Changes Coming to Wyoming’s Title 25 Process

By Kerry Drake
For The Wyoming Medical Society

The number of people experiencing a mental health crisis who are a danger to themselves or others has been skyrocketing every year in Wyoming. So has the cost of involuntarily hospitalizing these patients.

State lawmakers and mental health care officials combined their efforts in 2015 to find ways to reduce the problems in Title 25, the system that determines what mental health services the state will use to treat these high-risk individuals. Currently the law gives judges only two options: commit them involuntarily to the State Hospital in Evanston or let them go.

While they say more work needs to be done about the issue of payment reform, legislators believe changes approved during the recent legislative budget session could significantly lower costs.

But some psychiatrists in the state are worried that lawmakers may have created a system that puts non-medical professionals in charge of the treatment of severely mentally ill patients.

Wyoming is following a national trend — it is experiencing a sharp rise in the number of severely mentally ill people who must be involuntarily hospitalized. From Fiscal Years 2012-15, this population increased from 208 to 341, an increase of about 65 percent. Meanwhile, the state is projected to spend about $13 million more than it has budgeted for Title 25 in FY 2015-16.

The passage of Senate File 58, sponsored by the Legislature’s Joint Labor, Health and Social Services Committee, provides the courts with another alternative. Patients who are examined and determined to not need high-cost, high-maintenance hospitalization will be directed by the courts to obtain outpatient care at community mental health and substance abuse centers.

To understand the fiscal reason behind adding the option, compare the $4.4 million per biennium budgeted for the State Hospital to operate Title 25 and the $100 million in two-year funding available for community-based mental health treatment throughout the state.

The number of patients ordered by courts to be committed to the State Hospital every year far exceeds the 75 beds the facility has designated for the program. The average stay of a Title 25 patient at the hospital is 126 days, but judges may order hospitalization for up to two years, which greatly reduces the availability of beds and leads to long waiting lists for patients.

“Basically there’s no room at the inn,” said Stefan Johansson, administrator of the Wyoming Department of Health’s Unit for Policy, Research, and Evaluation.

The State Hospital’s overflow is now sent to hospitals throughout the state and facilities like the Wyoming Behavioral Institute in Casper, where mental health care is much more expensive. The funding shortfall has been intensified by the fiscal problems of Wyoming state government, which is struggling to make up revenues lost due to lower prices and production of oil, natural gas and coal.

In 2015 the Legislative Management Council directed a subcommittee to study the issue and make recommendations to the Joint Labor panel. The result was SF 58, which added the directed outpatient option and created a “gatekeeper,” a single entity that is responsible for determining what is the appropriate treatment for at-risk patients in their respective counties.

Karl Cline runs Peak Wellness Center in southeast Wyoming and said his group will likely apply to the county commission to become the gatekeeper in Laramie County. His concern is that the Title 25 bill as it stands is unfunded. An organization such as this will have to provide the service without any extra compensation. He adds that no one will override the provider in this setting, but does point out the gatekeeper can suggest other options and do so in front of a judge, if necessary.

“The gatekeeper is intended to be a voice of reason and a voice of advocacy for that client who is being held or potentially held against their will to go to the State Hospital or another hospital,” Cline said. “The intention is to divert that person if they can be diverted from the State Hospital system.”

While judges are responsible for signing the court order that states whether involuntary hospitalization or outpatient care is needed in each case, the gatekeeper in each county recommends a course of treatment to the court. The gatekeeper also keeps everyone in the Title 25 process — including courts and county attorneys — in the loop regarding how the patient is doing in treatment and provides updates at least every six months.

“There are two processes going on,” explained Republican Rep. Eric Barlow of Gillette. “There’s a legal process and a health care outcome that we’re looking for. We’re hoping to reduce the state’s costs because we will be diverting people away from the high cost of hospitalization into community care.

“The position could also be called a case manager or court liaison,” Barlow added. “But ‘gatekeeper’ was the phrase everyone kept using to describe the concept.”

But some mental health professionals are concerned that SF 58 is vague about the role of gatekeepers. Dr. Jason Collison of Cheyenne, president-elect of the Wyoming Association of Psychiatric Physicians, said the difference between “treatment centers” and “treatment providers” is not clearly defined by the new law. He pondered if it’s possible they could be defined as a jail.

“Are we using mental health patients as guinea pigs? What if a treatment center can be a non-locked, unregulated facility where someone has the potential to harm themselves?” Collison asked. “That would be very scary. These are life-and-death situations, and Wyoming has the highest rate of suicide in the nation.”

The psychiatrist said patients involuntarily committed have always been treated at hospitals. “Are non-physicians going to be treating people? If we’re experimenting with treatment that turns out to be lesser care, you would expect some negative outcomes.”

Johansson said the Department of Health, consulting with county commissioners, will decide what agencies, hospitals or others are qualified to be gatekeepers. The department is currently promulgating rules for the new gatekeeper system.

For the first 72 hours a person in a mental health crisis is detained, evaluated and treated, the county gets the bill. After that period, the state takes over.

Johansson said the Title 25 subcommittee recommended payment reform to the Joint Labor Committee but there wasn’t enough time to properly consider it. The group will continue to meet this year to examine how to provide funding incentives to community facilities dealing with “system shock” as reforms created by SF 58 are implemented.

“It’s the connection between the continuum of care,” he said. “We have the State Hospital and we have community resources, and they’re not communicating with each other. We’re trying to encourage that connection.”

Johansson noted that payment reform will involve targeting a lower-income, higher-need population than currently receives services at community-based treatment centers.

“In addition to increasing base payments to centers for keeping the doors open and providing access for patients, we want to carve out a significant amount of money to be geared toward rewarding providers for social services support and outcomes,” he said.

“If you keep a patient from being hospitalized that month, you would get a monthly reward payment,” Johansson explained. “If you are able to provide housing that is not available [from federal programs], or you help patients obtain employment, you would get monthly reward payments.”

But Collison said improving the lives of patients is part of the job and the responsibility of care providers, not something extra.

Johansson said the gatekeeping portion of Title 25 reforms will be tested before being implemented statewide.

“Very soon we will most likely try to pilot this gatekeeper concept in one or more counties,” he related. “We’ll designate a gatekeeper and see if this function has an impact on the volume [of involuntary commitments] and the high costs we’re seeing.”