It could easily be mistaken for a college campus, or a gated suburban housing development. Freshly cut grass gleams in the spring sun. A group of residents chatters away in one of the gazebos that dot the sprawling South Hills landscape, where low-slung red-brick buildings spread across the verdant expanse. Geraniums and other florals peek from the greenhouse. There is even a wooden chapel, with cracks on its door and a peeling coat of faded green paint.
Except for the "park at your own risk" signs, little in this landscape reminds one of the world outside. But the badge-bearing workers who bookend a line of residents belie the fact that this is a controlled environment: Mayview State Hospital, the largest mental institution in Western Pennsylvania. And these seemingly timeless surroundings may soon prove transitory.
Some 30 long-time residents are being prepared for discharge by the end of June, so that as many beds can be permanently closed by the start of the fiscal year beginning July 1. And that group of patients, called "Wave 1" by officials, will be only the first of the facility's 285 patients to be sent away.
The state Department of Public Welfare has approved tentative plans to close more than one-third of the hospitals' beds by next year ... and to stop offering long-term care at Mayview entirely by 2008. Other plans include halving admissions, which stand at roughly 150 a year, and diverting people on the waiting list for long-term hospital care to other facilities.
All these moves have led many observers, not least state Rep. Dan Frankel (D-Squirrel Hill), to believe that Mayview may soon go the way of Woodville State Hospital, in Collier Township, which shuttered in 1992.
"At this point," says DPW spokeswoman Stacey Ward, "there are no concrete plans to close Mayview or any other state mental institutions."
Even so, the emptying out of Mayview means that the counties it serves ... Allegheny, Beaver, Washington, Lawrence and Greene ... may bear a bigger burden in providing for their mentally-ill residents. It takes not just money but finesse to coordinate the services needed by patients who can be volatile and vulnerable at once. Already, family members of some Wave 1 patients worry that the counties are ill-prepared for the housing and service needs, especially of those who have been hospitalized for many years.
And in the long run, contend some mental-health advocates, the region still needs a hospital that can provide long-term care.
"Every range of service has to be available," says Sandi Hause, a New Castle, Lawrence Co., advocate who fought the closing of Mayview's adolescent unit in the early 1990s. "Sometimes a state hospital is what you need."
Pennsylvania was the first state to administer care to the mentally ill. Provision for the state's mentally ill began as early as the mid-18th century, with the opening of the Pennsylvania Hospital, in Philadelphia, where mental patients were banished to the basement
In later years, similar facilities to house the insane, the infirm and the poor were built in the western part of the state as well. Founded on a Homestead farm in 1897, and originally known as Marshalsea (after the debtors' prison where Charles Dickens' father was incarcerated), Mayview too housed the insane, the infirm and the poor. The facility was moved to its current location when Andrew Carnegie expanded Homestead's steel mills (though his business partner, Henry Phipps, donated a greenhouse to the newly founded asylum). Mayview was renamed in 1912. When the state DPW took over the management from the city, under the Full State Care Act of 1941, Mayview still housed some patients with physical ailments; by 1958, it was solely a mental hospital.
In the following years, however, reformers began arguing that long-term institutionalization had been neglectful, ineffective and even harmful to patients. They championed the idea of providing mental-health services within the community itself, a practice known as "community care." The advent of early-intervention techniques and antipsychotic drugs made it more possible to treat the mentally ill without locking them away. The movement to discharge patients into the community for recovery began nationwide in the late 1970s and early 1980s.
In 1999, the U.S. Supreme Court ruled that institutionalizing the disabled is discriminatory. The Court found that "confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment." The decision, which underscored the rationale behind an already existing trend, encouraged states to offer alternatives to confining the disabled in hospitals.
Between 1979 and 1984, five mental hospitals in Pennsylvania had been closed, beginning with the Hollidaysburg State Hospital, in Blair County. Philadelphia State closed in 1990. Another half-dozen facilites were closed by 1998. Most recently, Harrisburg State closed in January 2006.
Although no such plans have been announced for Mayview and its staff of 728, steps are being taken to drastically reduce its resident population.
