A confluence of events in late January led to dozens of mental health patients waiting for days in WakeMed’s emergency department and forced the hospital to turn some away.

By Rose Hoban

No one is exactly sure why, but the last week of January was a tough one for folks in Wake County with mental health issues.

So many people ended up walking into, or being brought to, Wake County facilities looking for psychiatric help that they filled up.

WakeBrook, the five-year-old mental health facility on Sunnybrook Road on the east side of Raleigh, was full of patients. Across the street, Holly Hill, the private psychiatric hospital, was also at capacity. Both facilities placed themselves on “diversion,” meaning they’d tell someone showing up at their doors to go elsewhere. That elsewhere usually meant WakeMed hospital’s emergency department, less than a mile away.

That week, WakeMed’s emergency department also had a steady influx of patients arriving in “crisis.”

WakeMed spokeswoman Kristin Kelly Gruman said that on Friday, Jan. 30, the emergency department was not uncommonly busy. She also said that it wasn’t unusual to have dozens of potential mental health patients sitting on gurneys in hallways or in holding rooms waiting for a psychiatric bed.

“On any given day, we may have anywhere from 25 and 50 patients in our halls for mental illness,” Kelly Gruman said by phone that Friday. But she checked and found that her ED hadn’t had an uncommon influx of patients – yet.

By Saturday, Jan. 31, the situation worsened, when 10 more people arrived at WakeMed. Some were brought by family members or police. Some walked in.

“Mostly, the folks in the emergency department weren’t people brought there through law enforcement, they actually came in on their own,” said Dave Richard, state Department of Health and Human Services’ Assistant Secretary for Mental Health, Developmental Disabilities and Substance Abuse Services. “Then they were involuntarily committed while they were in the emergency department,” which means they couldn’t leave even if they were feeling better.

On Sunday, Feb. 1, another nine people showed up at WakeMed, according to Sean Schreiber, chief clinical officer at Alliance, the mental health managed care agency that oversees Wake County.

Another seven or eight people showed up on Monday, but about 10 people were discharged.

At its most crowded, WakeMed’s ED had 62 people waiting for a psychiatric bed or other psychiatric services. When case workers from Alliance arrived on Monday, WakeMed’s ED was also on diversion.

At that point, there was nowhere for a person in Wake County in mental health crisis to go.

Stubborn problem

This problem isn’t new, said Burt Johnson, head of the N.C. Psychiatric Association, and, he added, it won’t soon be resolved.

As the state embarked on a mental health reform effort in the early 2000s, the theory was that the state could reduce the number of psychiatric hospital beds, saving some $51 million per year. That money was supposed to be plowed back into treating mental health patients in local community-based services.

But the community services never materialized. Immediately after Gov. Mike Easley signed the 2001 state budget that set aside $41.5 million for a trust fund to build community mental health services, he reclaimed $37 million of that money to help cover the state’s shortfall.

Years of subsequent cuts and near-constant change in the mental health system has resulted in too few beds, especially for people in crisis.

“You can’t keep cutting state services and expect this problem not to show up,” said Rob Robinson, Alliance’s CEO. “We’ve had a funding cut each year of the past six and we’re starting to see the results of that.”

The result is a shortage of publicly funded psychiatric beds. According to the Washington D.C.-based Treatment Advocacy Center, North Carolina dropped from 1,461 psychiatric beds in 2005 to 761 beds in 2010, or eight beds per 100,000 state residents.

TAC ranked North Carolina 44th in the nation in public beds per capita. There’s also a shortage of privately funded beds.

In Dec. 2014 (the most recent month with available data), patients around the state waited for an average of 75 hours for an admission to a state psychiatric facility or a bed paid for by state dollars in a community hospital, according to DHHS statistics.

A 2008 report issued by the U.S. Dept. of Health and Human Services found that such boarding of psychiatric patients in EDs “often creates an environment in which a psychiatric patient slowly deteriorates.”

Of the people waiting at WakeMed, 20 had either private insurance or Medicare, 18 were uninsured and the rest were “dual-eligibles,” people who qualify for Medicaid because they have a low income and also qualify for Medicare, usually because they have a disability. Those who are dual-eligible are particularly hard to place because in addition to their psychiatric condition they have profound needs stemming from their disabilities.

There are even fewer beds for dual-eligibles in North Carolina than for others with mental health issues.

Johnson said providers are impatient to see some resolution.

“It’s inhumane and immoral,” he said. “It’s something patients from any other specialty do not have to undergo. There’s an entirely different degree of indignity that psychiatric patients have to deal with.”

Scramble for beds

Each person’s crisis can appear different. Often it’s a need for detoxification from drugs or alcohol, sometimes it’s depression so profound that a person considers suicide. It could be a recurrence of symptoms, such as hearing voices, that require finding the person a safe place.

But the search for a bed can be frustrating. Schreiber said his agency has care coordinators at WakeMed who spend most of their time searching the state for a bed for psychiatric patients waiting in the hallways. “You call every hospital to see if they have open beds and then send information,” he said. Just finding a bed can take hours of calling and faxing, and that bed might then be located hours away.

“The receiving hospital has to determine if they have the right expertise to serve the patient,” Schreiber said. “They also will make sure that the acuity on their unit won’t be too high.”

He said hospitals might refuse people with special needs or who may be too aggressive.

In addition to Alliance’s two care coordinators who work Monday through Friday, the agency sent extra personnel to help get the patients still there on Monday discharged.

Some of the patients still waiting at WakeMed Monday were cleared to go home after being assessed by a psychiatrist, Schreiber said. “Once they’re cleared to be discharged back home, care coordinators make referrals to providers or we schedule appointments for people in the community.”

He said Alliance is now considering having a care coordinator at WakeMed on weekends too, to avoid a repeat situation.

Richard said he understands providers’ and patients’ frustration. He pointed to his department’s ongoing initiative to address the shortage of psychiatric crisis services.

“The issue is complex; there are no easy fixes,” he said. “The best fix is to continue to develop the kinds of community-based programs that will allow for people to go to places other than emergency departments when they have a mental health crisis, and do everything we can to keep people out of crisis.”

Richard has convened providers, mental health patients and advocates to address the problem.

Meanwhile, the state has been compelled by the U.S Department of Justice to create housing for people with mental health problems. And there’s some new energy and momentum around interventions such as crisis hotlines, peer-support services and recovery-oriented mental health care.

“We have all the right people at the table,” Richard said. “But there’s not any one thing that will solve this problem right away.”

Cover photo courtesy Paul Joseph Rio Daza, flickr creative commons

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