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The second of a three-part series on legislation regarding hospital-based psychiatric care. In this story we look at a proposal to build a new psychiatric hospital in the southern Piedmont.
By Taylor Sisk
In April, a bill was introduced in the North Carolina House of Representatives that proposed the construction of a psychiatric hospital in the south-central region of the state. If built, it would be the fourth state-operated psychiatric hospital, joining Cherry in Goldsboro, Central Regional in Butner and Broughton in Morganton.
The bill, House Bill 981, didn’t make it out of the appropriations committee.
“We’ve had a lot on our plate, obviously,” bill supporter Rep. Justin Burr (R-Albemarle) said in June, referring to the now-completed legislative session.
But it’s not dead.
“My hope is to continue and try to educate members on the importance of additional state beds and push again for [the hospital] next year,” Burr said.
A dozen years ago, the state launched a two-pronged reform of its mental health care system: the privatization of services and an initiative to move people with mental health issues out of state-run hospitals and back into their communities, where, presumably, those with less severe disorders can be better cared for.
Supporters of House Bill 981 said the state has gone too far in reducing the number of beds available to those who require institutionalization.
But many mental health care advocates counter that the reason there are waiting lists for beds in state-operated psychiatric hospitals is because North Carolina has failed to adequately invest in community-based services.
Taxpayer money allocated to a new psychiatric hospital would be better spent within those communities, they argue.
Laurie Coker, executive director of the North Carolina Consumer Advocacy, Networking, and Support Organization, said she believes that it’s within local communities that solutions must be found.
She pointed to the number of people who are showing up in emergency departments across the state with mental health issues.
“Our high ED numbers are indications that we don’t have the right kind of services,” said Coker, who has served on legislative committees considering the future of the mental health system.
A report released in June by the Centers for Disease Control and Prevention found that while the rate of people arriving in emergency departments with mental health issues is up throughout the country, North Carolina EDs see double the national rate.
And according to an April report to the General Assembly by a legislative mental health subcommittee, the average length of stay in 2012 for individuals arriving at an emergency department with a behavioral-health crisis was 15 hours and 52 minutes.
What we need, Coker said, are “low-intensity services to keep people out of the hospital.”
She advocates for a “recovery-oriented” approach to care.
In its 1999 Olmstead v. L.C. decision, the U.S. Supreme Court determined that in keeping with Title II of the Americans with Disabilities Act, Medicaid-eligible individuals with disabilities should not be discriminated against by being forcibly institutionalized when they might otherwise be provided services within their communities.
In short, government must make every effort to provide community-based services when they are appropriate and can be reasonably accommodated and the person doesn’t oppose them.
The April subcommittee report to the legislature stated that the number of state-operated psychiatric inpatient beds had decreased from 1,755 in 2001 to 850 in 2012.
This was in keeping with Olmstead: deinstitutionalization.
But, as in many states, a substantial investment in community-based services never materialized in the wake of decreasing psychiatric hospital capacity.
Emergency rooms and jail cells filled with those in need of mental health care.
The report also found that 72 percent of people admitted to state hospitals experienced a delay, with the average delay in the winter of 2012 being more than 84 hours.
In a January report, the Joint Legislative Oversight Committee on Health and Human Services encouraged the legislature to direct the state Department of Health and Human Services to explore the possibility of placing a new psychiatric hospital in the south-central region of the state to serve at least 14 counties, including Mecklenburg and Forsyth.
The April report was a follow-up to that, addressing the costs and feasibility of constructing a new facility.
Rep. Julia Howard (R-Mocksville), a co-sponsor of the subsequent bill, said in April that the private sector isn’t providing enough services and another state hospital is needed.
A few questions
Mental health care advocates say that before assessing the need for a fourth psychiatric hospital, state health officials and legislators should answer a few fundamental questions.
First: How many beds does North Carolina need?
“It’s tough to wrap your hands around what the best number of beds would be,” said Aisander Duda, development director for the N.C. Center for Public Policy Research (NCCPPR). “But it’s an important question to come to some kind of conclusion on, because it greatly impacts what you’re going to do moving forward.”
