MINUTES OF THE MEETING OF THE BOARD OF COUNTY COMMISSIONERS

BREVARD COUNTY, FLORIDA

 

 

May 29, 2008

 

 

 

The Board of County Commissioners of Brevard, Florida, met in special session on May 29, 2008, at 2:02 p.m. in the Government Center Florida Room, Building C, 2725 Judge Fran Jamieson Way, Viera, Florida.  Present were:  Chairman Truman Scarborough, Commissioners Chuck Nelson, Helen Voltz, Mary Bolin, and Jackie Colon, County Manager Peggy Busacca, and Deputy County Attorney Shannon Wilson.

 

 

 

County Manager Peggy Busacca stated the County has an ongoing agreement for HVAC maintenance; the RFP was put out in April; its original opening date was May 15^th; but it had to be extended because there were numerous questions from the bidders.  She stated staff would like permission to extend the existing contract for two months to allow the RFP to be worked out so the new contractors can be brought on board; and requested that the Board authorize the Chairman to sign the extension of the current contract at the current price for two additional months.

 

Motion by Commissioner Bolin, seconded by Commissioner Nelson, to execute Written Agreement of Contract Extension with Trane-Orlando for HVAC maintenance through August 31, 2008 allowing concerns about the RFP to be resolved.  Motion carried and ordered unanimously. 

 

 

County Manager Peggy Busacca stated she is requesting that the Board approve a meeting on June 3, 2008 at 2:00 p.m.; it has been approved with all of the Commissioners calendars; and it is to have the discussion about the Embraer Agreement. 

 

Chairman Scarborough passed the gavel to Commissioner Voltz.

 

Motion by Commissioner Scarborough, seconded by Commissioner Bolin, to approve rescheduling the meeting to consider an Agreement with Embraer to June 3, 2008 at 2:00 p.m. in the Government Center Florida Room.  Motion carried and ordered unanimously.

 

 

Commissioner Voltz passed the gavel to Chairman Scarborough.

 

Commissioner Voltz stated originally she planned on presenting a workshop on health; as she spoke to the different CEO’s of the hospitals it became clear that the Baker Act beds were extremely important; it is causing a lot of trouble within the hospital emergency rooms; and it takes up a lot of time, money, and effort when there is clearly not enough Baker Act beds at Circles of Care.  She stated because she works in the Baker Act unit as a nurse she understands the Baker Act more intimately; specifically this year because of all of the cuts coming from the State she wanted the Board to hear first hand from the CEO’s what impact no Baker Act beds have on them; and it is important that people who are policy makers and law makers who can provide the funding need to know and understand what the lack of Baker Act beds is all about.  She stated there are people coming in and out of the door on a revolving basis; the same people are there over and over again; Circles of Care has not had any increase in Baker Act beds; and the community has grown exponentially since then. 

 

Health First Vice President Jim Kendig stated along with him today is President and CEO of Holmes Regional Medical Center Jerry Senne, President of Palm Bay Community Hospital Judy Gizinski, and President and CEO of Cape Canaveral Hospital Roy Wright.  He stated he put together some notes in the last day or so to summarize the activities as a hospital, not only the Health First group, but across the spectrum what they have done; he understands the purpose of the Workshop is to help the Board understand the impact of the stagnant funding from the State and its impact to healthcare, specifically the acute care hospitals, and ultimately the community as a whole; so he has tried to keep that as far as a general goal.  He stated Health First expects to have 940 annualized avoidable days in 2007 related to the Baker Act; and this is approximately double the number from 2006.

 

Commissioner Voltz inquired if Mr. Kendig would explain what that means; with Mr. Kendig responding the avoidable days are the total number of days the hospitals wait until an inpatient psychiatric bed is available; avoidable days begin the moment the patient has been medically cleared to leave the hospital, but because of availability there is no place to transfer the patient; and that would be primarily to Circles of Care.  He advised direct costs, after the patient is medically cleared, can be as high as $407 a day per patient; direct costs, while the Baker Act person is a patient in their hospitals, includes sitters, lack of beds for other patients, medical, stroke, coronary patients, assaults on staff, related Worker’s Compensation costs, and transportation to the receiving facilities also has an impact; and costs for the sitters alone reach into the hundreds of thousands of dollars annually for Health First, which does not include security officers interventions, time, and support from local law enforcement agencies.  He stated length of stay after medical clearance has reached as long as 22 days waiting for a bed at Circles of Care and other facilities; there currently is a patient at Cape Canaveral Hospital that has been waiting 16 days for a psychiatric bed; the average is five to ten days of avoidable days; and it ranges anywhere from five to seven to ten, depending on the month, year, day, week, and impact at Circles of Care.  He stated impact to the patient themselves is obviously the lack of expertise, skilled care, and programs to meet the complex needs to meet these particular patients and programs.  He noted they were not built to address the needs of psychological patients.  He stated the Baker Act and Marchman Act Statutes have not been revised substantially since inception creating current conflicts with expiration of Baker Acts; everyone knows that the Baker Act Statute has kind of been put on hold while acute care medical conditions are addressed; it picks up once a person is cleared medically; and many times they have the Baker Acts expire in the organizations and there is not a current statutory remedy for re-Baker acting them or whatever the case may be for those particular patients.  He stated other issues that are not addressed are capacity, transfer out of county, out of region, and should assist with placement; hospitals, Circles of Care, and others have been participants in the County Commissioner appointed Community Mental Health Solutions Task Force since its inception many, many years ago as a result of an event at the Jail; and it was originally chaired by Paul Rumbley, then Sheriff Parker, and right now Wayne Holmes.  He noted hospitals convened their own meetings this past year; they met four times to look at best practices around Florida, including the Orlando market; they were unable to find any without increased funding from the County or other sources that would support additional beds.  He stated one significant outcome was a joint letter from leaders of each of the healthcare organizations, Mike Means from Health First, George Mikitarian from Parrish Medical Center, and Emil Miller from Wuesthoff Hospital to Commissioner Bob Butterworth describing and seeking assistance from his office addressing the Baker Act Program; and that was sent out on October 17^th and a response was received on November 21^st that Commissioner Butterworth will evaluate this as a Statewide issue, indicating that he hopes that Florida’s revenue forecast will have been improved by then.  He stated hospitals have continued to seek out innovative ways of addressing capacity, including sending Baker Act patients to other receiving facilities in the region only to be recently denied due to lack of available beds in each of the other counties; so this becomes a Statewide program.  He stated the other issue is how to get them back; they typically live in the community and now transportation needs to be provided to get them back; they conducted a failure mode and effects analysis through the Brevard Healthcare forum, which Wuesthoff, Parrish, Health First, and FIT participate in; it is done by a professor at FIT who is a former NASA Scientist, Dr. Deb Carstens; and she came up with a number of different opportunities for them, which they did proceed with and take care of.  He advised he brought examples with him today, including handbooks, posters, and what not; a lot of literature was provided to hospitals and law enforcement concerning the Baker Act, which are the top ten signs to look for; there was great success in publishing those; and he wants to give hats off to Jim Whitaker and Barry Hensel for providing many of the comments in those.  He noted hospitals in Brevard County have also reported the inability to place patients to the Regional Children’s and Families Office in Orlando; they are essentially breaking the law every day; they began reporting this on an annual basis to the DCF Office saying they have patients up to 22 days at the hospitals; and the average are five to ten days on each event.  He advised they called Carol Ann Duncan who was the DCF Administrator for that particular reason and informed her there was no way to move those patients; she did not have any options for them; and that was a collaborative project with Wuesthoff, Parrish, and Health First hospitals during many months of the year.  He stated in addition, they also hosted Martha Lenderman several times as the State’s leading expert; twice the hospitals underwrote the cost of that, including Wuesthoff, Parrish, and
Health First; they brought her in and had joint hospital law enforcement training sessions at the Brevard Community College in Melbourne and also the Solar Energy Center; and since that time they have brought her back at least two other times to support Sheriff Parker’s crisis intervention training.  He stated currently there are no guidance-related Baker Act orders that have expired; and the leading State expert has offered opinions but no formal interpretation exists to support patients awaiting transfer to the appropriate receiving facility while at an acute care hospital.  He advised to further reduce the length of stay for Baker Act patients at Health First they sought and obtained permission from Brevard County Fire Rescue to transport non-medical non-violent patients to Circles of Care, allowing them to get that length of stay even further by hours, minutes, or whatever the case may be; and at Palm Bay Hospital with over 100% routinely, occasionally at Holmes Regional Medical Center and Cape Canaveral Hospital, it is important to move those patients out quickly to make room for other medical patients; so they have been transporting, and reducing the length of stay by hours to support the hospitals. 

