Sudden Impact

A local program aims to assess student athletes before they are injured
Published Aug. 20, 2008 in the Keene Sentinel
By Casey Farrar
Sentinel Staff
Brows furrowed in concentration, a group of Keene High School football players sat in a computer lab last week watching a series of shapes and words flash across their computer screens.

Next came a set of questions testing their short- and long-term memory.

Training for the season had started, but this wasn’t a typical practice: Athletes on the football, soccer and spirit teams at Keene High School and Monadnock Regional High School this season are having their brain function tested as part of new program to assist athletic trainers and doctors when players suffer concussions.

The program, called ImPACT, or Immediate Post-concussion Assessment and Cognitive Testing, is one of the first of its kind — being used by more than 1,200 high schools, 300 colleges and universities and 30 professional football teams — to give doctors and trainers data about student athletes’ brain function before and after concussions.

And the information it has already provided has vastly changed the way doctors and trainers look at concussions in high school athletes.

Studies using the test, which was developed at the University of Pittsburgh, have shown that, unlike many other types of injuries, the younger an athlete is the longer it takes for his or her brain to bounce back from a head injury, according to Dr. Mark B. Silbey, director of the sports medicine department at Cheshire Medical Center/Dartmouth-Hitchcock Keene.

The aim of the project is to give doctors and trainers a more objective analysis of when it’s safe to send a young athlete back onto the field. Now local doctors and trainers hope to use the test as a tool for treatment of head injuries among Monadnock Region sports teams.

“When you put kids back on the field we now know that, especially in younger kids, it takes longer to recover,” Silbey said. “We’re only going to gather more data now, and the important thing is that these are objective numbers that can sometimes give us a better idea than subjective testing as to how the brain is recovering from trauma.”

This is the first season the hospital’s Sports Medicine Center has used the test.

Since 2004, the center has provided athletic trainers to Keene, Monadnock Regional, Fall Mountain Regional and Brattleboro Union high schools and Keene State College, the Keene Swamp Bats baseball team and the Monadnock Marauders football team.

Recently, it added Bellows Falls Union High School and Vermont Academy in Saxtons River, Vt., to its rolls.

While ImPACT testing is only being offered to Keene and Monadnock Regional high schools, with ice hockey, basketball and wrestling athletes also being tested before the winter season, Tate S. Erickson, sports medicine manager for the Sports Medicine Center, said if all goes well the center hopes to expand testing to more schools next year.

During the 2005-06 school year — the most recent statistics available — of the 4.2 million high school athletes across the country, nearly 760,000 were injured, according to a report by the U.S. Centers for Disease Control.

Nearly 15 percent, or about 100,000, of them suffered concussions, the report showed.

Last year, 54 student athletes from Keene, Monadnock Regional, Fall Mountain Regional and Brattleboro Union high schools suffered concussions, according to statistics from the Sports Medicine Center.

Concussions represented about 3 percent of the 1,610 injuries reported by athletes at the schools served last year by the center, but the severity of head injuries among high schoolers has only recently gained national attention.

“In the last two to three years it has become a national focus,” said R. Patrick Corbin, executive director of the N.H. Interscholastic Athletic Association. “The medical community didn’t ever pay as much attention as they should have to head injuries among kids, but now it has become a hot-button issue in New Hampshire and across the country.”

Part of what is behind the increased attention on the effects of concussion on high school athletes is the use of ImPACT testing, according to Erickson.

With more data available from the tests, doctors and trainers are better able to understand how the brain recovers, said Silbey, one of two doctors treating student athletes through the Sports Medicine Center.

A $2,500 grant from the Agnes M. Lindsay Trust in Manchester and a $1,000 gift from an anonymous donor paid for the ImPACT testing, according to Donna M. Dubuc, director of development at the hospital.

Erickson, who oversees the eight athletic trainers that work in the six schools in the region, said the pilot testing programs at Keene and Monadnock Regional high schools will complement the traditional assessments that trainers, doctors and coaches use when an athlete suffers a concussion.

Before the start of the season, athletes will take a baseline exam, which rates their reaction time and memory, over the Internet.

