To: Pennsylvania Department of Human Services

Health and Welfare Building

8th Floor West
625 Forster Street
Harrisburg, PA 17120

From: James R. Latronica, D.O.

Clarion Hospital Family Medicine Residency -- Chief Resident
Journal of Addictive Diseases -- Associate Editor
American Osteopathic Association -- TIPS Fellow
24 Doctors Lane
Clarion, PA 16214
(814) 226-2500

Re: Closure of Polk Center

Thank you for the opportunity to testify on the closure of Polk Center in Polk, PA. My name is
Jim Latronica, and I am in my final year of Family Medicine residency training at Clarion
Hospital in Clarion, PA, not far from Polk Center. I was distressed to hear the news of the
shuttering of Polk Center, and even more concerned about the obvious lack of foresight such a
closure indicates.

Most people know that physicians take the Hippocratic Oath, arguably the most important
component of which is primum non nocere--"first, do no harm." This is also known as the
"principle of non-maleficence." We also adhere to the principles of autonomy, beneficence, and
justice, which form the "four pillars" of medical ethics. Underlying these four pillars are two
basic "natural" rights: dignity and propriety. Specifically, dignity refers to one's right to respect
for their innate worth and the protection of their reputations, while propriety is the right to peace
and security in one's physical person.

I mention these ethical principles, not simply as an academic exercise, but as a preamble to
demonstrate how the closure of Polk Center is not only an act of cruelty to our 194 friends and
neighbors at Polk, but also an affront to the very notion of the ethical practice of medicine.

I see three--and only three-- potential, overarching points of rationale for closing Polk. The first
would be a "moral imperative"; a continued effort to "de-institutionalize" citizens of both the
Commonwealth and the United States in general. The second would be for medical reasons, as
an effort to increase the quality of comprehensive care. The third potential reason--which is also
the most odious--is for financial reasons, as an effort to cut spending. I don't have the time to
make an exhaustive case against each potential reason, but I do plan to touch on each one and
explain why those rationale are misguided at best.

As it currently stands, individuals at Polk receive comprehensive, medical, psychological, and

social care, under the watchful eye of numerous specialists, medical professionals, and staff
members. Some of the residents require twenty-four hour monitoring for their safety. Some of
the residents have lived at Polk for decades and literally know no other home. Whatever each
individual situation, the important point is that all of the care is individualized, and in many
cases has been honed and tweaked over many years of experience by the caring staff.

In fact, in the pamphlet given to families of individuals at Polk (which I do not have at my
disposal, but know of via local news reporting), ensures them that the residents of Polk will have
their current schedule and needs analyzed, so that they may receive the complete medical,
psychological/behavioral, and social care in the community. I think this sounds like a great plan.
In fact, we might consider these comprehensive needs and meet them in a residential facility of
some type, close to their families, while also allowing them to have twenty-four hour access to
nursing and other specialized staff. We could imagine building such a facility on a large, non-
apportioned property (say, in Venango County), and residents would receive everything the
Department of Human Services has promised, and then some. Clearly, I'm being sardonic here to
make a point, but that point is that no matter what DHS says or how well-intentioned they are,
the unique and sometimes intensive needs of our neighbors at Polk cannot be met, in any
reasonable facsimile, by community-based care. Every single physician in any specialty has at
least some exposure to long term care planning and would agree. So the "increased level of care"
rationale is dubious at best.

The "moral argument" as an effort to "de-institutionalize" individuals is also one that, while
potentially well-meaning, falls apart with even cursory examination. When state psychiatric
hospitals across the country were closed en masse in the 1980s, the United States experienced a
drastic increase in homelessness and untreated psychiatric illness, along with early, unnecessary
deaths. We are still feeling this ripple effect today as our prison systems are now the leading
providers per capita of psychiatric care in this country. This is an absolute disgrace. While the
needs of individuals in state psychiatric facilities differ from the residents of Polk, expecting
similar outcomes as institutions around the Commonwealth close is an entirely reasonable
expectation. The stigmatization of "institutionalization" was a shameful, concerted effort by
parties interested in cutting the budget at the expense of our most vulnerable and dispossessed,
and it stands as a mark of shame to this day.

In fact, we have a "natural experiment" in what may occur if Polk Center were to close. Hamburg
State Center in Berks County closed roughly one year ago, and we might do well to see how
those residents have fared. For privacy reasons, I'm sure that their current situations and medical
records are not publicly available, but I wonder how closely they are being monitored by the
Department of Human Services. There are important questions to be answered, not simply in an
epidemiological sense, but in the interest of their dignity and propriety.

