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Inside the State Hospital

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Secretary of Health and Social Services Rita Landgraf (left) and Kevin Ann Huckshorn, director of the Division of Substance Abuse and Mental Health, will play large parts in turning around the Delaware Psychiatric Center. Photograph by Joe del TufoIn the person-first, politically correct language of today, the teenage boy was “a person with an intellectual disability.”

He desperately wanted to join 11-year-old Rita Mariani and the other kids who hung out together in Brookdale Farms near Delcastle Park.

At first he was known as “Mike on the red bike.” Soon though, he was being called names such as “retard” and “dummy.”

More than 40 years later, Rita Landgraf recalls being caught up in the pack mentality, joining in the jokes and pranks her friends played on Mike, though she felt bad about her behavior.

“I can still remember how awfully we treated him,” she says. “We made fun of him. We set him up for things that were totally inappropriate. Finally, after about a week, he decided that he had had enough and he didn’t want to hang out with us. And I can remember as he rode away, I saw that he was crying.”

The episode set her on a career path. “It has left a scar in me,” says Landgraf, “but I turned that scar into a purpose in my life, to advocate for individuals with disabilities and vulnerable populations and to be more inclusive of diversity. I consider that a gift. Mike gave me a gift.”

She has spent a lifetime returning that gift, and she now occupies the ideal bully pulpit from which to achieve and perhaps exceed her most ambitious goals. She is the new secretary of Delaware Health and Social Services.

So much for the good news. The bad news: Her job includes responsibility for the Delaware Psychiatric Center.

Over the past several years, the center has been a veritable case study in all that can go wrong in a psychiatric hospital. Under the watchful eye of The News Journal—which regularly notes that it “published more than 100 stories” in 2007 alone about problems there—the hospital has spawned allegations of rape, assault and other forms of patient abuse, as well as retaliation against staff members who reported some incidents.
 

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Two employees were eventually charged with felony abuse and sexual assault. The hospital director and her boss resigned. There ensued two federal probes, a state investigation of excessive overtime, and the introduction of 16 bills and resolutions designed to overhaul hospital management and increase independent review of patient care.

The troubles continued with the new administration. On January 31—a little more than a month after Landgraf was tapped by Governor Jack Markell to head DHSS—a DPC patient hanged herself with a bedsheet. In contrast to former Governor Ruth Ann Minner’s stonewalling management style, and in keeping with Markell’s promise of transparency in government, he and Landgraf initiated an investigation.

A report released April 9 cleared DPC employees of any negligence. Surveillance cameras, installed in response to previous problems, showed staff properly checking the woman—who was not on suicide watch—every 15 minutes.

The investigation prompted Landgraf and hospital administration to implement several policy changes. Among them, a registered nurse would begin assessing patients at least twice per shift; DPC would organize “grand rounds” involving a group of healthcare providers for patients who have lengthy stays, difficult behaviors or who are not responding to treatment; and workers would be trained to identify changes in behavior of patients during 15- and 30-minute checks, which previously had been observational only.

The report and recommendations are typical of Landgraf’s analytical management style, a style she will apply to the entire DHSS.

“I like root-cause analysis, because I think it tells you a lot about your organization,” she says. “In order to influence and impact an organization, you have to know where your weaknesses are.”
 

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Changing Management Style

Landgraf was able to hit the ground running in her new post because she had co-chaired the Governor’s Task Force on the DPC from August 2007 to January 2008. Through the task force she learned that “the weak link at the DPC had a lot to do with the performance improvement unit.” Though all the proper data was being collected, Landgraf says, it wasn’t being analyzed for trends.

One-to-one work at the hospital—in which a hospital staffer is assigned to an individual patient—was another problem. For one thing, it led to a lot of overtime pay. For another, it was sometimes inefficient.

“It resulted in a babysitting function [aimed] primarily at making sure the patient didn’t harm himself or someone else, but not as an opportunity to incorporate treatment in that process,” Landgraf says. “So we’re spending more time looking at the treatment modality.”

Another area she and her staff are addressing is communications throughout the treatment support team. Though certified nursing attendants usually are the staff members who are most often “hands on” with patients, “they sometimes are the ones that we do not include in all of the communication.”

