This past legislative season, lawmakers introduced a bill proposing to build a fourth state-operated psychiatric hospital. It didn’t make it out of the House of Representatives Appropriations Committee, but supporters have vowed to bring it back next session.
The third of a three-part series on legislation regarding hospital-based psychiatric care.
By Taylor Sisk
Even as lawmakers continue to support building a new state psychiatric hospital, some of the state’s mental health care advocates and analysts are suggesting alternatives.
Two options they propose are three-way contracts that fund psychiatric beds in local hospitals throughout the state, and investment in smaller facilities, some of which are eligible for federal funding.
A third option is increased investment in outpatient community-based services such as peer support and employment assistance.
“We feel that before building another brick-and-mortar [hospital], the state really needs to focus on building a community-based infrastructure,” said Vicki Smith, executive director of Disability Rights North Carolina.
All the above alternatives, said Raleigh psychiatrist and former state mental health official Nicholas Stratas, “make a heck of a lot of sense.”
Smaller facilities
A provision of Medicaid law stipulates that inpatient psychiatric facilities with more than 16 beds are not eligible for matching funds for anyone between the ages of 21 and 65.
In communities where they’ve been built, these smaller facilities have been well received by local governments.
WakeBrook is a small crisis-care center in Raleigh operated by UNC Health Care, and is preparing to open a new 16-bed facility.
“In short, I can say that WakeBrook has worked wonders for Wake County,” said Ramon Rojano, the county’s Department of Human Services director. “This is one of the best things that ever happened for our mental health system.”
WakeBrook focuses on short-term interventions for people in mental health crisis. It was designed, Rojano said, to prevent longer stays in state hospitals for those who “could be served as part of a local community mental health structure.”
But when asked about the prospect of the state investing in facilities with 16 beds or fewer that could be federally funded, Rep. Justin Burr (R-Albemarle) disparaged the practice of creating programs “just to draw down federal dollars.”
“I think it’s got to be a two-pronged approach,” Burr said: more state-operated hospital psychiatric beds and more beds within community facilities.
Burr co-sponsored the bill to build a fourth state psychiatric hospital, which he proposed be built in his district. He said he’d like to see the bill revived in next year’s short session.
Limits of three-way beds
Three-way contracts between hospitals, the state government and local management entities (now called managed care organizations, or MCOs) that fund psychiatric beds in local hospitals have shown some success for patients with short-term needs. With more of them, beds are freed up in state-run hospitals for patients in need of longer-term care.
Marvin Swartz, head of Duke University’s Social and Community Psychiatry Division, wrote in a recent report that care in a hospital closer to home is a more “normalizing experience and one that carries less stigma.”
But the problem with the three-way beds, Smith said, is that they’re not always within the patient’s community; people must sometimes travel even farther from their homes than the closest psychiatric hospital.
“So [the program is] good in theory,” Smith said. “But like everything, it needs some attention in terms of implementation.”
The availability of staff trained to work with mental health patients in those beds has been another issue.
A report released by the N.C. Center for Public Policy Research (NCCPPR) last December recommended that the state Department of Health and Human Services require state psychiatric hospitals to open their training programs to local hospitals participating in the three-way contract program.
“Calling on the state to train non-state folks is ill-advised,” countered Swartz.
“The state has very limited training capacity and is already well beyond its capacity for training…. There needs to be a serious investment in workforce training, but not by the state.”
Community-based services
Grassroots advocates and policy analysts alike have said that developing a solid continuum of care – between inpatient and outpatient care and across a range of community-based services – and providing the necessary funding is the only answer to the state’s mental health care crisis.
“I think you can say there’s a crisis in North Carolina around mental health care; there has been for some time,” said the NCCPPR’s Aisander Duda. “There’ve been failures in terms of providing the community capacity.”
The objective of an effective mental health care system, he said, is to determine the appropriate level of care for each individual, preempting fluctuations in and out of crisis.
“But it’s hard to do that when the state continually changes direction, which it’s done for the past 10 years, essentially,” Duda said.
Sometimes reforms come by mandate.
Smith said that the state’s settlement with the federal Department of Justice regarding community-based care will require the state to deliver more services that help provide stability for those living with mental illness.
“If you look at the DOJ settlement the state entered into last year, it gives you a good idea of the building blocks” for a more effective system, Smith said.
In addition to more housing options, the agreement calls for an investment in job training, employment assistance and 24-hour crisis care.
Supported employment, Smith said, is another critical need: “Work is really the foundation of community integration.”
Mental health professionals also recognize the importance of connecting the dots on mental and physical health care.
In Minnesota, the state’s Department of Human Services launched an initiative, called MN 10 by 10, in response to research that indicates that those with a serious mental illness die 25 years younger, on average, than the general public. A primary reason is that they fail to get screened for heart disease, diabetes, cancer and more.
The state formed a working group with the goal of increasing the average lifespan of Minnesotans with bipolar disorder or schizophrenia by 10 years within 10 years.
Lost hope
More change is ahead in the state’s mental health care system – both by choice and by force.
Gov. Pat McCrory has called for an overhaul of Medicaid in which new comprehensive care entities will be tasked to integrate primary care and mental health services.
And the state will continue to respond to the mandates set in the Department of Justice settlement.
Laurie Coker, executive director of the North Carolina Consumer Advocacy, Networking, and Support Organization, suggested that “transformational changes” are imminent, to a large extent driven by the DOJ settlement.
Both she and Smith questioned how a new psychiatric hospital fits into the plan mapped out in the agreement.
Smith said she believes that if the state were to announce that it’s investing in a new hospital, “The Department of Justice would be here, probably, saying once again you’re investing in the institutional side of the equation and not adequately funding the community side.
“And even if the DOJ wasn’t here, Disability Rights would have no choice but to file an Olmstead claim, because the community system is inadequately funded at this time.”
“There is nothing we’re doing in terms of mental health treatment that really is geared toward … keeping people with behavioral-health needs out of emergency rooms and restrictive settings,” Smith said.
The state’s mental health care system is causing people to lose hope, Coker said. “Family members often don’t believe their loved ones can recover.”
That’s why she’s working with others to develop an agenda for a “recovery-oriented” system, which has included opening a peer-support center in Winston-Salem.
She’s hoping to see more “self-help environments” springing up across the state. It’s in recovery, Coker said, not institutionalization, that the state should be investing.
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One of the things that we keep leaving out of the picture is community-based treatment. As services expanded under mental health reform, we dismantled psychosocial treatment options in favor of services. We don’t have the right balance. Yes, peer support and employment services are important. But you need to treat mental illness in the community, not just in crisis centers and in psychiatric hospitals, in order for people to be ready for employment and full community inclusion. Our short-sighted focus on short term treatment leading to long-term recovery has missed some really key aspects of what it’s like to live with a severe mental illness. Interestingly, there is proposed federal legislation to create community behavioral health care centers, similar to federally qualified health centers. What does that sound like? the old community mental health centers?