Often, patients who are readmitted after being sent home from the hospital return through the emergency room. Photo shows nurses rushing a patient on a gurney into a doorway.
Often, patients who are readmitted after being sent home from the hospital return through the emergency room. Image courtesy Trust for America's Health

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<p>Psychiatric patients languish in hospital emergency rooms all over the state. Will it get better?

By Rose Hoban

During the first week in May, the emergency department at WakeMed in Raleigh went on diversion, meaning it could accept no more patients. Beds were completely full downstairs in the emergency department. On the upstairs floors of the hospital, administrators scrambled to discharge patients to make space for the folks crowded below.

In all, about 100 mental health patients stayed on beds, chairs and gurneys scattered in the ED, as well as in beds around the hospital. They were stuck there, all waiting for an opening in a psychiatric facility, some place that would be more appropriate for them.

At UNC, during the same time period, there were several dozen patients in the same situation, according to multiple sources; a handful were children.

And the problem wasn’t just isolated to the Triangle. According to Mike Stevenson, CEO at Murphy Medical Center in far west Cherokee County, their ED has also been socked in of late with psychiatric patients.

“It’s gotten worse,” said Stevenson, who said long distance from state psychiatric facilities is an exacerbating factor. “But the single biggest factor is the lack of available beds.”

While the situation reached a crisis point at the beginning of the month, data show that even with efforts by the state Department of Health and Human Services and willingness from Gov. Pat McCrory and lawmakers in Raleigh, wait times for care in North Carolina’s public psychiatric hospitals has remained stubbornly high.

Through the end of March, waits to get into Broughton, Central Regional and Cherry hospitals have averaged 92.8 hours – just under four days – for the 3,827 people who looked for emergency admission since last July (see below).

Small steps

In his budget proposal for the coming year, McCrory asked the General Assembly for about $30 million to address some pressing mental health needs: $13 million for case management for people with complex mental health issues, $9 million for substance-use treatment initiatives, $5 million for therapeutic courts and $3 million for transitional housing for people with mental health issues coming out of psychiatric hospitals and prisons.

Gov. Pat McCrory speaks to the Task Force on Mental Health and Substance Use in January 2016. The task force recommendations included $30 million for mental health services. Also pictured, N.C. Supreme Court Chief Justice Mark Martin, who leads the task force, and psychiatrist Al Mooney. Photo credit: Rose Hoban

Most of the governor’s requests made it into the final House budget, passed last week, and $60 million in cuts to local mental health management entities made last year were restored as well.

There’s also money from the sale of the Dorothea Dix Hospital property in Raleigh: about $49 million. Of that, the House appropriated $25 million to help pay for renovation or construction of new inpatient behavioral health beds in rural hospitals around the state.

“The challenge is the ongoing sustainment of that, because those are rural hospitals who don’t have a lot of additional capital and additional reserves,” said spokeswoman Julie Henry from the North Carolina Hospital Association.

Sitters

Henry said money to upfit beds was a good thing, but in the next breath noted that staffing and maintenance for those beds will be an ongoing issue. But those $25 million from the legislature are one-time dollars only.

“It’s not just space, it’s about hiring the staff and continuing to provide that level of care,” she said.

And reimbursements for mental health patients don’t nearly cover the costs, said Christine Craig, who works in governmental affairs for WakeMed. She noted that when a person gets sent to a room on, say, a general surgical floor to wait for an opening in a psychiatric hospital, they often have a “sitter” if there’s a concern about safety.

These sitters are usually not skilled in psychiatric care, and are there only to monitor the patient. At WakeMed, that cost about $10 million last year.

“This year, we’re trending towards $11 million,” Craig said. “And no one pays for that.”

In Murphy, Stevenson said his costs for sitters ran about a quarter-million dollars last year, a big hit for a facility with an average of 25 patients a night. And the hospital spent almost $400,000 to convert a walk-in clinic in the emergency area into a holding area for psychiatric patients.

Stevenson also expressed concern about staffing.

Wait times for North Carolina’s state-run psychiatric hospitals: July 2015-March 2016. Table courtesy NC DHHS

“It’s a small population and most people don’t want to live here. We’re two hours from everywhere,” Stevenson said. “We have one psychiatrist in three counties. He doesn’t cover inpatients.”

Residential or community

Problems getting people into psychiatric facilities ends up spilling into the judicial system, said Joe Buckner, the chief district court judge in Orange and Chatham counties.

“We’re seeing less placements that are appropriate,” Buckner said. “They are discharged and they’re not stable and then they commit some petty community nuisance, family nuisance event. The alternative is to take them back to the hospital, which quickly discharges them, and then they get rearrested because of their behavior.”

Buckner is a proponent of creating more residential treatment beds in the state.

Broughton Hospital in Morganton, one of North Carolina’s three state-managed psychiatric hospitals. Broughton is incorporating recovery principles into its treatment for patients. Photo courtesy Broughton Hospital staff

Meanwhile, his representative in Raleigh, Rep. Verla Insko (D-Chapel Hill), has been a proponent of getting more community-based programs to keep people from getting into crisis in the first place.

“UNC [Hospital] has regularly 27 or 28 patients waiting for two weeks to get into a state hospital bed,” Insko said. “Psychiatric doctors are telling me we don’t have the community-based services.”

She criticized the House budget for not putting more into the behavioral health system.

“We are really telling people who are mentally ill that we don’t have services for them,” she said. “We don’t need to talk about living in our means; we have the capacity to put money into these programs.”

Dave Richard, Department of Health and Human Services deputy secretary, said reducing those wait times will take time and that the moves the department has made over the past two years are starting to pay off.

He argued that “just throwing money” at the system wouldn’t fix it; the investments need to be strategic. He said they are.

“This is a big issue, everyone has a part,” Richard said. “Hospitals have a role to play in it, community services have a role to play in it and we’re all trying to work towards achieving the goal.

“It doesn’t happen overnight.”

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