The extraordinarily difficult struggle to find nurses licensed in psychiatric care has forced the state agency that oversees mental health care in Western North Carolina to discontinue crucial services for its most critical patients.

For months, the Smoky Mountain Center for Mental Health has tried desperately to lure psychiatric nurses to help staff the new inpatient psychiatric wing at Haywood Regional Medical Center, which opened in October. The Smoky Mountain Center succeeded in pulling together enough staff to run the unit — but only by stealing nurses from its existing psychiatric facility, the Balsam Center.

The diversion of staff to the HRMC unit left the Balsam Center with only half the staff it needed to operate safely. Such low staffing levels could have gotten the Balsam Center in trouble with healthcare inspectors.

As a result, Balsam Center stopped admitting patients Dec. 12 to its adult recovery unit, which offers detox to adults with mental illness, and the crisis management unit, where patients come to be evaluated.

Doug Trantham, director of services for the Smoky Mountain Center, justified the shift of nurses from the Balsam Center to the new hospital-based center.

“Some areas you can make do and come up with other ways to meet the need, but when you’re talking about a 24-hour unit (like that at HRMC), you have to have what you have to have to run it safely,” Trantham said.

Loss of beds, detox facility a blow

Ironically, the psychiatric unit at HRMC was supposed to alleviate the critical shortage of beds for mental health patients that has plagued the state.

Instead, the opening of the new unit has resulted in the opposite — a loss of bed space due to the lack of staff to run two facilities.

“It’s not square one, but it’s definitely a setback,” said Trantham.

“When we had a patient, that’s the first place we took them,” said Macon County Commissioner Chairman Ronnie Beale, who sits on the board of the Smoky Mountain Center.

Now, those in the far western counties must drive the additional distance to HRMC and hope the facility has an open bed. Only six beds are currently available for patients at the unit, though eventually it will house 16.

Extra beds are only one service that’s been lost with the closure of the Balsam Center. Also gone is a place to take patients who need detox from drugs or alcohol, which the adult recovery unit provided. Now, there isn’t anywhere that offers detox in the western part of the state.

“The one thing that has been critical that the Center has provided is detox,” said Trantham. “There is a tremendous need for it not just in our area, but across the whole state.”

The closure of the Center’s detox facility means there will be more competition for fewer places offering detox.

“We’re all going to be struggling to get access to that,” Trantham said.

Detox facilites are few and far between because they’re expensive to run, and 80 percent of individuals who use them don’t have insurance, said Trantham. That means the state must provide a significant amount of money to subsidize an often expensive detox program, and there’s inadequate funding to do so, Trantham said.

Addictions to drugs like methamphetamine are a critical problem in western areas of the state, so the need for a detox facility here is great.

“The real need today, more than ever, is for detox,” said Beale. Caring for drug and alcohol addicts who don’t get help can be a major drain on county services, Beale added.

Before the Balsam Center closed, it was actually in the process of expanding the detox services it offered, said Trantham. That would have helped alleviate the problem. Instead, it’s gotten worse.

Filling the gaps

Though the closure of the Balsam Center has been a blow to mental health care in WNC, there are some services coming online that could help improve care by making it more accessible.

The Smoky Mountain Center has plans to establish three mobile crisis teams, made up of psychiatrists and nurses, that will travel around the seven western counties so patients can get care locally rather than traveling to the Balsam Center in Haywood County.

Before, said Trantham, someone with mental illness in Murphy who needed help would have to travel all the way to the Balsam Center in order to be evaluated.

Now, “we can see them (in Murphy), and determine how to help them, and in the future respond to them there,” Trantham said. “It will be a timesaver for the hospital, for law enforcement, and for the client.”

Hospital workers and sheriff deputies must often watch over a mentally ill person until they can receive care, but now the mobile crisis teams can shorten that period by coming right to the patient instead.

“If there is a positive, it’s moving to using the mobile crisis unit and having them come to the location for an assessment,” said Sheila Price, Clinical Nurse Executive at WestCare hospital in Sylva.

Smoky Mountain Center hopes to have three mobile crisis teams operating in January, and officials in the far western counties are counting on it.

“If they do like they say and put these evaluators out in the area hospitals, it will work real good. If not, we’re going to be in a world of trouble,” said Beale.

Recruitment: the greatest obstacle

Providing mental health care services such as walk-in clinics and mobile crisis teams is contingent on being able to recruit trained professionals. Some wonder how the Smoky Mountain Center intends to recruit staff for new services when it had so much trouble filling positions at the Balsam Center.

“If we don’t have the staff for what we’ve got now, where are we going to get the staff for these other things?” questioned Haywood County resident Patricia Frisbee Meyer, whose son suffers from mental illness.

In truth, recruiting nurses is already competitive, but recruiting those licensed in psychiatric care can be even tougher because there just aren’t that many of them, said Trantham.

“Psychiatric nursing is a subspecialty within nursing, and only a relatively small percentage of nurses are interested and get the necessary experience in it,” he said.

The mountain region presents its own challenges. It’s rural, and not necessarily attractive to those looking for the excitement of a big city. It also lacks a large state psychiatric hospital, another big draw for those interested in mental health care.

Mental health providers are having to expand their search to the national level to find qualified nurses.

“We’re having to pull people from outside our area,” Trantham said. “If we were to compete for the same bumper of staff, you never get ahead because there just aren’t enough to fill jobs.”

Meyer suggests that universities should provide some type of incentive to encourage nursing students to enter the psychiatric field.

WestCare Medical System has had some success with another approach to recruit healthcare workers — capitalizing on the region’s abundant natural resources and outdoor activities. An ad on its Web site says “Work where others play,” and shows people kayaking and hiking.

“This is a vacation heaven for 90 percent of the United States,” said Price. “We are trying to monopolize on the fact that it’s a beautiful place to live.”

WestCare CEO Mark Leonard says the approach has worked.

“It has been effective both for nurse and physician recruitment,” he said. “Not only for recruiting, but identifying individuals and families that are going to be happy here, which is much more of an indicator that they’ll be here long term.”

What’s next?

The fate of the Balsam Center remains unclear.

“It is our intention to re-open the crisis unit next year, but the reality is we do not know when, and under what conditions, it will be re-opened,” Trantham wrote in an email to staff.

It’s all contingent on finding enough people to staff the Center. Though that’s proved challenging, Trantham says he chooses to remain optimistic.

“I think that when you’re in the business of providing services like this, you have to be hopeful, and you have to keep trying, even though it’s challenging,” he said.

Meanwhile, the HRMC unit is filling some of the gaps left by the Balsam Center and helping to improve mental health care in WNC, said Trantham.

“The inpatient unit at HRMC provides a higher level of care, and the capabilities are much greater than a crisis unit can ever have,” he said. “That program had to come first. We shifted our resources there to make sure we got that program off to a good start.”