N.H. struggling to solve a psychiatric problem that’s been years in the making

By ALLIE MORRIS

Concord Monitor
Saturday, February 25, 2017

Four years ago, mental health workers called a press conference to ring the alarm. On any given day, nine people sat in New Hampshire emergency rooms waiting for a bed to open at the state psychiatric hospital.

“Access to timely mental health care in New Hampshire is at a crisis point,” Ken Norton, the director of the state chapter of National Alliance on Mental Illness, proclaimed then.

Last Monday, 68 people were waiting – the latest record high. No one sent a press release, no one called a news conference. The wait list for admission to New Hampshire Hospital has become a new normal in state mental health care, much to the dismay of advocates. It means patients who are suicidal or in psychiatric crisis often languish for days in the hallways and holding rooms of hospitals without the treatment they need.

“What other illness would we allow people to suffer like this without treating them?” Norton said last week. “It’s absolutely inhumane.”

While there’s agreement on the problem, the mental health community is divided over the fix. Should the state spend to build more beds, or fund only community-based care meant to keep patients out of the hospital?

Right now the state is pouring most of its resources into the latter to comply with a 2014 mental health settlement. The agreement resolved a lawsuit alleging patients were needlessly institutionalized because they couldn’t get mental health treatment in their own communities.

A group involved in the suit says fully implementing those community services, like supportive housing and mobile crisis teams, will “dramatically” reduce the needs for beds at a fraction of the cost.

“We really don’t think the answer to the psych boarding problem is to increase the bed capacity,” Disability Rights Center – New Hampshire staff attorney Aaron Ginsberg said.

But a consensus is growing among providers that expanding community care alone isn’t enough to solve the wait list crisis – the state needs more beds.

“Part of the solution is more inpatient beds, whether people want to hear it or not,” Suellen Griffin, head of the state Community Behavioral Health Association said. “There are still a significant number of people that need hospitalization because it’s the only level of care that is appropriate.”

In his budget plan, Republican Gov. Chris Sununu proposed spending an extra $3 million on so-called ACT teams. The community-based teams are meant to help people with mental illness maintain a healthy lifestyle and prevent crises that could send them to a local emergency room or the state hospital. Sununu didn’t offer up money for new beds.

Health and Human Services Commissioner Jeff Meyers said the state needs to continue building community care, but would benefit from an independent evaluation of how many psychiatric beds the state may need.

“We do have to take a serious look at adding some additional inpatient beds in the state of New Hampshire,” he said. “Those don’t have to be at New Hampshire Hospital, they could be beds in the community, or a combination of the two.”

Lost beds

Across the country, the reliance on so-called psychiatric boarding is up as the number of inpatient beds has declined.

The wait list at New Hampshire Hospital started about five years ago, advocates say. Around that time, the state hospital lost beds to budget cuts and private hospitals began shutting down their psychiatric units due to workforce shortages. The financially-starved community health centers were unable to pick up all the slack. Together the changes left patients and emergency rooms in a crunch.

Health professionals suggest states should have at least 40 to 50 psychiatric beds per 100,000 people. New Hampshire has just 11.9, according to the Treatment Advocacy Center.

Between 2005 and 2013 the state’s psychiatric bed count fell from a total of 526 to 384, according to the Foundation for Healthy Communities. Over the last decade, New Hampshire Hospital’s bed count has gone from over 200 to roughly 160 now, state officials say.

No beds are left in the North Country after Androscoggin Valley Hospital closed its inpatient psychiatric unit a decade ago. New Hampshire Hospital’s 24 adolescent beds are among the only option for children in psychiatric crisis. Cheshire Medical Center used to accept minors, but the Keene facility closed its entire inpatient mental health unit last year when it couldn’t recruit permanent staff psychiatrists.

The state’s community mental health centers treat roughly 50,000 patients a year, according to the association. But the centers have also struggled to recruit workers and say the state hasn’t increased their Medicaid reimbursement rates above the 2006 level.

The wait time for an appointment at one of the 10 centers can be weeks or a month. During that period, patients’ conditions can worsen and land them in the emergency room.

The state is making some strides, but slowly. After a year-long delay, the new 10-bed crisis unit is up and running at New Hampshire Hospital. The ward is meant to ease the number of people waiting in emergency rooms, but advocates say it hasn’t made a major dent.

The state is spending roughly $30 million over four years to expand community-based mental health services in compliance with the settlement. Those include mobile crisis units that treat patients in their own homes, instead of at the emergency room and state hospital. An expert reviewer appointed by a federal judge to oversee implementation has reported progress is too slow.

Advocates say the state can’t fix a problem overnight that has been building for years.

“The system is so weakened it is very difficult to produce these new demands,” Mental Health Center of Greater Manchester President Bill Rider said.

No sense of time

As the number of people waiting to get into New Hampshire Hospital has grown, so too has the time they spend sitting in emergency departments.

Hopkinton teenager Zee Meister agreed to get help at the state psychiatric hospital last May after kicking a hole in his bedroom wall.

But first he had to wait three days for a bed to open. He spent the time bouncing between the bustling hallway of Concord Hospital’s emergency room, a windowless psychiatric holding pod where a video camera in the corner monitored his every move, and the pediatric wing. Instead of treatment, Meister got stress.

“I was feeling really nervous inside,” Meister, who was diagnosed with a mood disorder, said about the ordeal. “I was always moving.”

Not all mental health patients in the emergency room end up in New Hampshire Hospital, some are referred to outpatient services, sent to beds at other hospitals or released if their condition improves.

Almost all patients sent to the state hospital are involuntarily committed, meaning doctors deemed them a danger to themselves or others. Once an involuntary determination has been made in the emergency room, the patient can’t be released.

The wait time puts pressure on emergency room physicians and nurses, who must spend hours of staff time monitoring potentially suicidal patients. For patients, the days or weeks spent in a sparsely furnished holding room or in a noisy hallway can exacerbate a psychiatric crisis.

The weeklong wait at Southern New Hampshire Medical Center felt like a single, never-ending day for Ryan, a 17-year-old who has bipolar disorder. His holding room had no clock, and he kept vague track of time through nurses bringing him meals.

“It sucked,” said Ryan, who declined to give his last name for privacy. “Being stuck in a room isn’t really going to make me feel better. I spent most of the week with the door closed, the lights off and the TV on.”

For parents, the long waits are just as frustrating. Heidi Robinson spent four nights sleeping on a tile floor at the emergency room while waiting for a bed to open at the state hospital for her 13-year-old daughter.

“My daughter is an amazing kid who has a huge future ahead of her, only if she can get the help she needs,” she said. “All the times she spends sitting in a bed in the ER is just taking away from her future.”

(Allie Morris can be reached at 369-3307 or amorris@cmonitor.com.)