 

Commissioner Voltz stated if they get a patient at Circles of Care and they feel they need to be medically evaluated, they ship them right back to the hospitals and they go back and forth; a trip has been wasted to come there; and it is up to the nurse at the time when they come in the back door whether or not the patient will be kept at Circles of Care or if they will be sent back to the hospital. 

 

Mr. Kindig stated that creates a lot of angst for Circles of Care; they have met with Jim, Dr. Hensel, and the medical staff; that was brought up a number of times during the hospitals only meeting; they invited people from the County, DCF, and others to participate; and since that time they have shared the medical protocols amongst all of the players, Wuesthoff, Health First, and Parrish, and now they are handy for those people sending them, whether it be the Transfer Center at Holmes Regional Medical Center that takes care of Health First or otherwise.  He noted hopefully there will be less and less of that as an issue.  He stated the impact to the community is obviously through the jail; the Mental Health Community Solutions Task Force as a result of Jail events; the law enforcement communities impact, and certainly the community at large because of lack of medical beds as a result of these patients tying up hospital beds in the hospital and not suitable for psychiatric care.  He stated there is a lack of acute care medical beds for medical patients increase costs for all organizations involved in the process, both indirect and direct cost; increased number of assaults on staff and the concurrent Worker’s Compensation issues that tend to those events; and lack of expertise and programming at the hospitals to support these patients.  He advised it is costing the hospitals hundreds of thousands of dollars of direct costs and many, many more dollars in indirect costs.

 

Commissioner Voltz stated it is up to $407 a day for all of those 940 applicable days; and then there are all of the indirect costs on top of that.  Mr. Kendig advised it is depending on the insurance coverage and that is why he said up to $407 a day; it varies on insurance coverage or private pay; but some of those patients that have no insurance so it is $407 a day.        

 

Commissioner Voltz inquired how many patients actually have insurance; with President and CEO of Circles of Care Jim Whitaker responding it varies; stated a lot of them are Medicaid or HMO’s; Circles of Care receives $424 for Baker Act patients; and that is the drive out price as there is nothing else to bill on top of that.  Mr. Whitaker advised most of any paying patients go over to Sheridan Oaks; the vast majority Circles of Care sees have limited funds; just because someone has insurance it does not mean it pays for mental health care; and a lot of them pay at 50 percent, pay for two days, or they do not pay at all.  He stated many times it is optional in Florida so a person may have insurance for medical care but do not have insurance for that. 

 

Chairman Scarborough stated there may be people who are watching the Workshop who do not understand what the Baker Act is, why the Legislature passed it, and what it means to be Baker Acted; and maybe someone could explain it for those people.  Mr. Whitaker advised they would be showing a definition of that shortly; what is not shown on the slide is that Dr. Barry Hensel is very knowledgeable of the Baker Act; and stated he lectures and teaches about it.  He stated it is really Florida’s Mental Health Act as it is just named after a former Legislature Maxine Baker.  Commissioner Voltz inquired what are the total costs spent out-of-pocket direct and indirect costs; with President and CEO of Holmes Regional Medical Center Jerry Senne responding it would north of a million dollars; and stated there are opportunity costs of a bed tied up, as well as the indirect cost of staff and everything else.  Mr. Senne advised when he refers to beds it is not a piece of furniture; it involves the facility a person is housed in; it involves the license; but the real overbearing cost is the cost of staff.  He noted it is less of a facility issue in terms of places these folks can be placed than the funds to be able to adequately protect them and care for the patient’s needs.  Commissioner Voltz stated at any given time there are five to seven technicians on the floor, two to three nurses, and a secretary; and it is very staff intensive to fill the Baker Act unit if there are 35 patients.

 

Chairman Scarborough inquired if Baker Act beds are more costly because of the unusual circumstances; and where it does it fall within the bracket of costs per bed.  Mr. Whitaker advised a general hospital with a psychiatric unit will be more expensive to operate because the cost of the square footage at a general hospital is so much more expensive than a free-standing facility that was built just to take care of psychiatric patients; Circles of Care lost almost $400,000 last year with the State dollars; so the Circles of Care costs are more than the State gives it.  He stated with any State contract it may be paying $424 a day; that is so the facility earns the amount the State allocated; it does not pay $424 for every patient; but when the $424 runs out the patients are carried for free for the State.  Commissioner Voltz stated sometimes there is a one-on-one and that patient will cost a lot more money because he or she has to have someone with them all of the time; and there are a number of different types of beds like suicide watch.  Mr. Kendig advised in acute care hospital settings there are sitters sitting with most if not all of the Baker Act patients so there is a direct staffing cost in addition to what would be seen.  Chairman Scarborough stated the definition of the bed is the ancillary service that goes along with the bed.

 

Wuesthoff Health Services President and CEO Emil Miller stated dealing with someone who is potentially suicidal or other issues like protecting staff are very real issues.

 

Parrish Medical Center President and CEO George Mikitarian stated a Baker Act patient is a patient who is hospitalized and must be released to a State designated Baker Act receiving facility within 12 hours of doctors deeming them to be medically stable; those patients that come to the hospitals that have a combination of medical and mental health issues, once that medical issue is deemed cleared, the law says that within 12 hours the patient is to be transferred to a State designated receiving facility; over the past years what is had is poor policy, law, financial situations, and logistics relatively to caring for these very fragile people who reside in the community; those people are talked about as Baker Act patients but they are people; and those people reside in this community.  He advised no one entity has done a good job at looking at how the laws and policies affect those folks; those who provide acute care, which is medical and surgical kinds of healthcare, have two conflicting laws to deal with; one law says a hospital is not capable or by law allowed to take care of those patients; the other one says by law they have to take care of them; and what everyone forgets is in between is the patient.  He noted before those people are received into the hospitals there is a conflict within the law; once the people get into the hospitals the conflict multiply as the hospitals are not designed and equipped to properly take care of these patients the way he or she should be cared for; it would be an equivalent to sending someone with a broken leg to a hospital that specializes in heart care; and they are all deemed hospitals but it is not necessarily their area of expertise.  He stated the resources expended because they are not experts in it are exponentially higher than the resources being spent on other kinds of patients because of the dedication that it takes with the security force as it is one-on-one with sitters; the environments are not conducive to properly care for those people; so in order to protect, take care of them, and provide an environment that is safe someone has to be with them all of the time.  He advised the longer those people are in the hospitals, as much as they want to care for them, they are not receiving the care they should.  He stated he commends Circles of Care and Wuesthoff Hospital for wanting to care for folks, but having a financial and capacity burden, which does not allow to care for those people in the right place; so the longer those people are in the acute care hospitals the higher the risk for something adverse happening and the longer it takes them to get the care they should receive.  He advised once the people leave the acute care hospitals there are issues of getting the best proper follow up care; the two organizations do a great job once the people are gotten to them; but not everyone is able to get to those two organizations.  He stated the same people come back time and time again; that is one of the issues, especially for North Brevard County; but they just do not have the after facility care to take care of these people.  He stated there are not an abundance of clinics in facilities that can take care of these people on a regular basis; they end up at no point in time getting the proper care he or she needs or deserves; and what happens is there is a system that does not work.  He stated it does not work for the people who are seeking care; it does not work for the hospitals that are doing the best that they can give the resources and capacity of the law; and it does not work for society as it can create other trickle down issues within the society by not treating these patients properly.  He stated it is an incredibly difficult situation; and he commends the Board for having the Workshop and at least wanting to spend a bit more time understanding from the hospitals perspectives what the issues are; and it helps the hospitals and Circles of Care understands what the issues are as well.  He stated it is a conflict; it is going to be a combination of what can the hospitals do for these people, and what can the Board help them do; there have been many meetings with the hospitals and Circles of Care trying to come up with solutions; they have met with Sheriff Parker and his folks; and everyone is doing what they can within the rules of the game.

