Minnesota's eight state hospitals serve people with mental illness, mental retardation, and chemical dependency. As part of the study and plan regarding the state hospital system, the people receiving services must be given foremost consideration. While there are many factors which will affect the future of state hospitals (funding changes, demographics, and advancements in technology), one very important factor will be the changing characteristics and service needs of residents/patients. Thus, a major issue to be addressed is, what are the characteristics and needs of state hospital populations that must be considered in planning for the future of state hospitals?
II. METHODOLOGY
The information in this report was provided by the Department of Health (MDH) and the Department of Human Services (DHS). The information was analyzed by the State Planning Agency to illustrate present and historical trends in the size and characteristics of the state hospital population.
Data about mentally ill people were gathered by the Department of Human Services during the fall of 1984. This survey was a replication of a 1982 DHS study of patient levels and staffing needs.
Information about mentally retarded residents comes from the Department of Health Quality Assurance and Review (QAR) file. Data are available for the period of 1977 through 1982. An individual questionnaire is completed annually by QAR surveyors.
The Department of Human Services Chemical Dependency Division maintains a computerized information system on patients with chemical dependency. The Drug Abuse and Alcohol Normative Evaluation System (DAANES) provides comprehensive information on a semiannual basis.
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There are many ways of counting the number of people served by state hospitals, including the following:
1. A "census" gives the number of people who are patients or residents in the state hospital on a particular day.
2. The "total residents/patients" count includes all people served during a particular period of time.
3. The "average daily population" takes into account changes in the population over a year and provides a measure of operational size for a comparison measure.
III. RESULTS
There are five sections of this report presented in the following order: (1) current state hospital population and historical population trends, (2) catchment areas, (3) patients with mental illness, (4) residents with mental retardation, and (5) patients with chemical dependency.
A. Current s State Hospital Population and Historical population Trends
Figure 1 depicts the number of people with mental illness and mental retardation served by state hospitals which grew rapidly and continuously until about 1960. Recent resident/patient population trends indicate that:
Total state hospital population has dropped from 16,355 in 1960 to 4,006 in 1984, a decline of 75%.
Patients with mental illness dropped from 10,093 in 1960 to 1,230 in 1984, a decline of 88%. Development of new drugs since 1950 enabled many mentally ill people to return to their communities. In addition, greater attention has been paid to patients' rights, and services in the community have developed.
Residents with mental retardation dropped from 6,008 in 1960 to 2,182 in 1984, a decline of 64%. Reduction in the number of residents with mental retardation was required by the Welsch vs. Levine Consent Decree and facilitated by the availability community-based facilities. Full implementation of the Consent Decree would further reduce the number of residents with mental retardation to 1,850 by 1987.
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FIGURE 1
CHANGES IN MENTALLY ILL, MENTALLY RETARDED, AND CHEMICALLY DEPENDENT STATE HOSPITAL POPULATIONS, 1870 - 1984
Source: Department of Human Services "Resident Census of State Hospitals at End of Fiscal Years."
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The average daily population of patients with chemical dependency rose from 254 in 1960 to 594 in 1984, an increase of 134%. The average daily population with chemical dependency reached a peak in 1980 with 637 people. The increase in this group of patients is associated with heightened social and legal concern for alcohol and drug abuse.
During FY '84, the total average daily population in Minnesota's eight state hospitals was 4,006 people (Table 1). The average daily population includes:
1,230 (30. 7%) people with mental illness;
2,182 (54. 5%) people with mental retardation; and
594 (14. 8%) people with chemical dependency.
Since FY '78, the total average daily population of persons with mental illness and mental retardation has been gradually decreasing in all state hospitals. Over this same period, the population for patients with chemical dependency has remained approximately the same (see Figure 2 and Table 2 ). Specifically, the mental retardation population has declined 713 residents over the past six years; the mental illness population has declined 287 patients; and the chemical dependency population has declined 42 patients. The small change in the chemical dependency population since 1978, which may be a characteristic of institutional chemical dependency programs, is supported by the approximately equal number of admissions and discharges experienced by the eight state hospitals over the past six years.