In one portion of the test, blue and red dots flash intermittently on the screen. Students have to push the letter “P” on their keyboard when they see red and “Q” when they see blue. It is a test of reaction time.

Immediately following that, they are asked to recall a list of words they saw in an earlier portion of the exam — testing long-term memory.

If an athlete suffers a moderate or severe concussion — classified as a concussion with symptoms lasting more than 15 minutes or if an athlete loses consciousness — he or she will retake the test a day after the injury. The test will give doctors and trainers an idea of how badly brain function has been affected and helps to determine when an athlete is ready to return to the field, Erickson said.

But as trainers and doctors at the Sports Medicine Center analyze the tests over the next year, Erickson said the schools will continue to use the usual standards to determine when an athlete can return to play.

Typically, an athlete who suffers a mild concussion — with symptoms including dizziness, double vision and headache lasting less than 15 minutes — are out of sports for one week, Erickson said.

These athletes won’t be retested using ImPACT, unless a trainer or doctor recommends it, while athletes suffering moderate concussions will be out up to two weeks from the time their symptoms subside, according to Erickson.

Severe concussions, defined by an athlete losing consciousness, will mean an automatic two-week break from sports, and possibly longer depending on an athlete’s recovery time, Erickson said.

Erickson said while some teams and schools have decided to send athletes back to the field once their test results are within 10 percent of baseline, others have taken a more conservative 5 percent approach.

Because the program is new at the Sports Medicine Center, clinicians have yet to determine the level of function they will use to mark an athlete’s safe return to play, according to Erickson.

Because concussions cause swelling in the brain, doctors and trainers are concerned with athletes returning to play too quickly.

If the brain is still swollen and is injured again, it can trigger permanent damage including aneurysms, or bleeding in the brain, which can lead to death, Erickson said.

Since symptoms of concussion, which include headache, nausea, confusion, irritability, sleep disturbances, fatigue and memory loss, commonly have been self-reported, doctors have had to rely on an athlete’s own judgment of their symptoms.

“When a kid comes in and says their symptoms are gone, we can test them with ImPACT and see if their brain function has recovered,” Erickson said. “Everybody’s different in terms of how they will recover, but I believe the trends will be consistent with the traditional standards.”

Corbin, from the state high school athletic association, said the objective testing can be important in discouraging athletes from returning too quickly.

“Teenagers all think they’re invincible,” Corbin said. “It’s important to play in that game and you get banged in the head, your eyes are crossed, but you’ll be okay.”

A recent study involving ImPACT pointed out that while self-reported symptoms generally subsided in four days, tests showed memory decline lasted at least seven days after injury, according to Erickson.

Parental pressure can also push student athletes back onto the field too soon, according to Corbin.

“One of the biggest problems is parents who are so concerned about Susie or Johnny playing in that championship game, and fighting the whole mentality that a student getting their bell rung is okay,” Corbin said. “It boggles my mind, as a parent, to see parents putting kids back out.”

Erickson said he also has seen athletes pushed back into playing by overzealous parents, but trainers and doctors can now use ImPACT score reports to show solid data about the concussion.

“It’s not there to replace traditional testing, but it’s a great tool and we’re hoping, based on the results of the pilot group, to expand this to other schools,” Erickson said.

Casey Farrar can be reached at 352-1234, extension 1435, or cfarrar@keenesentinel.com.

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You’re home. Now what?

Local veterans counselors are few and far between in the region

Published June 25, 2008
By Casey Farrar
Sentinel Staff
The 15 people who gather weekly at Granite Hills Behavioral Consultants paint a complex picture.

A Vietnam veteran in his 60s who has been divorced three times and said sometimes he drinks his problems away.

An Iraq veteran and reservist who has applied for 63 jobs since he returned, but has never heard back from any employer after telling them he might be called back to war.

A veteran of the Gulf War who says he sought help for depression when he saw his children suffering from his mood swings.

All of them have seen the face of combat, and each has a very different story to tell.

But when they are in this conference room in Keene every Thursday among other veterans, they say they feel understood.

A 24-year-old veteran of Iraq from Keene, who asked that his name not be used, says it took a suicide attempt several months after his return to recognize the magnitude of his depression.