 

Commissioner Voltz inquired how much does Parrish Medical Center lose per year; with Mr. Makitarian responding the estimate is between $400,000 and $600,000, and it depends on the year and the circumstances.  Mr. Makitarian advised Parrish Medical Center is not licensed for those patients, and they will have three to five patients per day.

 

Commissioner Bolin inquired what is the average stay; with Mr. Makitarian responding about four and one-half days; but they have had patients up to three to three and one-half weeks in Parrish Medical Center.

 

Chairman Scarborough inquired if the statistics are put together with all of the hospitals and Circles of Care of how many people are classified as Baker Acted at any given time; with Mr. Whitaker responding there are up to 60 people waiting; stated sometimes there are 40 in-house; and what the judges may send the hospitals may not be counted.  Mr. Whitaker advised one thing he would add is that a law enforcement officer can bring a hospital a client at any time and they cannot be turned down; a person may be told it is okay to go to Wuesthoff Hospital at 4:00; three police officers may bring a person to Wuesthoff; and then the Hospital has to call the first person back and tell he or she that according to law the patient that is already there have to be accepted first.  He advised they keep track on a daily basis where every patient is that is waiting; they have worked with the hospital emergency rooms to try to triage and move people in as fast as possible; and sometimes it is a female bed and sometimes a male bed that becomes available.  He stated they try to keep the emergency rooms up to par when there is an opening; that will vary as low as ten to 15 people waiting for a bed; but more likely it has been adding up in the community to 30 to 40.

 

Chairman Scarborough inquired if a presentation is going to be made on how a person becomes Baker Acted; he stated there are people out there that do not know what that means; this is more than just psychiatric care; and people who endanger themselves or others who need to be watched.  Commissioner Voltz inquired if someone comes in from a nursing home who has been Baker Acted because of being violent how long does he or she end up staying in the facility at Sherman Oaks as it is almost impossible to find another place to send them.  Mr. Whitaker responded when he gives his presentation he will speak about some of the reasons the system is jammed up.  Mr. Kendig advised he wants to clarify this is not an emergency room problem it is a hospital problem; in one of the hospitals over 50 percent of the patients have to be admitted to the hospital because of lack of bed at Circles of Care; and the waiting list continues to grow.  Mr. Kendig stated they do share data Countywide through the Community Mental Health Solutions Task Force about avoidable days and the average of that; and it does give them some idea of the avoidable days.           

 

President and CEO of Wuesthoff Health Systems Emil Miller stated he put together a PowerPoint presentation; it is an overview of what is going on as it relates to Wuesthoff; Jim Kendig’s report, along with George speaking for Parrish, those are issues everyone agrees upon as far as the impact and challenges everyone is dealing with; and Wuesthoff Medical Center in Melbourne is in the same boat with the other acute care hospitals.  He advised there is a difference when it comes to Wuesthoff Rockledge; the difference is that Wuesthoff Rockledge is a designated Baker Act receiving facility; and it also is the only acute care hospital in Brevard County that has an inpatient psychiatric unit.  He noted involuntary examination of a patient must be initiated by the court system, law enforcement, or mental health professionals; the required evidence of a mental illness is shown to be harm to self, others, or self neglect; examinations are up to three days; and examinations occur in over one hundred sites throughout the State. 

 

Mr. Whitaker stated a person has to stay up to three days for examinations; if the person is not becoming stable enough to make a rational decision about his or her care they can be held over for further examination; but that requires a court hearing, which only occurs once a week.  He stated sometimes the people clear out before the court hearing and sometimes they stay with Circles of Care for three or four months depending on his or her condition.

 

Mr. Miller stated Wuesthoff Rockledge is the only hospital in Brevard County that is a designated Baker Act facility; Rockledge also receives patients from the other hospitals within Brevard County; and they also have an inpatient unit, which consists of 17 beds, runs about three-quarters full, and of that 75 percentile occupancy 24 to 30 percent of those patients do not have any resources to pay for medical or psychiatric care.  He advised that Medicaid patients have recently in the past year and one-half decreased by 30 percent; but previous to that Medicaid patients were paid at the traditional hospital rate; Medicaid pays on a per diem basis; they used the Medicaid payment rate to balance that unit financially and maintain its viability; and over the past year or so they have seen the number of Medicaid patients decline, which has hurt the revenue stream for the inpatient unit at Rockledge.

 

Commissioner Voltz inquired why if Wuesthoff Rockledge has an occupancy rate in the inpatient unit of 75 percent, how do they account for the people who are waiting in hospital emergency rooms; with Mr. Miller responding it is the type of patient; stated the decision is made by a Psychiatrist; they have a Psychiatrist on staff that assesses every patient who comes in from a Baker Act perspective or an admission into the unit; and those decisions are purely in the physicians hands.  Commissioner Voltz inquired if a person is sitting at Holmes Regional Medical Center and there are no beds at Circles of Care, and Wuesthoff Rockledge would be called because they have openings, will they take that person; with Mr. Miller responding yes.  Commissioner Voltz inquired why Wuesthoff Rockledge would not be full all of the time if there are people waiting in the emergency room elsewhere.  Mr. Miller advised it could be an adolescent patient, which is a separate and distinct level of care, or it could be something else; but it is a physician-driven decision.