B. Catchment Areas
Most state hospitals serve all three populations (mental retardation, mental illness, and chemical dependency) and have designated service areas (Figures 3 through 5). However, the state hospitals at Cambridge and Faribault serve only persons with mental retardation from their respective catchment areas; the Security Hospital at St. Peter serves persons who have mental illness and are a danger to society from anywhere in the state; and Anoka serves mentally ill patients and chemically dependent patients. Designated state hospital catchment areas also vary in their size and in the number of counties they serve with each service population.
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TABLE 1
STATE HOSPITALS AVERAGE DAILY POPULATION - FY '84
Source: Department of Human Services 1985 - 87 Biennial Budget.
(a) Includes 107 in Geriatric Unit.
(b) Includes 210 in Security Hospital.
(c) Includes 42 in Adolescent Treatment Unit.
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FIGURE 2
MINNESOTA STATE HOSPITAL AVERAGE DAILY POPULATION FOR MENTAL RETARDATION, MENTAL ILLNESS, AND CHEMICAL DEPENDENCY< 1978 - 1984
Source: Department of Human Services, 1984.
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TABLE 2
NET CHANGES IN STATE HOSPITAL POPULATIONS 1978 - 1984
Source: Department of Human Services, 1978 - 1984.
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FIGURE 3
STATE HOSPITAL RECEIVING DISTRICTS - MENTAL RETARDATION
FIGURE 4
STATE HOSPITAL RECEIVING DISTRICTS - MENTAL ILLNESS
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FIGURE 5
STATE HOSPITAL RECEIVING DISTRICTS - CHEMICAL DEPENDENCY
Source: Department of Human Services, 1984.
Patients with Mental Illness (MI)
Patients with mental illness have been classified into five levels of need based upon the severity of their illnesses as presented in Table 3:
Level I patients comprise 9% (91) of the total MI population and exhibit the most severe forms of mental illness. Patients in this category have a high risk of suicide, exhibit assaultive/threatening behaviors against others, and may experience auditory and/or visual hallucinations. They generally are confused and disoriented, can be dangerous, and may have a history of chemical dependency or abuse. Forty-two percent of Level I patients reside at Anoka State Hospital.
Level II patients comprise 27% (256) of the total MI population and exhibit slightly less severe forms of mental illness. Patients in this category are very disruptive noncompliant, and require protection from exploitation by others. They may attempt suicide, try to escape, expedience psychotic episodes, and be chemically dependent or abusive. Thirty-one percent of Level II patients are at Anoka State Hospital.
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Level III patients comprise 39% (386) of the total MI population and are deficient in self-care and social/interpersonal skills. Patients in this category generally show little initiative toward participation in daily activities and have difficulty with self-control. They need monitoring for medical problems and may have episodic substance abuse. Thirty-seven percent of Level III patients are at Willmar State Hospital.
Level IV patients comprise 13% (124) of the total MI population and show somewhat limited capabilities for social interaction, self-care, competitive employment, and the constructive use of leisure time. These individuals need a period of stabilization prior to discharge. Over half (52%) of Level IV patients are hospitalized at Willmar and Anoka State Hospitals.
Level V patients comprise 12% (122) of the total MI population. Patients in this category are frequently confused, disoriented, show limited self-care skills or daily living skills, may be assaultive, have memory loss, and are vulnerable to exploitation. Fifty-three percent of Level V patients are at Fergus Falls and Moose Lake State Hospitals.
TABLE 3
LEVELS OF CARE OF PATIENTS WITH MENTAL ILLNESS IN STATE HOSPITALS
Source: Department of Human Services' Survey of Mentally Ill People, 1984.
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2. Residents with Mental Retardation (MR)
Ninty percent (90%) of the residents in state hospitals are severely or profoundly mentally retarded. Disabilities may show themselves in many different ways. For example, persons with mental retardation may have adequate verbal skills but may be extremely limited in their mobility, vision, and self-care.