He said talking to the other veterans in the group has helped him understand that what he feels is normal.

Leading the group is Anthony “A.J.” Paige, a veterans readjustment counselor for Monadnock Family Services in Keene who is himself a veteran of the U.S. Army.

During his 23 years in the Army, Paige saw his share of combat in Somalia, Central America and the Persian Gulf.

In the nearly three years since Paige began counseling veterans at Granite Hills, a branch of Monadnock Family Services, the number of veterans walking through his door has increased seven-fold.

In 2006, Paige worked with eight veterans who had been referred from regional veterans centers. In 2007, 23 veterans sought treatment at Monadnock Family Services, and this year that number has jumped to 58.

All of the veterans Paige sees are men. He said a female veteran has also sought treatment with him, but because he counsels her husband, who also is a veteran, Paige is unable to see her. She is forced to travel to Manchester for treatment.

Nearly a quarter of the veterans he sees have returned from Iraq and Afghanistan. He also counsels 26 Vietnam veterans, nine veterans who served in the Gulf War, two veterans of Bosnia and Kosovo, two veterans of Somalia, three veterans of conflict in Central America, one veteran of World War II and a veteran of Grenada.

“(Veterans) are very proud people,” Paige said. “They have an enormously tough time talking because they come from our society, which tells people big boys don’t cry.”

That mentality is enforced in the military, Paige said, where losing focus for only a second can be the difference between life and death.

“You suck it up. You drive on. You accomplish the mission,” Paige said.

Most of the veterans Paige sees have symptoms of post-traumatic stress disorder including depression, trouble sleeping, anger, and isolation. Some battle substance abuse and several have been homeless. All said they’d considered suicide at one time or another.

The veterans at the group meeting said they are sometimes asked difficult questions about combat or feel people don’t believe their stories, making it hard to relate to those they were once close to.

“Sometimes people will ask, ‘Did you ever shoot anyone?’” said a recently returned Iraq veteran. “And you know they just don’t understand, but it makes you wonder how someone can ask something like that.”

Post-traumatic stress disorder was first recognized by the American Psychological Association in 1980. It is caused by exposure to a life-threatening situation and feelings of helplessness and can result in flashbacks of a traumatic incident months or years later.

Recent reports showing an increasing suicide rate among soldiers, combined with a rising number of diagnoses of post-traumatic stress disorder and traumatic brain injury, are leading Paige and others in the mental health field to say long-term care for veterans needs to improve.

“Unfortunately, we live in a nation that has a bad tendency to be a throw-away society,” Paige said. “Once we’re done using you, once you’ve served your purpose and the rounds are done going down-range and the bullets are done flying, ‘it’s have a nice life.’ ”

The U.S. Army recently reported 115 confirmed soldier suicides in 2007, both stateside and abroad — the highest number recorded since the Army began keeping such records.

In 2006, 102 suicides were reported. Neither of those figures includes suicides among veterans no longer in the service, which are not tracked.

Rates of post-traumatic stress disorder diagnosed by the Army also jumped in 2007, increasing by 50 percent.

A recent study by the RAND Corp., a health and government policy research program, showed one in five returning veterans from Iraq and Afghanistan report symptoms of post-traumatic stress disorder or major depression.

Of the nearly 1.6 million troops deployed to Iraq and Afghanistan, 300,000 have reported symptoms, yet only 53 percent of those sought help from a medical provider over the last year, according to the RAND study.

The U.S. Department of Veterans Affairs recently announced an effort to ramp up suicide prevention with the creation of an advisory panel.

The Department of Defense also announced it will expand the network of mental health care providers who accept the military’s TRICARE health plan and teach civilian providers how to screen for traumatic brain injury.

In New Hampshire, nearly 125,000 veterans have returned from Iraq and Afghanistan and 28,000 are registered for medical coverage with the Manchester Veterans Administration Medical Center, according to Debra N. Krinsky, a spokeswoman for the center.

Krinsky said many veterans in the state go to the White River Junction Veterans Administration Medical Center in Vermont, and with veterans traveling out of state for treatment, it’s impossible to pin down exactly how many of the state’s veterans are being treated for service-related injuries.