 

Mr. Miller stated in the Wuesthoff Rockledge emergency room they see 2,400 psychiatric patients a year; and the typical emergency room is one-third of that if not less.  He advised 59 percent of the top ten reasons for non-paying emergency room patients are admitted based upon psychiatric-related care; underneath that are four different diagnoses; clearly Baker Act patients co-mingled even in an emergency room setting results in an extremely chaotic environmental, one where they are endangering not just staff but the public as well; he can tell the Board a multitude of stories; those have played out in all of the emergency rooms throughout the County and State; but in Rockledge it is clearly overwhelming the number of patients brought in directly from the field or transferred in as the closest Baker Act receiving facility for Brevard County.  He stated with the designation of being a Baker Act receiving facility they are receiving patients to be evaluated in the emergency room setting, and then they are being held based on criteria for admission; and in many cases they have been forced to create a holding unit for patients above the 17-bed unit hoping to have placement elsewhere in a more appropriately-matched environment.  He stated the financials do not add up; people read every day healthcare articles that say reimbursement continues to decline; hospitals have seen a 7.2 percentage decrease in the coming fiscal year for Medicaid payments; these are all very real factors that roll into making the service not really a viable opportunity for Wuesthoff Rockledge on a going forward basis; and he feels sorry in bringing it to the Board based upon Wuesthoff being at that crossroad.  He advised Wuesthoff’s Board Chair and Dr. Cotton, leader of Atlantic Psychiatric Services, met with Chairman Scarborough three weeks ago, and Wuesthoff is seriously considering closing the psychiatric unit; and they are also considering releasing the Baker Act designation.  He stated the impact of that is that it will be a pushback to the other five hospitals in the County as far as Wuesthoff being able to accept patients even for evaluation; Wuesthoff Rockledge will shift into a mode similar to all of the other hospitals where they will be holding patients and waiting to place them in next available bed or transporting them to Circles of Care for evaluation and then maybe having to take them back; and those are the kinds of situations they are trying to evaluate when it comes to Rockledge for both the inpatient unit as well as the Baker Act component.  He stated the thing that is a little bit distinct and different between the two Baker Act receiving facilities in Brevard County is that Circles of Care offers that service, and Wuesthoff Rockledge offers that service; the difference in Wuesthoff Rockledge is that there is the full array of medical services; so many times these patients do have comorbidities; and many times the medical component must be addressed.  He stated George talked about the issued of training staff and having the expertise available in-house; that has been one of the things that has pushed the cost level way over the break even line into the negative arena is infrastructure that they are forced to keep in place to be able to provide all services underneath the same roof; a person might in other cases see the medical aspect of the patients needs addressed; but during that time period there is a full-time sitter or some other allied health professional that has mental health training present.  He stated they have had patients walk out of the facility against medical advice; from a liability perspective it is a real concern; and inquired if Wuesthoff Rockledge is really doing the right thing for the patient without having the appropriate level of care readily available and the capacity.  He noted in looking where they have been over the past three years economically, those are true real costs and they continue to mount; like most organizations they are struggling to balance the books when they look at the overall organization just on a breaking even level; and this is something that is clearly pushing them over the edge at this stage of the game.  He stated the problem has been very well defined, and the impact he spoke to will be a push back potentially to the other local hospitals that have Baker Act patients waiting.  He stated the potential options relating to Wuesthoff Rockledge are three-fold; they close the Baker Act service, which will impact the other five hospitals; Wuesthoff Rockledge closes Baker Act services and the inpatient unit, which results in more psychiatric patients being held in non-psychiatric environments; or potentially identifying some source for funding to help them stay whole as an organization.  He advised that is the overview of the snapshot of where Wuesthoff Rockledge sits today, and the secondary impact that the other providers in Brevard County are looking at if they were to follow number one or number two as an option.

 

President and CEO of Circles of Care Jim Whitaker stated about 32 years ago a slightly slimmer and a lot younger social worker who had just gotten the job as a mental health center director proposed that a group of five County Commissioners build a psychiatric hospital in Melbourne and that it do that with tax exempt revenue bonds backed by enterprise funds non-ad valorem revenue; that Board voted for it five to nothing; and that was Gene Roberts, Lee Winner, John Hurdle, Joe Wickham, and Val Steele.  He advised the Board went with him to New York, the bonds were sold, and to his dying day he remembers someone from Standard and Poor asking why a County Commission wanted to do that; and John Hurdle said it was the right thing to do for the community.  He stated last month the last payment was made on that loan free and clear.  He stated in 1980 Circles of Care had 28 beds; the population has almost tripled in the community and there are still 28 beds; and only the State and County match for that covers 22 beds.  He advised they are trying to add residential beds; it is one thing to have surgery and go through recovery but then a person has to go through rehabilitation, a place to live, and follow a diet; but they still have the 28 beds.  He stated Circles of Care is violating the law every day over its license capacity; one reason it opened up as a hospital is because they do not beat them up as bad as the State if it goes over capacity; and then another ten beds are spilled into the Sheridan Oaks unit where there are mostly geriatrics but they also have the Baker Act as well.  He stated when looking at any kind of service there has to be a system; Florida at one time designed a beautiful system that started out with the Baker Act and then a short-term residential treatment; had different levels of residential, aftercare, case management, work option programs, and job option programs; and it was a model for the country.  He stated the State funded the program for five years; it realized how expensive it was to implement; and then it passed the funding on to the counties and municipalities; so there are real gaps in the system.  He advised when Community Solutions helped solve the problems for the Sheriff by saying there is a law that says within 15 days or less a patient that is incompetent to stand trial due to mental illness must be moved to a State facility; the State was not doing that; people began to sue the State; the State ended up doing it by putting the patients in a lot of the existing State Hospital beds; and once that was done they cannot send anyone to the State Hospital beds.  He noted every day there are 12 people in those 22 beds waiting to go to a State facility or short-term residential treatment facility that are now waiting almost three months to be transferred; and that basically takes 12 beds out of the community every day.  He stated they have complained to the State; he suggested to the State that they be able to transfer some of the patients to another State Hospital in South Florida instead of trying to go to Macclenny; the State agreed with him and told him it would try to get some of the patients to that State Hospital; but it has been four months and there have been two patients transferred to South Florida.  He advised the State has cut State Hospitals, which are backed up and that is 12 beds; and that puts the pressure on everyone.  He stated he is sorry this number of people did not show up at the Legislative hearing when it was discussed that the number one need in healthcare in Brevard County was more Baker Act beds; it has been the number one priority for six years on the Legislative docket; it has been the number one docket given to the Legislators; but it has never gotten out of Committee.  He advised it is not just Brevard County as it is always popping up in Lee County and in the Tampa-Hillsborough area as well; a crisis is coming; unfortunately in Florida sometimes it funds things out of lawsuit and crisis; that is a sad commentary on people who almost have not other advocate but Circles of Care, hospital emergency rooms, and the staff; many of the are sick and need help; and if nothing else those people need to be screened and taken somewhere else out of the system.  He advised he does not have a total solution for it, but they are willing to work with all of the hospitals; he has said numerous times that they have facilities and property, they are willing to build, to do it themselves, and to borrow the money and pay it off; today at least 20 more Baker Act beds are needed in Brevard County; and if it was up to him those beds would be located in the central part of the County.  He explained that 16 short-term residential treatment beds are needed as well; rather than worrying about sending those people to the State, those 12 or 14 that need to stay longer could go there; that would clear up those 12 beds plus an additional 20 would add about 32 available beds to the community; that takes about a minimum of $3 million recurring dollars plus inflation every year to do both of those units; but that does not include construction because that is their deal.  He remarked he would like to be able to work with the hospitals; they are spending a lot of money and going nowhere; and Circles of Care is spending a lot of money trying to help the hospitals get somewhere.  He stated maybe a partnership is needed with the County, hospitals, and the State; and something needs to be done about this as it will get worst.  He commented that he would hate to see Wuesthoff not have the Baker Act beds; they have been a valuable asset to the community since he came to Brevard County; and they were the first hospital that even allowed Circles of Care to come and open a unit there.  He remarked they quit fighting with each other; but clearly there is the issue that some type of partnership is necessary.  He advised he is willing to come to the table anytime and so is his board; and his board has authorized him to build these facilities if the base funding can be found.  He stated this is not the total cost because there will be people who have Medicaid that will come in; it has shrunk; they have put them all into HMO’s; and that might reduce the money coming in by half.  He stated it makes it dicey whether a facility would want to take $500 a day when the costs are $200 or $300 more.  He stated there are opportunities to solve this; if they were to close those beds something would have to be done immediately to try to do this; but the costs that are out there run somewhere around $3,000,000 every year, plus an inflation factor; and that could give Brevard County about 36 different beds, which would double the capacity and take care of the County for a few years. 

