Breaking ground on mental health: An interview with Dr. Frank Shelp

Two years ago, Georgia reached a landmark agreement with the U.S. Justice Department to revamp its system of care for people with mental illness and developmental disabilities.

The Justice Department involvement followed articles in the AJC that reported more than 100 suspicious deaths of patients occurred in Georgia’s mental hospitals during a five-year period.

Dr. Frank Shelp was a key player in forging that agreement with the feds. And, as the first commissioner of the Department of Behavioral Health and Developmental Disabilities when it was created in 2009, Shelp had the task of carrying out the overhaul.

Before becoming a psychiatrist, Shelp dealt with these issues in his personal life.

His mother battled mental health problems, and he became her caregiver. In addition, a cousin was killed by a drunken driver while walking home from school, and another cousin with developmental disabilities choked to death, Shelp told GHN.

At DBHDD, Shelp has been credited with helping to turn around a failing system. He has also received criticism for some of his actions as commissioner.

The new Georgia system isn’t without problems,  from jails housing many people with mental illness to failures of  community teams formed to help people with mental illness.

Still, many mental health advocates say Georgia’s system has improved during Shelp’s tenure. He stepped down from his post in August.

In this wide-ranging interview, Shelp talks about terminating whole shifts of hospital staff, the negotiations leading to the DOJ agreement, and what he now wishes he had done differently.

Q: How did you come to be the agency’s first commissioner in 2009?

A: At the time, I had taken a temporary contract to be the clinical director at the state hospital in Savannah, with the goal of closing the hospital. . . . By March, there were a number of concerns about closing the hospital. I expressed some of those concerns to some of the people in DHR. . . . The idea of a new department was beginning to move through the Legislature. . . . I was invited to be part of the private discussions around how the new agency should look. Out of that came the invitation to meet with Governor [Sonny] Perdue. I went in to meet with him to talk to him about the mental health system in Georgia. What came out of that was this invitation to be the first commissioner.

Q: Where was Georgia at that time in terms of working with the Department of Justice, which had been investigating Georgia’s mental health system?

A: A settlement had been reached with the Department of Justice the last day of the Bush administration [in January 2009]. There were preparations being made to address that settlement. . . . But there were still many problems. In mid-April, there was an actual murder at Central State Hospital [in Milledgeville]. A patient managed to kill another patient while on one-to-one observation.

Q: How did the agreement with the DOJ come about?

A: In May 2009, the governor signed [the bill setting up the new department] and announced me as the first commissioner. Four days later, I met the Department of Justice for the first time in Augusta. . . . Those discussions were ongoing. We were meeting at the Carter Center with the [mental health] advocates. The argument that Justice was bringing was that hospital conditions could not be looked at in isolation, that re-hospitalization is primarily a failure of follow-up in the community after a hospital discharge.

I had agreed with that principle at the time. Dr. Bill McDonald and I personally visited all seven hospitals and walked their campuses. But the DOJ returned to Milledgeville to follow up on that murder, and they reported back to me that there was no [state] follow-up. It looked to the Justice Department like business as usual, that nothing had happened. I was two months into our administration.

I brought Dr. Karen Bailey-Smith and put her over that hospital, and gave her total authority. She ended up staying there a year. She showed up [on] all three shifts, [did] spot checks, walked around. She discovered a patient assaulted by a staff person. There was involvement of a whole shift. We made a decision to terminate the entire shift. It was a strong action, because the hospital was allegedly understaffed. . . . We started to see our hospital census go down, and incidents go down.

And during that time, the Justice Department was back at Central State. They delivered another fairly scathing report. . . . I again had to take some specific action. I put Central State on indefinite diversion, which means no new admissions would come. The census [patient population] went down. After four months, the Legislature was back in session. There were a lot of questions about what was going to happen. At that point, we made a decision not to reopen the Powell Building.

Q: But the state and the Justice Department were still far apart?

A: At the end of 2009, we were taking pretty strong actions in the hospitals. We were terminating individuals. We terminated a whole shift in Atlanta. They were found asleep at night. . . . But the Department of Justice was emphasizing the efforts in hospitals were not going to remedy the situation as long as the hospital was almost the exclusive resource for people with mental illness.

The re-hospitalization rate was north of 20 percent — one in five were coming back to the hospital within 30 days.

At end of  ’09, there was a meeting with Assistant U.S. Attorney General Thomas Perez, Governor Perdue and myself. Perez informed the governor he was going to initiate a new litigation. He acknowledged [our progress on hospitals], but said he was directing his staff to draft those papers. So we were looking at a court date for somewhere in March. We were still having some discussions with the Justice Department and the amici [friends of the court]. Somewhere in late February, pretty much at the last hour before court, the Justice Department asked us whether we would be interested in a settlement. We started a negotiation. Judge Pannell asked that the amici be heard, participate in some way.

