neon emergency room sign
Many hospital managers worry that too many patients use their emergency departments for routine care, at greater cost to the their institutions and the health care system. Credit: KOMU News, flickr creative commons

Reports from around the state show success in some mental health programs but there are still many barriers to getting people the services they need.

By Rose Hoban

A 50-year-old man sits continuously in an emergency department for 80 days after attempting suicide. A 4-year-old child with psychiatric problems is left in a different emergency department by her foster parents. On one day, WakeMed Hospital’s 80-bed emergency department has 100 mental health patients waiting for care.

neon emergency room sign
Many hospital managers worry that too many patients use their emergency departments for psychiatric care, at greater cost to the their institutions and the health care system. Image courtesy KOMU News, flickr creative commons

These were some of the episodes presented to state legislators during last week’s meeting of the Joint Legislative Oversight Committee on Health and Human Services, the first since last month’s election.

A stream of presenters emphasized North Carolina’s glaring needs for improvement in mental health services, as well as some small successes that they argued are helping chip away at the  longstanding problem of psychiatric patients appearing at emergency department doors because they have nowhere else to go.

“There are many different mechanisms of how somebody ends up in an emergency department in a mental health crisis,” said Julia Wacker, a social worker who develops behavioral health policy for the North Carolina Hospital Association. “Overall, it is a deeply flawed system and we are not doing a good job of truly assessing what the real needs are of people up front.”

She also noted that from 2012 to 2015 North Carolina was only one of three states to decrease behavioral health spending each year, “culminating in the loss of hundreds of millions of dollars.” And she said North Carolina currently has fewer beds per capita than in the 1850s, “before Dorothea Dix began advocating for the needs of the mentally ill.”

Small victories

In the 2015 state budget, lawmakers targeted $225,000 for a pilot program that provides extra training for paramedics on dealing with people in mental health crisis. The initiative is geared towards helping people who are suicidal, hallucinating or having other mental health symptoms to either resolve their issues at home or be taken to a more appropriate behavioral health center.

A trip to the emergency department is only a last resort  for patients evaluated by paramedics in the program.

Psychiatrist Venkata Jonnalagadda from the state Division of Mental Health, Developmental Disabilities and Substance Abuse Services told lawmakers that more than 800 patients in eight communities around North Carolina were either treated on the scene or transported to a more appropriate treatment center, other than a emergency department, at a savings of about $150,000.

“It’s a joy to present something that’s positive,” Jonnalagadda told the panel.

Disability status of individuals who were diverted from the Emergency Dept, 2015.
Disability status of individuals who were diverted from the Emergency Dept, 2015. Data and table courtesy: NC DMHDDSAS

Close to 500 of those patients were in Wake County, where the pilot has been running the longest and which has the largest population of the eight locations. In contrast, the Halifax County Emergency Management Services was able to divert only four patients in one year.

“Halifax, as a rural community, has much fewer resources,” in the form of crisis centers, detox centers and non-hospital mental health crisis facilities, Jonnalagadda said in response to a question from a lawmaker.

Despite the spottiness of the program’s successes, Jonnalagadda was upbeat about expanding the strategy to more communities.

“Consumers who would have been seen in the emergency department were successfully diverted to a more appropriate level of care that was beneficial for their health, their safety and their choice,” she said.

Need for crisis prevention, response

However, much of the news from the state’s mental health system is less upbeat, where in the 2016 fiscal year that ended June 30, the average waiting time for a bed in one of North Carolina’s three psychiatric facilities was about five days.

North Carolina is falling behind in the national statistics, Wacker told lawmakers.

“We were on par with national trends until about 10 years ago. We now have half the number of beds per resident than the national average and we are ranked 44th in terms of beds,” she said. “Only about 35 percent of North Carolina hospitals have a psychiatric unit.”

And Wacker said there’s anecdotal evidence that the mental health crisis that drives people to emergency departments is contributing to the risk of rural hospitals closing.

“Hospitals are experiencing tremendous staffing turnover because of this,” Wacker said.  “One of the rural hospitals out west told me that of the 12 nurses that … work in the emergency department, he’s losing about three of them a week because of the behavioral health crises in the EDs.”

“We don’t have the right services in the right places for the people who need them,” Jonnalagadda concurred, admitting that the emergency department diversion pilot didn’t work as well in rural counties as in urban.

Wacker suggested that lawmakers appropriate dollars to beef up crisis response, as done in other states, such as Texas, New York and Arizona.

“[They] have a fairly robust crisis response system where they’re doing things like… having mental health professionals embedded in the emergency management systems and with first responders, doing assessments in the homes… finding the services that are available to connect people to in the community,” Wacker said.

She also called for more robust case management services, creation of more transitional or “step-down” type care for people who are leaving hospitals, and support for the creation of more mental health courts across the state. Mental health courts aim to help prevent or treat people’s problems before things spin out of control.

“We have a ‘crisis-based’ mental health system,” she said. “But it’s an ineffective crisis-based mental health system.”

“We need to do something to get this fixed,” said Rep. Donny Lambeth (R-Winston-Salem), after hearing the presenters. He said he’d like to tackle some of the budget obstacles in the coming long legislative session that begins in January.

Task force priorities

Many of the fixes listed by Wacker and Jonnalagadda were in line with recommendations from a report issued last year from the Governor’s Task Force on Mental Health and Substance Use.

In last year’s budget, the General Assembly allocated $20 million out of the $30 million requested for the Task Force priorities.

While she said having the extra money was helpful, Jonnalagadda also said the money was a “drop in the pan.”

“Mental health supersedes cancer now, substance abuse supersedes cancer,” she said. “I appreciate the advocacy, but it’s just a beginning.”

Lawmakers also heard from Adam Zolotor, head of  the North Carolina Institute of Medicine, which just wrapped up its own mental health task force, which made 30 recommendations which emphasized preventive services.

“There are so many opportunities to intervene, but we’re always so busy putting out the fires,” Zolotor said.

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...