Some pertinent questions for the Department of Human Services might be:

 Are the former residents of Hamburg having higher rates off illness, hospitalization, or
death than the general population?
 Are the rates higher than the patient-matched rates for an equivocal period going back
into the recent past (perhaps 5-10 years)?
 Can you physically account for the whereabouts of each individual? As a corollary, are
any individuals currently homeless, or suffering from food or shelter insecurity?
  For those who take chronic medications, have their prescriptions all been appropriately
filled on time since their discharge from Hamburg, and do they now have a regular
outpatient physician to manage these medications?
 For those with mental or behavioral health diagnoses, are they seeing their psychiatrist,
psychologist, and any necessary therapists with the frequency required to maintain their
health?
 Have they had regular dental and vision care appointments?
 Can you provide a current list of all of the medical, behavioral, and social health
professionals caring for these individuals? If so, can these lists be submitted to
independent medical professionals for review?
 For those who may have been fortunate enough to have family care for them after being
discharged from Hamburg, have you interviewed the families to discuss their care, how
they feel their family member is doing, and to see if the needs of the family are being
met?

I suspect that few, if any, of these questions could be answered satisfactorily by the Department
of Human Services. On the other hand, all of these questions could either be immediately
answered, or answered after record review, by Polk Center (or, previously, Hamburg). And here
is where lies the fundamental issue, one which I stated earlier: for these patients, community care
is simply not an appropriate level of care. Closing Polk Center would constitute gross
negligence, an egregious encroachment upon the dignity and propriety of its residents, and a
fundamental failing of fellow citizens of the Commonwealth.

Human Services Secretary Teresa Miller has stated that “Having an intellectual disability does
not mean a person is incapable of making decisions, contributing to their community, or
exploring lifelong learning opportunities. Community-based settings honor the inherent value of
every person and empower individuals to choose the direction of their own lives." I completely
agree. But the gist of her talking point is that facilities like Polk do not honor the inherent value
of every person, which is fundamentally and objectively incorrect, and is something of a slur
aimed at Polk's expert staff.

Finally, we have the "financial reason" for closure. The Department of Human Services states
that this is not a factor in their decision to close Polk, but you'll find in Rep. Kerry A.
Benninghoff's Memorandum (dated 3/23/2017) to the State House that this is fundamentally
untrue. Rep. Benninghoff does cite (albeit without sourcing) research suggesting that
"...community settings result in improved quality of life in areas such as opportunities for
integration and social participation, participation in employment, opportunities for choice-
making and self-determination, contact with friends and relatives, adaptive behavior, and other
indicators of quality of life." While this may be true, I would need to see which specific studies
he is referencing, as I am aware of research which suggests the opposite. Overall, the literature is
limited, longitudinally, for individuals in institutions who are not children, and thus the results
suggest that a case-by-case basis is the most rational, evidence-based tact that we can take.

In addition, he describes the closures as a "...critical human services win while at the same time
delivering a taxpayer win", and goes on to cite the financial costs, and highlight the alleged
decreased cost for community-based care versus residential facilities. (You'll note here, another
figure cited without source). So I will not pretend, and neither should anyone here today, that the
cost of care is not a large reason--if not the largest--for these closures. And herein lies the
problem: we know that people with special needs require more financial investment for their
care. If we were discussing the education of special needs children in public schools, I don't
think anyone here today would suggest that uprooting children with special needs in the service
of financial savings would be a moral endeavor. Why then, should this be a consideration for
adults with special needs? And I already explained above that--at best--the care that they receive
in the community will be less comprehensive than what they are currently receiving. So the
simple question before us is: "How much of our fellow citizens' dignity and propriety are we
willing to sacrifice in order to fill the coffers of the Commonwealth?" As a point of reference, I
will note here that Shell Chemical was given a tax break in the form of credits for purchasing
ethane from Pennsylvania, after building its ethane cracker plant in Beaver, PA. Over the next 25
years it will amount to $1.65 billion, the largest tax break in Pennsylvania history. So while Rep.
Benninghoff may consider the closure of Polk Center a "taxpayer win", I would argue that
slashing funding for vulnerable citizens of the Commonwealth should not be considered any type
of victory, when a "taxpayer win" could easily be found elsewhere.

Thus, here are my recommendations:

 immediate halt to closure proceedings at Polk Center and White Haven

 independently-commissioned survey of all extant relatives and/or caregivers of residents
currently residing at Polk, with the intent of discovering current satisfaction with the
services at Polk Center, as well as satisfaction and concerns with closure
 full accounting of the medical, psychological, and social well-being of the individuals
who formerly reside at Hamburg, including all medical, behavioral, and social
professionals who care for them, to be submitted in writing for independent review
 creation of a special committee to produce a retrospective, evidence-based review of the
ramifications of closing state residential institutions--and similar institutions --may be
analyzed
 creation of a permanent committee charged with longitudinally monitoring the well-
being of individuals formerly residing at Pennsylvania institutions like Polk

Closing Polk Center is not just. It is not beneficent, it is maleficent whether intentionally or
otherwise, and it does not take into account the autonomy of these individuals. The Department
of Human Services' plan is not the best course for our friends and neighbors at Polk, and I thank
you for allowing me the chance to defend their dignity and propriety.