Marvin Swartz, head of Duke University’s Social and Community Psychiatry Division, wrote last year in the North Carolina Medical Journal that, “The larger problem underlying the growing shortage of psychiatric beds in North Carolina is the absence of a rational bed-need methodology for determining the required ratio of beds to population that would adequately serve diverse areas of the state.”
Swartz wrote that current bed allocations are based largely on historical trends rather than careful assessment.
The national nonprofit Treatment Advocacy Center has said that a minimum of 50 beds per 100,000 people is a “consensus target for providing minimally adequate treatment.”
DHHS officials have said they believe that number is too high, suggesting 22 to 31 per 100,000 people is a more appropriate target.
In research conducted in 2012, NCCPPR found that the state had 26.8 beds per 100,000 people. That included state-operated hospitals and other psychiatric facilities.
Another question is whether the south-central region would be the optimal location for a fourth hospital.
“It might make sense that it’s centrally located and in a major metropolitan area,” Duda said. “But are the people in Charlotte going to need something like that?”
The Charlotte area is relatively resource and treatment rich, Duda said, and he wondered if a hospital in that region would primarily draw patients from outside the immediate area, and, if so, if it makes sense to place it there.
The legislative mental health subcommittee’s report to the General Assembling stated that because Mecklenburg County has “significant inpatient resources,” the region admits relatively fewer people to state psychiatric hospitals than the rest of the state.
In addition to what’s now available, Carolinas HealthCare System is due to open a 66-bed psychiatric facility in Davidson (in Mecklenburg County) next year.
But rather than suggesting the hospital might be better placed in another region of the state, the report states: “Due to the lower usage of State hospital beds by Mecklenburg County, the new hospital in the proposed region is recommended to be 200 beds, the smallest of the four State hospitals.”
There are, as Duda noted, compelling reasons why Mecklenburg County would be better suited for a hospital than other areas – staffing being perhaps the most significant.
“Mecklenburg County is a draw,” said Nicholas Stratas, a Raleigh psychiatrist and former state deputy minister of mental health. Mecklenburg, he said, is “an attractive metropolitan area” and would draw mental health professionals from both within and outside the state.
“North Carolina does not have a great reputation at this time,” Stratas said, “but the state is still a very desirable place to live.” He said he regularly hears of professionals actively seeking mental health care jobs in the state.
But the foremost question, Duda said, is whether this is the kind of bed space the state needs.
He and others point out that the vast majority of people who end up in an emergency room with a mental health issue are in need of short-term, crisis treatment.
“These are not people you need to displace from their communities and their families,” Duda said, “and take down to Charlotte or one of the other three hospitals” – hospitals that are intended for those with longer-term needs.”
“If you’re worried about bed capacity, it makes sense to look toward making some solutions happen in the community and hoping you can bring those beds online in places where you already have standing facilities and you have efficiencies and economies of scale,” he said.
Bottom line, Laurie Coker and other advocates asked, is this the investment North Carolina taxpayers need to be making?
The legislative mental health subcommittee wrote in April that easier access to the level of psychiatric care currently provided by the state-operated hospital system should improve treatment for some of the state’s most vulnerable residents.
“The needs of individuals served in these hospitals are complicated and multi-faceted,” the report states. “They are individuals who typically have chronic, severe and treatment refractory illnesses and community hospitals consistently make clinical decisions that they cannot provide the care needed by the individual.”
But Stratas said the state doesn’t know enough about what the needs of North Carolinians living with mental illness actually are. The state’s record of tracking data on those needs, he said, “is just terrible.”
“Who will this hospital serve?” Stratas asked. He doesn’t believe data exists to adequately answer that question.
Increased capacity in the state-operated psychiatric hospital system would “ensure more timely treatment for people with the greatest psychiatric needs who currently experience significant delays,” the legislative report stated. “This coupled with comprehensive care in the community upon discharge from the hospital would offer the support people need to lead the fullest life possible.”
But, as Coker pointed out, community-based care is grossly underfunded, and prioritizing an investment in a hospital runs counter to the Olmstead decision.
“We spent so much time in the past 10 years redefining what we need to do in our communities,” Duda said, “and to then go and put down a big chunk of money on a new facility … You have to wonder: Are we really going to be serving people in the least restrictive environment, as required by the Olmstead ruling?”