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Mental Health Musical Chairs
Published Tuesday, October 9, 2012
by Erika Cohen

They are six people who may change the way the state funds mental health care.

Six people with serious mental illnesses who have cycled in and out of psychiatric hospitals because of a dearth of community support.

Mental health care in NH has become a game of musical chairs with few winners and many losers. Budgets are tighter, meaning fewer treatment beds. And patient numbers keep rising, meaning more people left without treatment.

Among the losers are the six people who are part of a class action lawsuit filed against NH and backed by the U.S. Department of Justice for violations under the Americans with Disabilities Act (ADA) as well as other laws requiring people to receive care in community settings when possible to avoid needless institutionalization.

The lawsuit details the plights faced by these six. One is a 45-year-old Rochester man whose wife was forced to sell their home “while he languished” at NH Hospital in Concord for lack of community services, according to the lawsuit. Another, a 54-year-old Danville woman, wants to return to her family and work, but remains institutionalized for lack of community treatment. And a third litigant is a 22-year-old Newport woman who has been hospitalized 20 times at NH Hospital in 10 years, but can’t access crisis intervention services, supported employment, or supported housing in her community.

All of this sheds light on a confounding and universal problem: The mismanagement of state resources. While it costs about $800 per day for treatment at NH Hospital, it’s less than $200 per day at a community mental health center. But with local resources strained, many in need are given only one option: NH Hospital.

And it’s not like the state hospital has plenty of room. The wait for a bed at NH Hospital, the state’s only psychiatric hospital, is often days, and those waiting stay in windowless emergency rooms occasionally requiring security if the patients get agitated. As many of those lack insurance or are insured by Medicaid (which pays below cost according to mental health providers), they rack up thousands of dollars in care. While the state hospital is a 202-bed facility and wait times for a bed vary, it is not uncommon for a dozen people to wait at Concord Hospital on a weekend hoping a bed at NH Hospital will open.

“The multiplier effect has landed on the community as a whole,” says Dennis MaKay, CEO of Northern Human Services in Conway, one of 10 community mental health centers statewide. Not only have budget cuts forced the closing of community residential treatment programs and staff reductions, but also Medicaid reimbursement rates have dropped. “We’re bounding toward a crisis,” he says.


An Unstable Situation

In April 2011, the U.S. Department of Justice issued a report finding the state had violated the ADA, requiring those with disabilities receive services in the most integrated setting possible. The report included the following line:

“The State acknowledges, and we agree, that there are serious ‘unmet needs’ and ‘weaknesses’ in the state’s mental health system that contribute to negative outcomes for persons with mental illness, such as day-to-day harm associated with improperly and/or under-treated mental health conditions, needless visits to local hospital emergency departments, needless admissions to institutional settings like NH Hospital and Glencliff [a state nursing home], and the serious incidents that prompt involvement with law enforcement, the correctional system and the court system.”

In a follow-up letter eight months later, the Department of Justice (DOJ) rejected the state’s response that NH was in compliance. In that letter, the DOJ noted that “New Hampshire is spending about as much to serve 5 percent of people with mental illness in NH Hospital as it spends to serve the entire remaining 95 percent in the community … the State could roughly serve six people in the community for each person it serves at NH Hospital.” The letter went on to say NH’s reliance on short institutional stays and psychiatric hospital admissions costs 40 percent more than the national average and reflects a lack of community services.

As a result, the state began shifting mental health dollars. The state hospital’s budget was cut about $21 million during the most recent budget cycle while 10 community health centers gained $7 million. Community Mental Health Centers received $98 million in direct appropriations for FY2013, up from $91 million.

The community mental health centers and the NH Disabilities Rights Commission charge that the state has not made progress on the 10-year mental health plan issued in 2008, designed to meet critical mental health needs.

Compounding the mental health centers’ challenges are the Medicaid cuts, which have resulted in 44 fewer beds and longer wait times for non-
critical care. 