Much of the blame for DPC’s spotty record was laid on Landgraf’s predecessor, Vincent Meconi, who served as DHSS secretary throughout Minner’s two terms. Ill will toward Meconi surfaced again in March when Markell appointed the former secretary to a part-time post (three months at a salary of $6,250 a month) to make sure Delaware receives every dollar of federal stimulus funds available to it.

Some legislators expressed shock at the appointment. Representative Richard Cathcart, a Republican from Middletown who had led an investigation into the DPC, was the most vocal. “I thought he was one of the most incompetent cabinet secretaries in the Minner administration,” Cathcart said.

In his first interview since leaving office, Meconi did not duck his role in the DPC’s problems.

“I was the captain of the ship, so I take full responsibility,” he says. “I’d also like to think I take responsibility for the good things in the department, as well as the bad. But you know how government works. Ninty-nine things you do right, and you don’t tend to get credit for that, but something goes wrong and you’re criticized for that. That’s the nature of the beast. I accept that.”

The 57-year-old Meconi says 98 percent of DPC employees did a good job during his tenure, though “about 2 percent were bad actors.” That, combined with staffing shortages, created the problems, he says. Because of the relatively low DPC wages for both attendants ($25,473 to $29,388 a year) and, to a lesser extent, nurses, staffing will continue to be a problem, he says. “In no way is this an excuse, but it will always be a challenge, and that’s one of the things I told Rita.”

Meconi believes a new facility would help equalize the salary disparity. “I hope Rita is able to get that done,” he says. “I was not able to.” Though building a new hospital has been discussed, the state’s financial straits make that unlikely to occur in the immediate future. An initial study, presented to the hospital’s advisory committee, estimated that a new 205-bed facility would cost $134 million. Cost comparisons to other states showed the figure to be unrealistically high. Another report is due soon.
 

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In Retrospect…

Meconi says the only major change he would have made during his tenure as secretary would have been to install security cameras earlier. (Two hundred additional cameras were installed in late 2007.) He put off buying cameras because he had hoped to get funding for a new hospital.

“You hate to spend money that [might] be wasted [if the new facility was built] a few years down the road, and you’re always short of money,” he says. “But that’s one thing I would have done differently. It’s made a huge difference.”

He points out that the cameras record not only what goes wrong at the hospital, but what goes right as well. The cameras were key in clearing staff members of blame in the January 31 suicide.

Besides Meconi, other targets of The News Journal and the public were Susan Watson Robinson and Renata J. Henry, DPC director and director of the Division of Substance Abuse and Mental Health, respectively, under Meconi. He refuses to criticize either woman.

“Of all the people I’ve ever worked with, Renata Henry probably is one of the top, if not the top person in terms of programmatic knowledge in her area, which is substance abuse,” he says. “Susan Robinson is a very dedicated administrator. She got, I think, unfairly blamed for some of the things that happened. People forget, she was only director for about eight months. Being beat up in the press every day was too much for her, and she opted to return to the merit system.”

Robinson is now assistant hospital director. In September Henry was named deputy secretary for Behavioral Health and Disabilities for Maryland. Meconi was among those who gave her a recommendation.

Having known Landgraf for years, he has total confidence in her, so he won’t be second-guessing her actions. “It’s good that there’s a fresh approach,” he says. “Eight years in that job, it’s better for me to move on, and it’s better for the department. Whatever their decisions are, I’ll be supporting them.”
 

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The New Team

Another supporter and Landgraf fan is Gary Wirt, chairman of the DPC Advisory Committee. “The thing I like about Rita is that she sees people who may have a disability rather than the disability itself,” says Wirt, who has worked in the mental health field most of his life. “Because of her wide range of background with different types of disabilities, I think she’s the perfect person for the job.”

He also praises Kevin Ann Huckshorn, who was appointed in March to Henry’s former position as director of the Division of Substance Abuse and Mental Health. Huckshorn, who lived in Virginia before moving here, served on Delaware’s Joint Commission Professional Advisory Committee for Behavioral Health. A veteran of 26 years in the mental health field, she is a leading advocate for reduction of seclusion and restraint in mental health facilities.

