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New Jersey Department of Human Services Division of Mental Health and Addictions Services

Plan for the Closure of Senator Garrett W. Hagedorn Psychiatric Hospital

Submitted for review to: State Mental Health Facilities Evaluation Task Force

October 2010

Chris Christie, Governor Kim Guadagno, Lt. Governor Jennifer Velez, Commissioner

Table of Contents


Executive Summary........................................................................................ 1 Introduction .......................................................................................................... 3 Hospital Overview



Why Hagedorn? ................................................................................................ 8 Is One Year Realistic? ................................................................................... 15 The Closure Process ..................................................................................... 17 Ingredients for Success ................................................................................ 20 Communication ................................................................................................. 32 Hagedorn Employees ................................................................................... 33 Advisory & Oversight Processes ............................................................ 37 Evaluation ............................................................................................................. 38 Closing Ceremony ........................................................................................... 38 Property ................................................................................................................. 38

Executive Summary

The Senator Garrett W. Hagedorn Psychiatric Hospital (HPH) Closure Plan outlines the context for closing the hospital and describes the activities that will be undertaken by the Department of Human Services' (DHS) Division of Mental Health and Addiction Services (DMHAS) to close the facility, provide quality, evidence-based care to older adults, and assist consumers,1 families, and staff with the transition. The hospital is located in Glen Gardner, Hunterdon County and is proposed for closure on June 30, 2012. The proposed closure advances DMHAS' commitment to reducing reliance on institutional services and expanding the community-based mental health system, evidenced by a system-wide 26% inpatient census reduction. These successful efforts are consistent with the United States Supreme Court decision in Olmstead v. L.C. 527 U.S. 581 (1999), which mandated that individuals with mental illness receive treatment in the least restrictive and most integrated setting as clinically appropriate. The Hagedorn Closure Plan (HCP) details the logical next step to rebalance limited resources within the mental health system. In 2006, the DHS' DMHAS (then the Division of Mental Health Services) initiated its recovery-oriented, community service model. As embodied in the recommendations of former Governor Richard Codey's Mental Health Task Force (2005) and DMHAS' Wellness and Recovery Transformation Plan (2008), "Home to Recovery" Plan (2008) and the Olmstead Settlement Agreement (2009), this new direction resulted in an additional $80 million in funding and a dramatic expansion of community services and placements that began in FY 2007 and are planned to continue through at least FY 2014. Between FY 2006 and 2009, these funds were responsible for 1,424 new community placements, and an additional 251 placements have been developed in FY 2010, dramatically expanding housing options for mental health consumers in all 21 counties. These include 201 placements for hospitalized consumers who are clinically-ready for discharge as well as 50 placements for consumers residing in the community who are at substantial risk of hospitalization. The acute care system has expanded to 401 Short Term Care Facility (STCF) beds that will also divert hospital admissions. The DMHAS has implemented a vast array of evidence-based practices to support individuals in the community, and continues to explore and pilot innovative programs. For most consumers, community-based treatment and living are both desirable and feasible. Further, DMHAS redesigned its state psychiatric hospitals within this community-based context. All hospitals have admissions units that provide treatment and return individuals to the community without requiring longer-term hospitalization. Consumers who are hospitalized for longer periods receive active treatment throughout their inpatient stay with planning for eventual discharge. The expectation is that most consumers will be treated successfully and released. As a result, the census at the four general adult psychiatric hospitals has been reduced by 572 (26.3%) from the July 2006 census of 2,173 to the census of 1,601 reported at the end of September 2010. Based upon the state hospital system's operational capacity compared to its occupancy as of September 30, 2010, there were 302 available beds at Ancora, Greystone and Trenton; some of these beds are on units that have been closed to optimize cost savings but can be reopened, while others are on occupied units but will be consolidated to provide separate units to treat older adults. It is projected that as a result of its compliance with the Olmstead Settlement Agreement, DMHAS will be able to further reduce the census by June 30, 2012, allowing for the responsible closure of Hagedorn. These census reductions will be sustainable. Beginning in FY 2010 through FY 2014, DMHAS will develop an additional 695 community placements for individuals who are currently hospitalized, and 370 placements to divert

1 Mental health consumers are individuals receiving treatment for a mental illness or disorder. The term suggests that these individuals can exercise choices regarding the types of services they use and their providers. The term will be used here in lieu of either client or patient.


hospital admissions, particularly among individuals in the community who are at risk of homelessness or institutionalization and who cycle in and out of acute care services including designated screening services, emergency rooms, early intervention support services, intensive outpatient services or psychiatric inpatient services.2 These additional placements will contribute to reduced lengths of stay at each of the state hospitals, and further census reduction. While there is still a need in New Jersey for long term level care provided in the state psychiatric system, the decline in the hospital census, both current and anticipated, allows for a redistribution of resources that will advance community integration for mental health consumers, while generating cost savings at a critical juncture for the state budget. The closure of a state psychiatric facility is reasonable given the system transformations over the past five years in both the hospital census and in community placements and services. It is critical that the Department act on these changes now. This HCP outlines the reconfiguration of the state hospital system and the closure of HPH by June 30, 2012. With this closure, the State will realize an estimated $9 million net savings in FY 12, annualizing to approximately $44 million, assuming the reduced disproportionate share hospital revenue (DSH) cannot be supplanted by qualifying expenditures from another source. Among the reasons for selecting HPH for closure were the following: · Closing Hagedorn and retaining three regional hospitals will preserve geographic accessibility to inpatient services. · Ancora and Trenton Psychiatric Hospitals operate and share complicated utility infrastructure with other state and private agencies on their campuses. Hagedorn's infrastructure is largely self-contained and not enmeshed with that of other organizations. · Hagedorn's lack of designation and security to serve the forensically-involved population would create access issues. · Hagedorn's census is the lowest of the four adult general state psychiatric hospitals. · Its closure will yield $9.5 million in infrastructure capital cost avoidance. The HCP provides a multi-stage process in which Hagedorn closes to new admissions beginning in July 2011, and the service catchment areas for the remaining three state hospitals are reconfigured to accept admissions currently served by Hagedorn. Available but vacant units at the remaining hospitals will be used to serve consumers requiring ongoing inpatient care after June 30, 2012. Discharge-eligible Hagedorn consumers will be placed in a clinically diverse range of community settings. Older adults requiring continued inpatient care will be transferred to alternative state hospitals. They will not be placed on units with a younger or forensic population. This process provides more opportunity for consumers to be treated in a hospital closer to their home communities. The closure of Hagedorn impacts a wide range of community stakeholders as well as its staff, consumers and their families, and loved ones. DHS and DMHAS had begun the process of engaging these individuals and organizations, prior to the formation of this task force, but will resume discussions as the process unfolds. Through a combination of advisory groups, town hall meetings, public hearings, and the timely dissemination of relevant information, policies and protocols, all those who are interested in or affected by the closure will be kept informed and have an opportunity to be heard. Affected staff at Hagedorn will be offered vacancies based on job classification seniority throughout the Department of Human Services and an employee resource and information center will be established at Hagedorn to assist staff with identifying employment opportunities. The DMHAS also will implement measures and oversight to ensure that, throughout the closure process, individuals who remain at Hagedorn and those who are either placed or transferred receive quality care. As such, an independent evaluation of consumer and family satisfaction will be conducted. The task force will report its findings and recommendations to the Governor and the Legislature no later than February 1, 2011.

2 It is common for such individuals to ultimately end up being admitted to a state psychiatric hospital for an extended period of time to stabilize psychiatric conditions. Once hospitalized, discharge is difficult because the individual does not have stable housing in the community. These diversionary placements should help to reduce use of long-term state psychiatric hospitals by this population


Introduction: A Milestone in the Transformation Process

The proposed closure of Senator Garrett W. Hagedorn Psychiatric Hospital and the reconfiguration of New Jersey's state psychiatric hospitals represent a significant achievement for a public mental health system that has substantially reduced reliance on institutional systems of care and expanded opportunities and supports for community living. This increasingly recovery-oriented system enables individuals to live in the least restrictive and most integrated setting appropriate to their clinical needs. The goals of wellness and recovery are central to all New Jersey Division of Mental Health and Addiction Services (DMHAS) planning processes, including its Wellness and Recovery Transformation Action Plan (2008),3 "Home to Recovery" Plan (2008)4 and the FFY 2010 Community Mental Health Plan and Block Grant (expiring 8/31/11),5 They are further reflected in the Olmstead Settlement Agreement reached in 2009 with Disability Rights New Jersey which seeks to ensure that individuals at state psychiatric hospitals who are deemed discharge eligible by the courts receive appropriate services and timely discharges into the most integrated community setting given their clinical status and personal preferences.6 To support its wellness and recovery goals, DMHAS initiated an expansion of community services and residential options that began in FY 2007 and will continue through FY 2014. Over $80 million in new funding has been expended to expand access to community-based services. This infusion of funds has contributed to the development of affordable, permanent housing and support services for mental health consumers, expansion of the state's acute care system facilitating diversion and local treatment for serious mental illness, and consumer-driven treatment options and evidence-based practices both in the community and state psychiatric hospitals. The additional funding and services have produced substantial reductions in New Jersey's state hospital population. From FY 2007 through September 2010, the state hospital census has declined by more than one-fourth (26.3%). This census reduction allows for a rebalancing of resources that will generate cost savings at a critical juncture for the state budget, while preserving geographic accessibility to inpatient services, addressing long-term inpatient staffing needs, and advancing progress in community integration for mental health consumers consistent with the Olmstead Decision and the State's Olmstead Settlement Agreement. Reconfiguration of the state psychiatric hospitals is not only feasible, but an appropriate response given the progress that has been made since FY 2006. To date, DMHAS, has responded to its declining census by closing hospital units. · At Greystone Park Psychiatric Hospital, the state closed the original facility and constructed a new hospital, closing thirteen of twenty transitional cottages on the hospital grounds. · At Ancora Psychiatric Hospital, five units with capacity for 150 consumers have closed, and · at Hagedorn and Trenton Psychiatric Hospitals, each has closed one unit. In addition to unit closures, the census on active units has also fallen. There are 168 vacant beds on active units at Ancora, Greystone and Trenton Psychiatric Hospitals, while Hagedorn's census is 42 below capacity. By utilizing about 134 beds on closed units that the Division can re-open and vacant beds on active units that can be filled there is currently unused capacity at Ancora, Greystone and Trenton hospitals for 302 consumers from Hagedorn. The Division will also be developing placements with additional funding from its Olmstead initiatives for discharge-eligible hospital consumers. These placements prioritize consumers who are currently discharge-ready. With 26.7% of Hagedorn's census on Conditional Extension Pending Placement (CEPP), a substantial portion of that hospital's census has been determined by the courts as eligible for discharge. Of the remainder, some will be discharged when stabilized and others may continue to require hospitalization. Additional placements will be created to divert those who are at risk of a state psychiatric hospitalization, thus minimizing unnecessary admissions.

