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Wednesday, 16 January 2008 00:00

The state of mental health care: A fractured system is in danger of breaking down completely, leaving officials wondering — how did it get this bad?

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By Julia Merchant • Staff Writer

Patricia Frisbee Meyer’s son needed help.

The mental illness he had battled since childhood stayed mostly under control, but Meyer knew the onset of a bad episode when she saw it. Meyer, along with her husband, took her son to the emergency room at Haywood Regional Medical Center that Sunday — beginning a saga in which her son was restrained for nearly 48 hours before getting the care he desperately needed.

The Meyers’ story unfolded as follows. After the initial visit to the ER and a battery of tests on her son, the Meyers were told that the hospital couldn’t accommodate him. They were sent to the Balsam Center, a regional mental health clinic that can accommodate patients for short stays.

The center was so full that upon their arrival the Meyers found a blanket and a pillow that had been laid on a couch in the lobby as a makeshift bed. That was OK, they thought — doctors, after all, had said their son would be sent to a hospital in King’s Mountain the next morning.

Early Monday, some bad news came in — their son’s needs were too acute, and the hospital couldn’t accept him. When his blood pressure began rising around the same time, the Balsam Center could no longer care for him either — it lacks the capability to care for someone with an unstable medical condition.

So it was back to square one — the ER — for the Meyers. By this point, the clock had been ticking for about 24 hours, and their son’s condition was deteriorating. The deputy sheriff — who had been assigned to stay with him at all times — and hospital security opted to restrain his arms and ankles to prevent him from harming himself or other patients.

Meyer’s son would lay like that until Wednesday, growing increasingly agitated, until a bed became available at Broughton Hospital in Morganton.

Seventeen weeks later, he’s still there.

“I said the longer he is in restraint, the longer it takes to get a bed, the sicker my son gets and the longer he will take to recover,” Meyers recalls.

Now, she says, “We have made progress, but he is not ready to be discharged.”

As tragic as the Meyers’ story is, it is not unique. The mental health care situation in North Carolina has reached crisis levels. From a lack of state hospital beds to overcrowded emergency rooms to deputies that must stay with patients for up to 60 hours at a time, the system is increasingly fractured and in danger of completely breaking down.

 

How did we get here?

The history of the mental health care problem is a complex one. As HRMC CEO David Rice points out, the problem dates back as far as the 1990s, when a focus in mental health care was diverted toward inpatient — rather than outpatient — care. This led outpatient facilities that provided preventive and maintenance care — like psychiatrists and counselors — to become more scarce. The model ultimately failed, and led to a series of mental health care reforms that culminated in 2003 with the state’s privatization of mental health care.

“All of this was predicated by the notion that people would be served more effectively with better outcomes, and they’d be able to downsize state hospitals because there wouldn’t be as much demand,” said Tom McDevitt, area director with Smoky Mountain Mental Health.

Trouble is, the vast majority of the mentally ill fall into the cracks of the health care system: either they don’t have insurance with mental health coverage or they don’t have health insurance at all, and they don’t qualify for Medicaid or Medicare.

“They decided to privatize mental health services for a population that was 75 percent indigent,” explains Sheila Price, chief nurse executive at Westcare in Sylva and Bryson City.

A mental illness, often coupled with substance abuse, can be so debilitating that patients can’t hold down a job that would provide them with insurance. Qualifications for federally subsidized insurance have gotten tougher over the years as well.

The privatization of the system led to an influx in the number of patients seeking beds at state-funded hospitals, like Broughton in Morganton, which serves the western part of the state.

The problem of overcrowding in state hospitals worsened recently, when a government inspection found some questionable practices at Broughton. The federal government revoked the hospital’s right to bill for Medicaid and Medicare patients, forcing the state — and ultimately taxpayers — to pick up the tab. As a result, job cuts have been made at the already short-staffed facility, and there is no longer enough staff to watch over patients.

