“We want to feel like we’re home, not in prison.”

“We need to be able to safely retreat when we need alone time.”

“We need the system to value us as human beings.”

Persons with mental health challenges interviewed by Dell Med’s Design Institute for Health, on what they need in a redesigned Austin State Hospital

When people arrive at Austin State Hospital (ASH), one of 9 inpatient state-run adult psychiatric facilities in Texas, they may be having one of the worst days of their lives.  Perhaps they’re suicidal, or disoriented and frightened, or unable to care for themselves. Yet the current ASH campus, established in 1856, does not optimally match the complex needs of people in crisis.  

Ten months into a $15.5 million planning process led by Dell Medical School at UT Austin, master plans for a new Austin State Hospital campus and location of the new hospital were unveiled in late January.  Pending funds from the state legislature, construction on the $283 million project could start in late 2019 and be completed by the summer of 2023.

How does a physical building impact mental health care?  The current hospital building was designed for “a different era of health care,” said Dr. Steve Strakowski, Associate Vice President for Regional Mental Health and Chair of the Department of Psychiatry at Dell Medical School. The campus has buildings up to 150 years old. While the current hospital building is newer at 60 years old, it serves 38 counties for adults in Central Texas, 57 counties for adolescents, and 75 counties for children.   The current building is “cramped, and there’s inadequate space to optimally deliver modern mental health care,” said Strakowski, who serves as the chair of the ASH Redesign Steering Committee.

For instance, contrary to modern best practices for patient care and healing, the design of the outdated ASH building requires up to four patients to share one hospital room. This increases the risk of violence for people receiving care and staff, as individuals have no personal space where they can retreat when stressed. The facility also lacks enough private rooms where people receiving care can meet with care providers, posing concerns for patient confidentiality.

The current mix of individuals treated in the hospital raised a larger, system-level quandary. Although psychiatric inpatient facilities are meant for intermediate-term stays, about 70 of the 252 individuals hospitalized at ASH in 2018 essentially live there long-term. ASH also serves people with mental illness from the criminal justice system whose length of stay is dictated by the legal system instead of by their clinical needs, which can lead to longer stays. Long inpatient stays at ASH mean fewer beds are available to serve new individuals.

Designing an ideal psychiatric hospital is challenging. To rethink how inpatient mental health care is delivered in Central Texas, Dell Medical School assembled a dream team of 18 mental health experts and stakeholders from across the service area to serve on the Steering Committee.  Their governing principle for the hospital redesign? “The number one priority is to improve the lives of people with mental illness,” said Mike Maples, Deputy Executive Commissioner for the Health & Specialty Care System at the Texas Health and Human Services Commission.

To get insider input, the Design Institute for Health from UT Austin led the qualitative fieldwork, interviewing 65 people who had experience with ASH and the mental health system across the ASH service area, including people receiving care, family members, care providers, administrators, judges, and law enforcement.  

The ASH redesign team learned that a successful new hospital building would need to hit several sweet spots. It must keep people receiving care and providers safe, but also provide a healing environment.  It must accommodate a wide range of severe mental health needs, while enabling consistently excellent care. And it must be embedded in a robust brain health system that offers different levels of care for individuals before and after a psychiatric crisis, if one cannot be prevented.

To envision how a person might move through the mental health system, the committee developed a visual model called the Brain Health Continuum, re-envisioning the existing continuum of care. This continuum illustrates four phases of optimal mental health care: 1) understanding and prevention of mental illness; 2) identifying a problem through early detection; 3) treating mental illness via outpatient therapies; and 4) sustaining mental health recovery through supportive services.  The model also includes a “crisis loop,” when a mental health condition becomes severe enough that emergency intervention is needed, which may land a person in jail, in an emergency room, or in an inpatient psychiatric hospital like Austin State Hospital.

The objective of the optimal brain health pathway is to “keep people out of the hospital, out of jail, out of court, and in their community and at home while receiving the care that they need whenever possible,” said Katherine Jones, Director of Strategy and Mission at Dell Med’s Design Institute for Health and a member of the ASH Redesign Steering Committee.

The Brain Health Continuum helped the committee design the new hospital in the context of the overall system, Jones said, and identified the services that individuals receiving care would need at each phase of their recovery journey.

The chance to implement an ideal brain health model in Central Texas galvanized the redesign team to shoot for the stars. “The building of the hospital is a catalyst for a bigger change,” Maples said. In a 106-page report to the Texas Legislature, the committee outlined a plan to comprehensively improve brain and mental health care for people in the region.  

Three options for the new Austin State Hospital building were proposed.  The team’s preferred option includes space for 240 adult inpatient beds as well as 48-72 beds in a long-term residential building extension. Additionally, the committee championed systemic changes that would help ensure that people receive the right care, at the right time, and in the right place, which also means that beds at the new hospital would be available to those who need them.  

Finally, the team advocated to eventually transform the grounds around ASH into a Brain Health Campus—a community of mental health services, social services, and brain health expertise that could meet the needs of people living with mental health conditions at every stage of their recovery.  With the addition of Dell Medical School as an academic partner, there could be teams able to advance and evaluate the most effective mental health care and treatments and export those best practices to the rest of the state.

“If you’re going to invest $300 million in something,” Committee Chair Strakowski said, “let’s make sure the investment is optimally used. Planning for the Brain Health Continuum of Care while we’re replacing the hospital has been revolutionary.”

The committee’s vision of optimal brain health care in Central Texas will take a number of years to actualize, but starting construction on a modern, effective ASH building will be a step in the right direction.