 

Commissioner Voltz inquired if he had the $3,000,000 how much could he potentially come up with; with Mr. Whitaker responding they will come up with the rest of it; stated it takes almost $6,000,000 to do what he is talking about; they are basically asking for 50 percent from somewhere; the economy has got to get better; and if it does not, he will be utilizing some of his own services.  Mr. Whitaker stated he would immediately like some support by everyone getting back with Secretary Butterworth and telling him to take care of these people who are supposed to be in the State Hospital or in an SRT; that would at least give Brevard County 12 more beds to offer to the community; it is not an obvious solution; but 12 more beds would certainly help.  He stated he does not think Secretary Butterworth will move or find places in State Hospitals until he gets some real pressure; and whether Brevard County can get its Legislative Delegation to make some calls he does not know.  He advised Secretary Butterworth is tired of his calls and letters.

 

Commissioner Voltz inquired what pressure would the addition of 20 beds take off of the hospitals; with Mr. Whitaker responding the hospitals would have to answer that; stated if it was located in Rockledge and they had 24-hour screening there then obviously they would try to get the police to bring the people there rather than the emergency room; that should help if they do it; and they would have to if Wuesthoff Rockledge closes.  Mr. Whitaker stated there cannot be a Baker Act Crisis Stabilization Unit without 24-hour, seven days a week screening and evaluation to see if a person meets the criteria for the Baker Act; if those people have medical problems a medical transport would have to be called and he or she would have to be sent to Wuesthoff or Cape Canaveral to get them screening and then take them back; and that would take pressure off North and Central Brevard to have 20 beds there.  Commissioner Voltz advised it would still take pressure off of South Brevard.  Mr. Whitaker stated he would have more there that would not be transferred down there; when there are 40 waiting at times it will not solve the problem; and that is why he said the County would also need the 16-bed Short-term Residential Treatment Facility (SRT).  He noted there is one in Orlando and in theory it is also supposed to cover Brevard County; they are going to work on that to see if they can get at least 25 percent of those beds designated for Brevard County so they can transport in the meantime; it would be better having it in Brevard County because of the transportation, family, case managers, and everyone back and forth across to Orlando does not make a lot of sense; but it is better than people sitting in emergency rooms not getting the treatment that he or she needs.  Commissioner Voltz stated she sees a real partnership brewing; the three hospitals that are running up the millions of dollars in costs could take some of those costs and provide it to Mr. Whitaker on a partnership collaborative effort to provide those beds; it would be less expense for the hospitals; and that is the right way to go.  Mr. Whitaker stated it would only be part of it as the hospitals should not have to pay the entire amount; the State has a major responsibility; it is State law; and obviously the counties and municipalities could choose to contribute.

 

Commissioner Voltz stated the medical providers spend millions of dollars each year on all of these costs; and requested someone address that.  Mr. Miller advised Wuesthoff Rockledge is separate and distinct as far as its level of exposure currently as it has an inpatient unit in addition to already receiving a disproportionate share of patients into the emergency room setting; it would be a relief to Wuesthoff Rockledge to drop the Baker Act designation, drop the inpatient psychiatric unit, or keep the inpatient psychiatric unit separate and distinct, but dropping the Baker Act patient is going to push more cost on a daily basis to the other hospitals; and there is a bit of a difference as it relates to Wuesthoff.  Commissioner Voltz inquired if Wuesthoff Rockledge no longer has those costs because it may not have the Baker Act and psychiatric unit anymore and it could take part of that money and put it towards something at Circles of Care.  Mr. Miller stated that this law is being place on them; they are not a State-funded organization nor are any of the other hospitals; they are private not-for-profit in the true sense of the word hospitals; and with these additional requirements for the hospitals to address, they are coming to the Board looking for suggestions.  

 

Commissioner Colon stated she would not recommend that government tell the hospitals what to do regarding this issue; they are already dealing with a lot; and this is just one of the many things that the hospitals are dealing with.  She advised she is reading the article from Lee County; it seems like it is not just a problem that Brevard County is facing; it is the entire State of Florida; and all 67 counties are dealing with this dilemma.  She inquired if there is any other State that the folks have actually researched that they would consider a model state that would help Brevard County to get an understanding of how does the other states do it or is it a nationwide problem; stated she always likes to learn what other folks are doing and not try to reinvent the wheel; but if they have reinvented it she would like to go ahead and get on board.  She stated it is such an issue with the State where this has been laid on the private sectors lap; and further inquired if there is any other state that they feel comfortable with that they wish Florida was modeling.  Mr. Whitaker advised it would be easy to model another state because Florida has now dropped to 48^th in the United States in the percentage of dollars that it spends for mental health; Florida is one of the top ten wealthiest states; and by adding substance abuse and children in the 48^th ranking in what it spends on mental health, it causes the State to drop to 49^th.  He stated Georgia is doing a fairly good job by redoing its entire system and has gone from a State system to a private not-for-profit sector; Georgia has a state income tax and also put part of the lottery assigned to that so it would go to mental health, alcohol, and drug abuse care; most of the money goes to education; and it has to be on top of other dollars being spent.  He stated South Carolina and North Carolina are both in a mess; Minnesota and Wisconsin are very progressive; Minnesota and Wisconsin have a long-standing designated tax that goes for mental health; that way it does not get ping ponged around; so the mental health centers in Florida has looked at other states.  He advised California passed a millionaires tax; if a person’s net gross was over a certain amount a certain percentage of that went to community mental health to build residential programs and crisis centers because the hospitals were experiencing the same thing the hospitals are here; and California fixed it by taxing the wealthy.  He noted during this same period of time on the federal level federal funding has dropped over the last eight years markedly; the dollars that are there have been in recovery resiliency; they recover but they skip all of the stuff in between; and it is sort of like putting someone in recovery but he or she has not been to surgery yet.  Mr. Whitaker stated that is fine as long as all of the other parts of the system are there and then progress through it; Florida has some great parts of the system and there is big gaps missing; and people fall into these gaps when he or she does not take medication.  He advised they used to have 36 full-time case managers; these case managers picked people up at the hospital and the emergency room when he or she was released and stayed in those people’s lives to make sure he or she took medication; and the recidivism rate dropped like a rock.  He advised Medicaid and the State are no longer paying for case management.  He stated most of the State General Revenue dollars were shifted over to make Medicaid work to draw down more federal dollars so they have very few disposable General Fund dollars for funds because the State is matching Medicaid.  He advised Judge Leifman from Miami has been on a real kick to change the system; he was supposed to get approximately $15 million this year to help keep people out of jails and prisons; and it would take at least $30 million a year for five years to just get the system where it should have been five years ago.  He stated the solutions will probably have to come among the medical professionals and the County; and he does not know where else to turn.

 

Commissioner Bolin inquired when Mr. Whitaker said that he was talking about 20 more beds and 16 residential beds if he was taking into consideration with those numbers the possibility that Wuesthoff Rockledge will be closing down the beds that it has; with Mr. Whitaker responding the 20 beds in Rockledge probably would move must faster unfortunately if it closed because there would be such a great need to do something there; stated if the unit is closed then the police will have to take them somewhere else or the person will have to stay where he or she is; and Wuesthoff Rockledge should get less patients because they would no longer be considered a designated receiving facility, which would free them of that.  Mr. Whitaker advised a few of that 20 people will have some ability to pay, which will help him pay for the balance of that unit as it has to be a partnership; and if Wuesthoff Rockledge keeps that unit up then he may not open there, he may try to do the 16 beds somewhere else.   