“It’s much more difficult to get an individual admitted from our attachment area now than one year ago. If you go back a couple of years, it’s night and day different. Today, it can take two to three days before there’s a bed available at Broughton,” said McDevitt. “The number one thing is that there are more demands for beds at Broughton than there are staff.”

“What we’ve got right now is an inpatient crisis so bad that what it does is back up the entire system. It’s just become really, really dire, where state hospitals are over capacity, and private hospitals are full and not taking referrals,” said Doug Trantham, director of clinical services for Smoky Mountain Mental Health.

In essence, centers like Smoky Mountain Mental Health that place patients in state hospitals are counting on places that simply don’t have any room.

“We’re relying on an institution that’s always full. Not a day goes by that we don’t have a challenge getting somebody hospitalized,” McDevitt said.

 

Law enforcement’s burden

The process of getting a patient the care he or she needs is a long one that involves many different people from start to finish. Local law enforcement — often the first to come into contact with a patient — must bear a brunt of the responsibility. And with waiting times exceeding four days, departments are being forced to put other duties aside and spend their own money to attend to mentally ill individuals.

Sheriff departments first enter the process when they are dispatched to collect a mentally ill patient at the behest of someone in their county.

“When somebody files an involuntary commitment order on a person, it is our responsibility to serve that order,” explains Macon County Sheriff Robbie Holland. “We pick them up and take them for an evaluation. After that’s completed, we have to transport them to a hospital with an (available) bed.”

Holland makes it sound like a relatively easy process, but in reality, it’s anything but. By statute, a deputy must accompany the mental patients at all times through the process of pickup, evaluation and placement. When the patient is ready to return home, the sheriff’s office is responsible for picking them up. The dire shortage of bed space in state hospitals means this process can take hours and even days.

“We’re picking up people like the orders say, we’re delivering them to the facilities and getting them evaluations, and that’s done very quick. But then there’s nowhere to put them,” said Haywood County Sheriff Tom Alexander.

“Sheriffs throughout the state are saying they’re spending hundreds and hundreds of hours sitting with people, because they can’t find beds,” he said.

In Haywood County, the average time for each commitment process is 22 hours, Alexander said. But “sometimes, you spend three to four days sitting somewhere with somebody.”

In Jackson, officers have had to wait up to 48 hours for bed spaces, according to Sheriff Jimmy Ashe.

“That means the respondent is to remain in our custody the entire period of time. That means going through four different shifts and four different officers,” Ashe said. “We’re sitting there and we’re waiting and we’re waiting and we’re waiting and the time goes on. It’s a very long process when you’re having to wait with someone that’s a danger to themselves or others.”

And when a bed is found, it’s not always at Broughton, which is the closest state facility. Officers might be dispatched anywhere a bed is available, including hospitals on the coast

“We’ve had to go as far as Wilmington. That’s a seven- or eight-hour drive one way,” said Holland.

The Haywood County Sheriff’s office initiated 279 involuntary commitments last year, and took them to eight or nine different hospitals around the state, according to Alexander.

Of the patients, 78 went to Broughton, 24 went to Frye in Hickory, nine went to Asheville-area hospitals, and 94 went to “other” facilities — places like Dorothea Dix or John Umstead, both near Raleigh.

Holland said that often, the drive is the easiest part of the entire process for officers.

“Seven or eight hours ... that’s nothing compared to 72. When we transport them, that last eight hours are a relief to us,” he said.

It wasn’t always like that. The process used to be much shorter, Ashe says.

“I can remember when it was as short as 40 minutes. The person was evaluated and you were on your way to taking that person to the hospital. At one time, it was an immediate process,” he said.

 

Who’s paying?

The job of looking after and transporting mentally ill patients costs the officers time — and money.

“You’re talking about sending sometimes two officers to Wilmington. (Factor in) the gas, the wear and tear on our automobiles, the salaries and overnight stays of transporting someone to find the care that they need,” and it can be pretty expensive, Ashe said.