Q: What were your goals?

A: I was becoming more firm around a couple of points. That the department maintain its autonomy and integrity and ability to run a system and be accountable for it. . . . The other piece was that it needed to be a reasonable plan that would not be seen as so onerous by the Legislature and others that as soon as it was over, it would be taken apart. I had seen that happen in other states. . . . But most of all it would have durability. It would be able to be done without so much sacrifice and so much intrusion that there would be a buildup of resentment.

Q: And eventually the agreement was reached?

A: It was reached, but not easily.

Q: What made it happen?

A: We agreed to agree to disagree at the end of June. . . . Justice mustered together another review team to go after the hospitals one more time, in early September. The hospitals were now very different places. It had now been a year and a half. Things had substantially changed. . . . In the midst of that review, Justice asked if we were still interested in negotiating further. . . . We did meet for about three days. We came to a settlement . . . Governor Perdue actually was very much in favor of signing it. Perdue is a strong individual, but he had a real sense that this area had not been attended to.

Q: He came around on this issue.

A: He came around to understand the problems. . . . In the end, he was ready to go to stand with me. When I assured him that this had a level of third-party validation without a monitor or court master . . . and the cost would not be so excessive . . . we all felt genuinely good about it.

Q: As you look at the settlement now, what have been its main accomplishments?

A: We have reduced our re-hospitalization rate from the 20 percent range. The national average is between 9 and 10 percent. We’re now in 5 to 6 percent, significantly under the national average. Our overall hospitalization rate had been higher than the national average. Now it’s lower.

When I started, developmental disabilities was the overwhelming majority of our census, nearly 50 percent statewide. Forensics [patients who were in the criminal justice system] was 35 percent. Adult mental health was about 20 percent. Now forensics is our largest line of business. Developmental disabilities went from 850 to about 350 now. They’ve been largely moved into host homes and group homes in community settings.

The adult civil [mental health] census has gone from close to 600 to around 330. We’ve now been below 300 several times, as low as 290s. We’ve cut that in half.

In January 2011, we announced we would close the hospital in Rome.

Q: That sparked a lot of local consternation, correct?

A: Yes. The Rome hospital was closed for a number of reasons. For one, it was in fact the most expensive. But it wasn’t just cost alone.

[The closing] met with a lot of hostility. I met with the Chamber of Commerce. I had people yelling at me in the men’s room.

The emphasis was that we were not just shutting down a hospital. We were going to build a continuum of services across that region. Acute hospitalization would be provided by general hospitals. WellStar was our first hospital, in Cobb County. Then we added some more hospitals. Now there are probably close to a dozen.

Q: And there are more community services, correct?

A: We’ve added [assertive community treatment] teams, we’ve built two extra Crisis Stabilization Units, we’ve added peer support services, peer wellness centers. There’s now actually more access. We’ve admitted 80 percent more unique individuals in acute hospitals on the same money. The length of hospital stay average [in state hospitals] was 18 days, and in our community hospitals, it’s less than five days. They’re being moved into a community continuum at a pretty good rate.

The sheriffs are now reporting they travel shorter distances in the northern region, have less time waiting for evaluations, and now they’re getting more support from safety-net providers and community service boards. We have a much broader continuum of options. We also put in place supportive housing and some supported employment.

Q: What about the rest of the state?

A: I originally thought it would be region by region, over more time. . . . In a recent tour around the state, there’s not a single private hospital right now that isn’t ready to sign and be part of the process. It has happened as far south as Columbus.

Q: How about the Atlanta region?

A: Grady Hospital is a much bigger component there.

What we did at Grady, we worked with Dr. David Satcher, we did partnerships with all our medical schools, Morehouse, Emory, GHSU, Mercer. With Bill McDonald now at Grady, the department has basically funded two positions under Morehouse. They have been specifically put in place to deliver more aggressive, more complete services in the Grady emergency room, and integrate the services better with the community clinics. They have effectively transformed the situation at Grady. We’re actually seeing a decline in census at Atlanta Regional.

Q: So Atlanta and Middle Georgia are on their way?

A: We have a really good partnership with Emory and Grady and Morehouse. We’ve become full partners with David Satcher’s Health Care Leadership Institute. We’ve had fellows in our department who have done real research. So those collaborations are starting to yield results on the ground. . . . We joined the Savannah hospital partnership with Memorial and the Mercer Medical School in Savannah. . . . We’re moving toward a merger of the Augusta hospital and GHSU.