 

Commissioner Bolin stated in Emil Miller’s presentation he made a statement that he would possibly keep the Baker Act designation and psychiatric unit open if there was financial assistance; stated in 2007 she understands Wuesthoff Rockledge had a loss of $1.1 million; and inquired if there is a figure he is looking at.  Mr. Miller advised they are projecting what the loss is for fiscal year 2008, which is $1.9 million; what they are saying is they would like to stay whole on that to continue the service; they just want to break even; they are not looking a margin out of it; and if they could identify that dollar amount obviously they would welcome the opportunity to continue the service.  Commissioner Bolin stated that would keep 17 beds at $1.9 million to do 20 and 16 he is estimating $3 million cost.  Mr. Whitaker advised to do both of them that is correct; and 20 beds would be approximately $1.6 million recurring dollars.  Commissioner Bolin inquired who the Baker Act contract is with; with Mr. Miller responding with the State.  Commissioner Bolin inquired if it is yearly; with Mr. Miller responding he believes they re-file with the State on an annual or every other year basis, but he not exactly sure.

 

Commissioner Voltz stated something Jim mentioned was that it is going to be up to everyone and that is why she brought up the fact that maybe he could look at those lost dollars and provide the services that are needed for the patients; it is up to the medical professionals, but at the same time the government is responsible for the Baker Act; and the County may need to come up with some dollars.  She stated one person cannot do it all; and it has to be a collaborative effort for government, private individuals, and the medical profession.

 

Dr. John Potomski stated he was on the police department in New Jersey for three years, worked in the hospital for ten years, and now he has been doing long-term care nursing homes for 25 years in Brevard County.  He stated one of the big issues is why the State does not have the beds; in the 1970’s they came out with all of these novel anti-psychotic medications; the government said if the people take these drugs they will not need to go to the State Hospital; he trained in the State Hospital and they had a work farm, manufacturing plants, and huge State mental facilities; since those facilities were closed often people do not take medication and go out and commit crimes; and Sheriff Parker is stuck with the folks in jail.  He advised since the closing and reduction of the State Mental Hospital beds two different populations have dramatically shot up; one is the Jail population; the other one is the skilled nursing facilities because a lot of them are taking the old folks; they still have the schizophrenia and bipolar patients; but when those people get worse he or she may have dementia and that further complicates the issue.  He advised the dementia patients may have other comorbidities; Wuesthoff Rockledge does not take any dementia patients; so even if a person has another mental illness if he or she has dementia they cannot go to Rockledge.  He advised if a person has a serious enough medical illness Circles of Care cannot take those people because it is a medical issue.  He stated he had a case a few days ago where he evaluated a patient for a Baker Act; the patient was violent; he hit two women; and he had to be gotten out of the facility.  He advised DCF was called to investigate and DCF said the other residents have to be safe; he sent the patient to Holmes Regional Medical Center for a medical evaluation to see if he could be sent to Circles of Care; they were told there was a waiting list at Circles of Care; and Holmes Regional was stuck with that patient and most of his issues were mental issues.  He stated that is one of the big problems they have as sometimes there is no place to send the elderly because he or she is too sick to go to Circles of Care but if they have dementia they cannot go to Wuesthoff Rockledge either; and they are caught between a rock and a hard place.  He stated one of the other issues they are facing in the skilled nursing facilities is that the State has cut funding for everyone; he is the President the Florida Medical Directors Association, Brevard County Association, and Chairman on the Brevard Commission on Aging; recently the funding for nursing homes has been cut because of Medicaid; they used to require 2.9 hours of CNA time per day; and now because of cut funding it has been reduced to 2.6 hours.  He stated it is a difficult problem for everyone; and he wanted to give the perspective from the skilled nursing facilities and assisted living facilities. 

 

Commissioner Voltz requested that the audience introduce themselves and tell why he or she is present at the Workshop; and all of the audience members stood and introduced themselves.

 

Commissioner Voltz stated the homeless people are a tremendous problem; in the winter he or she knocks on the door at Circles of Care threatening suicide; and they have ways to get into the facility. 

 

Regina Friedman stated she is present to give her personal observation of why she feels an increase in crisis beds and Baker Act beds is so important at this time is because of the falling economy; there have been many commercials about people who have to eat cat food or dog food because he or she cannot afford to eat; and some people have to decide whether or not to pay for medication or buy food.  She stated she has examples of two people who have not been able to get medications; one is a member of the Drop-in Center who recently had to take a generic medication instead of the medication that was keeping him stable; generics are cheaper; and the gentleman could not afford to get the mediation he needed.  She advised the gentleman attempted suicide this weekend; she hopes he does recover; but if he does not it is a direct impact of the economy.  She stated another example is of another man who because of Medicare Part D and its donut hole will not be able to get his medication; he is psychotic; he has said he will commit suicide; but he is angry and he wants to take other people with him.  She noted it will impact the patient, the family, and the community at large. 

 

Freda Schildroth stated May 13^th Circles of Care had 18 people and Behavior Health had zero people waiting for a crisis bed; Circles of Care had 16 and Wuesthoff had zero court ordered and waiting for long-term care; the worse case scenario for April was 22 for Circles of Care and seven for Wuesthoff Hospital; and that is how many days people were waiting to get a bed.  She advised Parrish Medical Center had 35 for the month of April and the worse case scenario was 12 days; Cape Canaveral had ten Baker Act clients; worse case scenario was five days; Palm Bay Community Hospital received six Baker Act clients; and the worse case scenario was five days.  She noted the Jail had 1,872 inmates on April 30, 2008; and the Jail had 1,772 a year ago.  She stated she is concerned that if Wuesthoff Rockledge closes and there is no Baker Act receiving facility in Central Brevard County that more people will end up in Jail; there has to be a receiving facility that they can get the client to quickly; the Jail is better equipped to handle mental patients than it used to; but the Jail is not the place for people with mental illnesses. 

 

Dr. Stephen Cotton stated he is the President of the Psychiatric Group that advises Psychiatrists for all of the hospitals; this all began in 2001; the hospitals were having a great deal of difficulty getting psychiatrists to come to the hospital to see those patients who had an acute crisis; his group responded to a Request for Proposals; and they won the contract and began to work to have psychiatrists come into the community in a private practice setting that could then respond to the hospital’s needs.  He stated for six years now there has been a very stable system; and now the Baker Act crisis is the first real threat that he has seen.  He advised a private-practice psychiatrist who goes into the hospital cannot bill for that service; when there ends up being up to five or six patients a day it begins to be a system that just does not work very well; so for the first time they are having a serious question about the ability of the psychiatrist’s to continue to involved with the hospitals to take care of those patients that have been admitted.  He advised they are also involved with the in-patient at Wuesthoff; it has been a very important part of what they do; and a very important part of the community to have those resources.  He stated it is difficult to have a large number of patients who are not able to pay for the service; and it can be some of the time but not all of the time as it becomes untenable.  He stated he would hate to see it reach the point that not only can the hospital not do it but them as a private practice group can no longer be involved in going to the hospitals to take care of these folks; and he is here today to be part of the effort to ask the support of the community to provide services for the patients who really need this service. 

