In the Hill Country, a new state psychiatric unit stays empty while waitlists swell

This article was published by the Houston Chronicle on February 21, 2023.

KERRVILLE – Overlooking the Guadalupe River in this bucolic city northwest of San Antonio, the sleek new facility at the Kerrville State Hospital was designed to offer the latest in modern inpatient psychiatric treatment.

Completed last fall at a cost of more than $30 million, the 70-bed facility was built to ease a costly and inhumane clog. The waitlist for state psychiatric hospital admission has ballooned to 2,500 people statewide. Criminally charged patients requiring high security wait an average of a year and a half to get in. Most mark time in county jails until a scarce bed opens up.

On a recent tour of the brand-new unit here, Tod Citron, head of the local Hill Country Mental Health & Developmental Disabilities Centers, recalled leaving impressed — and befuddled.

“It was state of the art,” he said. “And completely empty.”

Officials for the Texas Health and Human Services Commission, which oversees the state’s nine adult psychiatric hospitals, confirm the pristine facility has lacked a crucial component since its completion nearly five months ago: actual patients. Despite the desperate need, Kerrville’s six dozen new beds have remained untouched because Texas has been unable to find people to work there.

The hospitals face the same economic headwinds as many other employers: higher wages and fewer workers. Yet Kerrville’s hiring problem also is the latest development in a slow-motion, long-term disaster with consequences that echo far beyond the state hospitals.

County leaders say their local jails must spend millions of dollars every month for mental health treatment and housing that should be provided by the state facilities. The lengthy waits stall court cases, slowing down a system already bogged down by COVID-related delays.

And everyone agrees the backup at the psychiatric hospitals is failing thousands of mentally ill patients, who at best languish in cells while waiting for a treatment bed, and at worst never make it out of the jails alive before a slot opens.

“This has been going on for many years,” Rep. Toni Rose said at a House budget hearing last week. Rose represents Dallas, where the Morning News recently reported a mentally ill patient had been stuck in the jail for five years. She said she had tracked the growth of the lengthy waitlist problem since 2001, when she worked at the facility.

“And here we are in 2023, and all it’s doing is getting worse,” she said. “You all are hearing the stats and numbers. I see faces. I see the people impacted by this.”

‘No. 1 issue’ for law enforcement

Until relatively recently, Texas psychiatric hospitals primarily housed so-called civil commitments — people who needed a place to recover from a psychiatric emergency that rendered them a danger to themselves or others. Ordered there by a judge or checked in voluntarily, in 2001 about 85 percent of state hospital patients met this definition.

Since then, the typical patient seen at Texas state hospitals has changed radically. By the mid-2000s, nearly half of the residents were “forensic” commitments who arrived through the criminal court system.

Some are declared not guilty of a crime by reason of insanity. Most are people charged with serious crimes whose psychiatric disorders are so severe that they are considered incapable of standing trial. Mental health staffers use medication, therapy and time to restore their mental competency enough to face charges in a courtroom.

Texas’ psychiatric hospital census officially flip-flopped in 2016, when forensic patient admissions for the first time officially outnumbered civil commitments. Today, two-thirds of state hospital patients arrive via the criminal courts.

The switch has forced the hospital system to dramatically alter its operations. High-security settings require more employees and money.

Forensic patients also typically spend more time in psychiatric hospitals than civil commitments. In addition to restoring their competency, for example, staffers also must guide forensic patients through a months-long course on the criminal justice system, adding time to their commitment, said Andy Keller, chief executive of the nonprofit Meadows Mental Health Policy Institute.

On average, the Texas state hospitals also take longer to restore a patient’s competency than other, community-based hospitals, he added. As a result, the forensic shift has slowed the patient churn the system depends on to work, creating a growing logjam. After dipping before the pandemic, the average time a forensic commitment must wait today is 272 days — 621 days for those requiring maximum security.

Because many waiting for a psychiatric bed have been accused of crimes, they can end up lingering in county jails, which have had to adjust to provide more and more space for their mental health inmates.

At the end of last year, 382 inmates at the Dallas County jail — 6 percent of its total population — were waiting for a state bed to open up so their competency could be restored, according to a letter the county sent last month to the Health and Human Services Commission threatening to sue over the cost. Men requiring a maximum-security psychiatric bed waited an average of 831 days in jail, the letter said, adding that in December alone, the Dallas inmates-in-limbo cost local taxpayers more than $5.5 million.