The whole state is not done. There’s a lot be done. The tenor has been changed. This is evidenced by the recent closure in Milledgeville; we closed the last of our developmental disabilities units back in June. That had been the largest census when I started. Now adults [with mental illness] and developmental disabilities are gone from that facility.

Q: The community was critical of these changes in Milledgeville.

A: It was largely about jobs. Central State Hospital had been an economic engine for a long time. . . . In my entire history, I’ve heard of all kinds of things. Completed suicides, assaults. I had never heard of an actual homicide while on one-to-one observation. That is a complete breakdown [of care].

Q: In late August, the state requested and received a delay of a scheduled review, explaining that the assertive community treatment (ACT) teams were either disbanded or inadequate. Is this problem something you were aware of?

A: Many ACT providers struggled, and the department provided technical assistance and imposed corrective action plans. But over the course of a few months, we came to the conclusion that several of the providers were not up to the task and we would re-procure the ACT teams with an opportunity to both increase expectations from the department side and allow for vendors to make new cost proposals.

We reviewed all these issues and actions in real time as they occurred with Elizabeth Jones, our independent reviewer, and together we decided to speak to the DOJ about revising the ACT team assessments. . . . There had been provider failure beyond our control, and we were already initiating the most appropriate measures to provide for these services in the most thorough and expedient way.

Q: What didn’t get done in your tenure that you regret?

A: I think on the developmental disabilities side, it took me longer than I would have liked to have personally understood some of the nuances in the waiver process and how that side of the house operationally delivers those services . . .

In reality, it was more bureaucratic and redundant than it needed to be. In the last few months, I initiated a reform in that. But I wish I had taken more direct action in that area a year earlier.

Q: What are your current concerns?

A: My concern from the very beginning is durability, that this must be sustainable in the future. This project comes out of a very personal motivation. I have learned about mental illness in very difficult ways. . . . There needs to be continued growth.

Q: Adolescents and children were left out of the DOJ settlement. So how are they doing?

A: Mental health for children and adolescents around the country [generally] falls to Medicaid.

I’ve talked with many of the children’s advocates, and they’ve got many concerns. What I have asked for but have not been able to find is some concrete measures. For adults, you could see homelessness and people in jail. . . . For children and adolescents, the numbers are more slippery. Truancy, involvement with the Juvenile Justice are harder indicators. So I don’t personally know with confidence that the system is adequate or inadequate. The management is largely going to fall to the Department of Community Health and the CMOs and Medicaid. . . .  I think there’s a big question mark there. It wouldn’t surprise me if it needed work.

Q: You have heard a lot of criticism of yourself –- on employee bonuses, meals from lobbyists, etc. How do you respond to that?

A: The reality is, in closing the hospital in Rome, we had to offer some retention compensation for staff to stay till the end. You can’t close a health care facility without [doing that]. You have a responsibility to patients. So, what were called bonuses were a retention plan, involving over 100 employees, [getting] a couple thousand dollars apiece.

Lobbyists? Stan Jones [an attorney cited in an AJC article] is a man of known stature in the mental health community. He sits on the coordinating council of the department, he’s a voting member.

So criticisms around this, unfortunately, I understand the source. It goes with the territory.

Q: Any mistakes that you made?

A: Well, from Day One, I had said publicly that we would have to make mistakes, that no one likes to watch a basketball game where there are no fouls. A game with no fouls is slow and low-scoring and uninteresting.

We didn’t have room to foul out; the bench wasn’t that deep. At the same time, if we were going to move the needle, we could not be second-guessing every single move along the way. . . . We did not think about being flawless.

I didn’t expect my team to be flawless. I said, ‘If you’re not making some mistakes, I would have to question how hard you’re trying. [But] I don’t want you to be reckless.’ I promised I would not embarrass anyone in public. . . . I made all the department’s apologies myself.

Could I have done some things better? Absolutely. . . . In retrospect, I could go back and fine-tune the pieces.

Q: Why did you leave?

A: In the very beginning, I said publicly that this would take two to three years to turn around. . . . So what’s happened has happened exactly on that time frame. I thought in January that we’d accomplished pretty much what I set out to accomplish.

Q: Were you asked to resign?

A: No. I had met with the chief operating officer for the governor [earlier this year]. I told him that I was tired. . . . I was concerned as well that this project could not be allowed to become about me, that it needed to have durability for the future, . . . to be sustainable. So I gave them two months’ notice. Frank Berry [the new commissioner] I think is the right person.

Q: What are the biggest challenges for Commissioner Berry?

A: The biggest threat right now is a sense of resting on the accomplishments to date. . . . There will be a threat of compromise, and settling for arrangements, that will be the biggest challenge to overcome. [State officials should] maintain momentum, and anticipate and resist forces for a return to the status quo.