"Most people don't need to go to the hospital in order to get their medicine three times a day," says Mary Fleming, CEO of Allegheny HealthChoices, Inc. "The question is 'How do we support people?' instead of 'Where we should put people?'"
HealthChoices is a private, nonprofit agency created in 1999; it manages mental health services for federal Medical Assistance-funded patients in the five-county area. Since last July, Fleming has been convening monthly meetings with a 33-member steering committee to plan for bed closures. The committee is made up of HealthChoices staff members, state and local mental-health officials and two patient advocates.
So far, the steering committee has been mulling the fate of Wave 1 ... the 30 patients primed for discharge by June 30. All of these have been at Mayview for at least two years; some have been residents for a decade or longer. Mayview CEO Richard Kuppelweiser said those patients were selected after evaluations provided by hospital staff as well as by Allegheny County's Office of Behavioral Health.
Now the task is to devise housing and service plans for them once they are returned to their native counties. Of the 30 patients in Wave 1, nearly half are going to personal-care homes or nursing homes.
When surveyed by county-paid staff, most Mayview patients said they'd prefer to live independently, in their own apartments. County mental-health officials say they have a plan to respect that wish.
This May, Allegheny County began to execute plans for providing between 220 and 240 units of what officials call "permanent supportive housing." There, residents will receive clinical and social services, and a housing-support team will be staffed to assist them in moving, getting settled, housekeeping and tackling landlord-tenant issues. The idea is that most patients can receive treatment while living at least somewhat independently; patients will stay for as long as they need to become stable and self-sufficient.
To pay for the plan, the county will tap into $5 million of its federal Medical Assistance dollars, as well as federal housing money. The Allegheny County Housing Authority is slated to construct 60 to 80 of the new units; the remainder will be made available through federal rent subsidies offered to qualified landlords.
But the new housing units won't be ready until after 2008 ... too late for most of the Mayview patients scheduled for discharge by then.
"It doesn't work that neatly," Fleming admits.
Planning for discharge of as many as 90 more patients will get underway after Wave 1 is settled. Half of those 90 are to be discharged by March 2007. Ultimately, the committee's goal is to not have any patients at Mayview receiving long-term care, meaning any stay longer than two years.
Hard as it is to argue against the benefits of deinstitutionalization for most patients, some advocates say discharge isn't for everyone ... especially those who haven't known life outside a state hospital for years. Concerns are already being raised over the first wave of discharges, planned for June.
Sandi Hause, director of the Lawrence County Client Satisfaction Team, has a personal reason for worrying should Mayview drastically curtail its services or close. Her son has borderline personality and bipolar disorders and has attempted to kill himself. But he became more stable after being treated at the adolescent unit of a state hospital.
Moreover, among the three patients Hause has interviewed to prepare for discharge to Lawrence County, she fears that at least one may not be able to function outside Mayview. This patient, says Hause, has schizophrenia and a damaged frontal lobe. As a result, he can barely speak, though Hause says he has been able to communicate well enough to say he doesn't want to leave Mayview, where he's lived since the 1980s.
"He's lived there for 20 years ... the state hates to hear this ... but it's home," says Hause. "It shouldn't be a home, but it happens. For some people, it's a sad fact of life. Why should we feel guilty about it?"
Some family members would feel worse if their relatives left the hospital. Take, for example, the relatives of Joseph Pepe, who at age 68 has spent a decade in Mayview.
In 1959, as a junior at the then-Carnegie Tech, Pepe was diagnosed with paranoid schizophrenia. He went on to complete graduate work at the University of Pittsburgh, but mental illness overtook him. He would accuse people of following him. He became suspicious of gadgets such as the TV and microwave. He refused to take his medicine. Through the years, he would get stabilized at a hospital and be released, get his own apartment. Then he'd have a falling-out with people he came into contact with ... and end up back in the hospital.
Family members fear the same could happen again.
"It's been like a revolving door," says his younger sister Nancy (who asked that her married name not be used), of Bethel Park.
