Would that indicate there has been a great number of them in Kentucky?

Mr. TULLIS. As I stated, most centers are operating, to our knowledge, in an acceptable manner. I think the concern we have is that there may be more of these than we know about unless there is an outside group looking at them.

Mr. HASTINGS. We should follow that up. Then, too, you feel the State of Kentucky is not able itself to institute the procedures necessary to find out what the irregularities are?

Mr. TULLIS. I think there is an unwillingness to do so for the reason no one likes a citizen group looking over his shoulder.

Mr. HASTINGS. Isn't that inconsistent with what we are doing? We try to develop it with Federal seed money and phaseout so it becomes a community function.

Mr. TULLIS. With groups operating from the State level, I think this could assure that the Federal and State money is well spent.

Mr. HASTINGS. They want the Federal Government to pay for it? Mr. TULLIS. I think it should be mandatory at this juncture but not always paid for by the Federal Government any more than the total program would be paid for by the Federal program.

Mr. HASTINGS. I am appalled that you have to admit to us the State is not capable of taking care of such irregularities. I would hope this committee would never have to impose its views on every State in the Union.

Mr. TULLIS. I didn't think there was any suggestion in here that the State could not handle these problems or that the Federal Government should take care of these problems. I am suggesting there be an outside evaluation in each State. I think your own expression, the rabbit watching the lettuce patch, is the matter of whether the people who are involved in the program itself are really able to properly evaluate what is being done.

Mr. HASTINGS. We have some down here knowing what the lettuce patch is about, too.

I gather, from your testimony, that you are advocating that we start returning to the utilization of mental hospitals?

Mr. TULLIS. No, I do not. I thought we made that clear in saying we thought this was a refreshing development. What I am suggesting is-and it was the opinion of the committee and is the opinion of the

association-that certain things have occurred which would indicate that the State hospital needs to be maintained and needs to be maintained on perhaps a broader basis than it now looks.

Mr. HASTINGS. The language on page 4:

We believe that the deemphasis of the mental hospital and the resulting decrease in hospital population has not been due to the efficiency of the community mental centers *

Mr. TULLIS. May I give you an example?

Mr. HASTINGS. Yes, but it is inconsistent with the testimony we have received from across the country.

Mr. TULLIS. I realize that and, as I say, we are concerned-as I say in the testimony, we believe this is the direction of how things should go. However, there should not be a deemphasis of the quality of the treatment or that there should be an actual letting of patients out of the hospital for the purpose of depopulating the hospitals.

An example of what I am talking about is, for instance, in the Louisville area central State hospital, at one time in the period of one month, 499 patients who were on convalescent leave that means they were out in the community-they were cut off from the hospital. They were, by a stroke of the pen, eliminated from the hospital.

We were told, when we objected to this, that these names had been turned over to the community health center and it was their obligation now to look after these people. I appeared at that board that night to ask them what they were going to do about those 499 patients. They said they knew nothing of those 499 patients, they had not agreed to take them, had not been asked to take them, and they had no names for these 499 people.

It was only upon the urging of the association that we were able to get the centers to the point that they found out who these people were and tried to locate them. We have been working on this with them for about a year now in order to try to locate these 499 people. Mr. HASTINGS. Does this indicate a rivalry between the community mental health centers and the mental hospitals?

Mr. TULLIS. I wouldn't say there was any rivalry.

Mr. HASTINGS. There doesn't appear to be much cooperation? Mr. TULLIS. I would say there is a great deal of cooperation since

Mr. HASTINGS. 499 patients released from the hospital to the community health centers and they didn't know about it

Mr. TULLIS. Yes, I would say something is lacking. For that reason, we are saying there should be an evaluation of what is happening. Mr. HASTINGS. Don't misunderstand; I am not passing any judgment on the State of Kentucky, but we have an overriding concern about the total community mental health program. I would frankly think throughout the country the experience, particularly of the suicide, taking 312 days to get help

Mr. TULLIS. This is not the whole program. What we are saying is: There is enough of these things so that we believe there should be outside evaluation from citizens' groups with proper professional advice. We are not opposing the direction of the community mental health

centers.