 

Commissioner Voltz stated Louis Iparraguirre had to leave the Workshop early and asked her to read a letter to the Board.  She read, as follows:  “I am a SCAT Bus operator in the South County area.  I am also a member of Space Coast NAMI, and previous VP and President of NAMI South Brevard, a Member of Congregations for Community Actions, and the father of a 30-year old son diagnosed with Paranoid Schizophrenia when he was 18.  I’m also a friendly acquaintance and supporter of Jim Whitaker and I participate in some of the homeless surveys that Rosa Wright conducts annually.  My son was Baker Acted twice in the late 1990’s and has been under medication and psychiatric treatment since then.  He has recovered 70 percent since his diagnosis.  He is very stable and productive in this capacity.  Thank God for treatment.  Thank God for medication.  Thank God for Baker Act beds.  His goal, before he was treated, was he wanted to be homeless.  I invite you to hop in a bus on Route 21, or better yet 21A.  They are free of charge for Melbourne residents including the homeless, they are residents as well, and as co-workers put it, they are outdoor residents of Melbourne, and I will give you a free transfer so you can ride for free all day long on the other routes.  Not only will you experience the essence of the homeless population, the riders to no where in need of mental health programs, but capture the problematic mental health issues, lack of affordable housing and assisted living that our County is sweeping under the bushes, streets, and buses.  If Jim Whitaker had a way to put Baker Act beds behind the mall, at Daily Bread, or in our public transportation system I’m sure he would have done it by now.  He deserves a lot of credit for what he has creatively done about the Baker Act beds, but he needs more help to utilize his resources 100 percent.  His patients are waiting on the streets and so are the Jail inmates at Sharpes that has no place to send them.  Let us be pro bono publico to our residents in general by supporting mental health and Baker Act beds.”

 

Sheriff Jack Parker stated he wants to give the highest level of praise possible to Amal Miller and Wuesthoff, and to Jim Whitaker of Circles of Care; the reality of it is that it was an absolute crisis three years ago; and if it was not for these two gentlemen and their leadership it would have collapsed upon itself.  He stated Mr. Miller and he has had conversations in the past because they knew it was bad but there was hopefully light at the end of the tunnel; the State initiative of reducing the number of State hospitals was phase one; and phase two was pushing all of that money into the local communities for mental health care.  He advised that the State did a great job with phase one, but it forgot about phase two.  He stated the other thing that always causes him concerns is how Brevard County stacks up against other counties and the fact that Brevard has been stagnant for so long and Mr. Whitaker has been having to do a juggling act to make things work; it is just breaking down now; he appreciates all of the words about partnership because it is critical; it is the State’s responsibility to do this; and by pulling back and not being at the table, there is desperation to try to pick up and do the responsibility that it is required to do.  He stated the Board should be applauded; there has been tremendous things done in the past that are kind of overlooked; there is the creation of the CIT training, and creation of the mental health cell block in the Jail so the deputies can deal with those people who unfortunately end up there; the Sheriff’s Office does its best not to send people who have mental health problems to the Jail; and if those people can be diverted from the criminal justice system a much better job is done than it used to be.  He stated the Board approved the Coastal Contract for picking up Baker Act’s from law enforcement on the side of the road and getting them to either Wuesthoff or Circles of Care; those were incredible advances to making sure that the law enforcement officer who is making a decision between a criminal charge and a Baker Act always makes the right decision because it is easy to make the right decision and get those people the care he or she needs; there has been tremendous improvement on the local level; but there is a lot of disappointment on the State level.  He stated he is very concerned about the point that Wuesthoff is at right now because they are at their breaking point; they were probably three years ago; but he has asked them to try to hold on and hopefully the Calvary is coming, more State funds are going to come down, and Medicaid is going to get better.  He stated he stands in support of Amal and Wuesthoff and Jim and Circles of Care; he will do everything he can from the Sheriff’s Office point of view; and try to help with this incredible problem.

 

Commissioner Colon stated the Sheriff thanked everyone, and rightly so.  She stated the Sheriff should give credit to himself because of the fact that he grabbed the bull by the horn; that is where the folks were going; a huge percentage of the inmates were folks that were mentally ill; and what was wonderful about the partnership is that the Sheriff had that compassion as he was very interested in knowing what other communities were doing.  She advised the Sheriff went to Palm Beach to find out what that community was doing; he came back to Brevard and gave it his all; and Paul Rumbley’s participation was huge.  She suggested that Sheriff Parker share with the community the things the Sheriff’s Department did, which was that outside of the box thinking; then partnering with others in regards to the pods; and further requested that the Sheriff speak about things he actually implemented.

 

Sheriff Parker advised there is no way to say no to Freda Schildroth and Regina Friedman; they were so instrumental in this from the very beginning as they were such great communicators; it was not them telling the Sheriff how to do things better it was facilitating cooperation between all of the parties so things could be made better in Brevard County; in spite of all of the challenges there is one heck of a system locally; everyone is committed, including Coastal and any of the hospital systems; and everyone is committed in making the situation better.  He stated as far as what the Sheriff’s Office did, they did it as part of a team; the support of the Board to build that pod is a major improvement in the lives of the people who were at that Jail; there are people who do go to jail who have mental illnesses; and he or she has committed a criminal act and there is generally a victim.  He stated there is one example of the person who did not go to Jail and there was a victim; there is a lot of that happening now because when the Sheriff’s Office gets to the scene there may be cause for a criminal offense; the deputy tries to weigh it out; and if it possible not to levy that criminal offense and instead get that person to where he or she can be cared for.  He stated many times the level of injury is too extreme and the deputies have to take action; even though there may be a legitimate mental illness there has to be an arrest effective because it is too dangerous of a situation; and that is why there has to be a Jail setting that does accommodate that.  He advised the pod is a 346-bed pod; and gave thanks to Commander Jeeter because the pod is done, she has opened it up, it has two 78-person dormitories, and it has a special intensive acute area for those who are really problematic so they can be watched.  He stated there were five suicides the year before he took office and that was a fairly big issue; big jails such as Brevard County’s usually average two to three suicides a year; and he has had an average of one suicide every other year.  He stated he is very proud of what the Board, Commander Jeeter, correctional staff, and Orville Clayton and his team has done; Commander Jeeter has also been instrumental in the CIT training to train law enforcement officers and correction officers in how to deal with people who have mental illness as effectively as possible; and Melanie Goff is an expert and was instrumental in helping put that together.  He stated how the Sherriff’s Office can respond to someone who is in crisis without elevating the situation to becoming a barricaded suspect in a suicide situation without it getting really bad; and so there is a lot more training today than was had years ago.  He stated it comes down to resources, and there are not enough resources when it comes down to Baker Act beds.

 

Commissioner Bolin advised she was fortunate to have Commander Jeeter take her on a tour of the facility last week; she has been here long enough to see the before and after; and it is quite an improvement and a fine facility.  She requested that the Sherriff help the Board; the sheriff offices throughout the State of Florida are a close knit group and they communicate; and requested that anything the Sheriff hears that might help the Board locally she would appreciate him relaying it to the Board as fast as possible.  She stated it is a crisis and she does not know how much time there is to solve it before it gets beyond control.  Sheriff Parker stated Brevard County may be worse off than other counties when it comes to the number of beds per capita; everyone across the State is having the same problem; and the two people who really have the answers are Jim Whitaker and Amal Miller who know what it will take to be successful in the short and long-term, and hopefully between the two of them can give a corrective action thought of how the Baker Acts beds can survive and Brevard County can be improved.