"That is the only stable time in all these years," says Nancy of Pepe's tenure at Mayview. "He's adjusted, he takes his meds, he is not getting into trouble, he has clean sheets. It's been the happiest time of his life. This is the best I've ever seen of him. That doesn't mean he is okay to be released."
At an assessment meeting in April, Pepe said he'd like his own apartment in a secluded area. He's promised to do his laundry and take care of himself.
His other sister, Lee, who was at the meeting, said her brother is clever enough to say the right things to caseworkers. But she and Nancy say they know his history well enough to predict that, if left alone, he will struggle.
"That would be the end of him. He would stop taking his medication, and what would we do?" asks Lee.
Mental-health officials insist that Lee and Nancy won't be alone. Patients who live independently are promised a community treatment team, made up of a psychiatrist, a social worker, at least two nurses, and a few other professionals. HealthChoices' Fleming says currently there are four teams, each carrying a caseload of 90 patients.
Pepe's sisters worry that the teams are already stretched thin, and that there may not be enough money to go around. "They promise if he were to be on his own, there would be a treatment team for him forever. There will be funding for him forever," says Lee. "I just don't believe that. They painted a very rosy picture. They sound like the treatment team is coming out of the woodwork."
Both Lee and Nancy say that they would love nothing more than to see their brother living a good life on his own in the community, and that they didn't give up on that idea for lack of trying. But Pepe is too fearful even to step into their houses.
"They have no idea what he went through [and] what we went through," says Lee. "He is almost 69 right now. Why would you want to do something that would turn his life upside down?"
One reason is money.
The tranquility of Mayview's campus doesn't come cheap. In the current fiscal year, operating Mayview costs the state just over $63 million ... more than $500 per patient a day. Mental health officials believe patients can be served in the community for a lot less.
That's because once a patient is discharged, say state and county health officials, a substantial portion of the health-care costs can be transferred from the state to the federal government. The federal Medical Assistance program covers most medical services provided to the mentally ill who live on their own, or in certain types of residential programs. If patients they remain in a state hospital, meanwhile, the state has to foot the bill.
But Medical Assistance doesn't cover housing costs, or transportation for non-medical trips. These services, too, are important to the patients' well-being.
HealthChoices' Fleming said the steering committee is mindful of what it would cost to adequately serve patients in the community. For the 30 to be discharged from Mayview next month, the counties are asking for $3.2 million annually from the state Department of Public Welfare. Joan Erney, DPW's deputy secretary for the Office of Mental Health and Substance Abuse Services, says that the state's offer will be close to that, though it won't come until early or mid-June. HealthChoices' estimated cost for serving the Wave 1 patients "looks reasonable," Erney said after meeting with the steering committee May 19.
The state's ability to deliver on the $3.2 million "is a test of everything," says Fleming. "Everything written into our plan is contingent upon getting the money," says Fleming. If it doesn't materialize, counties aren't obliged to follow through on their plans to accept discharged patients. But "we're confident that we can work this out."
Skeptics, including family members of those facing the June 30 discharge, aren't so sure.
"I keep saying, 'Show me the money,' says Marge Kerns, a patient advocate at Mayview for the Mental Health Association of Allegheny County who sits on a subcommittee of the steering committee. "They have lovely plans, [but] where does this pot of gold sit?"
Some of it, at least, may be sitting right beneath the hospital itself.
Thanks to their once-rural surroundings, many state hospitals have proved desirable to suburban developers. The Collier Township property where Woodville State Hospital used to be sold for nearly $3 million in 1995; it is now a residential golf course. The Western Center property, in Cecil, was sold in 2003, for $2 million, for development into a complex of shops and offices. Mayview's 288-acre site is nestled against Upper St. Clair, and would also likely be desirable real estate.
Already, four of the long-vacated buildings on Mayview grounds are slated for demolition this summer.
"One of our concerns is they could start selling parts of [Mayview]," says Harriet Baum, executive director of the National Alliance of the Mentally Ill Southwestern Pennsylvania. Baum is concerned that if this happens, the sales proceeds will go into the state's General Fund, where it will cover the state's day-to-day operating expenses, instead of benefiting the patients.
