1981-82 District Mental Health Planr
PREFACE
r
In presenting this report the author feels it necessary to
briefly describe the framework in which it was developed.
A period of two weeks was allocated for the development of the
report while it is recognized that a study of several months
duration is needed to adequately address all of the issues included
in this report.
The basis for the information contained in the report.is the
author's knowledge of the mental health system in the community
and interviews with the following individuals:
Richard Matthews Ph.D. - Director, Guidance Clinic of the Upper Keys
Sema McAninch - Acting Director, Guidance Clinic of the Middle Keys
Nancy Slicner Ph.D. - Director, Community Mental Health Clinic
of the Lower Keys
Rollie Dudik - Administrator, Florida Keys Memorial Hospital.
This document is not intended to serve as a mental health plan
for Monroe County. The report rather, briefly outlines the issues
identified in the "Guidelines for the Development of Mental Health
and Alcohloism District Plan FY 1981-82". It is recognized by
the author that the issues are extremely complex and can only
be adequately through a community mental health planning process
during the coming year.
1�egjwise
Consultant Report - Presented to the
Dade -Monroe District Mental Health
Board - June 5, 1981.
f
TABLE OF CONTENTS
Page
I. UPDATE OF MONROE COUNTY DESCRIPTIVE DATA . . . . . . 1
Geography and Environment . . . . . . . . 1
Demographic Characteristics . . . . . . . . . 1
II. CIRC'(.TMSTANCES WHICH AFFECT THE NEED FOR AND
THE DELIVERY OF MENTAL HEALTH AND
AIMHOLISM SERVICES . . . • . • . . . • . . . 7
Geography . . . . . . . . . . . . . . . . . . 7
Transportation . . . . . : . . 8
Transient Nature of the Cannuni ty. . . . . . . 8
Alcoholism Rate. . . . . . . . . . . 9
Lack of Inpatient Psychiatric Beds . . . . . . 9
III. PRO<TDC.TION OF NEEDS FOR THE NEXT THREE FISCAL
YEARS . . . . . . . . . .. . . . . . . . . . . . . 9
Planning Needs . . . . . . . . . . . . . . . 10
Service Needs . . . . . . . . . . . . . . . 10
IV. ANALYSIS OF MENTAL HEALTH AND ALCOHOL PROBLEMS
IN MONROE COUNTY AS THEY RELATE TO STATEWIDE
PRIORITIES . . . . . . . . . . . . . . . . . . . . 12
I.
MONROE COUNTY POPULATION BY CENSUS DIVISION 1980
p.
2
II:
GEOGRAPHIC DISTRIBUTION OF MOiNRDE COUNTY POPULATION
p.
3
III.
TOTAL RESIDENT POPULATION BY AREA - MWE COUNTY
p.
4
IV.
MCNROE COUNTY POPULATION DISTRIBUTION BY AGE
p.
4
v.
PERCENTAGE CHANGE IN POPULATION 1970-1979
p.
5
VI.
MBE COUNTY POPULATION BY RACE AND SEX - I979
p.
5
VII.
DARE-MCNRCE COMPARISON - AVERAGE INCOME 1977
p.
6
r'
UPDATE OF MONROE COUNTY DESCRIPTIVE DATA
The description of Monroe County varies in practically every
aspect from Dade County. The information presented below provides
a review of Monroe County, specifically, the geography and environment,
demographics, -and -employment and industry.
Geography and Environment
The land area of Monroe County is approximately 1,034.square miles.
The vast majority of the land area is located on the mainland of
Florida and is virtually uninhabited. The populated portion of the
County is known as the Florida Keys, a series of.islands extending
120 miles into the Florida Straits.
There are four recognized subsections within the County which
are referred to as: Upper Keys, Middle Keys, Lower Keys, and Key
West. In terms of mental health services, the Lower Keys and Key
West areas are combined to form the services area of the Community
Mental Health Clinic of the Lower Keys.
The chain of islands are connected by one roadway - U.S.l: This
highway is also the road that connects Monroe County to Dade County.
The road is primarily two lanes with over 40 bridges. Transportation
along the highway is often restricted due to a number of circumstances,
such as, heavy traffic (particularily during tourist season),
traffic accidents and, at times, flooding. A major road construction
project is currently underway which oftentimes results in major
traffic delays, however when completed should improve -ground transporta-
tion.