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Given the fixed administrative and operational costs of maintaining hospitals, the State has determined that it is more fiscally efficient to close a facility rather than continue to close units. The State's budget deficit is not the only or even the primary reason for reconfiguring the state hospital system. However, despite savings that have been realized through reduced overtime and unit closures, a disproportionate amount of resources is dedicated toward keeping people institutionalized. Approximately 37% of the DMHAS state budgeted resources support the state psychiatric hospitals,7 but these facilities serve only 1% of the individuals served annually by the Division. Conversely, 99% of consumers served by the Division in the community are funded by only 63% of its resources. Given the state's economic crisis, it is more fiscally responsible for the state to rebalance resources to community services rather than to maintain four general psychiatric hospitals with sizable fixed facility costs, when substantially fewer state hospital-level beds are needed. The Division's progress under Olmstead and the need to utilize resources efficiently are significant factors in the closure decision. New Jersey's situation is not unique. A briefing for Congress prepared by the National Association of State Mental Health Program Directors (NASMHPD)8 found that as of December 2009, 41 of the 45 states responding to a survey anticipated state budget deficits in 2010 and 73% (33 states) expected deficits in 2011. Legislatures have responded by imposing median reductions of $12.9 million in 2010 for mental health budgets. The median percentage cut for state mental health appropriations was 4.7%.9 While only 3 states expect to make cuts of over 10% in 2010, 8 states expect to make cuts of over 10% in 2011. State mental health agencies have responded to budget cuts with: · reductions in administrative expenses (95%) · hiring freezes (90%) · reductions in community funding (81%) · employee furloughs (55%) · closure of state hospital units (48%) Twenty-five states have eliminated 1,858 state hospital beds with an additional 894 beds under consideration for closure. In addition, nine states of the 45 reported they either have closed or are considering closing state psychiatric hospitals. Included are four nearby states. Since 2005, Pennsylvania has closed two psychiatric hospitals and plans to close another, Allentown State Hospital, by December 31, 2010.10 Massachusetts also closed one of its state psychiatric hospitals in a nine month period, Westborough State Hospital, in SFY 2010.11 Maryland has closed two state hospitals in the past year, following census reductions at its facilities.12 Ohio has closed two facilities since 2008 and anticipates consolidating two additional facilities within the next two years.13


OlmsteadThe decision to close a state psychiatric hospital balances civil rights, the prudent allocation of resources, and the wellness and recovery principles guiding DMHAS' mission. For years, the mental health community has been advocating for a smaller patient census, improved quality of care, and a stronger community-based system. Each of these is successfully occurring right now. A significant achievement in New Jersey's mental health system has been progress under Olmstead v. L.C. 527 U.S. 581(1999).14 The 1999 U.S. Supreme Court decision prompted states like New Jersey to enhance protection of individual civil rights by ensuring that services are delivered in the least restrictive and most integrated setting. A lawsuit filed by Disability Rights New Jersey in 2005 that was aimed at accelerating progress was settled last summer15 and further solidifies the Division's commitment to the Olmstead principles. While the Olmstead decision does not require states to close state psychiatric hospitals,

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10 11 12 13 14 15

State of New Jersey Fiscal Year 2010-2011 Appropriations Handbook NASMHPD Research Institute (NRI). (2010). The impact of the state fiscal crisis on the public mental health system. [Powerpoint presentation]. Congressional Briefing, February 24, 2010. The median is the mid-point, with half of the states with reductions that are less than the median and half with reductions greater than the median. When the range of values is great, the median is a more accurate description of central tendency than the numeric average. In this case, the median is $12.9 million, while the average is $21.8 million. See See Bradley, S. (April 27, 2010). Personal Communication to M. Kruszcyzynski, DMHAS. Personal communication. NASMHPD, April 22, 2010. Olmstead v. L.C., 527 US 581 (1999). See


states across the country continue to close their state facilities because of a diminishing need for and reliance upon this level of care. Some proponents of keeping state psychiatric hospitals open argue that they are needed. However, the fact is that 37% of New Jersey's state hospital census in September 2010 has been determined by the courts to no longer need state hospital level care.16

Benefits of Hospital Closure & Reconfiguration

With the publication of the Surgeon General's Report on Mental Health17 came evidence of the widespread impact of mental illness on American society, affecting one-fifth of all Americans in a given year. At the same time, the report provided evidence for a range of well-documented and effective treatments for most mental disorders. This growing emphasis on evidence-based practices has transformed mental health care and brought new promise for wellness and recovery for mental health consumers and their families. Where decades ago consumers spent much of their time in institutional settings, they now can expect to enjoy improved lives and longevity in integrated community settings. State budgets that primarily were devoted to institutional care expend a larger share of their mental health funding on community services while maintaining access when needed to inpatient treatment. In 1981, states spent 63% of their mental health budget on inpatient care and about 33% on community-based services.18 By 2005, these proportions had been reversed, with 70% of State Mental Health Agency (SMHA) funding allocated to community-based mental health services and 27% to inpatient care. New Jersey has shown a similar pattern of change, with the state in 2008 spending 69% of its mental health budget in the community and 29% in its institutions (inclusive of State and other resources). About 1% was spent on SMHA support. As shown in Table 1, NJ ranked 9th nationally in per capita mental health expenditures, spends less per capita than Pennsylvania and New York, which are ranked 4th and 5th, respectively.19 More importantly, New Jersey ranks 4th in the nation in per capita state hospital expenditures. This contrasts with its ranking of 10th nationally in community-based mental health expenditures. New Jersey spends more per capita than all but three other states on its state hospital services. It is ranked 7th in the number of hospital beds in use per 100,000 population. Only Alabama, Delaware, North and South Dakota, New York and Vermont have more beds per 100,000 population.20 The state has made substantial progress in its expansion of community services and ranks 3rd nationally in per capita expenditures for residential services, which have been critical in diverting hospitalizations and shortening hospital stays, thus providing the opportunity for re-aligning resources.21

16 Office of Olmstead, Research, and Evaluation. Data as of September 30, 2010. 17 U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon GeneralRockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. 18 The remainder was spent on State Mental Health Agency (SMHA) support services. See National Association of State Mental Health Program Directors (NASMHPD) Research Institute (NRI). State Profile Highlights. November, 2007. 19 NASMHPD Research Institute (NRI) State Mental Health Agency Profiles Systems and Revenues Expenditures Study. Revenues and Expenditures Reports from 2008. Table 8. See: 20 Lutterman, T., Berhane, A., Phelan, B., Shaw, R. & Rana, V. (2009). Funding and characteristics of state mental health agencies, 2007. HHS Pub. No. (SMA) 09-4424. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, page 45. 21 NASMHPD Research Institute (NRI) State Mental Health Agency Profiles Systems and Revenues Expenditures Study. Revenues and Expenditures Reports from 2008. Table 5. See:


TABLE 1 Per capita expenditures for state psychiatric hospital and community-based inpatient services for selected states, 2008

State Hosp State Per Capita NJ NY PA D.C. ME $57.96 $62.02 $41.09 $169.08 $42.53 Rank 4 2 14 1 11

Community Per Capita $136.35 $158.19 $230.98 $178.78 $288.66 Rank 10 7 3 5 1

Total MH Per Capita $196.86 $230.80 $273.01 $381.90 $341.34 Rank 9 5 4 1 2

Source: NASMHPD Research Institute (NRI) State Mental Health Agency Profiles Systems and Revenues Expenditures Study. Table 8: SMHA Mental Health Controlled Per Capita Expenditures for State mental Hospital Inpatient Services, Community Services, and Research, Training and Administration, 2008. Note: Research, training and administration included in total mental health but not elsewhere in table.

New Jersey's focus on wellness and recovery for persons with serious mental illness is reflected in state budgets and planning documents including the recommendations of former Governor Codey's Mental Health Task Force (2005), the New Jersey's Division of Mental Health Services' Wellness and Recovery Transformation Plan (2008), the "Home to Recovery" Plan (2008) and the Olmstead Settlement Agreement (2009). Governor Codey's Task Force stated as its first recommendation that, "The public mental health system must continue to move from an institutional system of care to a community based system of care grounded in principles of wellness and recovery." New Jersey has developed and continues to fund a substantial range of evidence-based practices to support individuals with serious mental illness in the community, provide active treatment in the hospital and prevent the longterm hospitalizations that make community transitions more difficult. A 2009 report by the National Alliance for the Mentally Ill (NAMI) shows New Jersey with more hospital beds per 1,000 population than any other state (22.1) with only the District of Columbia having more per population.22 Closure of state psychiatric hospital beds, units and now Hagedorn Psychiatric Hospital is consistent with the state's wellness and recovery objectives and New Jersey's accomplishments. People should not remain institutionalized if, with appropriate supports, they can be integrated into their local communities. Hospital reconfiguration will benefit New Jersey consumers and families because individuals will receive clinically and age-appropriate services in facilities that are in most cases closer to their home communities, facilitating family contact and timely discharge.

22 Aron, L., Honberg, R. & Duckworth, K., et al.. (2009). Grading the States 2009: A Report on America's Health System for adults with Serious Mental Illness. Arlington, VA: National Alliance on Mental Illness, 34-35.


Hospital Overview

The Department of Human Services maintains five state psychiatric hospitals. In addition to Ann Klein Forensic Center (AKFC) (200 beds) in Ewing Township which provides care and treatment in a secure setting to individuals with mental illness involved with the legal system, there are four regional psychiatric hospitals serving a general adult population with serious mental illness: Ancora Psychiatric Hospital (APH) located in Camden County, Greystone Park Psychiatric Hospital (GPPH) in Morris County, Senator Garrett W. Hagedorn Psychiatric Hospital (HPH) in Hunterdon County, and Trenton Psychiatric Hospital (TPH) located adjacent to AKFC in Mercer County. Their locations are shown in Figure 1. Each of the four general adult psychiatric hospitals serves identified catchment areas:23 · Ancora Psychiatric Hospital is a 635-bed adult psychiatric inpatient facility serving residents from Atlantic, Camden, Cape May, Cumberland, Gloucester, Ocean and Salem counties. APH is also designated by Administrative Order as a facility that serves forensic consumers. Greystone Park Psychiatric Hospital, with a 510-bed capacity, consists of a new facility that opened on July 16, 2008 and cottages for individuals ready for transitional housing. Greystone serves residents from Bergen, Essex, Hudson, Morris, Passaic, Somerset, Sussex, and Warren counties and is designated to admit certain categories of legally-involved individuals. Trenton Psychiatric Hospital is a 500-bed psychiatric hospital located in Mercer County that shares its campus with Ann Klein Forensic Center and serves residents from Burlington, Mercer, Middlesex, Monmouth, and Union counties. The hospital has been designated to serve forensic consumers. The Senator G.W. Hagedorn Psychiatric Hospital is a 300-bed psychiatric hospital that historically served residents from Warren, Somerset and Hunterdon counties as well as a statewide geropsychiatric population. Administrative Order 1:90 explicitly precludes Hagedorn from admitting forensic consumers.

FIGURE 1 Locations of State psychiatric hospitals, FY 2010




23 The capacity reported for each facility is based upon the facility's maximum operating capacity.


Why Hagedorn?

In March 2010, the proposal to close HPH and reconfigure the three other state adult psychiatric hospitals was announced. The recommendation to close Hagedorn resulted from careful deliberations regarding possible options. Discussions focused on several considerations, including overall feasibility within a reasonable timeframe, facility census at each of the hospitals, statewide geographic inpatient accessibility for mental health consumers, capacity to serve a significant legally-involved population, financial considerations, and campus interconnectivity.

Facility Census

Hagedorn has the lowest census of the four regional adult psychiatric hospitals; in September 2010 the census was 258 residents compared to Trenton's census of 406, Greystone's census of 473 and Ancora's census of 464. Like the other hospitals, Hagedorn has experienced census reduction, and as of September 30, 2010 had a census that was 42 below total unit capacity. Of Hagedorn's population of 258, a total of 68 or 26.7% are currently on Conditional Extension Pending Placement (CEPP). Through its Olmstead initiatives, DMHAS will be continuing community placement efforts for consumers on CEPP status within 6 months of their CEPP designation. In FY 2010, DMHAS created an additional 201 placements statewide for consumers on CEPP status as well as 50 diversionary placements for individuals at risk of hospitalization.

FIGURE 2 Census at four state psychiatric hospitals. Source: Oracle hospital database, September 30, 2010


Geographic Accessability

Hagedorn serves a diverse statewide population. Historically, its geographic catchment area for 18-64 year olds included Hunterdon, Somerset and Warren counties. However, the Division has been moving its younger adult population from Hagedorn to Greystone. Warren County admissions shifted to Greystone in FY 2009 and Somerset County admissions were diverted to Greystone in July 2010. The census of younger adults from these two counties was 33 on September 30, 2010. The census from the remaining county, Hunterdon, was 9 on September 30, 2010. Obviously the smaller size of this population facilitates its reconfiguration to another general adult psychiatric hospital. In addition, the smaller number of counties (and persons) involved will also minimize difficulties in adjusting the schedules for court hearings held at the hospitals. Among 18 to 64 year olds, 73 come from counties other than Hunterdon.24 Some of County Hagedorn Census (9/30/2010) these individuals could be more appropriately served at hospitals that are situated closer to consumers' counties of residence. For instance, Ocean County sends a fairly significant number of consumers to Hagedorn; families of these consumers will no longer have to travel to North Jersey to visit a relative who has been hospitalized. Hagedorn also serves a statewide population of adults 65 years and older. Hospitalizing some of these older adults in facilities closer to home will improve discharge planning and facilitate family involvement. In fact, the TPH catchment area has the highest number of older adult admissions and the highest number of total admissions. Dedicated geropsychiatric beds at Trenton and Ancora will allow for clinically-appropriate and age-specific treatment for individuals requiring this level of care, with admissions from the southern counties served at APH, and admissions from the central and northern counties to be served at TPH. Furthermore, 2008 population data from the Department of Labor and Workforce Development suggest that the coastal and southern counties have the highest proportions of elderly residents in the state, with Ocean, Cape May, Atlantic and Salem counties ranked in the top five.25 A reconfiguration of the areas served by the three remaining state psychiatric hospitals still situates a general adult psychiatric hospital in each of the state's three regions. Figure 3 (next page) displays the current catchment areas for each hospital shown on the left, while the anticipated reconfigured catchment areas and hospitals are shown on the right.