In 1982, each state hospital resident with mental retardation was assessed in terms of his/her independence and dependence across 13 skill areas. Table 4 presents the extreme levels of independence and dependence with ratings between the extremes combined into the "other" category. The data presented in the table show the skill levels of all state hospital residents with mental retardation. In terms of extremes of these 13 skill areas, the 2,495 residents can be described as follows:
Orientation: 27% (683) of the residents are aware of events in the world around them; 23% (584) have no apparent awareness.
Self -Preservation: 43% (1,085) are physically and/or mentally unable to do so; 5% (124) of the residents are able to care for and protect themselves.
Communication: 31% (775) of the residents cannot express themselves; 18% (458) of the residents have adequate speech to express themselves.
Toileting: 39% (978) have adequate bowel and bladder control and use restrooms appropriately; 22% (543) are incontinent.
Behavior: 42% (1,064) residents exhibit severe behavior problems; 17% (425) show no behavior problem.
Vision: 61% (1,522) of the residents have normal vision; 7% (166) are blind.
Hearing: 83.0% (2,089) of the residents have normal hearing; 2.7% (69) are deaf.
Walking: 70% (1,757) of the residents walk without assistance; 21% (517) are nonambulatory.
Bathing: 45% (1,113) require complete assistance; 9% (213)of the residents bathe without assistance.
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TABLE 4
SELECTED CHARACTERISTICS OF PERSONS WITH MENTAL RETARDATION SERVICE BY MINNESOTA STATE HOSPITALS - FY '82
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TABLE 4
SELECTED CHARACTERISTICS OF PERSONS WITH MENTAL RETARDATION SERVED BY MINNESOTA STATE HOSPITALS - FY '82
(continued)
Source: Quality Assurance and Review File.
(a) total of 320 persons were served.
(b) total of 506 persons were served.
(c) total of 727 persons were served.
(d) total of 204 persons were served.
(e) total of 191 persons were served.
(f) total of 195 persons were served.
(g) total of 263 persons were served.
(h) During FY '82, a total of 2, 495 persons with mental retardation were served.
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Bed Mobility: 80% (2,000) of the residents turn and position themselves while in bed; 12% (297) must be turned and positioned while in bed.
Eating. 32% (794) of the residents eat without help; 13%31) must be fed.
Groominq: 46% (1,148) of the residents require complete assistance; 10% (248) groom themselves.
Dressing: 32% (798) of the residents must be dressed and ~; 17% (424) of the residents dress/undress themselves.
Overall, the abilities of residents with mental retardation vary widely over the 13 skill areas assessed. Many residents are quite capable in some skill areas (e.g., walking, transferring, and bed mobility) while quite dependent in other skill areas (e.g., communication, dressing, and grooming ).
More up-to-date information on mentally retarded residents is currently being analyzed and will be published later.
Over the period of 1977-1982, resident capability changed some-what but not dramatically for most skill areas according to Tables 5 and 6. Between 1977 and 1982, the percentage of residents with mental retardation who were at an independence level decreased by 1% to 12% across all skill areas (see Table 5). The 12% decrease was in the skill area of eating; the 1% decrease was in bathing. During the same period, the percentage of residents at the level of total dependence increased by 1% to 20% for all but four skill areas. Hearing did not change, while grooming, bathing, and eating dependence decreased each by 2%. The smallest increase in dependence (l%) occurred in vision and toileting, while the largest percentage increase (20%) was inappropriate behavior. Overall and percentage wise, the resident population with mental retardation became more dependent over FY `77-'82.
Data from the Minnesota Department of Health's 1982 Quality Assurance Review described the percentage of 2,495 state hospital, 3,174 Class A ICF-MR (Intermediate Care Facility for Men-tally Retarded), 164 Class A and B ICF-MR, 737 Intermediate Care Facility and skilled nursing facility (ICF and SNF), 325 generic ICF, and 306 SNF residents who are independent and dependent in the following five skill areas: eating, grooming, dressing, walking, and toileting (see Table 7).
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In general, Class A facilities had the most independent residents with MR, followed by Class A and B facilities, generic ICFs, and ICF and SNFs. Class B facilities, SNFs, and state hospitals all had residents with roughly similar levels of independence and dependence over the five skill areas.