The Bexar County jail had 288 inmates awaiting competency restoration, Rep. Trey Martinez Fischer, D-San Antonio, added at last week’s budget meeting. Of those, he said, 44 had been there more than 500 days.

Even outside big cities, “it is a huge issue,” said Rep. David Spiller, R-Brownwood. In the nearly 30 rural counties he has represented, “if I polled every sheriff and asked them, ‘What is the No. 1 issue affecting you in law enforcement right now?’ they would say mental health. At any given time, 30 to 35 percent of their jail population is made up of mental health folks.”

Frustrated by the growing waits, Harris County, whose jail is often referred to as the state’s largest mental health facility, recently announced it was doubling a local program to help restore competency to jail inmates. “I think we would all rather see people be restored to competency in the hospital,” Wayne Young, CEO of The Harris Center, which operates the county’s mental health services, told the Chronicle.

“But unfortunately there’s 2,500 people on that waitlist, and the alternative is that they continue to linger in jail.”

700 of 2,300 beds offline

Situated on an old dude ranch, the Kerrville facility initially opened as a tuberculosis sanatorium for African American patients. Purchased by Texas in the early 1950s, the facility initially treated mentally ill geriatric women. It later widened its doors as the Kerrville State Home, and by 1959 had 1,200 patients.

The hospital’s mission has evolved with advances in how mentally ill patients are treated. In response to the growing need to treat court-ordered patients, the Kerrville State Hospital was designated a secure forensic-only unit with a capacity of 270 patients.

With patient waitlists growing and its psychiatric facilities in need of repairs after years of neglect and deferred maintenance by state lawmakers, in 2017 the Legislature committed $2 billion to update the state hospital system over the next decade. Some facilities were slated for total replacement, while others were targeted for expansion.

Although the Kerrville addition added only 70 beds, it was seen as crucial to easing the immediate need. While the backlog of beds for patients who don’t need the extra security has leveled off, the waitlist for maximum security spots has continued to climb.

“It will help dramatically on our waiting list,” Mike Maples, a deputy executive commissioner for HHSC, said in a video introducing the project. (The agency declined to make any executives available for an interview and said it could not accommodate a facility tour.)

Construction began in August 2020. Slated for completion in September 2021, the project was finally ready for move-in a year late. By then, there was no one to work there. The number of psychiatric patients waiting for a high-security forensic bed has climbed by 60 since then.

Charts depicting the state hospital system’s workforce shrinkage show a steep and steady decline since COVID’s arrival in early 2020. By the beginning of 2023, it was short about 1,800 workers, Scott Schalchlin, a HHSC deputy executive commissioner, told legislators last week. The shortage has kept more than 700 of the system’s 2,300-bed capacity offline. Health officials said Kerrville’s new unit needs 260 employees to open.

The state of Texas isn’t the only employer experiencing post-COVID worker shortages. Yet thanks to the hurdles of a cumbersome bureaucracy, it has been slower to adjust, said Keller, citing other Texas psychiatric hospitals’ ability to raise wages more quickly and remain fully staffed.

The state acknowledged it had fallen behind on pay rates and bumped compensation for psychiatric hospital positions last spring and again earlier this month. The latest starting salary for nurses will jump from $57,000 to $69,000; psychiatric nursing assistants can expect starting pay of $16 an hour, up from $12.50.

Keller applauded the efforts to attract more workers. But, he added, he worried that without also increasing wages for workers at local psychiatric facilities, state hospitals would plunder their staffs and simply move the shortage elsewhere. “I’m worried about robbing Peter to pay Paul,” he said.

Others pointed to longer-term issues that have dogged the state’s ability to find and keep employees. The latest raises put state hospital nurses, who work under trying conditions, at about the state average — even as Texas faces a statewide nursing shortage. The new wage for psychiatric nursing assistants is comparable to those offered at Buc-ee’s.

“When we’re in the people-helping business,” Rep. Jarvis Johnson, D-Houston, said the recent budget hearing, “from the state of Texas we are nickel and dime it. Then we get this problem. And here we are.”

The story is available on the Houston Chronicle’s website here.