Statistics on the number of veterans in the state diagnosed with post-traumatic stress disorder are not available.

Nine of 14 research studies at the Manchester medical center this year focus on post-traumatic stress disorder, according to center officials. The research is funded through grants from the Veterans Administration, the National Institute of Mental Health, the U.S. Army and the American Society of Addiction Medicine.

Paige says many soldiers returning from war are discouraged from seeking help because of the stigma attached to a mental health diagnosis.

They also face mountains of paperwork and frequent office visits to file claims with the Veterans Administration, Paige said.

Many are referred to Granite Hills by the veterans center in White River Junction, Vt. Others come after being treated at area emergency rooms or walk in from the streets.

For some veterans, getting counseling in Keene is easier than traveling to White River Junction or Manchester, which are each about 60 miles away.

The centers are also overloaded, meaning the average counseling session lasts about 20 minutes there, Paige said.

In contrast, at Granite Hills veterans are scheduled for hourly sessions, and sometimes stay longer if they need extra time, he said. They usually begin group therapy weeks or months after their counseling begins.

Since he is the only counselor at the center working full-time with veterans, the number of veterans who can receive treatment locally is limited, Paige said.

But funding at Monadnock Family Services and other counseling services around the state is tight, making it difficult to beef up veterans counseling staff.

“The Easter Seals, the Veterans Administration, the federal government and the Army all have a lot of money they want to shift toward the vets,” Paige said. “The problem is they haven’t quite figured out how to shift it down here to the trenches.”

In the meantime, several veterans gathered at the group counseling meeting in Keene last week say they have to wait months, and in some cases years, to get treatment for medical and mental health problems related to their time in the service.

For the Veterans Administration to cover the cost of treatment, veterans have to file claims that take an average of nine months to receive approval. Denied claims can be held up in the appeal process for more than two years, Paige said.

But the veterans who take part in the Keene group meetings say in the end, not coming in for help would be worse than jumping through the federal hoops.

“The more and more you wait around, the more and more isolated you feel and the worse all those feelings become,” said one veteran of the Gulf War at a weekly group meeting. “At least here we can talk to each other about it and feel like someone understands.”

Casey Farrar can be reached at 352-1234, extension 1435, or cfarrar@keenesentinel.com.

War-related brain injuries usually treated elsewhere

Published June 25, 2008 in the Keene Sentinel
By Casey Farrar
Sentinel Staff
Traumatic brain injury is gaining a reputation among military and civilian doctors as the signature injury of veterans returning from Iraq and Afghanistan.

Caused by the blast waves from an explosion or a blow to the head, the injury can result in short-term memory loss, headaches, ringing in the ears, mood changes and depression.

However, the way brain injuries from blasts differ from those typically suffered by civilians is a growing topic of study among experts in the field, according to Dr. Rocco A. Chiappini, director of brain injury services at Crotched Mountain Rehabilitation Center, a treatment center in Greenfield.

The Department of Defense estimates there are more than 22,000 soldiers who have survived blasts, about 25 percent of whom are probably affected by traumatic brain injury.

This month, officials from the department broke ground in Bethesda, Md., on a $70 million clinical research and education facility for the treatment of traumatic brain injury and psychological health.

In New Hampshire, moves are being made to meet the need for treatment at the local level.

The Manchester Veterans Administration Medical Center has opened three clinics for brain injury and neurological assessments for veterans since March, according to Debra N. Krinsky, a spokeswoman for the medical center. The third, a neuropsychiatric clinic, opened on Tuesday.

In the year since all soldiers returning to New Hampshire have been required to undergo assessment for traumatic brain injury, 131 have tested positive for traumatic brain injury at the Manchester medical center, according to a press release from the center.

Until the Manchester clinics began in March, those who tested positive for this injury were sent to Veterans Health Administration medical centers in Boston and White River Junction, Vt., for further treatment.

Since March, 70 veterans have been treated for traumatic brain injury in Manchester; another 13 are scheduled for assessments at the new clinic, according to officials at the medical center.

Federal officials are also considering using Crotched Mountain as a place to treat wounded veterans.