TABLE 5
PERCENTAGE OF MR POPULATION INDEPENDENCE BY SKILL AREA OF MINNESOTA STATE HOSPITALS FOR THE PERIOD OF 1977 - 1982
Source: Quality Assurance and Review File.
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TABLE 6
PERCENTAGE OF MR POPULATION DEPENDENCE BY SKILL AREA OF MINNESOTA STATE HOSPITALS, 1977 - 1982
Source: Quality Assurance and Review File.
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TABLE 7
PERCENTAGE OF MR POPULATION INDEPENDENCE AND DEPENDENCE BY SKILL AREA BY TYPE OF SETTING - 1982
Source: Quality Assurance and Review File.
Class A = Residents can egress the building on their own in case of emergency.
Class B = Residents cannot egress the building on their own in case of emergency.
ICF = Intermediate Care Facility.
SNF = Skilled Nursing Facility.
(a) Percentage of facility population independent in this skill area.
(b) Percentage of facility population dependent in this skill area.
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3. Patients with Chemical dependency. (CD)
Patients with a dependency on one or more drugs and/or alcohol spend a relatively short period of time in state hospitals, when compared to persons with mental illness and mental retardation. While the average daily population of patients with chemical dependency in state hospitals during FY '84 was 594, a total of 5,327 patients were served with an average per patient stay of 38 days.
Selected characteristics of the 5,327 patients with chemical dependency served during 1984 are presented in Table 8. In general, most patients with chemical dependency were:
Males (85% ); White (87%); Less than 30 years old (55% ); Single (48%); High school education or less (85%); Admitted informally (95%); Not involved in criminal activity in the previous six months (51%); Dependent on alcohol (55% ); Left the program without completing it (42% ); and Indigent and sought free treatment at a reduced fee (79%).
IV. FUTURE PATTERNS
Minnesota's eight state hospitals currently serve over 4,000 persons with mental illness, mental retardation, and chemical dependency (see Table 1). As a whole, each service population presents a unique picture of characteristics and service needs, and these in turn vary dramatically within each service population (see Tables 3 through 7 ). Each service population's characteristics and needs require a different level, type, and configuration of service.
Drawing general conclusions about the total population served by state hospitals is difficult because of the differences in each service group. Nevertheless, two general trends can be highlighted. First, the average daily state hospital population is declining. The population has dropped by over 1,000 persons since FY '78. Second, the state hospital population (for mental illness and mental retardation categories) is a dependent population in need of supervision and assistance, and it is becoming slightly more dependent over time.
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TABLE 8
SELECTED CHARACTERISTICS OF PERSONS WITH CHEMICAL DEPENDENCY SERVED BY MINNESOTA STATE HOSPITALS DURING FY '84
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What future trends will affect each of these groups?
1. Mental Retardation
a. The Welsch vs. Levine Consent Decree will reduce the number of mentally retarded people in state hospitals from 2,250 to 1,850 by July 1, 1987.
b. The Title XIX (Medicaid) Home and Community Based Waiver will also reduce the number of mentally retarded people instate hospitals.
c. Every mentally retarded person has been screened using the Title XIX waiver instrument. The data indicate that 1,313 mentally retarded residents have been recommended for continued placement in state hospitals; 560 are recommended for community ICF-MR placement; 32 for placement with family, foster care, or relatives; 21 for ICF; and 48 in some type of 24-hour supervised out-of-home care.
d. Because of several reasons, it is not really known how many mentally retarded children are born every year. The following variables affect the incidence level of mental retardation:
(1) Increase in teenage pregnancies;
(2) Extraordinary life-saving measures for very premature babies;
(3) Poor health care practices (diets, drugs, smoking, and health);
(4) Limited prenatal care; and
(5) Exposure to environmental hazards (lead, etc. ).
The number of mentally retarded children is also affected by practices after birth such as diet and early intervention.
Trend Line: The number of mentally retarded people in state hospitals will continue to decline.
a. There is no court case at this time affecting the number of mentally ill people in state hospitals.
b. There is no waiver at this time affecting the number of mentally ill people in state hospitals.