“For most of the priorities, we had a back slide,” says Jay Couture, the president of the NH Community Behavioral Mental Health Association and executive director of the Seacoast Mental Health Center. “Across the state community hospitals have reduced or closed psychiatric wards, and mental health centers have closed group homes because there wasn’t adequate funding to sustain them.” The one improvement she notes is that there were 36 people with mental illnesses who received a housing subsidy until subsidized housing units were available.

Balancing Needs and Budgets

In the ongoing game of musical chairs—or musical beds—the state faces two opposing realities. The first is patient need; the second, funding.

While the state falls short, and violates the law, in institutionalizing those with the right to be served in the community, it must also provide institutional care for those who are a danger to themselves and others. “The demand for acute inpatient services and the demand for community-based services are exceeded by the resources that are available to them. The broader question is are we allocating funds over the whole system as we should?” says Steve Norton, executive director of the NH Center for Public Policy Studies and former head of NH’s Medicaid program.

Nancy Rollins, associate commissioner of the NH Department of Health and Human Services, could not comment on anything related to the lawsuit, but says the state has “continued to work with partners relative to obtaining additional support from a variety of services including the Centers for Medicare and Medicaid Services” to provide more community services. She says NH recently received a four-year $26 million federal grant to re-balance community and institutional care and provide better settings for care.

For their part, mental health advocates and providers say the state is not allocating funding as it should.

If a person has an emergency on a Saturday, Riverbend Community Mental Health in Concord provides an Assertive Community Treatment (ACT) team to give comprehensive, community-based treatment. However, if the emergency happens after 9 p.m. or on a Sunday, the only option for patients becomes emergency rooms, as Riverbend doesn’t have the money to staff the entire weekend.

Louis Josephson, president and CEO of Riverbend and vice president for behavioral health at Concord Hospital, says the psychiatric department of the emergency room has four secure rooms and two swing rooms, and they are often all full. He says if all 10 community mental health centers had a fully funded 24/7 ACT team, many more people could be treated in the community. Unfortunately, only five centers have them.

The cost of emergency room care is enormous for local hospitals. Not only are most patients either uninsured or on Medicaid, but hospitals can bill only a one-time charge regardless of how long patients use their facility. The result is $1 million a year in uncompensated care or more than double what it was only three or four years ago, Josephson says.

Amy Messer, legal director for the NH Disabilities Rights Center, points out the $130 million the state budgeted for NH Hospital for the 2012-2013 biennium serves about 2,300 people while the $195 million for the 10 community mental health centers serves about 50,000 people. And the state receives matching funds for each $1 spent on community-based services, but not for inpatient services. So why, she asks, wouldn’t the state put their funds into the community pot? 

Messer adds providing services to people in the wrong setting has broader economic implications. “People with serious mental illness can be and are very productive members of the workforce,” Messer says. “But when services are unavailable, it is often difficult for them to obtain housing and maintain employment. There is a large cost to not providing the kind of supports people need to engage actively in the workforce.” And when people are hospitalized, family members lose work time and productivity accessing treatment for them and visiting them, she says.

In some cases, those who don’t receive care end up in the court system, and then possibly in prison. “It is not uncommon for us to see people coming into prison for some low-level non-violent crime where a mental health issue put them in that circumstance,” says Jeff Lyons, spokesman for the NH Department of Corrections. As of June 2012, 25 percent of male prisoners and 65 percent of female prisoners have a diagnosed mental health issue. It costs about $34,000 to incarcerate a person for one year—significantly more than it would cost to treat mental health  issues before they led to crime.

As to the question about allocating resources: NH will need to make changes to comply with federal standards. But even with more and better community support, some people will still require hospitalization. Meanwhile, the number seeking community-based care is expected to grow beyond the 50,000 people now served, according to Couture of the Community Behavioral Health Association. So that leaves legislators and providers with the task of ensuring that those on the sideline receive the minimal services they need and are afforded by law—even if it is not the ideal way to provide those services.

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