The development of the community support system model and other efforts to decentralize psychiatric care for the severely disabled has made the future role of the state psychiatric hospital uncertain. The authors studied patient admissions from a community support program in New York State to a state psychiatric hospital over a period of 18 months. They found that the program made very little use of the state hospital, accounting for only ten of the county's 33 admissions. The findings also suggest that refractory patients, staff fatigue, and restrictive utilization review criteria applied to the local general hospital were the primary reasons for continued use of the state hospital. The authors conclude that while the state hospital's front-line treatment role may no longer be necessary, the institution may be needed to care for those few patients whose illnesses do not respond well to current treatment alternatives.