Haywood County spent 73 percent of its part-time budget — used to pay part-time transporters’ salaries and travel expenses — in six months and put 14,000 miles on the department’s new van in the same amount of time, according to Alexander.

The Macon County Sheriff’s Department doesn’t have dollars in its budget specifically set aside for transportation.

“We have zero dollars related to the transportation of mental health patients. Every time we do a transport, we have to utilize funds,” Holland said.

“It’s a drain on the budget, it’s a drain on the personnel, and they have to sit with these people at different facilities for hours and days at a time. It just eats up a lot of money,” said Alexander.

 

Whose job is it?

Just whose responsibility it really is to transport mentally ill patients is unclear. By law, sheriffs must pick up involuntary commitments and bring them to get evaluated. After that, N.C. General Statute 122C-251(a) puts the county in charge of transportation to a psychiatric facility, but doesn’t specifically say it is the sheriff’s responsibility.

“Where it gets into a gray area and differences in opinion is ... what happens then?” Ashe said.

In most instances, the job has fallen to law enforcement because it involves dealing with potentially dangerous individuals.

“It’s always been assumed that the sheriff does it, but that doesn’t necessarily mean it would have to be that way,” Ashe said.

A decade ago, Westcare Health System had its own transportation team. The western counties contracted out with the team at no cost for 18 months thanks to a grant that funded the transportation team. After the grant expired and counties had to pay, some dropped the service. Eventually, it got too expensive for the remaining counties to pay for it, and the transport service went away altogether.

Ashe said he would like to see the service back as a partial solution to the issue of time-consuming transportation responsibilities that sheriffs have taken on.

The sheriffs in Haywood and Macon counties are taking advantage of the unclear laws governing commitment of the mentally ill to try and cut down on the amount of time they must sit with patients.

“There are gray areas in it. One is whether we need to sit with them the whole time,” Alexander said.

State law says that an officer must stay with a respondent until they are sure the patient is under “appropriate supervision.” If patients are determined to be nonviolent during their evaluation, Haywood and Macon officers have concluded that appropriate supervision can be provided without their presence.

“Just because a person is being committed or is suicidal doesn’t mean they’re a risk to me or you. Sometimes they’re very offended that a uniformed deputy sheriff is transporting them. It makes them look like a criminal,” said Holland.

“We have looked at the law and changed the policy of what we do, and it’s cut down on the amount of time spent with these people. Nothing really says we have to stay with them. If they’re nonviolent we’re not spending as much time, but if you get somebody that’s a problem, you stay with them as long as you have to,” Alexander added.

Haywood officers have partnered with the county’s hospital to provide security. Now, one deputy may stay with two or three patients in the emergency room rather than having one officer for each.

“I’m sure it puts a burden on the hospital, there’s no doubt about it, but before I don’t think they realized how much time we spent,” Alexander said.

Because of Alexander’s stance on the issue, the Balsam Center no longer accepts patients from Haywood County that could be left unsupervised.

“The Balsam Center does not have the security force. Many hours of the day, there is just one licensed clinical social worker on duty. They can’t maintain the security and custody of people from seven counties,” Trantham said.

 

Clogging the ER

Along with law enforcement, local hospitals are the other entities struggling under the weight of the mental health care crisis. When a patient is involuntarily committed in WNC, he or she is taken to a hospital to be evaluated. If the Balsam Center has no room or the individual has a medical condition too acute for the center to handle, the patient winds up in the ER of the area hospital. There, they may stay for days until a bed can be found at a state hospital.

“We’ve had people four or five days in our ICU, just waiting for a place to go,” said Price, who describes the hospital’s role in the mental health process as that of a “catchment basin — people are picked up for whatever reason and brought to us to make sure they’re OK.”

Mentally ill patients who stay in the ER for several days take up valuable bed space — a problem in small hospitals that only have a nine-bed unit, like Westcare in Sylva.