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c. Information about every mentally ill person in state hospitals is being collected at this time. Analysis has not been completed, but will be published in 1985.
d. What affects the incidence of mental illness? The New York Times (December 11, 1984) recently reported that there are "high risk" indicators for children who might become schizophrenic. This approach combines both genetic and environmental factors including:
(1) Childbirth problems;
(2) Poor emotional bonding with mother;
(3) Poor motor coordination;
(4) Separation from parents;
(5) Intellectual deficits;
(6) Cognitive defects;
(7) Social incompetence; and
(8) Confusion and hostility from parent to child.
e. There are two emerging groups of people experiencing mental illness. The first is young white single men with little education, who are unemployed and have serious problems related to the use of drugs.
The second group is characterized as "psychogeriatric" or older individuals with various conditions such as Alzheimer's.
f. The Commitment Act makes it more difficult for people to enter state hospitals.
g. Financing mechanisms such as Diagnostic Related Groupings (DRGs), flat rates for Medicaid and General Assistance for Medical care put pressure on psychiatric units in hospitals to discharge patients with mental illness. These individuals seek state hospitals' care because of inability to pay.
Trend Line: The number of mentally ill people in state hospitals will continue at the same level.
a. There is no court case at the time affecting the number of chemically dependent people in state hospitals.
b. The heightened social and legal awareness of chemical dependency has actually increased the number of people who use state hospitals.
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C. The demographics of the people with chemical dependency seeking services from state hospitals reflect an indigent population with little or no family structure. The use off stage hospital chemical dependency units is a function of financing mechanisms and access to services.
Trend Line: The number of chemically dependent people will continue at the same level unless funding changes.
V. SUMMARY
1. In 1960, a peak of 16,355 residents/patients were served in the state hospital system.
2. In FY '84, the average daily population of the state hospitals was 4,006 people:
1,230 mentally ill people
2,182 mentally retarded people
594 chemically dependent people
3. Mentally ill patients range from the severest forms of illness (9%) to the least severe symptoms (12%). Patients who experience psychotic episodes, attempt suicide, and abuse drugs comprise 26% of the state hospital population; and patients with poor social skills, little initiative, and difficulty controlling emotional control comprise 39% of the population. The remaining 13% have limited social interaction and self-care skills.
A. Ninety percent (90%) of the residents in state hospitals are severely or profoundly mentally retarded.
5. Mentally retarded residents are highly dependent in areas such as self-preservation (43%), behavior problems (42%),bathing (45%), grooming (46%), and dressing (32%)
6. Mentally retarded residents are independent in transferring out of bed (75%), toileting (39%), vision (61%), hearing (83%), and walking (70%).
7. Patients with chemical dependency are typically young white males who are single, unemployed, have a high school degree or less, are alcohol dependent, and indigent.
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The 1984 Legislature mandated that a study and plan for Minnesota State Hospitals be prepared (Chapter 654, Section 19).
An Institutional Care and Economic Impact Planning Board was created composed of the following state agency heads: Sister Mary Madonna Ashton, Dept. of Health; Barbara Beerhalter, Dept. of Economic Security; Gus Donhowe, Dept. of Finance; Bill Greg, Dept. of Veterans Affairs; Sandra Hale, Dept. of Administration; Leonard Levine, Dept. of Human Services; Orville Pung, Dept. of Corrections; David Reed, Dept. of Energy & Economic Development; Nina Rothchild, Dept. of Employee Relations; James Solem, Housing Finance Agency; and Tom Triplett, Chair, State Planning Agency. Responsibility for the studies was given to the Developmental Disabilities Program/Council of the State Planning Agency.
Eight technical papers have been prepared to respond to the legislative requirements. This paper may be cited:
State Planning Agency. (1985, January). Policy Analysis Series Paper No. 6: Residents/patients in Minnesota State Hospitals. St. Paul, MN: Developmental Disabilities Program, State Planning Agency.
"Residents" refer to people with mental retardation who live in state hospitals.
"Patients" refer to people with mental illness and people with chemical dependency who receive services at the state hospitals.
Additional free copies of reports or information about this project can be received from:
