Grading the States 2006: Nevada - Narrative
Nevada offers excellent transparency into the workings of its mental health system, and provides an expanding array of high quality services, but the needs of those with mental illnesses are outpacing the capacity of facilities and services, particularly in Las Vegas. The city, commonly associated with high rollers, wealthy real estate magnates, and fun times, has become overwhelmed by growing numbers of mentally ill people in need of treatment, and lacks adequate infrastructure or funding to address those treatment needs.
To the outsider, Nevada is perceived as a wealthy state with two large population centers - Las Vegas in the South, and Reno and Carson City in the North - where 85 percent of the state's population is concentrated. In fact, most of Nevada is extremely rural, with few communities and even fewer mental health resources. In 2004, Clark County formally declared a "public health disaster" because large numbers of people with serious mental illnesses - and nowhere else to go - were occupying hospital emergency rooms in Las Vegas. Even the population centers have been ill-equipped and ill-prepared to provide high-quality treatment and services to people with serious mental illnesses.
On a positive note, the Nevada Division of Mental Health and Developmental Services is not trying to hide these problems. In fact, the Division in recent years has frankly acknowledged high levels of unmet need among people with serious mental illnesses in the state, and has engaged in a number of efforts to try to bridge these gaps.
While there are examples of excellent programs and services emerging, Nevada continues to face numerous obstacles and barriers in its efforts to develop a statewide system of high-quality services and supports. Growing numbers of people with serious mental illnesses seek treatment in the emergency rooms of Nevada's general hospitals. This increasing burden on emergency rooms, law enforcement, and other "front-line" crisis responders reflects an overall lack of programs designed to address treatment needs before they become acute emergencies. The Las Vegas Sun has reported that on any given day, 60 to 100 people with mental illnesses seek help, cannot get it, and end up in emergency rooms.
The Nevada legislature has approved funding for the construction of a new, 150-bed psychiatric hospital in Las Vegas, slated to open later in 2006. In view of the rapid growth in the population of Las Vegas in the 1990s, construction of a new psychiatric hospital would make sense. The potential development of a triage center in Las Vegas to provide crisis services would be helpful as well. However, the overall lack of housing and community-based mental health services - in Las Vegas and throughout the state - contributes significantly to the growing numbers of people in emergency rooms, jails, and other crisis environments.
Although the benefits of Assertive Community Treatment (ACT) in reducing hospitalizations is well established, there currently are only three ACT teams in Nevada - two in the Las Vegas area, one in the Reno area. This is not nearly enough to address the needs of people with schizophrenia and other serious mental illnesses who reside in dense urban centers. Those groups must have access to intensive and multiple around-the-clock services.
Homelessness and lack of supported housing options also are significant problems in Nevada. The Division acknowledges that homelessness in Nevada appears to be higher than the national average, and, while the Division works with housing and homeless service providers to use federal resources such as PATH and Shelter Plus Care to address the housing needs of these individuals, it appears that these services are concentrated primarily on people who are currently homeless, not on people who are at imminent risk of homelessness if they do not receive the services they need. The Division must expand its collaborative efforts to create an array of supportive housing options for people with serious mental illnesses if these problems are to be meaningfully addressed. And these efforts must extend to the rural regions of the state. Rates of homelessness in these regions also are significantly higher than the national average.
Finally, although some efforts are being made to improve services for people in rural sections of the state, the services that are available are basic, with large gaps from region to region. Although it is clearly a challenge, the state must increase its efforts to address the needs of persons with serious mental illnesses in these rural regions by using telepsychiatry, implementing satellite clinics, providing psychiatric beds in rural hospitals, and providing services through rural community health clinics.
Despite its many problems, Nevada is making progress in improving its mental health system, thanks in no small part to strong leadership within the Division. Since FY2003, there has been a 33 percent growth in the state's mental health budget.
Budget increases have made possible the development of 98 new staff positions primarily devoted to direct services. Due to the continuing emergency room crisis in Las Vegas, it is very possible that additional staff increases will be forthcoming.
Nevada's jails, like those throughout the nation, contain a disproportionate number of inmates with serious mental illnesses. These jails are not set up or staffed to provide quality mental health treatment. Between 1999 and 2003, there were 12 suicides in the Clark County Detention Center, many of which involved inmates with serious mental illnesses and substance abuse disorders. In an effort to address this, the Nevada legislature since 2003 has provided funding for mental health courts in the state. And the Division has sunk some of its own resources into mental health court support services - specifically, $640,000 in FY2004 and FY2005 for services such as supportive living assistance and intensive service coordination. There are currently two Mental Health Courts in Nevada - one in Clark County, the other in Washoe County (Reno).
At the prodding of Nevada State Senator Randolph J. Townsend, who served on the President's New Freedom Commission on Mental Health, the Nevada legislature established a Nevada Mental Health Plan Implementation Commission in 2003, with the specific goal of developing an action plan to operationalize the recommendations of the New Freedom Commission. This plan was completed in 2004 and includes 239 recommendations for developing a more effective mental health system. The success of this commission ultimately will be determined by whether these recommendations are implemented.
The Division is engaged in ongoing efforts to reduce the use of restraints and seclusion in its psychiatric treatment facilities. And in response to a little-known but disturbing statistic that people with serious mental illnesses die of HIV infections at four times the rate of the general population, the Division was instrumental in obtaining a federal Ryan White grant to serve HIV-positive people with mental illnesses in Las Vegas.
Finally, the Division deserves praise for its willingness to be transparent and open about the performance of the mental health system it operates, including both its strengths and problem areas. This is best illustrated by a 2005 report posted on the Division's website entitled "How Nevada Stacks Up: National and Regional Comparisons of Nevada's Public Mental Health System." This report provides performance data on a number of measures and compares it with national data, as well as with data from neighboring states drawn from the Center for Mental Health Services' (CMHS) Uniform Reporting System. In some areas (e.g., the amount spent per person served, and consumer satisfaction) Nevada rates high relative to neighboring states. In others (e.g., the proportion of people with mental illnesses served, and Medicaid funding of mental health services), Nevada rates lower than most of its neighbors. Most importantly, the Division is willing to post information about these performance measures for all to see and pledges to use this data to improve services and to continue measuring its performance. This is truly an exemplary practice that should be emulated by all states.
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