Air transportation is also available between Miami and the Key
West and Marathon areas by commercial airlines.
Demographic Characteristics
When considering the demographic information for Monroe County
there are two factors that should be kept in mind. 1). With the
exception of the preliminary 1980 General Population Census Data,
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all of the figures presented in this document are based on the 1970
Census. Like so many areas of Florida, the 1970's were a time of
tremendous change in the demographics of Monroe County, therefore
projections based on 1970 data must be considered with some caution.
The information contained in this document is the latest data
available to the author. 2) Until very recently the -demographic
imf.ormation that was generally available regarding Monroe County only
differentiated between incorportated and unincorporated areas,
therefore information on the Lower, Middle and Upper Keys as seperate
areas was not available.
According to the preliminary 1980 Census data the population
of Monroe County is 62,798. The distribution of the population
throughout the County is shown in Table 1.
TABLE
MONROE COUNTY
I
POPULATION_
BY CENSUS DIVISION
1980
Census Division
Number
Percentage
1
Key West
31,488
50.1
f Lower Keys
1
7,497
11.9
' Middle Keys
10,265
16.4
Upper Keys
13,548
21.6
TOTAL
`
62,798
100.0
* she Kev West Division includes, the City of Key West, Stock Island,
Boca Chicha, and Big Coppitt. The population of the City of. Key
West only is 24,204 (38.5%).
SOURCE: 1980 Census Data - Preliminary
During the past several years the population in the County has
been shifting. It has only been in the last ten years that the City
2
n
of Key West has not had a majority of the County's population. Table
2 shows a breakdown of the County's population by area since 1950 and
Table 3 shows the population projections by area to 1985.
TABLE 2
GEOGRAPHIC DISTRIBUTION OF MONROE COUNTY POPULATION
(Permanent Residents Only)
(1) - (2)
i950 � 1900
1970 (3)
]977 (4)
Number
h
Number . k
Number
Y
Number
a
Key West
26,443
88.3
33,956 71.0
29,312
56.0
25,382
46.2.
Lower Keys
1,550
5.2
5,733 12.0
10,352
19.7
8,772
16.0
Middle Keys**
925
3.1
5,000 10.5
5,756
11.0
7,995
14.5
Upper Keys
1,025
3.4
•3,126 6.5
7,012
13.3
12,785
23.3
Total* 29,943
100
47,8l5 100
52,432
100
54,934
100
Notes: Lower Ke, s - From
Cow Key Channel to Seven
Mile Bridge
.
Middle Keys- From Seven Mile Bridge to Channel
Five
(just
past Greyhound.
Key)
Upper Keys - From Channel Five to the County boundary
* Total population of
**
Monroe County excluding
mainland
portion
Middle Keys include
Key Colony Beach and Layton
SOURCE: Monroe County
Statistics - June 1979
Monroe County
Planning Department
As is shown in the above table, prior to 1970 the vast majority
of the population resided in Key West, primarily due to the military
presence in.the City and the fact that is was the only major area
of development.
TOTAL
TABLE 3
RESIDENT POPULATION
MONROE COUNTY
BY AREA
Estimate
Projection
Projection
Area
1978
1980
1985
Key West
25,387
37
25,514
36
25,832
34
Lower Keys
13,063
19
13,706
19
15,718
21
Middle Keys
12,141
18
12,276
18
12,944
17
Upper Keys
18,235
26
19,089
27
21,823
28
TOTAL
68,826
100
70,585
100
76,317
100
Notes: The estimate and the projections are for the peak permanent
and seasonal resident population excluding tourists.
The Middle Keys include the City of Key Colony Beach and the
City of Layton,
SOURCE: The Monroe County Planning Department
If the trends presented in Table 3 continue, the impact
on the delivery of numerous services, including mental health
and alcoholism services, will be considerable.
As is the case throughout the State of Florida, a larger percentage
of Monroe County's population is over 65 than was the case ten years
ago. Table 4 provides a breakdown of the County population by age.
MONROE
COUNTY
TABLE 4
POPULATIONV DISTRIBUTION
BY AGE
1979
Age
#
%
#
%
#
$
14
& Under
13,617
28.4
13,509
25.7
12,948
22.9
15
to 24
9,883
20.6
11,015
20.9
9,965
17.6
25
to 54
18,438
38.5
18,467
35.1
15,455
27.3
55
to 64
3,302
6.9
5099
9.7
10,960
19.5
65
& Over
2,681
5.6
4,496
8.'5
7,181
12.7
TOTAL
47,921
100.0
52,586
100.0
56,509
100.0
SOURCE: U.S. Dept. of Commerce, Bureau of the Census, General Population
Characteristics, 1960 and 1970. Bureau of Economic and Busihess
Research, University of Florida.