TABLE 2 Hagedorn census by age group and county Source: Oracle hospital database, September 30, 2010.

24 In three cases, the county is unknown (See Table 2). 25 See Economic Indicators article published July 2009, and also county data for July 1, 2008 by selected age categories for both males and females


FIGURE 3 Comparison of hospitals and county catchment areas prior to (left) and following hospital reconfiguration

Consumers with Legal Involvement

Another factor considered in the decision to close Hagedorn is the designation of this hospital by the Commissioner of the Department of Human Services under N.J.S.A. 30:1-2.4 as a facility that cannot admit individuals with legal involvement. True forensic consumers include those judged "not guilty by reason of insanity" (NGRI/KROL); civilly-committed sex offenders and Megan's Law registrants;26 Department of Corrections or jail inmates hospitalized for psychiatric treatment (Detainer); Department of Corrections Megan's registrants whose sentences have "maxed out" but who are not considered able to be safely released;27 and individuals who are "incompetent to stand trial" (IST). It is more realistic economically, politically, and clinically to enable the other hospitals to enhance their geropsychiatric capabilities than to prepare Hagedorn and its surrounding community for forensically-involved patients. Under N.J.S.A. 30:1-2.4 the Commissioner of the DHS has discretion in determining the most appropriate settings in which to serve legally-involved mental health consumers. Under Administrative Order 1:90,28 the Commissioner designated psychiatric hospitals that could serve consumers with current legal charges. Ann Klein Forensic Center, as New Jersey's only forensic facility, is designated to serve all legally-involved consumers, including those

26 Sex offenders falling under Megan's Law registration requirements. 27 Convicted sex offenders who have maxed out of DOC prison sentences and have been transferred to DMHAS for treatment. 28 See


with the most violent charges. Ancora, Trenton, and Greystone are designated to serve some legally-involved consumers. Currently, Hagedorn is the only one of the four general adult psychiatric hospitals that is not designated through Administrative Order as able to accept individuals with legal involvement.29 It also lacks the physical plant and staffing security that exists at the other facilities. Nationally, state hospitals are playing more of a role in treating this forensic population and a declining role in cases of general civil commitment.30 A study of trends in state hospital use showed increased admissions in eleven states from 2002 to 2005 that were primarily attributable to a single factor, the increase in forensic admissions.31 Reports suggest that the proportion of forensic admissions can range from 35% to as much as 69% of state hospital patients.32 In Ohio, 60% of all hospitalized consumers in general facilities have legal involvement.33 With the decline in New Jersey's state hospital census, the overall proportion of legally-involved consumers has been increasing and now constitutes about one-third of consumers (with AKFC included).34 As of January 30, 2009, the unduplicated number of legally-involved consumers at each state psychiatric hospital was as follows: 155 at Ancora, 115 at Greystone and 79 at Trenton. Hagedorn had one, admitted by exception due to advanced age and/or special medical needs. It is essential that New Jersey maintain its capacity to serve a growing forensic population. To retain Hagedorn and close another facility would necessitate a redesignation of the hospitals in the system and a concomitant change in Administrative Order, a separate public hearing and process, and additional expenditures for physical plant and human resource security improvements for patient, staff and public safety at Hagedorn consistent with what exists at Ancora, Trenton and Greystone.

FIGURE 4 Legally-involved consumers, 4 adult state psychiatric hospitals Source: Oracle Hospital Census database as of January 30, 2009 for FY 2010 Appropriations Hearings Briefing.

29 Section IV.D. of Administrative Order 1:90 permits limited exceptions on a case by case basis. 30 See Bloom, J.D., Krishnan, B. & Lockey, C. (2008). The majority of inpatient psychiatric beds should not be appropriated by the forensic system. Journal of the American Academy of Psychiatry and the Law, 36, 4, 438-442. and Levin, A. (2009) State hospital admissions on unexpected upswing. Psychiatric News, 44, 3, 8. 31 Manderscheid, R.W., Atay, J.E., & Crider, R.A. (2009). Changing trends in state psychiatric hospital use from 2002 to 2005. Psychiatric Services, 60(1), 29-34. 32. Atay, J.E., Crider, R., Foley, D., Male, A.A., & Blacklow, B. (2007). Background Report, Admissions and Resident Patients, State and County Mental Hospitals, United States, 2005. Rockville, MD: Center for Mental Health Services. See also State Forensic Mental Health Services, 2004, State Profile Highlights. Alexandria, VA: National Association of State Mental Health Program Directors Research Institute, 2005. 33 Personal communication. NASMHPD, April 22, 2010. 34 Personal communication. R. Eilers, June 2, 2010.


Cost Savings

Ample research suggests that the cost of providing community-based care is less than institutional care. These findings also apply to the care of older adults. An evaluation by St. Dennis et al. (2006) compared the costs of community-based services to hospital care for gero-psychiatric patients discharged into the community following the closure of a state inpatient gero-psychiatric unit. The researchers found that the costs for community-based services were significantly lower than comparable hospital care.35 The closure of Hagedorn and the reconfiguration of the remaining facilities will help the state address its budget deficit and avoid additional infrastructure expenses while continuing investments for Olmstead. Savings come primarily from reductions in operating costs (i.e., salary and non-salary) and overtime. As shown in Table 3, the total net cost savings to the State's FY 2012 budget is about $9 million and about $44.1 million for FY 2013.

TABLE 3 The $11 million reduction in hospital operating costs in FY Projected cost savings of hospital reconfiguration (millions) 2012 include salaries, overtime savings at Hagedorn, and other non-salary operating expenses of the facility, such as decreased maintenance and utility costs. The closure also will allow DMHAS to better meet its long-term staffing needs and reduce overtime costs, yielding reductions of about $901,000 at the other state psychiatric hospitals. The state will also receive less DSH (Disproportionate Share Hospital) revenue for low-income individuals not covered by public or private insurance due to the decreased census,36 about $2.9 million in FY 2012. Therefore, the total savings in FY 2012 is anticipated to be about $9 million.37

The impact on the census of the closure of the hospital to admissions will be immediate, occurring early in FY 2012; the impact of discharges and transfers will be felt more radually until the facility closes at the end of the fiscal year. Starting in FY 2013, savings in operating costs at Hagedorn will increase by a factor of five, to $57.519 million. However, there will be a loss of $13.43 million in DSH revenue, resulting in total savings of about $44 million in FY 2013 after Hagedorn closes.38

Infrastructure Cost Avoidance

Although a new building was constructed in 1998, there exist urgent facility-wide infrastructure costs at Hagedorn that still would have to be addressed should the facility remain open. These costs do not exceed those of other facilities, but they represent an added expense, $9.5 million for new capital budget requests and current projects that will now be avoided. Included are asbestos abatement, water tower refurbishment, roofing, water and wastewater treatment, elevator repair, phone system upgrades and a host of other projects essential to maintenance and ongoing life safety. Capital expenditures for security improvements also would be necessary for patients, staff and public safety.

35 St. Dennis, C., Hendryx, M., Henriksen, A.-L., Setter, S.M., and Singer, B. (2006). Postdischarge treatment costs following closure of a state Geropsychiatric ward: Comparison of 2 levels of community care. The Primary Care Companion to the Journal of Clinical Psychiatry, 8(5), 279-284. 36 Loss of DSH revenue is a product of a decreasing census, not closure. DSH revenue would be lost even if Hagedorn remains open. In addition, additional DSH revenue will be lost as a result of the Patient Protection and Affordable Care Act (PPACA); these additional reductions have not been determined. 37 Projected savings are based upon conservative projections of census reduction; other models that predict greater census reduction would yield greater savings than shown here. 38 There has been some discussion about privatization of a facility. Privatization would yield administrative savings, but there would still be fixed costs of operating facilities that may no longer be necessary.


Campus Interconnectivity

Most state psychiatric hospitals share their campuses with other state and/or community agencies. Hagedorn hosts only one community provider, Freedom House, on its campus, and offices of the New Jersey State Police and the Department of Human Services Police. Relocation of these agencies is more feasible than reconfiguring the other campuses. Ancora, shares its campus with the following State and private entities: · · · · Bayside State Prison, Ancora Unit, operated by the Department of Corrections (281 prisoners) Veteran's Haven, a 54-bed residential facility, operated by the Department of Military and Veteran's Affairs Two private, not-for-profit organizations that provide residential services on grounds Division of Mental Health and Addiction Services Southern Regional Office

All of the utilities for these agencies reside on the same system that is hosted and operated by Ancora. As a result, closing Ancora would have a significant negative impact on these facilities, while significant capital expenditures would be needed for them to become self-sufficient. Also Ancora recently has expended several million dollars to replace its wastewater treatment facility by connecting to the Camden County Municipal Utility Authority (CCMUA). The presence of these other agencies constrains the facility's re-sale potential and redevelopment of the campus would be limited as these other agencies remain functional. The campus boundaries are deed restricted as Open Space by agreement with the Pinelands Commission. Trenton Psychiatric Hospital shares its campus with the following agencies: · Department of Corrections Central Reception and Assignment Facility (CRAF), which houses the central processing unit for all adult males sentenced to the Department of Corrections, and is responsible for providing intake examinations as well as medical, dental, educational and psychological evaluations before objectively classifying all state sentenced inmates. CRAF processes over 600 individuals per year. · Ann Klein Forensic Center (AKFC) operated by the Division of Mental Health and Addiction Services (200 patients) · Department of Transportation, which operates a vehicle maintenance facility · Department of Human Services Police, which occupies "Our House" building Like Ancora, Trenton provides the underground steam system (heat and hot water) for all facilities on its campus. Closing Trenton would therefore require that these other facilities invest significant funds to become self-sufficient. The complexity of the campus would also limit its redevelopment options. Greystone, which hosts the state's newest, state-of-the-art psychiatric facility, has a residential provider on grounds that operates ten cottages for individuals transitioning to the community and, which shares some utilities with the hospital.


Comparative Fiscal Analysis

The goals of a state hospital closure are to balance the sizing of the state hospital system, the State's responsibility in providing for consumer needs, and the prudent management of resources. The intent is not solely about budget savings; otherwise, a larger State hospital would have been chosen with a more extended period to effect closure. The operating budget for each hospital is driven by several factors. Operating costs, physical plant layout and composition, shared resources, patient attributes and volume, concomitant staffing composition and volume, and other factors are included. For revenues, disproportionate share hospital (DSH) reimbursement, Medicaid, Medicare, county cost sharing, insurance coverage and other revenues offset State costs indirectly by being paid directly to Treasury. Proponents for keeping Hagedorn open have asserted that it is the most cost efficient hospital to operate. As stated above, there are several factors involved when the Division of Mental Health Services Central Office establishes and manages hospital budgets. As the state hospital system is reconfigured, the per person costs at the remaining hospitals will decrease further. Rebalancing the hospital system also will result in revenues being reallocated, thus further reducing the operating costs at the remaining hospitals. Nevertheless, once Hagedorn is closed, the State will realize significant savings to the system, and still be able to support community placements. Hagedorn currently receives higher Medicaid revenue in relation to its population, which reduces the proportion of the total operating cost of the hospital funded with state resources. The current configuration of New Jersey's state hospital system accounts for Hagedorn's larger share of Medicaid revenue. Reconfiguration of the state hospital system will enable the Division to claim similar levels of Medicaid revenue, while reducing expenses spread over five campuses. Each of the hospitals is considered an Institution for Mental Disease (IMD) by the Federal Government. As such, they are excluded from Medicaid reimbursement for individuals between 22-64 years of age. Each of the hospitals can and does claim Medicaid reimbursement for treatment delivered to consumers outside of this age range, including older adults. Because Hagedorn currently has a significant proportion of the State's older adult population, it claims more Medicaid revenue than other hospitals. However, as the other hospitals assume responsibility for gero-psychiatric care, they will draw down the federal offsetting Medicaid revenue for eligible consumers. A complicating factor for the state hospital system budget that will materialize over the next three years is a significant loss of Disproportionate Share Hospital (DSH) revenue. Disproportionate Share Hospital (DSH) payments provide financial support to hospitals that serve a disproportionate number of low-income patients; eligible hospitals are referred to as DSH hospitals. States receive an annual DSH allotment to cover the costs of DSH hospitals providing care to low-income patients whose care is not reimbursed by other payers, such as Medicare, Medicaid, or other health insurance.39 An immediate loss of revenue will occur with the end to stimulus funding from the American Recovery and Reinvestment Act of 2009. The ARRA included a percentage increase in DSH revenue based upon per capita income and unemployment rate, and brought an additional $1.88 billion in DSH revenue to New Jersey in 2009-2010. In addition, under the Patient Protection and Affordable Care Act (PPACA), states will face significant reductions to DSH revenue as more people avail themselves of health insurance coverage.40 These revenue reductions will occur regardless of whether inpatient utilization declines. The state psychiatric hospitals whose costs are underwritten with significant DSH revenue will lose a portion of this funding starting in 2014. This revenue will not be compensated for by Medicaid for people in the 22-64 age range, because the federal government designates state psychiatric hospitals as IMDs. This loss of federal revenue will have a significant impact on the State's ability to cover expenses in its state psychiatric hospitals.