The rehabilitation center has been certified as meeting military requirements to treat veterans, said Michael D. Redmond, vice president of advancement for the Crotched Mountain Foundation.

Officials at Crotched Mountain have discussed with the Veterans Administration the possibility of treating one local injured veteran who may stabilize enough to begin rehabilitation, Redmond said.

Chiappini, who is a physiatrist, or doctor specializing in rehabilitation, said while the center hasn’t seen any veterans yet, he sees demand for local treatment services increasing in the near future.

“There hasn’t been a lot of good research done in a methodical way to understand brain injury,” Chiappini said. “It has started and it’s increasing now because of the wars.”

Casey Farrar can be reached at 352-1234, extension 1435, or cfarrar@keenesentinel.com.

Six to lose jobs at counseling center

MFS $500,000 short; more trouble expected

Published June 12, 2008 in the Keene Sentinel
By Casey Farrar
Nearly two months after announcing a $500,000 budget deficit, a Keene-based mental health organization has begun shifting its focus to cut costs.

The organization is shrinking its adult outpatient counseling services, which resulted in $190,000 in losses last year from unpaid fees, according to Jayme J. Collins, chief operating officer of the nonprofit organization.

The cuts mean long-term treatment for people who are not deemed at risk of harming themselves or others and can’t pay will no longer be available, Collins said.

Six full-time clinical therapists were notified last month that they will be let go on July 1, Collins said.

And by expanding services for severely mentally ill adults and children, who are eligible to receive state and federal funding, administrators at Monadnock Family Services hope to bring in more money for the organization, according to Jayme J. Collins, chief operating officer of the nonprofit organization.

The organization’s budget deficit came from unmet Medicaid deductibles, unmet deductibles from clients with commercial health insurance and people who couldn’t pay.

Meanwhile, a giant question mark looms over the 10 community mental health centers, including Monadnock Family Services, around the state as they wait to find out the possible financial impact of new federal Medicaid rules.

Then new rules, which would affect treatment plans and payment methods for patients covered by Medicaid, could lead to as much as a 40 percent reduction in reimbursement rates for the centers, according to Jay Couture, chair of the N.H. Community Behavioral Health Association.

The centers, which receive as much as 80 percent of their reimbursements from Medicaid, could see $20 million in losses next year, Couture wrote in a letter sent to health care advocates and legislators last week.

Monadnock Family Services is the first of the state’s centers to announce cutbacks. Last month, the organization’s 260 employees took a 7 percent pay cut when their work week was reduced by 2.5 hours.

Collins said nearly a third of the organization’s 3,300 adult clients will be affected by the cutbacks to the outpatient counseling services.

While the organization is required to treat severely mentally ill adults and children, it has been providing the same level of treatment to anyone who comes in, whether they can pay or not, Collins said.

By absorbing unpaid fees from people who are uninsured or can’t meet their insurance deductibles, the organization has been falling further behind, Collins said.

She said many of the outpatient clients receiving treatment are facing difficult situations like a recent divorce or move and are looking for help, but aren’t at risk of harming themselves or others.

“We have to use our resources efficiently so that we can provide services to those we’re mandated to treat by the state,” Collins said. “The thing that got (Monadnock Family Services) in the bind that they were in … is that they tried to treat everybody that same way.”

Collins said the organization will assess everyone who comes in, and offer short-term treatment for people who are not considered high-risk.

“We’ll try to give them a lot of tools to work with that they may have to do on their own or come back for a check-up a couple of months later,” Collins said. “We just can’t do traditional weekly kind of therapy in the same way.”

Collins said the organization is working to increase its group therapy offerings, which would cost about a third less than meeting individually with a therapist.

Up to eight people with similar diagnoses meet with one clinical therapist in typical group therapy, according to Collins.

It’s not a popular choice for many people, who don’t feel comfortable discussing personal issues with others, Collins said, but offers an option for people unable to afford individual therapy.

Emergency mental health services offered by the organization will not be affected by the cuts, Collins said.

Expanding services for severely mentally and emotionally ill adults and children will also help the organization financially, Collins said.

Because the organization is required to treat those clients, community, county, state and federal funding is available to cover unmet fees.