But if Mayview is closed and the property sold, advocates want to earmark the money for the patients it used to serve. In order to recoup more dollars for patient care when a hospital closes, state Rep. Dan Frankel introduced a bill May 2 to establish a mental-health community-services trust fund. The money will come from sales of closed hospital compounds.
"The state has generally not followed through on providing service to these people when they're deinstitutionalized," says Frankel, who was involved in the establishment of Jewish Residential Services, a Squirrel Hill human-services agency which houses and counsel the mentally ill. "It's a very expensive proposition to provide services and housing to these people."
He plans to hold public hearings soon on the legislation, House Bill 2654, which he says has bipartisan support.
Frankel also says that although he has no confirmation that Mayview will close, given that more and more patients are being discharged, a "logical conclusion" he'd draw is that it soon could.
If passed, he says, the bill will help provide for those mentally ill, including Mayview's patients, who are being reintegrated in the community.
"Mayview is one cog in a very complicated system serving many different people," says Ray Firth, behavioral-health policy director at the University of Pittsburgh's Office of Early Childhood Development. In the early '90s, as deputy director of policy and planning of the then-Allegheny County Office of Mental Health and Mental Retardation, Firth oversaw the closing of Woodville State. "It seems to me myopic just to look at the closing of Mayview" just in terms of its effect on the patients already housed there. "The real question to ask is: 'Are you looking at the community need?' You have to evaluate the community need that Mayview serves."
Currently, there are 17 patients waiting at community hospitals, such as the Western Pennsylvania Psychiatric Clinic, to be admitted to Mayview. The $3.2 million that the counties hope to get from the state to serve the Wave 1 patients accounts for some ... but not all ... of the needs of those on the waiting list.
As Mayview prepares to scale back, concerns also abound for those who need the kind of intensive, long-term care that is available only at a state hospital.
When asked what the future Mayview would be like, DPW's deputy secretary Erney said the hospital may still be positioned to provide specialty care. The mentally ill "can get treatment and assessment and return to the community for rehabilitation," she says, "just like when you have to get a leg set" after a fracture.
But "it's not that simple," says Eleanor Slater, founder in 1980 of the local chapter National Alliance of the Mentally Ill. "Trying to fix somebody with a mental illness is a life-time goal." Slater's daughter was last treated at Mayview, in 1980, for schizophrenia. "Once they're diagnosed, sometimes they'll have it for a long time."
Just ask Virginia (who prefers her last name not be used), of Daisytown, Washington Co. She's heard many versions of the plan for the discharge of her only daughter, Tracy, who was first admitted to Mayview, in 1982, at age 14. For half her life, she's been re-admitted to the facility repeatedly, though she has yet to receive a definitive diagnosis. Virginia says the best guess is that her daughter suffers from a mix of schizoaffective and obsessive-compulsive disorders. She's been at Mayview since 1992.
Says Virginia, "She said to me, 'I just want out of here.'"
There are signs it won't be that easy. In her interviews with HealthChoices staff and other members of the assessment team, Tracy said she wanted to share a house with two roommates, her mother says. The providers assured her that all she has to do is to scan real-estate ads for a suitable house. But recently, the assessment team told Tracy they would buy her a trailer instead. Then they asked whether it could be staged on her parents' property.
"I just find it shocking that they'd ask that," says Virginia. "They just got her hopes up. ... They made all these wild promises."
Both Virginia and Tracy were confounded by the changes of the plan.
"I told her, 'They're just blowing smoke,'" says Virginia.
HealthChoices' Fleming, who oversees the drafting of all housing and service plans for Wave 1, said she can't comment on specific patient cases.
Although Tracy has been well enough to come home every other weekend since Easter, she has had episodes of paranoia and delusion; one ended with her being taken from home in an ambulance. However much Tracy desires to be on her own, her mother worries, an adolescence and early adulthood spent at Mayview hasn't prepared her for independent living.
"They're trying to put those incapable of taking care of themselves out into community homes. I cannot see the reason of this," says Virginia. "My fear is that, in the end, they won't care."