39 40


Closing units as the census has declined has resulted in savings over the past two years primarily in the area of overtime as staff who work in closed units have been redeployed to the remaining open units. However, closing additional units while retaining all of the regional adult psychiatric hospitals is not an efficient long term solution, because of duplicative administrative overhead and fixed facility maintenance costs. It is unclear at this time whether privatization of the state hospitals, as suggested by the New Jersey Privatization Task Force,41 would yield additional administrative savings. Nevertheless, privatization does not address the issue of excess capacity by operating five hospitals - any discussion of privatization should pertain to four state psychiatric hospitals, rather than five. Long term retention of all four of the non-forensic state psychiatric hospitals with the attendant physical plant operating and capital costs, as well as administrative and support costs spread over increasing smaller populations is untenable. Consistent with the provisions of the Olmstead Settlement Agreement, the Division's focus has been on the assurance of care in the least restrictive and most integrated setting, consistent with individual clinical and legal need and personal preference. Some individuals using inpatient services in state psychiatric hospitals are now being served in the community as additional community resources have been made available; the population in state psychiatric hospitals has been declining as a result. With regard to remaining hospital inpatient bed need, the Division has focused on maintenance of reasonable geographic access, the continued provision of appropriate active treatment and quality care, and the efficient use of state resources. Together, these factors make a compelling case for closing a state psychiatric hospital and, in particular, for closing Hagedorn rather than another of the State's general adult state psychiatric hospitals.

Is One Year Realistic?

Typically, the closure of a state psychiatric hospital takes several years from the date of the announcement. In most instances, a closure is deliberated and announced, planning for discharge and transfer occurs, bridge funding is established for community programs, and then, the closure occurs over a period of time ranging from 1 to 3 years. The entire process therefore usually takes 2 to 4 years. However, because of New Jersey's significant investments in community services and successful efforts under Olmstead over the past five years, the community mental health system has been prepared in advance of a Hagedorn closure announcement to serve individuals no longer needing hospitalization, while the hospital system has sufficient unused capacity to consolidate services in fewer facilities. Essentially, much of the de-population necessary to facilitate a closure within the hospital system has already occurred. These tandem developments make closure of Hagedorn within a shorter timeframe feasible. The pace of this closure process, given the community development that has taken place over the preceding four years, and the additional development that will occur over the next four years, is therefore reasonable.

TABLE 4 Population projections 2009-2014 for New Jersey population and state psychiatric hospital admissions, 65+ years old Source: U.S. Census Bureau


41 The New Jersey Privatization Task Force Report, May 31, 2010. 42 See . Projected state hospital admissions were calculated by adding the percent population increase over the prior year to the hospital admissions for the prior year. Admissions for 2009 are average monthly admissions obtained from the Hospital Census Monthly Reports, Division of Mental Health Services. Calculations by the Office of Olmstead, Research and Evaluation.


The closure does not involve discharging all current Hagedorn consumers into the community. Instead, its success is contingent upon the continuation of the current census reductions occurring at the other hospitals, freeing up hospital beds that could be occupied as needed either by individuals at Hagedorn who are not ready for discharge or by individuals who would previously have been admitted to Hagedorn but will now be served at another facility. There are currently 302 available beds at Greystone, Ancora and Trenton Psychiatric Hospitals. Census reduction should yield at least an additional 50 beds before the end of FY 2011. As a result, inpatient beds should be available for consumers needing them. Re-shaping of discharge practices, balancing of county catchment areas and improvements at the hospitals have served to further lay the foundation for hospital closure. The U.S. Census Bureau provides annual census projections by age group. In 2005, projections were developed on an annual basis through 2020. These projections show a 27.8% increase in older adults through 2020 and an 11.4% increase through 2014. Based on these figures, in 2014 one would expect an additional 2 admissions per month or 24 per year. By 2020, there would be an average of 20 admissions a month or an additional 4 admissions per month and 48 annually. However, projected additional admissions (see Table 4) may not result in an increase in the hospital census. Population estimates from the U.S. Census Bureau show that the estimated number of older adults increased by 5% from SFY 2003 through SFY 2010. During the same timeframe, the census of older adults at the state psychiatric hospitals decreased by 5.6% (Table 5). Thus, a population increase can be addressed through community services expansion, reducing the need for state hospital-level care. Fiscal resources have created 1,424 community placements to serve individuals who are being discharged, some of whom will be Hagedorn consumers and others who will be discharged from other hospitals. Over $80 million of new community resources coupled with a $200 million Special Needs Housing Trust Fund (SNHTF)45 have served as "bridge funds" that have facilitated census reduction at the state hospitals and prepared the hospital system for a closure. An additional 230 community placements were created in FY 2010. In FY 2011, 145 community placements will be created for individuals with CEPP status, including those at Hagedorn. Seventy additional placements will be created for high risk consumers in the community to help divert state hospital admissions, resulting in a total of 215 community placements in FY 2011.

TABLE 5 5 Estimated state population, 65+ years and end of year census 65+ years at state psychiatric hospitals, SFY 2003-2009

43 44

43 See for state population estimates. 44 State Hospital Census Monthly Reports, Division of Mental Health Services. 45 The Special Needs Housing Trust Fund was established as a result of Governor Richard Codey's Mental Health Task Force to provide capital funds to create permanent supportive housing and is managed by the NJ Housing and Mortgage Finance Agency (HMFA).


The Closure Process

The Department is committed to a successful hospital closure process. The Department's plan for closing Hagedorn and reconfiguring the state hospital system will be implemented in three overlapping phases. During the first phase, all consumers at Hagedorn will receive clinical assessments of their discharge readiness and current service needs. Any consumer who is clinically determined to be ready for discharge prior to the closure of Hagedorn will be discharged into an appropriate community placement. Upon discharge, consumers will receive a minimum of 12 months of Integrated Case Management Services46 (ICMS) to link them to services and facilitate the transition into the community. Some consumers who may experience particular difficulty maintaining community tenure may receive PACT services (Programs of Assertive Community Treatment).47 During the second phase, the hospital will begin to divert new state hospital admissions to other hospitals. From now until July 2011, admissions to Hagedorn will continue from Hunterdon County and among older adults statewide as needed. In July, 2011, Hagedorn will close to new hospital admissions. From that point forward, younger adults who need state psychiatric hospital treatment will be admitted to the psychiatric hospital serving their county as shown in Figure 2. Older adults needing gero-psychiatric care from South Jersey will be admitted to dedicated gero-psychiatric beds at APH, while those from central and northern New Jersey will be admitted to TPH's dedicated gero-psychiatric beds. The reconfiguration of the hospital system will be designed to ensure that many consumers receive services near their counties of residence. During the third phase, consumers who are assessed as requiring longer-term inpatient treatment or who refuse community placement will be transferred to other state psychiatric hospitals. These transfers will be based upon the consumer's clinical needs, and will consider county of residence in order to facilitate family contact and eventual community placement. For many consumers these transfers will enable them to receive treatment closer to home. Older adults needing gero-psychiatric inpatient care will be transferred to dedicated gero-psychiatric units at Trenton or Ancora. It is anticipated that transfers will begin to occur after September 2011 for consumers needing continued commitment. As Hagedorn is closed to new admissions and consumers who remain are discharged or transferred to other hospitals, it will be possible to close units at the hospital and re-assign staff. However, consumers remaining at the hospital will continue to receive active treatment and appropriate staffing will be maintained to ensure quality care.

46 ICMS is a consumer-centered service provided predominantly off-site in the consumer's natural environment. Personalized, collaborative and flexible outreach services are designed to engage, support and integrate consumers, 18 years of age or older who are severely and persistently mentally ill, into the community of their choice and facilitate access to needed mental health, medical, social, educational, vocational, housing and other services and resources. 47 PACT is the most intensive program element in the ambulatory continuum of community mental health care and delivers comprehensive, integrated, rehabilitation,treatment and support services to those individuals most challenged by the need to cope with serious and persistent mental illness, as evidenced by either repeated hospitalizations or identification as at serious risk for psychiatric hospitalization. Services are provided in vivo by a multi-disciplinary service delivery team.


Individualized Assessment

Discharges and transfers will occur as the result of a clinically-driven assessment process in which consumers will be discharged into appropriate community placements with support services that enable them to maintain community tenure and transfers will ensure continuity of care and treatment. It also means that consumer preferences and family input48 will be incorporated into the assessment process. DMHAS has begun to collect clinical data about consumers at Hagedorn and is forming clinical teams independent of the hospital staff to conduct individual evaluations of consumers over 55 years old and/or needing possible nursing home referral to determine their clinical readiness for discharge or need for continued inpatient treatment. These independent clinical teams will be composed of clinical staff from the DMHAS Medical Directors' Office and geriatric specialists from the University of Medicine and Dentistry-New Jersey (UMDNJ). The independent clinical teams will be meeting with consumers' treatment teams and conducting their own evaluations when indicated. In addition to making recommendations to treatment teams at the hospitals, the independent teams will be compiling detailed clinical information for a comprehensive patient database that will be used for further planning. The timeframe for completing this process is the end of July 2011. This process will augment results obtained from the Individual Needs for Discharge Assessment (INDA). Currently the INDA is being used to evaluate the clinical and discharge needs of hospitalized consumers. The INDA is a multi-dimensional instrument completed by consumers' treatment teams that individualizes discharge planning and matches consumers with appropriate housing and community supports by examining personal strengths, needs, and barriers to discharge. Among the domains assessed are psychiatric rehabilitation, family supports, substance abuse, medical needs, functional needs, legal issues, finances, and motivation for discharge. Family input will be incorporated consistent with HIPAA regulations.49 The assessment process will incorporate consumer choice by eliciting consumer preferences regarding housing and supports. The Housing Preferences Interview (HPI) is a self-administered tool that examines the consumer's preferred living arrangement, including housing type, location and roommate preferences, the perceived need for assistance, and the services and supports needed in the community setting, including skill development, socialization/recreation opportunities, employment, education and illness management. The INDA and HPI assessments also are being augmented by information from community providers who have had contact with the consumer either prior to hospitalization or following admission. In addition, for individuals who may be appropriate for nursing home placement, a two-part PASRR (Pre-Admission Screening and Resident Review) assessment will be completed. This process is federally-mandated and designed to ensure only appropriate individuals are accepted into nursing facilities. According to the Centers for Medicare and Medicaid Services (CMS) website, "Federal law requires that a Medicaid-certified nursing facility (NF) may not admit an applicant with serious mental illness (MI), mental retardation (MR), or a related condition, unless the individual is properly screened, thoroughly evaluated, found to be appropriate for NF placement, and will receive all specialized services necessary to meet the individual's unique MI/MR needs." 50 This process is initiated when it is determined thata hospitalized consumer is a potential candidate for nursing home placement. The INDA will figure in the decision to make a referral for a PASRR assessment, along with the consumer's diagnosis, medical co-morbidity, and level of functioning. Federal and state laws require that all referrals to nursing facilities have a two-step PASRR screening. Staff nurses from the NJ Department of Health and Senior Services (DHSS) conduct an initial

TABLE 6 PASRR reviews at Hagedorn, CY 2007-2009

48 Consistent with HIPAA regulations 49 The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104-191) was enacted by the U.S. Congress and includes a privacy rule creating national standards to protect personal health information (PHI). 50


evaluation to determine whether a consumer meets the level of care requirements for a nursing home. If the consumer with mental health history qualifies for nursing home level of care, then he or she must also receive an independent evaluation by a psychiatrist or Advanced Practice Nurse, and this second level evaluation must be reviewed by the DMHAS PASRR Coordinator in order to determine whether the consumer's behavioral health treatment needs can be managed in a nursing facility. The INDA reviews and independent assessments being conducted at Hagedorn will assist treatment teams in determining whether all eligible consumers are being recommended for a PASRR evaluation for nursing home referral. DMHAS will be working with DHSS to facilitate PASRR reviews and identify other placement opportunities for older adult consumers who do not need continued hospitalization. When PASRR reviews indicate that consumers need a higher level of care than a nursing facility, they will likely require further treatment for behavioral problems or continued hospitalization. As of September 30, 2010, 26.7% of Hagedorn's census was designated CEPP; these individuals will need to be discharged. The assessments will be used to identify and expedite appropriate placements for them. For those who are not assessed as discharge ready or who refuse placement, assessments will be used to identify clinically-appropriate transfer placements and treatment needs. Other barriers to nursing home placement include difficulties meeting Medicaid funding/eligibility requirements or obtaining family/guardian consent for referral. DMHAS will be working with the Department of Health and Senior Services to refer these cases to the statewide Waiver Triage Committee,51 so that these barriers can be addressed.