“Last winter, we had seriously ill folks that we sent to other hospitals because our beds were tied up with mental patients,” Price said.

The mentally ill require constant attention from nurses and doctors in the ER, taking the focus away from critical patients that also need care. On an average weekend day at HRMC, the ER might see 90 patients and have four or five nurses on the floor, said Eileen Lipham, director of critical services for HRMC. If three mental patients are brought in, three nurses must give them one-on-one attention, leaving just one or two nurses to attend to all the other patients. That, Lipham said, “causes chaos.”

“It’s creating a major problem in processing time for other patients,” Rice agreed.

ER workers aren’t always equipped to handle mental patients either. Price said that she’s seen patients be so violent that the hospital was unable to restrain them and had to let them go. Other times, hospital officials are powerless to calm patients down.

“You may have somebody in there all weekend, screaming for 12 or 18 hours,” Price said.

In the mental health care crisis, hospitals have become stopovers on the way to treatment — unable themselves to provide the help the patient truly needs. By the time they end up in the ER, the condition of mentally ill patients is often an emergency warranting the same quick attention as other patients. Their condition can worsen the longer they wait.

Sheriff Jimmy Ashe used a metaphor to describe his frustration with the situation.

“If you broke your arm, would you want to wait in the emergency room for 16 hours? If Haywood’s hospital couldn’t see you, you would drive to the next town. In this particular situation, there is no other choice,” he said.

 

Staying out of the ER

“Hospitalization is really a last resort for any type of illness,” Lipham says. So why, then, are so many mentally ill patients ending up there?

The answer, like much of the mental health care situation, is complex. Some 70 percent of the mentally ill population is indigent, meaning they don’t have private insurance and don’t qualify for Medicaid or Medicare. As McDevitt explains, this is a population hindered by substance abuse and disability. Some are homeless, and many are unemployed. Though they might be the ones who most warrant medical attention, the mentally ill are also least likely to be in a situation where they can afford it.

The funds to help the indigent mentally ill population are hard to come by.

“This is a population of folks that are invisible, that most people want out of sight and out of mind,” Price says. “Funds for the indigent are so small, they’re just not touching the population.”

Because they don’t have insurance, many individuals with mental illness have never sought treatment for their condition. In fact, the first exposure some have to treatment is when their situation has gotten so dire they have to be hospitalized.

“A substantial number of the people we see in crisis are touching our system for the first time,” Trantham explains. “As many as 50 percent are not in treatment at all — they’re just kind of showing up.”

Because the mentally ill don’t see primary care doctors, “they’re not being supported until they crash and burn,” says Price.

“That makes it much harder to care for them,” Trantham said. By the time many of these patients seek help, their psychological and medical conditions are already much worse because they’ve never gotten them treated. And hospitals aren’t clamoring to treat patients requiring complicated care when they won’t be able to pay.

“Facilities are reluctant to admit indigent people with expensive medical conditions that need treatment. That’s becoming a greater and greater problem,” says Trantham. “Even if they are equipped, it will likely cost a lot, so hospitals are reluctant to take that on.”

Especially when outside resources to continue treatment aren’t widely available.

“Some of these folks absolutely have to be maintained externally,” Price says adamantly, whether it be counseling, rehabilitation support or medication management.

“If all we do is dry you out and send you home, we just put a dropleak in your radiator. If you’re going to be detoxed, you should be getting counseling and support,” she said.

“It’s like putting a bandaid on a leaking jugular vein,” Lipham agreed. “These patients need ongoing care.”

Since some psychiatric units were downsized or taken away altogether several years ago, “the system has not been able to rebound with enough community based services to help people avoid being in crisis,” McDevitt said. Having a consistent, cohesive network of outpatient care within a community is a big part of an eventual fix to the mental healthcare crisis in the state.

“If you have primary care in the community, then a smaller population will need emergency care,” Price said.

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