Mr. HASTINGS. I think you made that very clear.
Thank you, Mr. Chairman.

Mr. ROGERS. Let me just ask you: Have you requested an outside. evaluation from the Department of HEW!

Mr. TULLIS. Not from HEW.

Mr. ROGERS. It is permitted in the law that evaluation of programs may be conducted by contract, by grant, or any other payment on provision of the act up to 1 percent of the authority HEW has. I think, if the situation is as bad as you say, you could request that the Department have an outside group come in under contract. Perhaps you could get funding from HEW.

I am concerned that a State hospital would cut off people without making contact with the community mental health centers to see that they would be picked up. I don't think that is a criticism of the community mental health centers, but it is a criticism of the State hospitals that they would release people like that.

Mr. TULLIS. It is a criticism of the system itself.

Mr. ROGERS. How would the centers know unless they told them? Mr. TULLIS. The State hospital felt they had told them.

Mr. ROGERS. Did they have it in writing?

Mr. TULLIS. Not that anybody could find. We couldn't find the names for a while.

Mr. ROGERS. That is absurd.

Your testimony has been most helpful, and we are grateful to you for being here.

Our last witness is Dr. Dale H. Farabee, Commissioner of the Department of Mental Health, Frankfort, Ky. Dr. Farabee, we welcome you to the committee and will be pleased to receive your testimony. If it is agreeable with you, we will put your full statement in the record and, if you would highlight the points you think the committee needs to know, that would be helpful.

STATEMENT OF DR. DALE H. FARABEE, COMMISSIONER, KENTUCKY DEPARTMENT OF MENTAL HEALTH

Dr. FARABEE. I am Dr. Dale H. Farabee, Commissioner of the Department of Mental Health about which you have just heard, and I am prepared to discuss that.

The basic statement that I have here will be entered into the record with exhibits and two addendums for your perusal, if you will.

Mr. ROGERS. Yes; I think we will have the statement and addendums for the record and the report "Patterns of Progress 1971-72," by the Kentucky Department of Health for our committee file.

Dr. FARABEE. Would you look at these pictures, Mr. Chairman? These are simply to provide you with some visual information about the community mental health center programs.

Mr. ROGERS. Certainly.

Dr. FARABEE. I would like to enter into the record for the committee's consideration the record of the State and National Institute of Mental Health original examination of the Bowling Green and Barren River operation. I will provide a copy for you for your files.

Mr. ROGERS. I see we have a vote. We have 5 minutes before we have to go.

Dr. FARABEE. I would say very quickly that the primary points brought up in my statement that affect the relationship of the Ken

tucky program to the national program is that-in my opinion and on judgment from other persons around this country including NIMHthe Kentucky program is one of the better programs in this country with respect to the comprehensiveness and administrative integrity in the program and so forth.

I make no excuses for the difficulty and problems that have occurred in starting from scratch and developing a massive program in a very short period of time.

One of the primary problems encountered anywhere in the country, and particularly in Kentucky, is the development of sufficient adequate administrative personnel. Much information has previously been relayed on this matter to Congress toward the development of training programs with the universities for administrative personnel in this field-they are a breed in themselves-to run the complicated community mental health care centers.

Our program is comprehensive in that it is operated in all 15 regions set by the Kentucky government through the Kentucky program planning office, and it operates in 15 regions in terms of planning and development.

Consequently, in the community mental health program, we operate along with the health department, department of economic security, and others, in developing unified programs. We have an arrangement of exchange of moneys, interaccountability between both rehabilitation, department of economic security, under 4-A and 16, and such other programs as title I of ESA. The centers are duplicating on a regional level the cooperative interdepartmental programs of the State departments. The centers are operated in fact by regional boards of private citizens who constitute their own local review and evaluation boards, who are not coerced on the board by any means, and who are acting in a partnership with the State, with the Federal Government and with local governments to carry out a program involving the community and looking for the development of all possible programs.

The main emphasis is on catalytic action for the development of additional programs where they do not exist; but, as the previous gentleman testified with respect to the development of affiliation agreements, the primary emphasis has been on the development of affiliation agreements to get private programs that were already in existence to affiliate and involve themselves as part of the overall program.

Consequently, the money situation has been one which Kentucky has fortunately worked through over the past 7 years. Two of our centers are in their seventh year and seven more are in their next-tolast year. We feel that the present circumstances are such-with the multiple sources of financing established over the years that the centers will be able to operate to a great degree without additional Federal funding, if that is the final decision.

However, we feel it would have been impossible for the centers to have been established without the initial staffing grants. Like any man running a grocery store, it costs as much money to operate a store for one customer as for a hundred. If you don't have the basic starting costs and your operating and administrative costs, you can't produce the volume that will cut your costs.

Mr. ROGERS. You are saying: For the establishment of a community mental health program, they do need start-up money?

Dr. FARABEE. Yes, because the amortization of initial start-up costs is necessary, and to recruit professionals.

I would like to show you this "Pattern for Change." This was a pattern adopted by the Kentucky commission which was funded by the 1963 Congress, and this has been the operational guidelines under which the Department of Mental Health has set the program. We are following it to a "T."

[Testimony resumes on p. 108.]

[Dr. Farabee's prepared statement and attachments follow:]

STATEMENT DR. DALE H. FARABEE, COMMISSIONER, KENTUCKY DEPARTMENT OF MENTAL HEALTH

The Kentucky Department of Mental Health has endeavored over the past few years to implement a systematized comprehensive program to alleviate multiple mental health problems in the Commonwealth, specifically in the areas of diagnosis, treatment and rehabilitation of mental illness, mental retardation, alcohol and drug abuse and addiction and to abet preventive services through education. The word "system" pinpoints the essential ingredient in this program, for it is a coordinated, integrated method of delivery of services rather than a package of disjointed, unrelated programs and facilities. The system connects and utilizes an extensive array of state, private and quasi-public agencies, including 64 state and local hospitals; 139 day care training units for the retarded; 26 adult activity centers; 16 sheltered workshops (in cooperation with the Bureau of Vocational Rehabilitation, Department of Education), and numerous other private physicians and caregivers. The program is generating much of its own financial and professional staff support and is flexible enough to respond to changes in the years to come. Through such a system of affiliated organizations, Kentucky has become the first state in the nation to achieve a realistic continum of care between inhospital services and community programs throughout its geographic

area.

The recommendations of the Kentucky Mental Health Planning Commission, whose report, Pattern for Change, was accepted by the Commonwealth in 1966, have provided direction and authority for the Department in the development of the program through the past three state administrations. Re-evaluation and study of mental health services by that Commission only seven years ago, charted the new directions of progress for the Commonwealth.

The Department of Mental Health utilizes as its primary philosophy the following excerpt from Pattern for Change:

I quote:

"To realize the full potential of our mental health and mental retardation services, which a proper organization can bring, we must establish a new pattern of developing services, a pattern of strong community involvement and support. It has become clear that the treatment of the mentally disturbed can be shorter and more effective if carried on close to the home base of the patient. The local community is the natural setting and population base for coordinated programming-for the prevention of mental illness and mental retardation, for the promotion of mental health, and, to an increasing extent in the future, for the treatment of most persons with mental health problems. Therefore, to meet the challenge confronting us in providing for the mental health needs of Kentucky, the direction we must move in is abundantly clear. It is towards meeting these needs in the community. It is a continuation of the direction in which we have already begun to move, leaving behind traditional concepts of custodial isolation and embracing new potentialities of prevention, treatment and rehabilitation through community-based services."

Gentlemen, these words were written in 1966. Are they any less true today? It was in response to this clear charge that the Department of Mental Health set forth to develop the "circle of services" which is the fundamental strength of the program as it is now existent.

In keeping with the Kentucky Program Development Office decision to initiate 15 regional planning areas encompassing the 120 Kentucky counties, the Department of Mental Health implemented Pattern for Change by developing in each region (as permitted under Kentucky statutes) a regional mental health-mental retardation board composed of citizens willing to function as the operators of

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