Transfer Process

Consumers who are not ready for discharge will be transferred to other facilities, most in closer proximity to their counties of residence. The DMHAS has a protocol for such transfers, "Clinical Protocol Regarding Hospital Transfers," which is described in Administrative Bulletin 3:16.52 This protocol establishes requirements for the administrative transfers of state hospital residents from one facility to another, much of which was developed in preparation for the closure of Marlboro Psychiatric Hospital in the late 1990's. The transfer protocol: · ensures continuity of care · requires that the information and records transfer precede any movement of consumers · mandates direct communication between treatment teams and medical staff at the "sending" and "receiving" hospitals · provides for the full participation of family and community providers before and after the transfer · requires that the "sending" hospital prepare consumers in advance of the move for the impending transfer, providing time for the information to be processed and dealt with therapeutically. · requires the hospital to identify higher risk transfers, which include those where there is advanced age, medical or physical complications and/or limited capacity to change; in these instances, both the "sending" and "receiving" hospitals is required to take additional steps including direct contact between treatment staff at the two facilities. In addition, DMHAS will minimize hardships for families with relatives who have been transferred. Each hospital has an admission packet that will be provided to families of consumers being transferred that explains contact information, visitation, and other facility information. In addition, open houses may be arranged where families can visit the receiving hospital before the patient is transferred.

51 The Waiver Triage Committee is an intra-divisional committee that began March 19, 2009 and meets biweekly to discuss patients who have funding and/or placement issues. The committee consists of representatives from DHSS and the following DHS Divisions, DDD, DDS and DMHAS. Committee members are knowledgeable about Medicaid, waiver requirements, global options, funding sources and various placement options. As a result, patients with problematic funding and/or placement issues throughout the state are often referred to the committee. 52 See:


Ingredients for Success

The long-term success of the closure plan is predicated upon the continuation of: · · · · Census reduction Admissions diversion Community placements and supports Evidence-based practices for older adults in state psychiatric hospitals

Census Reduction

Since FY 2007, the census at the four facilities has declined 26.3% from 2,173 in July 2006 to 1,601 in September 2010, a reduction of 572 persons.

FIGURE 5 State psychiatric hospital census at four adult hospitals: July 2006 ­ September 2010

Census reduction already has allowed for the closure of five units at Ancora, one unit each at Trenton and Hagedorn, and 15 cottages at Greystone. In addition, a smaller inpatient facility was constructed at Greystone. Some of these units have been repurposed for other uses, most notably 13 of the transitional cottages at Greystone and units at Ancora that now serve as treatment malls. Of the units that have closed, 2 cottages have re-opened at Greystone and one unit at Trenton is slated to add to existing inpatient capacity. If needed, 2-3 units at Ancora also will re-open.


In addition, many active units at Ancora, Greystone and Trenton are well below capacity and could either accommodate consumers from Hagedorn or be consolidated as the census continues to decline. Such consolidation would allow for additional, separate gero-psychiatric units for the older adult population. By reconfiguring the hospital population, it will be possible to accommodate consumers needing hospital services previously served by Hagedorn in facilities that are more apt to be closer to their communities of residence and on units that do not mix the older adult population with a more active, younger or forensic population. As of September 30, 2010, GPPH's census was 37 below operational capacity; TPH was 94 beds below capacity, and at APH the census was 171 below capacity. These reductions provide additional opportunities for rebalancing the system to absorb the consumers who are either currently at Hagedorn or who might need long-term inpatient treatment in the future. As Table 7 shows, capacity currently exists on units at the other three facilities for 302 consumers who would have been served at Hagedorn. This capacity at the three regional adult hospitals will accommodate the decreasing admissions to Hagedorn.

TABLE 7 Available beds at state psychiatric hospitals. Source: Office of Olmstead, Research, and Evaluation. Census Episode Records, September 30, 2010.

53 54 55 56

Key to further census reduction is diversion of individuals who can benefit from less restrictive community options, additional placements for those being discharged, successful hospital discharges, and community services development to maintain and stabilize individuals in the community. These initiatives should allow DHS to responsibly take sufficient beds off line by June 30, 2012, allowing for the closure of Hagedorn. New Jersey DMHAS efforts related to the Olmstead Settlement should further reduce the census in the forthcoming year and through 2014.

Admissions Diversion

Census reduction also benefits from community inpatient options that can divert individuals who would otherwise be placed in state hospitals. Short Term Care Facilities (STCFs) provide acute care on adult psychiatric units in general hospitals for the short term admission of individuals who meet the legal standards for commitment and/or require intensive treatment. Admissions to STCFs must be referred through a designated screening center and individuals who can be appropriately treated in an STCF can be diverted from a longer stay in a state psychiatric facility. A total of 401 beds are operational through 24 Short Term Care Facilities.57 As shown in Figure 6, beds are available for consumers in all 21 counties. An additional 28 beds have been approved but are not yet operational for Atlantic/Cape May (4), Passaic (8), Morris (4), Union (3) and Middlesex, Somerset and Hunterdon counties (9). The number of persons served in FY 2009 was 14,243, an increase of 1,816 or 14.6% over the previous fiscal year.58 In addition to STCFs, the Division also contracts for beds at two private hospitals. Hampton Hospital admits residents of Atlantic, Camden, Cape May, Cumberland and Salem counties who may need treatment of longer duration than available through an STCF, but do not require the restrictiveness of a state psychiatric hospital, while Carrier Clinic admits Ocean County residents with similar needs. DMHAS has contracted for occupancy up to 12 beds at each facility. These beds may divert admissions to Ancora for some older adults who would have gone to Hagedorn.

Available beds include a combination of vacant beds on active units and currently closed units that could be re-opened as needed. 81 vacant beds and 3 units with 90 beds that can be re-opened if needed. 21 vacant beds and 2 cottages with approximately 16 beds that can be re-opened. 66 vacant beds and one unit with 28-bed capacity that can be re-opened Quarterly Allocation Distribution for Mentally Ill Indigent Care Report. January 1, 2010 ­ March 31, 2010. Updated information June 1, 2010 from personal communication by J. Verney. 58 Statewide Systems Review Committee data. Fiscal years 2008 and 2009.

53 54 55 56 57


Finally, DMHAS has implemented a new Centralized Admissions (CA) unit that screens admissions to the state psychiatric hospitals, diverting those who can benefit from less restrictive options and expediting treatment for those needing admission. One goal of this additional oversight in the admissions process is to identify and divert admissions of individuals who can be served in less restrictive settings, including some individuals with diagnosed organic conditions or dementia, whose problems could be more effectively addressed by short-term community inpatient services or behavioral interventions. In October and December 2009, the CA Office began screening admissions to Trenton, Greystone, and Ancora, respectively. Then, in February 2010, CA began screening admissions to Hagedorn. Centralized Admissions is located at TPH, but reports directly to the DMHAS Medical Director and the Assistant Director, Office of State Hospital Management. Clinical staff within the unit reviews referral documents and then determines the most clinically-appropriate treatment setting. Implementation of CA should divert admissions from the state psychiatric hospitals to clinically suitable less restrictive settings. As an example, admissions to HPH averaged 34.1 per month for the seven months prior to the implementation of CA (from July 2009 through January 2010), but in the subsequent five months averaged 23.6 admissions per month. A significant proportion of the declining admissions to Hagedorn resulted from fewer referrals of older consumers and those in nursing facilities. If annualized, implementation of CA would contribute to about 125 fewer admissions to Hagedorn.59

FIGURE 6 Number of STCF beds by county, June 2010

59 Centralized Admissions was implemented at Greystone and Trenton Psychiatric Hospitals in mid-October 2009 and at Ancora in December 2009. Greystone's admissions were about 3 less per month, Ancora's was about 3 less per month over a 6-month period, while Trenton's admissions were 4 per month higher over a six month period.


Olmstead Settlement Agreement to Create 1,065 Placements

The Olmstead Settlement Agreement should substantially reduce the state hospital census. In July 2009, the Department signed a settlement agreement outlining the development of additional community placements (1,065) over a five year period in order to facilitate the integration of hospitalized individuals with CEPP (Conditional Extension Pending Placement) status into the community. Persons on CEPP status have been determined by the courts as eligible for discharge pending a clinically-appropriate placement. The agreement called for the creation of 1,065 housing and community support placement options over a five-year period from FY 2010 to FY 2014, with the vast majority created for individuals with CEPP status (695). The remainder (370) represents diversionary placements created to prevent homelessness or institutionalization among a high risk population cycling in and out of acute care services. Figure 7 shows the projected CEPP and diversionary placements by fiscal year.

FIGURE 7 CEPP and diversionary placements by state fiscal year

It is common for such individuals to end up being admitted to a state psychiatric hospital for an extended period of time to stabilize their psychiatric condition. Once hospitalized, discharge becomes difficult because of the lack of stable housing in the community. The availability of diversionary placements should help to reduce the use of long-term state psychiatric hospitals by this population. The Olmstead Settlement Agreement mandates the creation of community placements and establishes placement targets. 60 The 297 individuals who received their CEPP designation before July 1, 2008 are expected to enter community placements by the end of FY 2014. This group of discharge-ready individuals has been occupying beds for an extended period of time. As these consumers are discharged, the census will continue to decrease. For those who were placed on CEPP status after July 1, 2008, the Settlement Agreement requires that by the last year of the agreement 95% be placed in the community within 4 to 6 months of their CEPP designation, depending on their legal status. These mandates should substantially reduce hospital lengths of stay and contribute to continuing census reduction.

TABLE 8 CEPP Discharges to community placements required by the Settlement Agreement by state fiscal year

60 A recent report shows that 65.2% of consumers designated CEPP in FY 2010 were discharged within six months of designation. Numbers for the fiscal year will not be finalized until after December 31, 2010 to allow for six months post-designation for all CEPP during the fiscal year. While the Division has already exceeded its Olmstead target for FY 2010, the percentage discharged within six months should improve when information is finalized.


Impact on Emergency Departments

The reconfigured state hospital system will continue to accommodate the current level of state hospital admissions without placing additional burden on emergency departments at general hospitals. All consumers leaving the state hospitals under the Olmstead Settlement Agreement are discharged with a range of services that promote community tenure. These include a minimum of twelve months of Integrated Case Management Services (ICMS) as well as a host of other services based on clinical needs and personal preferences. The Division acknowledges that the wait for placement from an emergency room is often long. The Acute Care Task Force, comprised of hospital providers, free-standing mental health centers, consumers and family members, was convened by the Division in 2008 to examine these issues. Its recent report makes several recommendations for improving movement through the acute care system.61 The recession may have exacerbated demand because of the increase in individuals without health care coverage and the greater emotional stress. However, the vast majority of consumers waiting for placement need a less restrictive level of care than a state psychiatric hospital. A report by the Robert Wood Johnson Foundation (RWJF) found that although emergency department visits by patients with psychiatric diagnosis are increasing faster than emergency department visits overall, patients with psychiatric needs still comprise a small share of total ED volume ­ 5 to 8%.62 The report notes that a relationship between psychiatric emergency department visits and emergency department overcrowding has not been quantified in any study. Another two-state analysis of emergency room use by persons with mental illness, conducted by the National Institute of Mental Health, revealed ED volume for this group to be between 3.3% and 5.2%.63 In addition, the Division has implemented a variety of community crisis support services to address the need for crisis and off-hours services, including a Peer Recovery warm line sponsored by the NJ Mental Health Association, Intensive Outpatient Treatment and Support Services (IOTSS), which provides intensive outpatient services 24/7 to deal with short-term symptom exacerbation, and Early Intervention and Support Services (EISS), which provides short-term crisis support and mobile outreach. Plans call for expansion of pilot programs (EISS), and expanding off-hours availability for the warm line to allow consumers more community options when crises occur outside of normal program hours. These initiatives provide alternatives to emergency departments.

