Tonda Smith moved to Atlanta in search of stability.
At 16, the Miami native enrolled in Job Corps and trained to become a medical assistant. But her life started to unravel after her sister died. Smith fell into a severe depression and began experiencing symptoms of bipolar disorder. She lost her job, her apartment, and became homeless for 13 years. The estranged mother was assaulted on the city's streets, wrestled with cocaine abuse, and attempted suicide three times.
After receiving treatment at Grady Memorial Hospital, doctors recommended that Smith meet with an Assertive Community Treatment, or "ACT," team. The group of mental-illness professionals, nurses, and other experts placed her on a medication regimen, scheduled psychiatry appointments, and arranged group counseling. They even helped her find permanent housing.
"This time last year, I didn't believe in myself," says Smith. "Nobody was capable of helping me. I'm now working toward being stable."
Every year, more than 10,000 residents from DeKalb and Fulton counties like Smith rely on Grady for mental health treatment. But they might be forced to look elsewhere when Fulton signs off on its 2014 budget next Wednesday. County commissioners are considering cutting its contribution to Grady in half, from $50 million to $25 million. Without that cash, Georgia's largest public hospital, which also happens to be the state's second-largest mental health provider after its prisons, might have to close the mental health clinic's doors. That would potentially leave Smith and thousands of poor, uninsured, and homeless individuals without the care they desperately need.
Grady's behavioral health department currently boasts a wide range of services. Staffers help with people living with more debilitating chronic mental illness and short-term crises such as suicide threats. In addition, they operate clinics to help remind people to take medication and mobilize ACT teams, such as the one that helped Smith. "More than 230 staff members saw patients approximately 66,000 times last year at either their Downtown headquarters or traveled to meet with clients at their homes, inside coffee shops, or under bridges. The department considers itself a "hospital without borders" for Atlanta's mentally ill.
Since 2007, Fulton has lowered its annual Grady contributions by $36 million. With another $25 million in proposed cuts slated for 2014, the public hospital could find itself in the red. Grady CEO John Haupert says he understands the importance of the mental health department. But he's also trying to make sure the hospital — which after years of running deficits finally turned a $20 million profit in 2012 — doesn't shut its doors.
"This is not something we're looking to push off on anyone else," Haupert says. "We need to continue to provide it. We just need the funding."
While the state provides Grady with some grant funding for the hospital's community-based mental health services, Michael Claeys, executive director of Grady's Behavioral Health Services, says the contributions aren't enough, requiring the county and hospital to cover the rest. Grady's department ranks among Georgia's best mental health providers because its staff goes beyond minimum requirements. The hospital covers medication costs, helps patients replace personal documents needed to qualify for Medicaid and Medicare, and will even pay some overdue utility bills to help homeless men and women secure housing. These comprehensive services cause the department to lose as much as $8 million each year. But hospital officials think they're necessary.
"We've created a medical home for people who have never had health care access," Claeys says. "If what Grady does gets taken away, they won't get the care they need outside of the emergency room."
Fulton Chairman John Eaves remains "optimistic" that commissioners will sustain 2013 funding levels. They might try to find $25 million elsewhere in the budget to offset Grady cuts or increase tax revenues. Both options are on the table, but hardly a done deal.
Haupert thinks a $25 million funding cut would be a grave mistake. According to Grady, an estimated 80 percent of the hospital's mental health patients are Fulton residents. If the department closes, Fulton's mental health clinic or nonprofit organizations such as Community Friendship, St. Jude's House, and St. Joseph's Mercy Care Services could try to pick up some of the slack. But that probably won't be enough. Atlanta, which already lacks enough proper mental health resources, would be faced with a dangerous shortage of treatment options. Many uninsured patients would flood to the public hospital's emergency room — which averaged an estimated 7.5 hours per visit in 2013 — and hurt Grady's bottom line even further. The state would need to immediately find a new partner to handle inpatient admissions.
Even if Fulton's commissioners sustain the hospital's funding, there isn't anything preventing the same problem from occurring again. Eaves thinks Grady and Fulton could collaborate to make their services more efficient and serve more patients. Those conversations haven't happened yet, but Haupert says he has started initial "high-level" talks with outgoing Atlanta Chief Operating Officer Duriya Farooqui over City Hall possibly picking up part of the mental health tab for Atlanta residents.
The ultimate solution, however, will likely need to come from the state. For Eaves and other activists, that means fully implementing the Affordable Care Act and expanding Medicaid. Only Gov. Nathan Deal can make that decision.
Until then, there's a chance that patients like Smith or Joseph Scott, a 62-year-old Atlanta resident with chronic depression and a history of hearing voices, could lose their treatment. The former tombstone engraver contemplated suicide after an unfortunate string of life circumstances — the theft of his car and tools, the splintering of his church, and the loss of his job — left him without access to his anti-depressants.
His mental state spiraled downward and his family admitted him to Georgia Regional Hospital in Decatur. After finishing another stint at a group home, he turned to Grady's psychosocial rehab designed to help the mentally ill re-enter society through classes and group therapy.
Scott today says he's become less "fearful, paranoid, and unsociable." He can leave his house again, has become independent, and feels better about his future. He hopes Grady's support system doesn't disappear - his health depends on it.
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