She said by broadening treatment options for severely mentally ill adults, including transportation to medical appointments, life skills training and career counseling when possible, the organization will be eligible to take in more Medicaid money.

The expansion of those services over the next year means the organization could offer jobs in other areas to the people it has had to let go from the outpatient counseling staff, Collins said.

“There will be new opportunities, but unfortunately they’re not happening simultaneously,” Collins said. “I’m afraid some of that talent will move on.”

Couture, who heads the state association of community mental health centers, warned in her letter that other centers in the state may face cut backs or even closure if the new rules are too costly.

“Clearly, the centers will not be able to operate if their reimbursement is cut by 40 percent,” Couture said in a press release.

With more than 41,000 people in the state turning to the state’s mental health centers for treatment in 2006, Couture said hospital emergency rooms, county and state correctional facilities and local police and welfare departments could be affected by the reduction of services in the centers.

The new rules, which were set to go into effect in March, have been delayed until August. Congress is considering a one-year moratorium, which was placed in the language of an Iraq war appropriations bill.

The bill passed in the Senate, but has been stalled in the House.

Casey Farrar can be reached at 352-1234, extension 1435, or cfarrar@keenesentinel.com.

Keene group to lose contract

Part of cost-cutting at Monadnock Family Services

Published April 21, 2008 in the Keene Sentinel
By Casey Farrar
Canceling a cleaning contract with Wyman Way Cooperative is the next in a growing list of cutbacks for a Monadnock Region mental-health organization.

Monadnock Family Services CEO Kenneth Jue said he met Friday with Matthew P. Haas, board president of the cooperative, to discuss ending cleaning services at Monadnock Family Services’ offices at 64 Main St. in Keene.

The cooperative, which is a nonprofit organization aimed at rehabilitating people with mental illnesses, emotional disturbances and substance-abuse problems, will continue to clean Monadnock Family Services’ offices on 93rd Street, Jue said.

With devastating deficits statewide, Monadnock Family Services might be only the first of the state’s 10 community mental-health centers forced to make cuts, according to according to Roland P. Lamy Jr., executive director of the New Hampshire Community Behavioral Health Association, a group formed by the state’s centers.

Jue estimates Family Services will save $10,000 per year by hiring another cleaning company to provide the service on Main Street.

James P. Noyes, general manager of the cooperative, said the the contract brings in $2,700 per month.

The cooperative, which employs 19 people, is making plans to place affected employees in other jobs in the community, including cleaning, grounds keeping and painting, according to Haas.

Haas said he doesn’t yet know what the financial effect of the contract loss will be.

“It’s a very big contract,” he said. “If anything, this is kind of a good time of year to have the contract cut, if there is a good time, only because had it been winter time it would be very difficult to find jobs to do indoors.”

Haas said the board of the cooperative had been informed that cutbacks were coming before the announcement last Monday that Monadnock Family Services was dealing with a $500,000 deficit this year.

The cooperative also offers moving services and is considering expanding a service providing transportation to people for medical appointments, such as doctor visits and prescription pick-ups, Haas said.

“Our income is going to be very different for a while, but knowing (about the changes) ahead of time helps,” Haas said. “We need to see how it plays out and probably we’ll get a better picture of things in November and December, when the summer rush ends.”

Last week, Monadnock Family Services announced major employee and service cutbacks in response to its budget deficit.

Jue said the contract with the cooperative won’t be cancelled until after a new contract is negotiated with another company, adding that he doesn’t know how long it will take to make the change.

A contract with the cooperative costs more than other cleaning services because members of the cooperative often work together on jobs and sometimes require additional time or training to complete tasks, Jue said.

“I hate to do it,” Jue said. “It’s purely a financial decision.”

Other mental-health centers in the state feel the pinch

Losses from unmet Medicaid deductibles have cost the 10 centers across the state nearly $4.5 million this fiscal year, leaving all of them grappling with budget deficits, Lamy said.

Lamy said the amount each center has lost varies by the population served, but Monadnock Family Services falls in the middle of the group, having lost $436,000 this year.

Other centers are located in Derry, Nashua, Dover, Laconia, Manchester, Conway, Concord, Portsmouth and Lebanon.

The 10 centers served 41,353 people in 2006, according to the New Hampshire Community Behavioral Health Association’s Web site.

The association was formed in 2001 to coordinate efforts to inform the state Legislature and Department of Health and Human Services about the issues and financial difficulties faced by the centers, Lamy said.

Lamy said financial shortfalls have been gradually building at centers all over the state, stemming mostly from unmet Medicaid and commercial health insurance deductibles.

With Medicaid reimbursement rates, set by the state and matched by the federal government, holding steady and health-care costs climbing, the centers are absorbing more expenses for services, Lamy said.

“It’s a dramatic issue and I think we’ll see more strain and stress on the centers all over the state,” Lamy said. “Across the board, they are looking at what they have to do to remain financially viable.”

So far, Monadnock Family Services is the only center in the state to make cuts this year, according to Lamy.

“It’s a very difficult decision to make, but when you reach the threat of having to close your doors or make these decisions you have to take care of the most needy,” Lamy said.

Changes implemented this month in federal case-management regulations may compound the financial difficulties the centers face, Lamy said.

As a requirement of Medicaid regulations, the centers create plans for treatment for all patients covered by Medicaid. The centers are then paid by Medicaid for providing these services.

The regulation changes will affect the type of treatment covered under the plans, as well as how the centers are paid for these services, Lamy said.

New York, Tennessee, Kentucky, Maine, Maryland, Oklahoma and New Jersey have filed a lawsuit seeking to block the Medicaid regulation changes, according to a report by the Associated Press.

The association of community mental health centers is working with the Department of Health and Human Services to define the changes to the regulations, but the full financial effect on the centers probably won’t be clear until after mid-May, according to Lamy.

“This rule came upon us pretty suddenly and it has a significant impact on the system of care,” Lamy said.

Monadnock Family Services is overhauling its computer coding system to meet the new regulations, Jue said.

Jue said he fears the changes will only add to the growing financial strain on the organization.

“We’re just going to have to wait and see what happens,” Jue said.

Casey Farrar can be reached at 352-1234, extension 1435, or cfarrar@keenesentinel.com.

Mental-health group faces cuts

Monadnock Family Services projects $500K shortfall; jobs and programs will be lost

Published April 16, 2008 in The Keene Sentinel
By Casey Farrar
Caught in a perfect storm of rising health care costs, tightening insurance and Medicaid benefits and a faltering economy, Monadnock Family Services announced major staffing and service cuts Monday.

The organization says it is facing a $500,000 deficit this fiscal year, and will have to cut pay and benefits for employees and reduce counseling services for people in Monadnock Region communities.

With more people unable to pay rising insurance and Medicaid deductibles, the nonprofit organization, which primarily offers mental-health services, attributes its financial woes to absorbing unpaid fees for services, CEO Kenneth Jue said.

It’s a problem seen at varying levels in all of the 10 community mental health centers in the state, according to Jue.

“All of the centers are struggling with the deductible issue,” Jue said. “Across the state we’re talking millions of dollars and shifting that cost into a community and its provider system.”

To rein in shortfalls, in May the Keene-based organization will cut the work week of its 260 employees from 37.5 to 35 hours, translating to an annual pay drop of nearly 7 percent. The organization will also discontinue payments to employee retirement funds at least through June 2009, Jue said.

This reduction in office hours also means nearly a third of the group’s 3,330 adult outpatient counseling clients may have to find help elsewhere, Jue said.

The organization already shaved expenses by eliminating eight positions earlier this year, Jue said.

But it wasn’t enough, and Jue predicts that if the restructuring announced Monday doesn’t fix the mounting expenses more job cuts may be on the way.

The number and type of cuts would depend on the restructuring process, but could amount to six full-time positions, Jue said, calling this the worst financial crisis the organization has faced.

The last time Monadnock Family Services faced such financial difficulties was 25 years ago, when it had to lay off employees because of deficits, Jue said.

An increase in the number of people covered under a form of Medicaid that includes monthly deductibles as high as $1,000 is a significant contributor to the organization’s bulging expenses, according to Jue.