Community Services and Supports

Advances in treating mental illnesses among older adults allow older consumers to live successfully in non-institutional settings; state psychiatric hospitals are no longer optimal choices for older adults with serious mental illness or those with significant medical conditions and behavioral challenges. A 2004 report by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), Community Integration for Older Adults with Mental Illnesses: Overcoming Barriers and Seizing Opportunities, describes the need for public mental health systems to support the community integration of older adults, and outlines the important service delivery considerations for this population. Hagedorn serves older adults and adults under the age of 65 with serious mental illness. While the unique needs of older adults must be considered in service delivery, DMHAS must be cautious not to establish additional community service "silos" that create unintended access barriers. Programs that incorporate outreach, screening and assessment, treatment and integrated service delivery have been shown to decrease mental health symptoms and the number and length of psychiatric hospitalizations.64 Many of New Jersey's community-based outreach

61 62 Robert Wood Johnson Foundation (2009). The Synthesis Project: New Insights from Research Results, Report No. 17, Emergency Department Utilization and Capacity. 63 64 Community Integration for Older Adults with Mental Illnesses: Overcoming Barriers and Seizing Opportunities. DHHS Pub. No. (SMA) 05-4018. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Administration, 2004.


services, such as supportive housing, Integrated Case Management Services (ICMS), and peer support also are recommended specifically for older adults. The integration of mental health and primary care services for this population, a primary focus in the field right now, is particularly important. New Jersey DMHAS funds numerous services designed to support successful community integration for all mental health consumers. Most of these programs also serve older adults now. SAMHSA's Center for Mental Health Services (CMHS) has identified, and requires state reporting on evidence-based practices. New Jersey DMHAS provides and reports outcomes for all of the mandated evidence-based practices identified in a recent SAMHSA report:65 · · · · · · · Assertive Community Treatment (Programs of Assertive Community Treatment or PACT) Integrated mental health and substance abuse (Integrated Dual Diagnosis Treatment or IDDT) Supported employment Supportive housing Consumer-operated services Illness self-management (Illness Management and Recovery or IMR) Family psychoeducation (Intensive Family Support Services and Multi-Family Group Treatment within three IFSS programs) · Medication algorithms for schizophrenia New Jersey provides these evidence-based practices statewide, along with a host of other innovative programs, including supported education, consumer-operated self help centers at the state hospitals, intensive outpatient programs, and Early Intervention and Support Services (EISS).66 Many of these programs are critical for the successful community tenure of consumers being discharged from state psychiatric hospitals, including: · Integrated Case Management Services (ICMS)67 available in all 21 counties. · Programs of Assertive Community Treatment (PACT)68 available in all 21 counties · Intensive Outpatient Treatment and Support Services (IOTSS)69 ­ Available in 17 counties; by the end of 2010, programs will be available in 19 of the state's 21 counties. · Early Intervention Support Services (EISS) ­ Pilot programs operating in two counties to be expanded to five counties in FY 2011.

65 The NJ equivalent is noted in parentheses if different from national nomenclature. See Lutterman, T., Berhane, A., Phelan, B., Shaw, R., & Rana, V. (2009) Funding and characteristics of state mental health agencies, 2007. HHS Pub. No. (SMA) 09-4424. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. 66 EISS provides 24/7 access to crisis support, including a toll free support line, mobile outreach and time-limited case management of up to 30 days. Services are intended to reduce the need for and utilization of acute care services by providing crisis intervention and mitigation, linkage or re-linkage to clinical services and community supports, development of a crisis plan or Psychiatric Advanced Directive, linkage to entitlements and social services, and stabilization of community living situation including temporary crisis housing or residential placement as needed. 67 For description, see footnote 30. 68 For description, see footnote 31. 69 Community-based intensive short-term (up to 90 days) outpatient services providing rapid access for adults who have exacerbation of symptoms of serious and persistent mental illness (SPMI). IOTSS delivers services 24/7, both on and off-site, by a multi-disciplinary team on a flexible schedule that includes evening, weekend and holiday availability. Appointments are available based on individual needs up to 4 times per week and up to three hours per day as clinical and support needs dictate. The service has been developed as a clinically appropriate alternative to hospitalization with access based upon referral from an acute care service (such as an STCF, Designated Screening Service, Affiliated Emergency Service, Crisis Residential Program, Jail Diversion/Re-entry or another acute care program). Services include comprehensive assessments, Wellness & Recovery Action Plans (WRAP's), medication administration and education, individual, group and family therapy, relapse prevention groups, and referral and linkage to ongoing clinical and support services.


Community Placements

Individuals are discharged when they no longer meet the civil commitment criteria as determined by the clinical judgments of licensed medical professionals and the courts. The range of appropriate placements will vary. Community placements, particularly flexible supportive housing models facilitate successful hospital discharges. Numerous studies have shown that permanent supportive housing reduces hospitalizations by individuals with serious mental illness, and research stresses the importance of housing to consumer efforts to achieve and maintain wellness and recovery.70 Most individuals at state psychiatric hospitals can be discharged to supportive housing with varying levels of intensity (up to 24 hours), while some may require more intensive residential supports. Supportive housing is a supportive service in the consumer's housing location and may or may not provide a housing unit. This is the preferred option for many consumers. Supportive housing is intended to meet consumer needs while promoting permanency and community tenure. The Division has a wide range of supportive housing options available for mental health consumers based upon their clinical needs and individual preferences: · RIST: Residential Intensive Support Teams provide support services to individuals in shared or individual apartments that are partially funded with rental subsidies. · Medical: Housing model developed to serve consumers with insulin dependent diabetes, polydypsia, incontinence, limited mobility, COPD, Oxygen dependence, feeding tubes, and other significant medical issues. · Enhanced: Housing model developed to serve consumers with challenging behaviors resulting from long term institutionalization, cognitive impairments, dual diagnosis, substance use, and other issues. · In addition to supportive housing placements, some consumers receiving Integrated Case Management (ICMS) or Programs of Assertive Community Treatment (PACT) services may be eligible for housing subsidies. Individuals may also choose to reside alone or with family or friends. DMHAS has developed 1,424 placements from FY 2006 through FY 2009. Of the 1,424, about 84% or 1,201 have been awarded to providers in 19 of the 21 counties (see Figure 8). An additional 49 have been awarded to Southern Region providers. The remaining 174 beds have been developed by providers as shown in Table 9.71 Since FY 2004, the number served in supportive housing has increased 124.9%, more than doubling from 1,482 in FY 2004 to 3,333 in FY 2009.72 In addition to supportive housing, DMHAS funds more intensive residential supports, including 307 supervised apartments and 173 group homes with a total licensed capacity of 2,016 consumers.73 The median maximum capacity of supervised apartments is 3 consumers with most having 2 or 3 consumers; the median maximum capacity for group homes is five with more than 70% having a maximum capacity of 6 or fewer. Regardless of their housing arrangements, all consumers upon discharge receive a minimum of 12 months of case management services (ICMS) to facilitate their transition to community living. The level of service provision is con-

70 Schiff, J.W., Schneider, B., & Schiff, R. (2007, May). Literature review on housing persons with a severe mental illness, with, and without co-occurring substance abuse. Report prepared for the Mental Health Housing Subcommittee, Calgary Homeless Foundation. Retrieved from http://www.path and Martinez, T.E., & Burt, M.R. (2006). Psychiatric Services, 57, 992-999. doi:10.1176/ Retrieved May 13, 2010. 71 In FY 2010, awards were made for 251 placements, 201 placements for individuals with CEPP status and 50 placements for consumers in the community, but at risk of hospitalization. 72 Office of Olmstead, Research and Evaluation. Memo. October 20, 2010. 73 J. Redmond. (June 3, 2010). Excel spreadsheet query from DHS Office of Licensing (OOL) database of DMHAS adult group homes and supervised apartments. Analysis conducted by G. Riesser (June 3, 2010).


tingent upon clinical need. In addition, individuals who need more intensive services or present with more complex needs may be enrolled in PACT services at discharge. To assist with the community transitions of older adults, additional training will be provided to ICMS and PACT providers in the needs of the older adult gero-psychiatric population through a Geriatric Mobile Outreach (GMO) program that will be initiated in FY 2011.

TABLE 9 Beds awarded to serve multiple counties

The growth in services has been accomplished by substantial investment in community services, about $80 million in new funding since FY 2006. Included in this services expansion were programs that met the needs of individuals who either have been discharged from psychiatric hospitals or were at risk of hospitalization. Funding for community mental health services has increased by $34 million from FY 2008 to FY 2011, an increase of 12.1%. As shown in Figure 9, proportional increases have been greatest for Supported Housing (41.6%), Screening services (21.3%), and PACT services (19.6%). Other services have experienced smaller increases of 10% or less, while a few services have experienced funding reductions. It should be noted, that budget reductions do not necessarily imply service reductions. For example, ICMS experienced a 2.4% decrease in appropriations, but no change in the number of consumers served; while Short Term Care Facilities experienced a 2011 budget reduction of 17.4%, but no change in the number of contracted beds. Despite target reductions in various programs, additional funding has been made available to support Olmstead placements and census reduction.

FIGURE 9 Budget appropriations for community mental health services from SFY 2008 to 2011. Source: Recommended State of New Jersey Budget: Fiscal Year 2010-2011. Office of Management and Budget, March 16, 2010.


DMHAS is also discussing options under the currently available Money Follows the Person (MFP) program for older adults leaving Hagedorn for community-based settings. MFP is a federal demonstration project that helps eligible individuals who have been residing in nursing facilities and institutional settings for six months or more to move into a community setting.74 DMHAS will work with its continuum of current providers to facilitate their participation in the MFP program. Several additional programs will help maintain older adults in community settings. A statewide Geriatric Mobile Outreach program will be fully established in FY 2012 to work with community residential providers, families, mental health providers, screening centers, and others who work with older adults who have challenging emotional disorders and complicated medical conditions to provide education, technical assistance, and evidence-based solutions to address their complex needs. This program will be modeled after the Statewide Clinical Consultation and Training (SCCAT) program through Trinitas Hospital. The SCCAT program assists mental health agencies and screening centers in understanding and addressing the needs of individuals with mental illness and developmental disabilities, some of whom are served at Hagedorn and in community residential settings. For those already in nursing homes, Geriatric Mobile Outreach will provide another diversionary option to state hospital admission. Presented with challenging behaviors, these individuals often are referred unnecessarily to screening centers and from there to inpatient settings. The training program assists providers with behavioral interventions and staff training that allow these individuals to remain in the community. As indicated in the Individualized Assessment section of this plan, some individuals may benefit from nursing home care as indicated by the PASRR process. Currently, consumers already in nursing home care have access to Special Care Nursing Facilities (SCNF), which offer more intensive behavioral management designed to address the severe, combative, aggressive or disruptive behaviors that cannot be managed in more conventional nursing facilities. A SCNF is a nursing facility or unit that is distinct from a conventional Medicaid-certified facility because it has been approved by DHSS to provide care to Medicaid beneficiaries who require intensive nursing services beyond what is available in conventional nursing homes. While these are not intended as discharge options, these settings serve a stabilization and diversion function for consumers living in nursing homes. Statewide, there are 136 such beds.75 The Division will issue an RFP in FY 2011 to create additional local psychiatric inpatient capacity for older adults. By supporting more specialized, local treatment for adults who require brief periods of inpatient hospitalization, consumers can be discharged back to their place of residence in a more reasonable timeframe. This will avert a longer state hospital stay and reserve state hospital beds for consumers who require this longer term care. Community-based providers also must collaborate with aging systems locally so that services are coordinated effectively to support older adults in the community. DMHAS will facilitate these discussions at the state and local levels. The Mental Health Association of New Jersey's Mental Health Cares (NJMHCARES) statewide information and referral service has a growing list of older adult services by county that should be used as a resource for mental health providers, consumers and families.

74 75 Personal communication. R. Eilers. June 1, 2010.


Evidence-based Practices for Older Adults in State Psychiatric Hospitals

Nationally, states are just beginning to develop and implement evidence-based practices for older adults in community and state psychiatric hospital settings. Older adults include a growing but diverse population. A recent report by the Older Adults Technical Assistance Center presents data that one in five older adults has a significant mental illness. About 16% exhibits a primary mental illness, while 3% have dementia complicated by mental illness.76 The most common primary psychiatric disorders are depression and anxiety disorders. However, while some individuals have long-standing mental illness that began well before they reached late adulthood, for other individuals, this may be their first episode and initial exposure to specialty mental health services, including psychiatric hospitals. For some, problems may be manageable with appropriate community supports and coordinated care, allowing them to live, as other older adults do, in community settings. For others, the severity of their behaviors and co-morbid conditions, including diabetes and heart conditions, substance abuse, and physical and cognitive issues, may require more extensive coordination or longer term inpatient treatment. Regardless, their medical issues must be addressed as this population is prone to falls, incontinence, choking and aspiration pneumonia, and therefore, is at higher risk for injury and disease. They are more likely to have mobility issues and may require care to prevent and treat pressure ulcers and other problems related to immobility. Aging also results in vision and hearing losses that impair ability to socialize or understand and follow directions regarding self-care and treatment. These problems also may require elderly individuals to reside in specialized living accommodations, including nursing homes. In addition, there are adults who are not yet 65 years old, who have brain injuries and diseases producing cognitive deficits and that present similar behavioral challenges, and clinical needs. Thus, age is not the only consideration in appropriate treatment and placement. The Division will address these needs by opening additional gero-psychiatric units at TPH where there is capacity. This facility already has a medical-psychiatric unit that accommodates geriatric patients, along with specialized rehabilitative services to restore functional limitations and address gait instability, choking risks, and other age-related issues. By the end of FY 2011, the plan is to have three gero-psychiatric units at Trenton, one of which will be a specialized gero-psychiatric admissions unit. In addition, there are two gero-psychiatric units at Ancora that are available for these consumers, if needed. As discussed later in the section on Hagedorn employees, many staff will be able to bring their expertise to other facilities. Both Trenton and Ancora have geriatric psychiatrists and nursing staff with training to care for older patients, in addition to physical rehabilitative services that are comparable to those at Hagedorn; this includes Occupational Therapy, Physical Therapy, and access to Speech-Language Pathology Therapy. In order to ensure access, these services along with the hospitals' medical consultant clinics, are all located within the same buildings as the geropsychiatric units (Main building at Ancora and Raycroft building at Trenton), and geriatric patients at Trenton also have use of the main treatment mall. The Medical Director's Office will review protocols and practices, including assessment tools for the gero-psychiatric population currently used at Hagedorn. These will be compared to those in use at Ancora and to practice guidelines for older adults developed by the American Psychiatric Association (APA). The Medical Director's

76 Blow, F.C., Bartels, S.J., Brockmann, L.M. & Van Citters, A.D. (no date). Evidence-based practices for preventing substance abuse and mental health problems in older adults. Report written for the Substance Abuse and Mental Health Technical Assistance Center. Retrieved from the Federal Substance Abuse and Mental Health Systems Administration at


Office, along with staff expertise from Hagedorn, will develop consistent standards for inpatient practice and ensure training as needed for staff at Trenton and Ancora. Policies will be developed to prevent falls and suicide among this population. Treatment malls will incorporate programming appropriate for this population, including:77 · · · · Behavior-oriented treatments (to reduce problem behaviors) Stimulation-oriented treatments (recreational and art therapies) Emotion-oriented treatments (e.g., reminiscence therapy to stimulate memory and mood) Cognition-oriented treatments (e.g., reality orientation and skills training)

Consumers at Hagedorn who are on CEPP status will receive individual assessments and this information will be used to develop tailored age and clinically-appropriate placements in the community or will be used to inform and prepare staff at the "receiving" hospital if consumers are transferred. In addition, it is anticipated that to the extent possible, older adults on units at Hagedorn who continue to need inpatient treatment can be moved together, with their staff. However, the state's commitment to lateral in-title reassignment based on job classification seniority may preclude some staff from moving with the consumers with whom they previously worked.

Marlboro ­ Lessons Learned

The closure of Marlboro Psychiatric Hospital in 1998 has informed the Department's planning for the closure of Hagedorn. It must first be acknowledged that the closure of Marlboro brought about many positive changes for consumers. Additional funds were directed toward community services that provided many consumers with successful transitions into community living. Staple programs, including PACT and ICMS, got their start with the Marlboro Redirection Plan. Self-help centers grew along with support programs for families (Intensive Family Support Services or IFSS). Consumer perceptions were integral to the evaluation of the closure and were largely positive. The Division also invested in a broader range of residential services, including the first supportive housing placements. Still, there were a number of aspects to the closure that were not as successful as hoped. Several years after the closure of Marlboro Psychiatric Hospital, Ancora's patient census increased significantly and this surge was a factor in quality of care issues that surfaced there during the past several years. Contributing factors included significant population growth in several of the southern counties during the same period.78 Community service capacity did not develop commensurate with population growth and placed added burdens on Ancora. Current census trends suggest that overall population growth has leveled off in southern New Jersey and precipitous rapid growth is not anticipated. In the Marlboro closure, bridge funds were used as the process occurred, and then funding was "re-directed" to the community system. A more effective approach being applied now is to build up the community infrastructure in advance of the closure with a continued increase in budgeted funds, enabling continued development of community infrastructure for an additional four years in accordance with the Olmstead Settlement Agreement. Further, many of these funds have resulted in additional capacity in the acute care and diversionary systems so that consumers do not necessarily end up in the most restrictive end of the service continuum. This includes individuals who probably were not appropriate for institutional systems of care, consumers who had a developmental disability or a substance abuse problem without a co-morbid serious mental illness or those who, with appropriate community services, could be stabilized without a state psychiatric hospitalization.

77 American Psychiatric Association (no date). Treating Alzheimer's disease and other dementias of late life: A quick reference guide. 78 Two counties in Ancora's catchment area, Gloucester at 13.4% and Ocean at 12.3% led the state in population growth from 2000-2009. Source: Wu, S. (April 2010). 2009 Population estimates for New Jersey by county and metropolitan area. New Jersey Economic Indicators.


The Marlboro closure relied heavily on novice programs such as PACT and ICMS for admissions diversion. However, these programs were not fully mature and may have needed time for their impact to be felt. The Hagedorn closure relies primarily on existing programs and ongoing placements for sustainable census reduction. New diversionary programs are being implemented to reinforce programs already in place. Marlboro accepted admissions until its last month of operation resulting in a substantial number of transfers at a time when continuity of care concerns were paramount. At Hagedorn, closure to admissions will occur earlier in the process to minimize the number of transfers needed. In addition, as practicable, individuals will be moved as a group with staff. Reciprocal familiarity should reduce (although not eliminate) risk. To the extent possible, Hagedorn employees will be given job opportunities within the Division of Mental Health and Addiction Services to lessen the learning curve that accompanies working with different populations. Employees who transfer to other Divisions will receive advanced training to minimize quality of care issues. Until 2006, each of the hospitals operated as independent entities. This fragmentation of state hospital operations meant that there was no standardization as exists in community mental health services. In 2006, the Division of Mental Health Services began to reorganize the management of its four general state psychiatric hospitals so that they functioned as one system rather than four disconnected operations. Each hospital is now organized along similar lines with admissions units from which individuals are either discharged or transferred to another unit, and treatment malls that house consumer wellness and recovery programs, including group and individual therapy, medication, health and discharge education programs, rehabilitation services, peer counseling, and discharge-oriented planning. At the time of the Marlboro closure, DMHS had disjointed, limited data available to continuously monitor and finetune the closure process. The Division now has extensive hospital data available to inform decision-making. The Oracle hospital database contains information on individual consumers, including demographic and clinical characteristics, health insurance, service history and needs, treatment unit, movement and other status changes while an inpatient, and discharge and placement information. The database incorporates information that previously resided on separate databases, such as the Unified Services Transaction Form (USTF) completed at program admission, discharge and transfer. A recent addition now includes the INDA assessments. In FY 2011, discharge planning and placement information, including patient placement preferences, treatment team placement recommendations, and information about individuals who refuse discharge will also be incorporated. The presence of information from multiple sources allows for routine reporting of a variety of key system attributes (such as admissions, discharges, average daily population, length of stay, time from CEPP designation to discharge), and examination of information across previously isolated databases, e.g., the age and diagnoses of those who refuse discharge or the handicapping conditions and diagnoses of persons 65 years and older in relation to recommended placements. The hospital database is used to generate a variety of monthly reports, including census data for units and hospitals and individuals on CEPP status. Historical data allow the Division to examine trends and address emerging issues. It is possible to determine when the census is going up or going down and to better understand why these changes are occurring. The database is not static, but continues to expand and improve. In FY 2011, DMAHS will be creating more user-friendly interfaces for data entry, further improving on data quality. In addition, routine data regarding the status of the acute care system are obtained and evaluated monthly by System Review Committees in each county. Information from designated screening centers and STCFs is transmitted electronically to the Division and analyzed; web-based applications are under development to simplify data entry.



Smooth transitions during a closure and reconfiguration require an informed mental health community. Consumers in the hospitals must be apprised of the changes; the same is true for family members and staff.79 Community providers, the judiciary which conducts hearings at the hospitals, acute care providers, and others must all be advised of forthcoming changes and their timing so that they can adjust their activities to align with the reconfigured state hospital system. The Department has adopted a multi-faceted informational approach focused on ensuring a smooth transition that minimizes the impact on consumers and others. The Division will do the following to assist consumers and their families: · Maintain continuity of care and information for consumers throughout the transition · Provide the closure/reconfiguration plan on its website along with answers to frequently asked questions posed by consumers and by their families; answers specific to older adults will be developed separately · Meet regularly with consumer and family organizations to keep them informed and answer their questions · Respond promptly to individual concerns expressed by Hagedorn consumers and family members · Develop and disseminate information regarding the discharge and transfer processes to consumers, families, staff and community providers as well as ensure that they receive regular updates until the hospital closes · Prepare an informational brochure regarding access to services for older adults and their families The Division will ensure dissemination of public information about its reconfiguration plan by: · Holding a public hearing to elicit community input · Meeting individually with key constituent groups, including provider organizations and advocacy groups, affected communities, and other stakeholders · Publishing information on the DMHAS website, including the closure/reconfiguration plan and answers to frequently asked questions · Holding internal `town hall' meetings with Hagedorn consumers, family, and staff to discuss the closure/reconfiguration plan. · Responding promptly to public information requests from the public and the media The Department will communicate with key stakeholders through multiple media, including publications, official websites, and oral presentations and discussions. All public documents will be published on the DMHAS website.

79 See pages for a discussion of the plans to assist Hagedorn employees during the closure.


Hagedorn Employees

It is the intent of the Department to minimize the impact of the Hagedorn closure on its employees. The decision to close HPH is not a reflection on the caliber of staff at the hospital or the high quality of care that they have long provided. The Department hopes to be able to reassign many of the staff to other facilities and offices so that the consumers the Department serves can continue to benefit from staff knowledge and dedication to service. The Department will: · Provide employees with timely and accurate information about the closure process and employee rights and options · Guarantee permanent employees the right of first refusal based on job classification seniority for any lateral intitle reassignments that become available within the Department of Human Services · Provide access to resources to assist other employees with their efforts to identify possible employment and training opportunities

Employee Characteristics80

As of April 2010, Hagedorn employed 777 staff. Almost threefourths (74.5% or 579) of all staff are full-time employees. Of the remainder, 8.9% (69) are employed part-time and 16.6% or 129 were Temporary Employment Services81 (TES) staff. Hagedorn employs 648 permanent full or part-time employees (excludes TES staff). Most of these employees have fewer than ten years of service; 418 or 64.5% have less than 10 years of service, while 151 or 23.3% have between 11 and 20 years of service, and 79 or 12.1% have over 20 years of service. Hagedorn's permanent full and part-time employees are a diverse group. As shown in Table 10, most (68.1%) are female, but almost one-third (31.9%) are male. Two-thirds (66.8%) of the employees are white, while one-fourth (24.8%) is African-American and almost 5% are Asian; about 4% are Hispanic. Employees range in age from their twenties to over seventy years old. More than half (57%) are between 40 and 59 years old. Addresses provided by Hagedorn employees were analyzed using GIS (Geographic Information Systems) to identify county and state of residence.82 Data were available for 730 employees. Results show that 462 or 63.3% live in New Jersey while 268 (36.7%) reside in Pennsylvania. Approximately 62% of full-time employees and 60% of part-time employees live in New Jersey, while a larger percentage (70.7%) of TES employees live in New Jersey.

