Austin State Hospital and Austin State Supported Living Center
Location Feasibility Study
June 30, 2016
Thank you for the opportunity to provide input regarding the Austin State Hospital (ASH) and Austin State Supported Living Center (AuSSLC) location feasibility study. TCDD is established by federal law and is governed by 27 board members, appointed by the Governor, 60% of whom are individuals with developmental disabilities or family members of individuals with disabilities. TCDD’s purpose in law is to encourage policy change so that people with disabilities have opportunities to be fully included in their communities and exercise control over their own lives.
Senate Bill (SB) 200 requires the Health and Human Services Commission (HHSC) to conduct a study to determine the feasibility, costs, and benefits of transferring operation of ASH from its current facilities to a new facility at a new location. Recognizing the need for action regarding state supported living centers (SSLCs), Rep. Workman requested the inclusion of AuSSLC in the study. The two facilities are located in nearby locations. AuSSLC in particular struggled with serious deficiencies, and the high cost of replacing the facility is documented in the Department of Aging and Disability Services’ (DADS) own reporting. While it is clear the infrastructure at our state facilities is crumbling, ASH provides services for which there is great need and no other source, while AuSSLC represents an outmoded and expensive way of serving individuals with intellectual and developmental disabilities — especially because community based services are available to provide higher quality services. While TCDD supports evidence informed ways to expand mental health service system capacity, the evidence shows declining demand for the SSLC system.
Different Services, Different Needs
Despite concerted investment in mental health by the Texas Legislature, availability simply has not kept pace with growing need. Nearly 400 people were on waiting lists for state hospitals as of April 1. ASH covers 30 counties, has 299 beds, and admits about 1600 people a year. The facility focuses on helping people return to the community following treatment, and provides peer support programs as well as other recovery-based initiatives. Renovation, relocation, and reconstruction of ASH may serve to provide more beds and better facilities to a system that desperately needs it.
By contrast, the demand for SSLC beds has continued to decrease. There is no need for increased capacity — indeed, the time, effort, and funding put into studying relocation options for AuSSLC would be better spent on promoting transitions to more independent and less restrictive living options for AuSSLC residents. The AuSSLC census has decreased from 361 in 2011 to 185 as of April 2016, or roughly 49%, and enrollment is projected to further decrease. The evidence does not support investment in the AuSSLC institutional capacity, particularly allocating state funds toward relocating and rebuilding an unneeded institution when there are still 78,034 people waiting to receive Home and Community-based Services (HCS). DADS’ own analysis indicates the cost of replacement is more than four times the total market value of the facility — nearly $104,000,000 for replacement, with total market value at just over $25,000,000.1 That’s nearly $79,000,000 to support less than 200 individuals that would be better spent elsewhere.
The needs of people admitted to AuSSLC and ASH are not necessarily the same. AuSSLC is a long-term residential facility, where residents often live for many years. This is not the case with ASH, where many admissions are forensic in nature and the average length of stay is 50 days.2 ASH is comprised of multiple locked and contained units and is designed to address the needs of people experiencing serious behavioral health crises; by contrast, AuSSLC is part of the broader Long-term Services and Supports (LTSS) system, which aims to support people in the activities of daily life in the least restrictive living environment of their choosing. The working culture on a locked ward is very different from the working culture in a residential environment. Co-location of the two facilities would require staff, who already fall below standards of care, to be cross-trained in different treatment modalities and ways of interacting with residents. Given that ASH and AuSSLC are both plagued by high turnover, it seems likely increasing staff workload and scope of care would only lead to more turnover.
Co-location and staffing shortages would be further complicated by DADS’ plan to offer SSLC services to people living in the community. This is a plan where people who have clearly chosen to receive community based services would spend their Medicaid acute and home and community based services waiver dollars coming to AuSSLC (or other SSLCs) to receive services that DADS and the Department of Justice (DOJ) report do not meet the agreed upon integrated standard of care. With recent directives by the Texas Legislature, evidenced-based downsizing and rebalancing recommendations, as well as critical (and growing) staffing challenges have been ignored in favor of prioritizing unwarranted institutional expansion. Efforts to expand SSLC services while also attempting to co-locate with a facility that serves a disparate population risks further eroding already questionable care.
SSLC Systems Change
Finally, replacing or relocating AuSSLC will not address some of its most pressing problems. Seven years into the DOJ settlement, the system still lacks substantial compliance with about 70% of the provisions. Barriers to compliance are not limited to the physical plant. It is not clear how the $79 million investment in construction of a new AuSSLC facility would give rise to an acceptable community living discharge process, fill perpetually empty behavior analyst positions, or reduce unnecessary restraints. Given these concerns and the substantial work necessary to meet agreed upon standards of care we believe it is unnecessary to divert attention and resources to options that would involve the renovation, relocation, or co-location of AuSSLC with ASH. HHSC, DADS, and DSHS must prioritize the treatment needs of the individuals served at ASH and the long-term support needs of residents at AuSSLC, and co-location or relocation does not meet this goal.
Thank you for the opportunity to provide input on behalf of the Texas Council for Developmental Disabilities.