By Rose Hoban
Mental health crisis can be difficult to define. For one person, it’s an attempt at suicide; for another person, crisis occurs when they are experiencing hallucinations or delusions; and for another, it can be alcohol intoxication or overdosing on drugs to quell the symptoms of a mental health problem.
The commonality for all those kinds of mental health crises is that in North Carolina, people in crisis frequently end up in hospital emergency departments, often for days at a time.
According to statistics from the state Division of Mental Health, Developmental Disabilities and Substance Abuse Services, about 150,000 people with psychiatric needs ended up in emergency departments around the state in 2012. Not everyone needed to go to a psychiatric hospital; but for those who needed to be admitted, that time in an emergency department stretched to an average of 3.5 days, or more than 84 hours, until they were admitted to a state hospital.
That’s why leaders of the state’s mental health system gathered in Raleigh on Thursday with mental health and emergency medical providers to announce an initiative to improve psychiatric crisis services throughout the state.
“Our state has tried and not really succeeded in our attempts to reform the public mental health system,” said Dave Richard, director of the Division of Mental Health, Developmental Disabilities and Substance Abuse Services. “The result is a system that is focused on reacting to people when they experience a mental health crisis, but not focusing on prevention.”
“We hear it from consumers and family members who are frustrated by a system that waits for an emergency to happen instead of being focused on regular consistent treatment,” he said.
Richard also noted that practitioners and hospital have borne the burden of mental health patients coming to emergency departments designed more for people with physical health needs.
“Their emergency departments are overwhelmed and their staff are overwhelmed,” Richard said, announcing the formation of a work group to provide suggestions to the Department of Health and Human Services to improve crisis services.
However, Richard and other leaders gave few details on what the changes would be, when they would be implemented or what costs would be incurred, if any.
Unique setting
The press conference to announce the initiative was held in the courtyard of WakeBrook Crisis Center in Raleigh, a facility that has a 16-bed crisis care unit, a 16-bed addiction treatment unit and an additional unit for short-term inpatient psychiatric care. The facility, which opened in 2010, was funded with money provided largely by the Wake County Board of Commissioners, more than $20 million in county funds.
In 2012, UNC Healthcare signed an agreement to run the facility, and according to UNC CEO Bill Roper, the health care system plans to put about $40 million in additional money into the facility.
Roper said the crisis and assessment clinic at WakeBrook serves about 400 patients every month, patients who otherwise might end up taking up valuable bed space in emergency departments.
“Our plans now call for adding 12 more inpatient beds, raising the level of behavioral care available in Wake County and reducing the strain on hospital emergency departments,” Roper said.
He added that UNC Healthcare is also opening an outpatient psychiatric clinic down the street and adding inpatient medical capacity at WakeBrook to avoid “complicated transfers to other facilities for patient care.”
Part of the success of WakeBrook lies in its location, down the street from WakeMed Hospital and the Wake County Human Services building and across the street from Holly Hill Hospital, a private psychiatric facility.
WakeBrook has also coordinated with Wake County Emergency Medical Services to help ambulances come directly to the psychiatric facility instead of stopping at an emergency room.
“What many do not know is that our reimbursement and many of our rules tie us to taking all patients we encounter to the emergency department,” said Brent Myers, head of Wake County EMS, who noted that 5 percent to 10 percent of any community calls on EMS annually. Since 2009, Wake County EMS has been working with the county mental health system.
“When EMS providers encounter a patient with a mental health or substance abuse crisis, we offer these patients the full menu of services directly from the scene,” Myers said. First responders in Wake County have been trained to assess patients for potential psychiatric issues, consult with doctors and can bypass the ED and go straight to a psychiatric facility.
“During the calendar year 2012, we did this approximately 250 times. This returned 3,400 emergency department bed hours to our community,” Myers said, adding that Wake EMS is on track to redirect more than 320 such patients in 2013.
Richard acknowledged that not every community will have the money or infrastructure to replicate facilities such as WakeBrook, but he pointed out other initiatives in the state that are slated to reduce the load on emergency departments.
“The telepsychiatry program is a great example, in that it will make a big difference across the state in terms of the ability for people to have access to psychiatric services, especially in rural areas,” Richard said, referring to the scale-up of a program to put two-way video links to psychiatrists into emergency departments statewide. “We had additional monies for community-based hospital beds, so we’re expanding that across the communities that have never had that option before.”
Richard also said that DHHS will create a website that will list statistics collected by the department on the number of psychiatric admissions to hospital emergency departments, the wait times for psychiatric beds and the number of patients who are readmitted for psychiatric problems within 30 days of discharge.
According to state statistics, about 13 percent of psychiatric visits to emergency departments were from people who had been in an ED within the past month.
Individualized solutions
WakeBrook has the advantage of being close to other services, said Brian Sheitman, medical director at WakeBrook, something other counties may have trouble replicating.
“I think if people are going to set up these crisis centers, ideally it would be next to some hospital-based functions,” he said. “They can’t be in the middle of nowhere, or it’s going to be a complete mess.”
Richard said some other counties are experimenting with creating similar facilities, but on a smaller scale, such as in Cumberland County.
“They are developing a similar kind of service for people right close to the hospital. I believe they said it is costing between $250,000 and $300,000 to renovate the facility to do that,” Richard said. “It won’t be the Cadillac that this building is, but they’re moving in that direction.”
“Every county, every part of our state is going to have to have a different solution,” he said.
Laurie Coker, a longtime advocate in the mental health community and head of the N.C. Consumer Advocacy, Networking and Support Organization, said she’s encouraged by the increased focus on improving mental health crisis services.
“For many years, I tried to advocate with the Division [of Mental Health, Developmental Disabilities and Substance Abuse Services] about the need to take a serious look at how we respond to people in crisis,” said Coker, who has been asked to serve on the work group. “A crisis shouldn’t be a time to stick a little medical Band-Aid over a major life situation. A crisis should be and could be the first step toward recovery if people have the right response and the appropriate services for the level of need.”
When state lawmakers overhauled the mental health system in the early 2000s, the state eliminated the old area agencies, which Deby Dihoff, head of the North Carolina chapter of the National Alliance on Mental Illness, said were reliable places for mental health consumers.
“They used to know who was their therapist; they could call at midnight. All that went away,” Dihoff said, “and that’s what used to stabilize people.”
Dihoff said the current mode of addressing crisis in communities – mobile crisis teams on duty 24/7 and staffed by psychiatric nurses and doctors – is a more expensive way of dealing with acute problems.
“Not that there’s anything wrong with that, unless, like in North Carolina, you don’t implement them properly,” she said. “When you send a pricey mobile crisis team to the hospital and then you have the core hospital costs plus the mobile crisis costs, then you just have a financial nightmare.”
She called for more low-cost, low-intensity solutions, such as walk-in centers, and she likes the idea of giving EMS workers more training to get psychiatric patients to the right place when they’re in crisis.
Dihoff also said one big problem in the past decade has been the constant upheaval in the mental health system.
“if we could quit doing expensive solutions and put that money into housing and getting people jobs and having a therapist that doesn’t change every six weeks, then things would simmer down and people won’t always be in crisis,” she said.
“People don’t want to be in crisis; they want to have lives,” Dihoff said.
The work group is slated to start their work in December, but no timeline for a report or for outcomes was given.
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