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Emerging Progress on State’s Mental Health Crisis System


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According to advocates and officials at a meeting in Raleigh this week, North Carolina’s network of help for people in mental health crisis is improving.

By Rose Hoban

A man calls North Carolina’s suicide hotline saying he wants to kill himself. He tells the counselor on the phone that he tried the week before but didn’t take enough of his blood pressure medication. This time though, he says, he will, and starts taking them as his counselor tries to persuade him to change his mind.

“We were helping her out,” recounted Mary Smith, who manages a crisis hotline for REAL Crisis Intervention, the organization that answers the phone anytime someone with a North Carolina number calls 1-800-273-TALK, the National Suicide Prevention Lifeline.

NSPILogo_lgSmith was telling her anecdote to some 400 health care officials, advocates and providers gathered on Wednesday at NC State’s McKimmon Center to discuss ways to improve North Carolina’s mental health crisis system.

The meeting was sponsored by the Practice Improvement Collaborative, an initiative launched last year by the state Department of Health and Human Services’ Division of Mental Health, Developmental Disabilities and Substance Abuse Services to bring together varied stakeholders in the mental health system to generate ideas for improving the way people in North Carolina get help during a psychiatric crisis.

Smith continued her story.

The counselor was eventually able to get the man to provide his name. A LinkedIn search revealed that he lived in Indianapolis, still using his North Carolina cell phone number.

The man was taking the pills, one at a time, while drinking bourbon. He passed out and woke up again. The counselor stayed on the line with him, her hands shaking all the while.

Then the counselor, who was on her second full day on the job, wheedled a location out of the caller. Her co-workers called a police crisis team in Indianapolis; they found him at the cheap motel where he intended to end his life.

“He says, ‘I can’t do this. You need to let me die,’ and [the counselor] said, ‘Nope; I can’t let you die,’” Smith recalled. “And about that time, we heard a knock on the door,” the arrival of the police and EMS.

“Well, we just started screaming.”

Smith’s organization received more than 44,200 calls in 2014.

But thousands more people suffered mental health crises in North Carolina. Without assistance, they landed in emergency departments, county jails or psychiatric hospital beds, or died.

An obligation

Some people contend that individuals have the right to take their own lives, said David Covington, who has run mental health recovery services in Georgia and now Arizona. But he reminded the audience that as mental health providers, they have an obligation to provide assistance through crisis.

“If we can intervene with someone who is actively suicidal, 19 out of 20 will survive to go on and live,” Covington said. “We always have two partners in saving a person’s life: their body and their brain. We’re wired to survive.”

David Covington, from Arizona, described the "No Force First" approach to working with people in mental health crisis that eschews the use of restraints and seclusion.

David Covington, from Arizona, described the “No Force First” approach that eschews the use of restraints and seclusion to working with people in mental health crisis. Photo courtesy David Covington

He told how Georgia made a big investment in mental health crisis services in the wake of a settlement with the US Department of Justice over a lack of community services.

“And it turns out that serving people saves money,” Covington said. “Go figure.”

Becky Stoll, who runs the crisis line in central Tennessee, told how her organization has deployed inventive initiatives to do longer-term support for people who call them in crisis, including follow-up calls, texts and chats.

“[People] feel like they’re more connected,” she said. “Someone is keeping up with them, someone is calling them, someone is texting them.”

Stoll’s organization has also piloted a program that gives people iPhones loaded with suicide-prevention and mental health-wellness apps.

It’s also provided Fitbits to encourage exercise, which has been shown to decrease depression. And the organization has partnered with emergency departments, pediatric clinics and mobile crisis teams to provide telepsychiatry services to accelerate care.

Strategic investments

But North Carolina’s crisis services have long been lacking. The evidence is in anecdotes about people not saved from suicide and the data on long wait times for psychiatric services in hospital emergency departments.

WakeBrook

The WakeBrook campus in Raleigh opened in 2010. Photo credit: Rose Hoban

Improvements are being made, such as the deployment of telepsychiatry services in emergency departments and the creation of WakeBrook, an outpatient crisis center in Wake County. Advocates and health officials alike say they’re determined to create more facilities like WakeBrook and make crisis services easier to access.

“I’m overly optimistic on our ability to get this right,” said Dave Richard, DHHS’ assistant secretary for mental health, developmental disabilities and substance abuse services. “There are some good things happening.”

Richard said North Carolina’s “pyramid” of services has at its foundation the suicide hotline and a peer-run “warm” line to connect people with mental health problems to someone who’s been through a similar experience. He said other pieces of the state’s pyramid, such as the development of crisis centers, is moving the system in the right direction.

But DHHS Sec. Aldona Wos admitted there’s no money to fund new initiatives.

“I think we have to use what we have, use it very wisely … and build from what there is,” Wos said. “Asking for new money, [it] may not be the right time for it.”

She and Richard said that instead, they’re pushing for improved coordination of services and for mental health managed care organizations that they believe will offer more accountability and transparency.

“You can go to every [mental health managed care organization] and there’s something they have done in the past six months to reorient their system that is absolutely in line with what we are saying,” Richard said.

He admitted the data isn’t yet indicating progress, that metrics such as emergency department wait times for psychiatric admissions are still unacceptably long. Nonetheless, the Division publishes the wait times.

“We don’t back away, we don’t try to hide from it, because we know change will take time,” Richard said.

“It doesn’t mean we’re not going to change the course,” he said. “We know what will work and we know if we move those services downstream and get more community services … we’ll get there.”

Advocates such as Laurie Coker, who runs the North Carolina Consumer Advocacy, Networking, and Support Organization, say they’re cautiously hopeful. She was particularly excited about the creation of services that address mental health crises in a more humane way and emphasize recovery from those crises.

“It’s like a dream come true to hear this discussion happen in my state,” said Coker, who has been pushing for more than a decade for more peer-supported services and community-based crisis services.

“My hope is that people left the meeting feeling somewhat inspired that we can do something creative,” she said.

Diagram of the range of crisis services developed by the Division of Mental Health, Developmental Disabilities and Substance Abuse Services.

Diagram of the range of crisis services developed by the Division of Mental Health, Developmental Disabilities and Substance Abuse Services.

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