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of the year.

There are more admissions per year, but in the face of increasing admissions, there is still a declining rate of resident patients at the end

Mr. Brown. It is 226 per 100,000 ?
Dr. YOLLES. It is about 226 now.
Mr. ROGERS. In the hospitals?

Dr. YOLLES. Yes, in State and county hospitals in the United States.

Mr. ROGERS. 226 per 100,000 ?

Dr. YOLLES. Yes. Here are the actual numbers. This table (fig. 2) is in terms of numbers, rather than rates. From 1946 to 1955—and preceding that, you will note that there was an increasing rate of patients remaining in mental hospitals. Now this is a continuation of that rate projected to the present time.

If that rate had continued, we would have 702,000 patients in mental hospitals in the United States today. In 1955 a break in that upward trend occurred, due to a number of factors. Perhaps the principal factor involved was the introduction of the psychoactive drugs, but there are other factors. The actual numbers of patients remaining in hospitals at the end of 1955 started to come down.

You will note that the rate of decrease is much more rapid in the last few years. This is the result of the introduction of inpatient services in general hospitals, and the introduction of more community mental health approaches. We have over 1,000 general hospitals in the United States today that now accept mental patients who did not accept them before. The introduction of those services has caused the decrease in resident patients.

For this year, we are happy to report that the largest single decrease in the 11- or 12-year period involved an average per year rate decrease PROJECTED AND ACTUAL NUMBERS OF RESIDENT PATIENTS END OF YEAR, IN STATE AND COUNTY MENTAL HOSPITALS - UNITED STATES -1946-1966

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of 4.9 percent, and a decrease between the 2 corresponding months of December 1965 and 1966 of 7.2 percent. This is a very significant decrease.

Mr. ROGERS. What year was the turning point ?
Dr. YOLLES. 1955.
Mr. ROGERS. Thank you.

Dr. YOLLES. There is one other point. There has been a decrease from the projected number of 702,000 patients to 452,000. In terms of dollars to the State and local governments, this amounts to $4.4 billion of expenditures, both for cumulative cost of care of the patients over these years, as well as the capital improvements, that would have been built to take care of them. Those funds were used for other purposes during these years, and not used for mental hospitals.

I would like now to present three examples of community mental health centers that have been funded under this program. The first of these is purely a construction grant, the second purely a staffing grant, and the last is a combination of both.

This construction grant was awarded to the Swedish-Saint Barnabas Community Mental Health Center. (See fig. 3.) Actually the joint applicants were the Saint Barnabas Hospital and the Swedish Hospital in Minneapolis, across the street from each other. These two hospitals joined to provide community mental health services. They closed off the street and plan to construct the community mental health center between them, uniting the two hospitals.

This new structure will provide to central Minneapolis, which has a population of 200,000, all of these services which were not available to this population before except in fragmented or partial form. They will provide outpatient, inpatient, day and night or transitional services, consultation and education services to schools, courts, welfare departments, and other agencies as well.

In addition, the St. Barnabas hospital and the Swedish hospital will provide emergency services to this total community and by contractual arrangement with private physicians, some patients will be given outpatient care. Further, through a backup arrangement, to be sure that they can serve all of the people in the community when demand is heavy, there is a backup service with the county general hospital to provide outpatient and inpatient services.

The Federal share on this project was $828,000. The total, including local and private financing, was $1,700,000. This project was approved June 27, 1966, and the ground-breaking ceremony was July 10, 1966.

The second example is of a pure staffing grant. This is the Tacoma Mental Health Center in Tacoma, Wash. (See fig. 4.) Prior to the award of this grant, there were some five agencies delivering mental health services within the city and counties surrounding Tacoma, Wash. None of these provided a total service. No total service was available to the city of Tacoma.

By joining together these five agencies to set up the Tacoma Mental Health Center, a total program of services was devised. This is what Mr. Cohen referred to as a program of services with these agencies joining together to provide total services to the city of Tacoma, with a population of 153,000.



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FEDERAL SHARE $78,264 STATE AND LOCAL FUNDS (12 mos.) $180,642




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Dr. Yolles. The staffing grant provided funds for the initial partial support of professional and technical personnel for emergency services, day and night services, inpatient services, as well as consultation and educational services. The totality of services provided by the stimulus of this grant was far greater. We have inpatient care being rendered to this total population, as well as for children and adults by the Western State Hospital. We have inpatient services rendered by the St. Joseph Hospital. We have child guidance services available to the total population.

The Department of Public Health has cooperated in providing aftercare services, and the community mental health clinic is now providing consultation and education services to the community, as well as outpatient services.

The Federal share on this project was $78,000 to provide 75 percent of the cost of initial staffing in the first year for St. Joseph Hospital, and the community health center. The others have provided their services without the aid of the Federal grant.

Mr. ROGERS. Mr. Chairman, may I ask a question there for a moment?

It is my understanding that when we passed this bill the concept was to put it all in one building, a community mental health center; to put all five services in one center. It appears that this is not the way you are administering the act. I thought the intention was to require that the services, all five services, be given in one area. I don't know how far it is between these hospitals. Does a person have to go across town? How do they know where to go for which service, and so forth?

Dr. YOLLES. The original intention was to have a single building which would have all of the services as well as for a number of individual services to join together to form a center. The act also calls for agreement by contract to show that the center will render all services to the individual.

The center itself will have a basic or central location in terms of a headquarters operation where patients can be referred. All of the units must be easily accessible to the patient and fairly close together. They may be in different parts of town. However, a patient who is in an inpatient service, and the stage of his illness now suggests that he be in outpatient service, can be moved without any redtape to the outpatient services that are available because of this contractual arrangement between these services. He can move easily and freely, and his records can move as well.

Mr. ROGERS. If this can be arranged, then, anyone could do this with existing facilities and there is not much need for construction.

Dr. YOLLES. Some communities have a very definite need for appropriate facilities in which to house these services. A good example of this was in one of the counties in Florida, in your own State, where no services at all were available in a group of counties--no mental health services at all. The hospital had no inpatient psychiatric services. They have asked for and are receiving a construction grant to construct an inpatient psychiatric service. In addition, however, they have joined with other agencies in other communities to provide a totality of services over and above the inpatient services, which may

be the only part constructed.

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