The State’s Safety Net

Wyoming State Hospital Provides Mental Health Services for The State

By Tom Lacock
Wyoming Medical Society

Rich Dunkley has had time to hang pictures on the wall of his new office but little else, less than three months after taking the job as the superintendent of the Wyoming State Hospital in Evanston.

Dunkley got his start in healthcare as a college student in Provo, acting as a CNA at Utah Valley Hospital. Since then he has run state facilities in Thermopolis, Buffalo and Basin. During his short time on the job in Evanston, one thing has taken him by surprise.

“I had no idea about the waiting lists and just the hard time the state has in getting evaluations done and getting people discharged to community settings,” Dunkley says. “I had no idea we had that type of demand on the Wyoming State Hospital from people of the state of Wyoming.”

The Wyoming State Hospital, by the numbers
The State Hospital was established in Evanston in 1886 and called the Wyoming State Asylum for the Insane, with the first building being completed in 1887. The campus has 150 acres and 36 buildings, and it hasn’t experienced much capital construction recently. Hospital administration maintains its offices in a building erected in 1918, and of the six buildings built on the State Hospital campus since 1999, one is a storage shed, another is a park shelter and a third is a small greenhouse.

There are around 90 patients at the hospital, which runs a biennial budget of $76,959,306 for its mission of also placing Title XXV clients in other more costly facilities when full. Taking care of this caseload is:

• A team of five psychiatrists

• Two advanced practice nurses who work in psychiatry

• Four forensic psychologists who perform mental health evaluations on Title VII patients

• Four more psychologists working on the adult psychiatric services side

• One medical doctor

• 20 case managers and more than 170 nursing staff.

Provider recruiting remains a challenge because of Evanston’s rural setting, though Dunkley says the state benefits do help. He admits there simply isn’t a large pool of psychiatrists and psychologists in Wyoming to recruit from. State Hospital business manager Paul Mullenax called a change that let Advanced Practice Nurses work at the hospitals “unbelievably great.” Another more recent change to compensate providers for being on-call has also helped.

Two types of clients come through the State Hospital’s front gate. One group is civil clients with mental illnesses so severe that community services in Wyoming can’t address the illnesses. These clients are sent to the State Hospital through the Title XXV process after being deemed a danger to themselves or others or unable to meet basic needs as a result of a mental illness.

The second set of clients are those sent to Evanston through the Title VII process. Charged with a crime, they have come to Evanston seeking either an evaluation on their mental capacity to stand trial, or they have been found not guilty by reason of mental illness of committing a crime. These patients stay in Evanston until a judge determines they are fit to transition out of the hospital, though some never leave. Mullenax noted one patient sent to Evanston after being found not guilty of a crime by reason of mental illness died about five years ago after arriving at the state hospital in the mid 1960’s.

“We are the safety net and the end stage, meaning we (the state of Wyoming) have exhausted our resources and they are being sent to the state hospital,” says Dunkley. “Operationally, we are within our budget with the exception of our Title XXV expenses (monies paid to other contracted hospitals), which is over budget and of which we use operational budget money to support.”

The Forensic Side of the Hospital
Forensic patients in the hospital are in a setting similar to a jail. They live in individual cells and spend their days going through therapy, exercising and reading in pods. Guards and hospital workers tend to the forensic unit without weapons and are trained in using submission holds which are used if patients become violent.

The Wyoming State Hospital also employs forensic psychologists whose job it is to evaluate clients and offer an opinion on whether the patient is fit to stand trial. The state hospital employs two evaluators and is in the process of trying to hire two more. Finding time to address a backlog of evaluations is difficult, and Dunkley admits the hospital routinely asks the state’s judges for an extension from the 30 days it receives to complete an outpatient evaluation.

“For an outpatient evaluation, it is running around 90 days from when we get an order until we are able to complete an evaluation,” Dunkley says. “The rule is we have 30 days and we are constantly asking for extensions just because if you are the judge, you call up and say you need this person, the evaluation completed, we say to you, ‘Okay, but that person is number 27 and we are not going to get to them for a while.’”

In March, Dunkley says the Wyoming State Hospital had around 30 on its outpatient waiting list for an evaluation. He says hospital staff can complete 30-35 outpatient evaluations in a year. The state hospital also performs inpatient evaluations, but also deals with a lack of beds. Patients generally must stay in jail, or a facility such as Wyoming Behavioral Institute or Cheyenne Regional’s Behavior Health Services – if space is available – until a bed opens at the State Hospital. This comes with a cost of $787 per night plus the cost of treatment and is paid for by the State.

Civil Adult Care
On the other side of campus is the 61,000-square foot Adult Care Facility, which was built in 2004. On the civil commitment (those sent to the hospital through the Title XXV process) side, the state hospital is battling increased numbers of patients and nowhere to put them. Mullenax touts the strong care at the state hospital, but in mid-March the waiting list for the facility was 21-deep. He says the average length of stay on the civil side is 130 days.

Dunkley says the hospital’s 24.5-percent readmission rate on the adult psychiatric services side is about average for state mental hospitals in the West. He adds that the hospital did a study a few years back that suggested 60 percent of civil placements done a year ago had a co-occurring diagnosis of substance abuse as well as mental illness.

“I don’t know that you can separate them, the mental illness or substance abuse. It is always a question for the physician (of) which comes first,” says Mullenax.

Task Force Could Lead to Some Relief in Evanston
For someone who has seen two other studies of the state hospital, its mission and its future with little change, Mullenax has a remarkably rosy outlook concerning the current Joint Legislative and Executive Task Force on Department of Health Facilities. The task force has a request to examine the missions and facilities at state-owned facilities in Lander, Thermopolis, Basin, Evanston and Buffalo and offer a road map for their respective futures.

“(When) I started here in 1994, they had just completed the facility study for this campus,” he says. “The recommendation out of that study was to (demolish) this whole campus and build south of us. Since then we have had two other facility studies that have, in essence, recommended the same thing. This study makes me hopeful. This has been a much more thorough and organized and supported study.”

Rep. Lloyd Larsen (R-Fremont County) leads the task force and says work was done both in addressing state law and in setting aside state funds in order to address building concerns in Evanston and Lander at the Wyoming Life Resource Center. Larsen says the task force recommends moving some of the geriatric psychiatric patients from the state hospital in Evanston to the Wyoming Life Resource Center into a Greenhouse model. A Level I and Level II study of the facilities in Evanston led to the task force recommending the razing of a majority of the older buildings at the state hospital, and new construction being added to the south end of the campus where the adult care facility currently exists. New wings would be added for both Title VII and TItle XXV patients. Areas for acute access would also be addressed.

“This task force has not let the grass grow,” Larsen says. “They have been very engaged over the last two years in identifying how these populations are served and the state’s role. I think we met 11 times last interim because we know we have pushed this off for about eight years now, and we need to make sure we aren’t just piddling around. These people are important to the state and we need to make sure we are addressing their needs.”

The construction in Evanston and Lander will cost in the neighborhood of $150-160 million and, if state investment income comes through as expected, Larsen said shovels could be in the ground in 2017 or 2018 at the latest. These buildings could also better address the needs of the population served in Evanston in a safer manner for staff and clients. In addition, Larsen says some of the current facilities would be built to address a concern of a fault line that goes through Southwest Wyoming near the State Hospital.

“There is hope, not dread,” says Dunkley. “The task force has really taken this project seriously and we are grateful for that. Our director has supported these facilities along with the task force. There are probably no individuals who are more involved than they are. Something good will come of their studies.”