The percentage of the population in Monroe County that is 65 and
over is higher than the National average, but lower than both the
Florida and Dade County averages. However, the percentage changes
during the last ten years, as shown in Table 5, indicates that the.
elderly population in Monroe County is growing at a rapid rate.
i
TABLE 5
PERCENTAGE CHANGE IN POPULATION
1970-1979
i
% of Total Population 65+ Percentage Change 1970--79
1970 1979 65+ Total Pop.
Monroe 8.5 12.7 59.7 7.5
Dade 13.6 16.3 43.5 19.8
Florida 14.6 17.7 65.1 36.1
SOURCE: Florida Statisitcal Abstract 1980
Bureau of Ecomomic and Business Research, Univ. of Florda.
As shown in the above Table, while the overall population in Monroe
County increased by 7.5% between 1970 and 1979 the 65 and over
population increased by 59.7% over the same period.
The racial breakdown of the Monroe County poulation is shown in
Table 6.
TABLE 6
MONROE COUNTY POPULATION BY RACE AND SEX
` 1979
Number Percentage
White
Male 26,084 46.5
Female 25,123 44.2
Black and Other
Male 2,607 4.6
Female 2;695 4.7
SOURCE: Florida Statistical Abstract 1980
There was no information available regarding the age and racial
breakdown of the population by area of the County,
Employment and Industry_
Tourism is the largest industry in the County, followed by
Government which includes local, State and School Board employees.
The personal per capita income in Monroe County in 1978 was
$8,009 compared to $8,567 in Miami and $7,578 in the State. According
to information compiled by the U.S. Department of Labof, the average
wage and. salary income for various industries was lower in Monroe
County than in the State. This information is presented below.
FIVE -61 ,t_ r tiC2, 14E
GOLL6RS
$16.00G�
ONION
012.000
010,000
$ 81000
50.E
G 6.000
7 4 .000
0 21000
N
T
M0NRP,E
1977
FLORIDA
C)
C7
cnJ3m
m
�t
- f
In order to fully appreciate the economic situation in Monroe.*
County it must be also kept in mind that for the past several years
Monroe County has had the highest cost of living of any County
in the State.
CIRCUMSTANCES WHICH AFFECT THE NEED FOR AND THE DELIVERY OF MENTAL
HEALTH AND ALCOHOLISM SERVICES
In reviewing the various circumstances which affect the need
for or the delivery of services there seem to be two general
categories to consider. The first are those circumstances that impact
on the community at large, and therefore affect mental health and
alcoholism services. Included in this category is the geography
of the County, difficult in tranportation, and the transient
nature of the community. The second category are those circumstances
that specifically impact on the -mental health and alcoholism services.
Included in this category are the high rate of alcoholism is the comm-
unity and the lack of psychiatric inpatient beds in the County.
Geography
Traditionally the geography of the Keys has been identified as
the factor that impacts on virtually all aspects of life in the
County In terms of mental health and alcoholism services, the
geography has had a major impact particularly on the delivery of
these services. Services are provided through three seperate
clinics which are located in the different subsections of the
County. The three clinics are approximately fifty miles apart and
thereby maximized access to the outpatient services.
Because the population is spread over such a large are it is
difficult to plan for some services that may require a fairly large
population base in order to be provided efficiently. Trade-offs
between maximizing access while at.the same time ensuring an adequate
population base is an issue which must be continually addressed when
• considering the delivery of mental health and alcoholism services.
In addition, the geography plays a part in affecting the
need for mental health and alcoholism services. Planning for
services must consider not only County -wide needs, but also
specific area -wide needs inasmuch as the problems and needs may
vary from one area to the next.
