Sustaining a public mental health clinic

I operate 3 public mental health clinics, 3 school mental health programs, and 1 prevention program on Maryland’s rural Eastern Shore. I was raised here and I love being here. The good news is that I get to do what I love in a place I love every day of the week; the bad news is that it is nearly 7 days and nights a week. (It’s a good thing I love it.)

In our clinics we have seen thousands of clients and we have done some very good work in multiple counties. We have sites on Talbot, Wicomico, and Somerset Counties. Several years ago we moved into Talbot and Somerset counties when other clinics closed down. (What were we thinking?) Managing sites in 3 counties is a major challenge, but I have excellent managers. Problems such as an “us and them” mentality crop up and we have to work against that. Communication can be tricky and sometimes difficult among sites. On the other hand, we have economy of scale for benefits for employees and other goods and services. Psychological testing is located in one site, but can be offered in other sites, as well. Consequently, we have contracts that cover many counties on the Shore.

Being in a rural area and serving an economically disadvantaged population, client transportation to services has been a major hurdle. We have had several used vehicles that sites have shared so that children can be picked up for services. This is a necessary, but not reimbursed service. We bought our first new van after 10 years of providing services. Employees also transport children in their private cars, which means that we have had to have policies and insurance for employee use of vehicles. In ten years we have had one van break down with children in it. It was because employees “forgot” to put oil and water in it and killed the engine, so we needed a system and policy for that.

In the present day environment, mental health has to be run as a business. It has been a paradigm shift for those of us who have believed that we are here to help others whether we get paid or not. So, we have had to learn and to teach others how to balance clinical with fiscal responsibility. It has been a shift for me as well. My first mission statement read, “the highest quality services for everyone regardless of their ability to pay.” Now, employees have minimum productivity requirements. They must see 25 clients per week for a full time position. Additionally, I must make payroll regardless of whether the state pays me on time or not. Managers must ensure that expenses do not exceed income. This has been difficult especially since we have grown from 5 to 80 employees in 10 years and we were under capitalized.

Therapists and PRP (Psychiatric Rehabilitation Program) workers must have excellent paperwork skills. Public mental health paperwork is massive and very specific. Some people have not been able to keep up with the paperwork and have had to undergo disciplinary action. Some have not been able to meet the paperwork standards even after supervision and training and we have had to dismiss them. (Now there’s a joyful time for all.)

We maintain the highest quality of clinical services through supervision, clinical meetings, training, and grand rounds. Employees can use paid time off to attend training and we offer free training on site. I have tried to maintain that the most complex cases require the most intensive and complex interventions, but this has been a difficult concept for some to understand, as well. We serve a forensic population and the therapy for them is different than for those with no forensic issues. Working with Court ordered clients requires training and a paradigm shift. It is not for everyone. Some have tried it and found they are not suited to it.

We have maintained our business through multiple streams of funding, such as fee for services, contracts, consultation, and grants of all kinds. It has been our survival and our vitality. We have a contract with the department of Juvenile Services for psychological testing and contracts with State and Federal Parole and Probation. Healthy Families is our prevention program and it is funded through a grant. We will be expanding our grant funding for research in the future.

Some examples of situations a public mental health clinic faces may make the picture clearer. Several years ago I had a phone call on the emergency pager from a desperate father of three. His wife was severely mentally ill. He had no health insurance. He made $10 an hour, too much for his wife to qualify for medical assistance. He could not afford medical appointments for his wife or medication. She could not take care of her three children. I stayed on the phone with him to help him figure out some options that might work and told him to call back if they didn’t work. He didn’t call back, so I am hoping something worked. These are the types of dilemmas we face in public mental health.

Funding has been cut back severely for public mental health in these tough economic times. Clinic directors were told recently to prepare for another $23 million in cuts, which turned out to be $11 million in cuts. Still a lot of money, and we tightened our belts one more time. The Upper Shore Hospital Center closed and RICA lost more beds. Many people lost jobs.
Plato said “the true creator is necessity, who is the mother of invention, while Nietzsche said, “That which does not kill us makes us stronger. So, I think they are both right. I certainly am stronger for the experience of creating and maintaining this public mental health clinic and it has not killed me. I have created many new things (programs, books, assessments) out of the necessity of meeting the mental health needs of Eastern Shore people. In conclusion, running 3 public mental health clinics is the toughest thing I have ever done in my life, but it was well worth it.