“Kevin Ann Huckshorn will bring a philosophy, a set of guiding principles,” Wirt says. “She’s traveled all over the country, and she understands what good practices are in terms of limiting or removing seclusion and restraint.”

Wirt says he is excited about the team that now has responsibility for the DPC: Landgraf, Huckshorn and Hussam E. “Sam” Abdallah, who became DPC director in February.

“You’ve got a secretary who focuses on the strength of people and finding the optimal placement of services for them, and a new division director who brings a national perspective,” says Wirt. “And Sam has brought some really good things into the state. He reaches out to learn more. He believes in accountability. He monitors the cameras. He’s taken a very hands-on attitude.”

Like her boss, the high-energy Huckshorn made a smooth transition into her new position. One of her first projects is to upgrade training with a 19-module curriculum recently developed by the National Association of State Mental Health Program Directors. “That will really help the staff at DPC get up to date about what recovery is about,” she says.

Abdallah will focus the staff on patient recovery while reducing the instances of seclusion and restraint. He says that restraints at the hospital have dropped from 39 in February 2008 to three in February this year. Meanwhile, he is fostering better relationships among staff and patients through friendly basketball and volleyball games. Abdallah, a former college hoopster, participates.
 

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Drawing on Experience

Landgraf brings to her job a statewide reputation for passionate, intelligent leadership in the social services. She spent much of her career at the Arc of Delaware, a non-profit organization of volunteers and staff working to improve the quality of life for people with cognitive disabilities and their families. Her work produced a network of friends and resources that should serve her well as DHSS secretary.

She will use that network in pursuing one of her primary goals: giving patients a higher quality of life by integrating them into the community or into group homes.

For several years, observers have questioned whether the state needs to hospitalize all of the patients in the DPC—204 in the 231-bed facility as of May. Too often, says Landgraf, patients become residents. “Warehousing” is the term that’s sometimes used.

Meconi says a study conducted during his time as secretary revealed that 25 percent of DPC patients had no psychiatric illness. “They maybe had dementia or Alzheimer’s, which are not psychiatric disorders,” he says. “They maybe were there simply because the state had no other place for them. We also had a number of people who, basically, the hospital had gotten well, but there was no place for them on the outside.”

Landgraf is addressing the concern.

“[The DPC] should revert back to a hospital setting for people who have the disease of reoccurring substance abuse or mental illness,” she says. “People don’t live at Christiana Care. If they have a chronic type of illness, they may have to return to Christiana Care, but they don’t live there. I see DPC as more of that acute setting for people who have ongoing mental illness and reoccurring substance abuse. But I don’t want them living there. It’s not healthy for them. That is the area we have to continuously strengthen.”

She points out that it’s far more cost-effective to serve people in the community than in facility-based care. The average daily rate at DPC is $649. An individual in a group home costs $164 a day.

Staffing, training, treatment aimed at reducing length of stay—all are issues that must be addressed at the DPC. But the hospital represents just 1 percent of the DHSS’s $43 million budget for fiscal year 2009. With 12 divisions and 4,800 employees, it is the largest cabinet department, accounting for 35 percent of the state government’s payroll. DHSS is the fifth-largest employer in Delaware.

Landgraf understands that many observers judge the entire department based on their perception of the DPC, and she no doubt will give it far more attention than its minuscule budget position would seem to require. Like public officials everywhere, she’ll be faced with limited funding, but she’s determined to make marked improvements.

“Too often, funding dictates what services we provide, and it should be the other way around,” she says. “We need to look at how to support people so they can reach their maximum potential, then talk about how we fund that. The mission for the department is to promote self-sufficiency, good health and well-being, and to protect vulnerable populations.”

Her idealism is based on reality. She knows that government and the community working together can produce positive results. Case in point: Mike on the red bike. Landgraf reconnected with Mike some years ago, when she was executive director of the Arc of Delaware. She reports that he is married and working and “is living a very purposeful, meaningful life, and is a very delightful man.”

Meanwhile, four decades later, Rita Mariani Landgraf continues to pay forward the gift Mike gave her.

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