Transportation
The transportation problems in the community are a result of
the geography and they also impact on all aspects of life in the
County.Transportation problems have historically been a major factor
in the delivery of mental health services in Monroe County. Mental
health patients needing inpatient services have to be transported
up to 150 miles. This becomes a particular problem in an emergency or
crisis situation. In 1977 the tranportation of these patients was
identified as the major problem in mental health services in the County:
This determination was made during the development of the Mental
Health Plan for Monroe County by the Health Systems Agency Subarea
Council. At that time patients were put in the County jail until
transportation t Dade County could be arranged. Since that time
a tranportation program has been developed through the Community
Mental Health Clinic of the Lower Keys which has greatly improved
the situation. In addition, during the last year Florida Keys
Memorial Hospital has opened two psychiatrict holding beds and the
Guidance Clinic of the Middle Keys has opened a Crisis Stabilization
Unit.
While many of the tranportation problems have improved the issue
must continue to receive a disproportionate amount of time and
resources when planning for the delivery of mental health.and
alcoholism services.
Transient Nature of the Community
The transient nature of the community is also a factor that impacts
on numerous services in the community, especially tourist related
services; however it also should be considered when analyzing the
need for services. The transient population in the County not only
increases the caseload of the mental health providers, but also
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may increase the demand for specific services, such as drug abuse.
Alcoholism Rate
According to the 1981-1986 Health Systems Plan the mortality
rate for cirrhosis of the liver in Monroe County was well above the
rates of both Dade County and the State of Florida. In addition
it was the fourth leading cause of death in Monroe County compared
to seventh in Dade County. A detailed analysis of the problem and
how it impacts on the various areas of the Keys is not available at
this time, however the Mental Health Board further study this problem to
ensure that it is receiving adequate resources to meet the needs.
Lack of Inpatient Psychiatric Beds
The unavailability of inpatient psychiatric beds has had a
major impact on the mental health services in the community. The
problem has been somewhat lessened by the availability of holding
beds -and the crisis stabilization unit. In addition, Florida
Keys Memorial Hospital has obtaineda certificate of need for the
establishment of a ten bed inpatient psychiatric. unit._
PROJECTION OF NEEDS FOR THE NEXT .THREE FISCAL YEARS
A projection of the needs for mental health and alcoholism
services should include a method for determining needs, a
specific plan for developing needed services, and an analysis
of resource requirements. Due to the time limitation in developing
this document the preparation of such a needs assessment was not
possible. Rather, this section will provide a general discussion
of what services may be needed and issues that must be addressed
in the coming years.
The discussion of projected needs will be divided into two
area : 1) planning needs and 2) service needs.
Planning Needs
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The need. for the initiation of a major mental health planning
effort in fiscal year 1981 cannot be overstated. Without such
an activity the second portion of this section.- the discussion
of service needs- can never be accurately developed and will be
nothing more than a "wish list" for mental health services. A
planning effort of this kind can provide the -.type of in-dpeth
needs assessment that was described earlier.
A major planning effort is particular important at this time
in view of reductions that are taking place in public spending for
health and social services. These budgets reductions are going to
require that some very difficult choices be made in the delivery of
community mental health services. The options are that these choices
can be made in a reactionary, irrational manner or they can
be made after a rational process of re-examining the role of
community mental health and analyzing the most appropriate and
efficient method to fulfill that role.
Service Needs
As noted above, the following discussion of service needs
cannot adequately be prepared until an in-depth needs assessment has
been developed. The information presented below is intended to
provide a general framework for analyzing and assessing needs.
The greatest service need in Monroe County at the present time
appears to be the development of a comprehensive program for
providing services to the chronically ill. The current situation
results in chronic patients repeated utilizing the crisis stabilization
unit and inpatient services in Dade County. During the past year
this has produced such a drain of the services and resources in the
community that the Lower Keys and Middle Keys clinics may face the
remainder of the current fiscal year with no Baker Act funds.
The development of a comprehensive program for the chronic
patients must first resolve the preadmission screening and
evaluation process in the County. The Mental Health Board must
also address the need for crisis stabilization in the community
both in terms of the level of services to be provided and the most
appropriate location for these services. The crisis stabilization
unit in the Middle Keys has apparently not been allocated adequate
resources to meet the needs of the community. The ability to
handle "acting out" patients and the need for psychiatric services
are two issues that have been problems in the operation of the
unit during the past year.
Another element of a comprehensive program for the chronic
patient is the availability of residential or day treatment
programs in the community. At present these services are not
available in the County. The lack of these services has been
a major reason for chronic patients to continually use the crisis
stabilization unit and inpatient services in Dade County.