TABLE 10 Characteristics of Hagedorn employees

80 Information reflects employees who were on the payroll from April 10 through April 23, 2010 (Pay period 9). 81 Temporary Employment Services staff are hired in a temporary capacity, are not within the Civil Service System, and can only work 944 hours after which they must be released (although they can be rehired during the next fiscal year). 82 Some addresses could not be located, while post office boxes were excluded because they may not be located where employees reside. Of the 579 full-time staff, 542 were located using GIS. Of the 69 part-time employees, 64 could be located, and of 129 TES staff, 123 could be located.


The Hagedorn staff with New Jersey addresses show the highest concentration in the two counties closest to the hospital. The largest number lives in Warren County, with 226 employees. Hunterdon County contains the next largest number of employees, with 93 staff. However, there are employees residing in 16 of the state's 21 counties, including Essex (36), Middlesex (17), Union (17) and Mercer (14) counties. Employees residing in Pennsylvania primarily live in the two counties closest to New Jersey. Northampton County is home to 188 staff, while 51 staff report residence in Monroe and 17 reside in Lehigh County. Staff residences are close to major highways that provide access to other New Jersey state psychiatric hospitals and developmental centers in the Northern part of the state. Interstate 80 travels north of Greystone Park Psychiatric Hospital, while I-78 travels south of Hagedorn.

FIGURE 10 Hagedorn employees' residences by county

FIGURE 11 Location of state psychiatric hospitals and developmental centers in relation to major roads, Northern and Central New Jersey

Route 31 (to the west of Hagedorn) provides access to hospitals and facilities in and near Trenton as well as Hunterdon Developmental Center. The accessibility to major roads in the densely-populated northern half of the state should mitigate the impact of closing Hagedorn on New Jersey communities. Employees residing in Pennsylvania may experience longer commute times should they choose to take positions further east of Hagedorn.



Employees perform a wide variety of essential job functions at Hagedorn. Job titles encompass non-medical/clinical direct care staff (e.g., Human Services Assistant, Human Services Technicians) as well as medical/clinical staff (e.g., physicians, psychiatrists, nurses, psychologists, vocational and occupational therapists, social workers and others) which account for the greatest number of full and part-time staff. Together, employees in these two categories account for more than two-thirds (449 or 69.3%) of all employees at the hospital. Staff responsible for building, facility and maintenance functions includes grounds workers, housekeeping or laundry workers, plumbers, electricians, and other trades workers; these staff account for almost 10% of permanent full and part-time employees. Food services accounts for 36 staff or 5.6% of the full and part-time workforce. There is seven management staff within the hospital along with 49 professional and administrative staff and 43 clerical (e.g., clerks, secretaries, and bookkeepers) employees. The professional/administrative staff includes accountants, as well as information technology, medical records, and human resources staff and others.

TABLE 11 Job functions of permanent staff at Hagedorn Psychiatric Hospital

Plans for Employees

The Department is committed to the establishment and implementation of employee supports that will promote workforce stability and provide opportunities for employees to make choices for the future. Employee retention during the closure and transition process remains a high priority to ensure continuity of services, maintain quality inpatient care, and safeguard a dedicated and committed workforce. To ensure a fair process that protects the collective bargaining rights of employees and guarantees the safety of consumers, the NJ Department of Human Services' Human Resources Office has been working closely with its counterparts within the Division of Mental Health and Addiction Services and Hagedorn Psychiatric Hospital. Initial discussions also took place when the closure was first announced with AFSCME, CWA, and IFPTE leadership for impacted employees. Every effort will be made to respond to the concerns of staff, union representatives, legislators, consumers, families and local communities.

Placement Assistance Program

DHS will initiate a Placement Assistance Program for permanent employees at Hagedorn. This program adheres to collective bargaining agreements in guaranteeing Hagedorn staff the right of first refusal for lateral in-title reassignments within DHS based upon job classification seniority. The Department has developed a policy that clearly describes for employees how this process operates, and also will provide answers to frequently asked questions relating to the implementation of the policy. The Department intends to provide information on an ongoing basis to assist staff in identifying available opportunities and minimizing a reduction in force. Information will be provided through a variety of media to ensure communication with staff affected by the closure.


Employees interested in lateral in-title reassignments for posted positions will contact the Human Resources (HR) staff at Hagedorn. Staff may request informational meetings about these positions by contacting the appropriate DHS division or facility.83 Appointments will be based upon the employee's job classification seniority, with the right of first refusal going to the individual with the most job classification seniority. A Division or facility will not have the right to refuse a permanent employee a lateral in-title reassignment. In order to ensure continuity of operations at Hagedorn during this phase-down, critical positions may be temporarily filled by Interim Appointments (IA). Interim Appointments also will be utilized to "hold" positions for individuals who have accepted lateral in-title reassignments but whose services are still needed at Hagedorn. All IA positions will terminate when they are no longer needed, but no later than June 30, 2012 when Hagedorn is closed. Hagedorn staff can apply for lateral reassignment opportunities or other vacancies within the Department as they become available. After a position is filled, the actual reassignment date will be contingent upon Hagedorn's staffing needs. However, as the hospital's census declines, units will be closed and staff on those units will either be reassigned to other units or facilities or, if they are not permanent employees, they will be released.

Employee Resource and Information Center

In addition, the Department will open an Employee Resource and Information Center (ERIC) at HPH. This Center will be accessible to all staff on all shifts and provide a range of services. Notices of fillable vacancies occurring in DHS and its Divisions and facilities will be promptly posted at the ERIC. The ERIC also will host presentations and workshops by the Department of Labor and Workforce Development's (LWD) Rapid Response Team, which assists staff with resume and other professional services to help them successfully identify and pursue appropriate opportunities. Among the services that can be provided are the following: · · · · Job search workshops Resume workshops Information about job retraining programs Targeted job fair assistance

It is expected that many permanent employees at Hagedorn will fill vacancies within DHS, maintaining critical functions and reducing overtime use. The Department recognizes that this process can be stressful for both employees and consumers and will do everything possible to minimize the impact. For staff, leaving colleagues and friends, their patients and a long-time workplace can be distressing; for that reason, individual or group counseling can be made available if needed. Any employees remaining when the facility closes who do not have positions awaiting them will be subject to a reduction in force as outlined in NJ Title 4A:8.

83 Meetings must be scheduled during off-duty hours or by using personal benefit time. Contact information is available from the Hagedorn Human Resource Office.


Advisory and Oversight Processes

The Division of Mental Health and Addiction Services will establish an advisory committee known as the Hagedorn Closure Implementation Advisory Committee (CIAC). The CIAC will be comprised of stakeholders with broad perspectives, many of whom experienced the closure of Marlboro. The CIAC will begin meeting monthly in June 2011 to provide recommendations to the Division throughout the closure process. The Division also works closely with numerous advisory groups and planning bodies that represent key stakeholders and provide guidance to the DMHAS leadership regarding key initiatives, including the State's Mental Health Plan, the Home to Recovery-CEPP Plan and other planning efforts. These entities have differing roles and responsibilities, but all collaborate with the Division and provide input and feedback to assist its leadership: · Mental Health Planning Council is comprised of constituents of New Jersey's mental health community including advocacy groups, mental health providers, consumers, family members and DMHAS staff. The role of the planning council focuses on oversight of DMHAS planning and activities specific to the New Jersey Mental Health Block Grant. · County Mental Health Administrators Association is comprised of the Mental Health Administrator from each county. The county mental health administrators fill a critical role in advising the Division on all issues related to mental health, particularly at the local level. · County Human Service Directors Association is comprised of the Human Service Directors from each county. The county human service directors play a critical role in advising DHS on all human service issues, particularly at the local level. · The Olmstead Work Group is comprised of the consultant for the Olmstead Settlement Agreement and representatives from the New Jersey Mental Health Planning Council, the state psychiatric hospitals, DMHAS management, and Disabilities Rights New Jersey (DRNJ). The Work Group provides ongoing advice to DMHAS on implementation of its Olmstead Plan. · The Statewide Consumer Advisory Committee (SCAC) is a diverse group of emerging leaders throughout the state who are experiencing recovery in their own lives. SCAC has been instrumental in working with the Division on many aspects of its Transformation Plan. The SCAC meets one time per month in each of the three regions of the state, and is facilitated by the DMHAS' Special Assistant for Consumer Affairs. SCAC meetings are frequently used to provide important input into specific DMHAS-sponsored projects and initiatives. Members of the DMHAS' Management Team are frequent visitors to SCAC meetings. · Northern & Southern Region Advisory Committees provide regional forums for participants to come together and discuss issues, share information and concerns related to mental health services in the respective region. The Northern Regional Advisory Committee meets at Greystone Park Psychiatric Hospital and the Southern Regional Advisory Committee meets at Ancora Psychiatric Hospital. Participants include representatives from consumer-operated self-help centers, family members, county Professional Advisory Committees (PAC), community provider agencies, regional staff from DMHAS, staff from county hospitals, county mental health administrators and administrative staff from state hospitals. In addition to these advisory bodies, the Division leadership meets regularly with advocacy groups for consumers (Coalition of Mental Health Consumer Organizations or COMHCO) and family members (National Alliance for the Mentally Ill-NJ or NAMI-NJ), and with numerous provider associations. These meetings address topics of mutual concern and provide opportunities for candid discussions with DMHAS leadership. DMHAS will utilize these advisory bodies and organizations to provide feedback and oversight for the proposed closure and reconfiguration plan.



The Division of Mental Health and Addiction Services will conduct an evaluation of the closure/reconfiguration plan focused on consumer and family satisfaction with placements and the discharge/transfer process. The Division will work with the University of Medicine and Dentistry (UMDNJ) to complete this evaluation. The CIAC will provide guidance on what will be included in the evaluation.

Closing Ceremony

After the hospital is closed, a closing ceremony will be held at the facility for former consumers, family members, employees and other interested individuals. The purpose of the ceremony will be to celebrate the history of Hagedorn, advancements in psychiatric treatment, the consumers who received care there, and the dedicated employees who have delivered over a century of quality tuberculosis and psychiatric care during their tenures.


Senator Garrett W. Hagedorn Psychiatric Hospital is located in Lebanon Township in Hunterdon County, New Jersey. Once the hospital is closed, the property will be turned over to the New Jersey Department of the Treasury for disposition. DHS has advised Treasury of the intent to close the facility as a state psychiatric hospital. It is expected that local and county officials will inform Treasury on reuse of the property. The complex originally opened in 1907 as the New Jersey State Tuberculosis Sanatorium (in 1950, it was renamed the New Jersey Hospital for Chest Diseases). It continued to serve persons with turberculosis until its conversion in 1977 into Senator Garrett W. Hagedorn Gero-Psychiatric Hospital. From 1977 to 1986, much of the hospital was licensed and configured as a long term care facility/nursing home. Prior to that time, geriatric services were provided at Trenton Psychiatric Hospital and Marlboro Psychiatric Hospital. After the completion in 1998 of a 100-bed general adult psychiatric facility (North Hall), the complex was renamed Senator Garrett W. Hagedorn Psychiatric Hospital reflecting its broader mission. The facility originally occupied over 580 acres. However, in 2000-2001 parcels representing more than 200 acres were deeded to the New Jersey Natural Lands Trust. The facility currently comprises 31 buildings located on about 240 acres. Buildings include garages, a laundry, a pump house, powerhouse, sewage plant, and an office building (see Figures 12 & 13). One building is occupied by the Human Services Police and another by an Investigations Unit of the NJ State Police. Freedom House, a private residential provider, leases a building to provide services under a contract with the DHS Division of Mental Health and Addictions Services (DMHAS) to non-hospitalized individuals with substance abuse issues.


There are several main residential buildings on the campus (see Figure 13). North Hall has a 100-bed capacity and was completed in 1998 on the site of the original Children's Unit of the New Jersey State Tuberculosis Sanatorium. East Hall has capacity for 100 beds. Two wings of the Administration building (West Hall Units A, B, C & D) provide residential space for an additional 88 consumers on four units. The campus is connected to Jersey Central Power and Light (JCPL) for electricity, has one deep well for domestic water and an on-site sewage treatment plan. The Power Plant (see Figure 12) contains one 19,458 pound per hour Cleaver Brooks water tube boiler, one 10,350 pound per hour Cleaver Brooks fire tube boiler, and one 6,900 pound per hour Cleaver Brooks fire tube boiler. Each boiler uses #6 oil as the primary fuel source. There are four emergency generators located throughout the campus. All four generators use #2 off road fuel oil.

FIGURE 12 Map of Hagedorn Psychiatric Hospital and surrounding property


FIGURE 13 Detail of Hagedorn Psychiatric Hospital, inpatient units and support buildings



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