 

Commissioner Voltz stated that Mr. Miller talked about a two-fold Baker Act for people who are medical and people who are just there for Baker Act; and inquired if Mr. Miller means to leave the medical part of the facility open or close the entire thing.  Mr. Miller responded it is a two-step Baker Act designation in-patient psychiatric unit; stated when he was talking about commingling the patients they were holding whether it be Wuesthoff Melbourne or Rockledge that is not unique; but he is talking about the designation as a Baker Act receiving facility, which they are the only one that has that currently, and the in-patient 17 beds.  He stated they could drop out of the Baker Act, keep the unit open, but he is not sure that doing so would be a solution for them as there are some patients that come through in Baker Act status that provide a level of reimbursement that is good for the in-patient unit.  He stated they could discontinue both or just discontinue Baker Act. 

 

Commissioner Voltz stated Chairman Scarborough mentioned the cost of Baker Act beds at Wuesthoff is far greater than the cost of beds at Circles of Care.  Mr. Miller advised he would have to get the Board those hard numbers.

 

Treasurer of Circles of Care David Feldman stated he met with Wuesthoff yesterday and tried to discuss some of the issues.  He stated Wuesthoff is stuck with a 17-bed unit; the math of a 17-bed unit, given the current rates that are reimbursed by third party payers, just does not work; and he does not think it will work in the future.  He advised the difference with Circles of Care is that it loses so much less because it can spread that cost over 52 beds as it has a private and public unit.  He stated the cost at Wuesthoff is close to $900 a day; and the best payer at Circles of Care is $750 a day, plus doctor.  He advised years ago Medicaid paid based on a blended rate through a hospital, a psychiatric unit would get reimbursed with other costs thrown in like cardiac care, obstetrics, and everything else, so they would get back over $1,000 a day; the State ended that for everyone; and now they pay Circles of Care $650 a day all inclusive of a doctor.  He advised there was a better rate ten years ago than today.  He stated Circles of Care has a facility in Rockledge that has been rented to Devereaux for years; they have looked at that to be a CSU for quite a lot of years; and never could do it as the math will not work.  He stated the State will give Circles of Care $448 a day next year; with picking up most of Wuesthoff’s paying patients if they were out-of-business they could get by on $1.6 million and provide 20 beds of which would stay 100 percent full; but then 20 beds will not be the answer either as it would just replace what left. 

 

Mr. Miller stated there is advantage to having the medical side of care underneath the same roof as opposed to transferring medial patients back and forth to other hospitals, and the infrastructure and training that would have to go into all of the hospitals in Brevard County. 

 

Mr. Feldman stated in a perfect world there would be a psychiatric bed in a general hospital but the State created Crisis Stabilization Units strictly to drive the costs down; his version is a hospital version; there are only six mental health center hospitals in the State; so they have a lot of that expense.  He stated the unit at Sheridan Oaks costs more because there are elderly people there; it has more technicians; it is about $530 a day; the Baker Act unit is $448 a day and that includes everything; and Circles of Care breaks even at $448 a day. 

 

Chairman Scarborough stated one of the reasons he thinks it is good the Workshop was held today is because when there is no money and everything is going the wrong way the Board cannot let the system fall apart; with the jail there was a suicide that happened; and the trouble is hitting on crime and homelessness, and none of these things sit in isolation. 

 

Chairman Scarborough stated the Board has been told more beds are needed and it sounds like it is not going to happen; it sounds like Wuesthoff is being pushed to the point that they are going to have to make decisions; it would be a shame to walk away; but it would be nice to meet with this group to see if there is a consensus.  He stated he does not mind voting for some money; it will be a difficult vote; but the Board cannot let a whole system fall apart.  He requested Commissioner Voltz undertake that task and thanked her for today.  Commissioner Voltz stated she will do that.  She advised there is also the Brevard Healthcare Network.  Mr. Kendig stated the Community Mental Health Solutions Task Force has served the Board well, brought people to the table, and worked things out; and it is established and has good staffing with it.  Commissioner Voltz stated when talking about the Board funding some of those, maybe it may be better if she meets with the rest of the hospital CEO’s and Mr. Kendig to see what can be worked out.  Mr. Kendig advised it should not be a problem for any of them at any time.

 

Commissioner Colon stated the County has about $20 to $30 million that will not come to Brevard County so it is already in the hole; and she wants to make sure people know this as it is a huge number.  Chairman Scarborough stated the Board is going to have to cut programs depending on how valuable it thinks having a viable service for those persons who do suffer; it is not those people’s fault; but he or she can do terrible violence to themselves and others and the Board cannot just walk away.  He stated the Board appreciates the dedication, competency, and professionalism of the people present at the Workshop today because the Board would not be sitting there but for them bringing the issue to it in such a great forum.

 

Commissioner Nelson stated George started with the fact that there is an issue that both the hospital and the Board has; the problem is really the State because it has not stepped up; Sheriff Parker made that point very clear; he was the first one to really talk about the gorilla as the State has not done its share; and he hopes the Board, if it finds itself in the position where it does fund additional dollars for mental health, that it is used as leverage against the State.  He noted it is amazing that with the Sheriff and mental health people out there that there has been so little impact on the problem from the State.  He advised it will be a tough budget year; if the Board finds itself in that position he would like to see the Legislative Package include something that indicates that the County has stepped up to the plate; and if the Board cannot do anything else but embarrass the State, that would be fine.

 

Commissioner Voltz stated that is why she wanted to bring the issue up because it has been in the County’s Legislative Package; but there has not been a concerted effort by the Board or the community to do something; and should go to the State in mass to do something about it.

 

Commissioner Nelson stated mental health issues in the community are out there; a person can think about his or her own neighborhood and some of the circumstances that he or she runs into; those problems are not getting fewer; and that is troubling as there are a lot of folks out there who frighten people. 

 

Chairman Scarborough stated some of the most violent things that have happened in Brevard County have happened because of mental illness; and anyone who wants to forget some of those things are really walking the wrong path. 

 

Commissioner Voltz inquired if Circles of Care provides free or semi-free medications for mental health patients; with Mr. Whitaker responding Circles of Care works with the drug companies who have programs that give out free medication and they do all the paperwork so people can get the free medication.  Mr. Whitaker advised Circles of Care also does the Schedule D donut hole and will carry people until he or she gets onto regular schedules; with a lot of the HMO’s they have to fight hard because they want to push everything back to generic drugs; and for some people generics do not work. 

 

Commissioner Voltz stated when someone is discharged from Circles of Care he or she is discharged with an appointment, prescription, and a follow-up; a lot of times a person cannot get transportation to the facility; and transportation has become a big issue. 

 

Commissioner Colon stated looking at the whole picture Brevard County is really on its own; yesterday she was at a graduation and she was able to speak with Dr. Murray regarding the School Board; she asked how is the School Board doing based on the fact that other counties are having to let go of teachers; and inquired how desperate is the State.  She stated the School Board had to think outside the box and so far it does not look like the teachers in Brevard County will be effected; it is due to the leadership and creative thinking by the School Board; and reiterated that it basically comes down to Brevard County is on its own.  She stated it is going to depend on the Board to try to figure it out.  She stated crime prevention dollars, at risk programs, and senior programs have been cut by the State; and the budget cuts this year will be huge.  She advised she is proud of the School Board; and she does not know how it did it when she knows the neighboring counties have laid off teachers.

 

Commissioner Voltz advised she will be in touch with the other participants of today’s Workshop setting up some meetings before July 15^th.

 

 

 

Upon motion and vote, the meeting adjourned at 4:18 p.m.

 

 

 

ATTEST:                                                        

                                                                         _________________________________

                                                                         TRUMAN SCARBOROUGH, CHAIRMAN

                                                                         BOARD OF COUNTY COMMISSIONERS

                                                                         BREVARD COUNTY, FLORIDA

__________________

SCOTT ELLIS, CLERK

       (S E A L)