In view of the State requirement of assuring care in the least
restrictive environment and the limited resources available for
Baker Act patients, it is essential that the Mental Health Board
give high priority to developing a comprehensive program for
services for the chronic patients. The development of this
• program could be incorporated into the planning efforts for the
coming year.
As additional service need that seems to exist in Monroe County
is the expansion of general outpatient services to meet the changing
population. As noted in the descriptive section of this report there
are certain areas of the population growth in the County. The
Upper Keys is growing to the point where it is projected that
28% of the population will live there by 1985, as compared to
13% in 1970. Similarly, the Lower Keys area, particularly
the Big Pine Key area has grown tremendously in recent years and
it is expected that that growth will continue. In view of the distance
between Big Pine Key and Key West one alternative for consideration
is the establishment of a part-time satellite clinic of the
Community Mental Health Clinic of the Lower Keys Keys in order to
ensure the accessibility of these services to the residents of
that area.
ANALYSIS OF MENTAL HEALTH AND ALCOHOL PROBLEMS IN MONROE COUNTY
AS THEY RELATE TO STATEWIDE PRIORITIES
- The development of community alternatives. to the innapropriate
use of State and/or local inpatient treatment facilities in order
to assure care in the least restrictive treatment setting.
As noted in the section on projected needs, there are no existing
residential or day,treatment programs for the chronically mentally ill
in Monroe County. The lack of these services has resulted in the
inappropriate use of inpatient services by these individuals.
The Mental Health Board must begin immediately to develop a
program for providing care in the least restrictive setting. The
Board must also resolve whether a need exists for a crisis stabilization
unit and emergency holding beds. The resolution of this issue will
also be a major step in solving the problem of serving chronic
patients.
- Provide a continuum of mental health services to children
and adolescents.
Mental health and alcohol services for children and adolescents
are provided through the general outpatient services at each of the
clinics. The patient population of these groups does not appear to
suggest the need for, or the ability to support, -specialized
programs in this area.
In addition to the clinics, services for children and adolescents
with emotional handicaps are available through the school system's
Center for Exceptional Student Education.
-Insure continuity of care for the chronically mentally ill.
The issue of the chronically mentally ill pateint has been
addressed at various points throughout this document. The present
system is not only extremely cost inefficient, but it does not
provide. the patient with the most appropriate services to. meet
his/her needs. The action that must be taken by the Mental Health
Board to solve this problem was outlined earlier.
I
If additional funds -are not allocated by the legislature to
provide comprehensive services tc the chronically mentally ill the
problem will continue in the community. The funds that are allocated
will continue to be used inefficiently and clinic will continue to
run out of Baker Act funds prior to the end of the year. In
addition patient will continue to receive care that does not
meet their need - which oftentimes means placement in inpatient.
treatment .facilities. In other words, the State regulation
regarding least restrictive setting for treatment will not be
able to be implemented if funds are not allocated to establish
the services .
-Improve mental health services to the elderly.
Mental health and alcohol services for the elderly are provided
through the general outpatient services of the three clinics. At
present there are no specialized programs specifically for the elderly.
The Mental Health Board in planning for future services should
' keep in mind the increasing percentage of elderly persons that are
in the County. If the rate of growth of the elderly continues at the
present rate it may be necessary for more emphasis to be placed
on the delivery of these services in the future.
-Provide services to underserved groups.
There were two groups that were identified as being underserved -
the Hispanic population and the gay population.
The largest hispanic population on the County is located in Key West.
The Upper Keys, however, also has experienced an increase in the
number of hispanic clients as a result of the influx of Cuban
refugees during the past year.
The increase in the hispanic population in Dade County has
also impacted Monroe services in a more indirect way. Dade County
psychiatrict beds that once may have need available for Monroe County
patients may now be unavailable due to increases in the inpatient
hispanic patients.
The gay population in Key West was also identified as a potentially
underserved group. Currently services are provided through the outpatient
program, however , resources are not availble to ensure that any special
-------------
counseling services that may be needed are provided.
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- Develop and implement community forensic services.
While all of the clinic deal with some forensic patients, only
the Community MEnt?1 Health Clinic of the Lower Keys identified it
as the second biggest problem facing the clinic. This is under-
standable in the view of the fact that the major County jail
facility is located in Key West. It was estimated that one
full time equivilent staff person could be utilized to meet the
needs of the forensic patients. In the planning effort during the
coming year the Mental Health Board should include a detailed analysis
of this problem and the most appropriate method for rpoviding the
needed services.
0