After efforts by the state in the 1970s and 1980s to scale back the number of people living in state mental hospitals, more people with mental illnesses are working and contributing to Social Security than in previous decades, Jue said.

But if a person is no longer able to work due to mental illness, he or she qualifies for a form of Medicaid that doesn’t cover all medical expenses, said Sandra M. Metivier, Medicaid specialist for Monadnock Family Services.

“It’s that period of time before they go back to work where we absorb a huge cost for providing those individuals services who have very serious mental illness,” Metivier said.

The number of people with Medicaid deductibles treated by the organization grew to 185 last year, from 50 in 2006, Jue said.

When people are unable to pay the deductibles, the organization absorbs those costs, which has taken a bite out of its $11.5 million budget.

With Medicaid reimbursement rates – set by the state and matched by the federal government – holding steady and health care costs increasing, the organization is spending more to provide services, Jue said.

Medicaid also sets limits for how many visits customers can make for a specific illness, Metivier said. Most adults in the outpatient counseling department are limited to 18 visits, unless they are approved by Medicaid for expanded care.

“In many cases, however, that’s not possible,” Metivier said. “For a lot of people – for example for a parent who loses a child – the act of being in therapy for 18 visits doesn’t cover such a severe loss. So what does that individual do who’s getting up and working every day?”

Once a person reaches this limit, Medicaid coverage ends and the client is responsible for paying for further care. If they can’t pay, the organization takes a loss, Jue said.

Unmet deductibles from clients with commercial health insurance have added to the burden, costing the organization $436,000 last year, Jue said.

“Since the 1990s commercial health insurances have been increasing their costs, employers have been cutting back on their share of the costs and passing more and more of that to the employees and their families,” Jue said, adding that the higher costs have left some people unable to pay their bills.

This has put the organization in a tough spot.

“We have been reluctant to tell people to stop coming,” Jue said. “We’ve tried to absorb those losses for a number of years now. We’ve made adjustments in our own benefit levels for our employees so that we could afford to continue to serve people.”

A residential treatment facility for people living with mental illnesses run by the organization is another example of a program that costs more to run than it earns, Jue said.

Designed as a transitional facility meant to teach participants independent living skills, the program costs the organization $123 per day for each of the nine people who live at the center, but Medicaid covers only $94 per day, according to Metivier.

Jue expects a Medicaid rate increase, to nearly $100 per day, next January. But even then, the organization will fall short of its daily expenses, Jue said.

With offices in communities including Keene, Peterborough, Winchester, Walpole and Jaffrey, the organization receives about 60 percent of its funding through a contract with the state Bureau of Behavioral Health. The state pays half of this money, with the other half coming from federal funds, Jue said.

The other 40 percent of the organization’s operating budget comes from grants, client fees, donations, contracts with other state agencies and fees to insurance companies, according to Jue.

Jue said the organization’s children’s department, which has four child psychologists on staff, might be emphasized in the restructuring to help bring extra money.

By increasing the number of clients in this program, which is becoming a rare resource in the country, the organization may be able to make up for some shortfalls, Jue said.

The organization could also be forced to consider cutting some of its contracts, most notably with the Wyman Way Cooperative, which provides maintenance services in two of the organization’s buildings, Jue said.

The cooperative is a program that employs people with mental illnesses.

Francis Silvestri, former CEO of Monadnock Family Services, proposed starting the program in Keene after visiting a cooperative in Trieste, Italy.

A Bureau of Behavioral Health grant in 1985 got the program off the ground.

The program is funded by grants, donations and contracts for various services, including those with Monadnock Family Services.

Jue said the organization will be reviewing contracts and may have to eliminate services to one or both of its offices.

“It would be a crippling blow depending upon how much we cut back,” he said. “If we cut the maintenance contracts in both buildings, that would have a good chance of putting them under. If we only change it in one building, they may still be able to function but probably at a reduced level.”

Jue said he hopes all programmatic and staffing changes will be in place by July 1, the start of the new fiscal year. Then the full impact of the restructuring will become clearer.

“I think that so many of the communities are used to feeling like they can turn to us,” Jue said. “And they still may, but we might have to redirect some of them.”