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Wednesday, 23 January 2008 00:00

The search for solutions: HRMC steps up to help fix mental health care

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By Julia Merchant • Staff Writer

Emergency rooms crowded with mentally ill patients. Sheriff’s deputies spending 96 hours supervising one individual. A sick man or woman whose situation is growing more dire by the second. It all adds up to a recipe for disaster — and North Carolina’s mental health care system is in imminent danger of becoming just that.

At the root of the state’s mental health care crisis is a severe shortage of places to put sick patients. With the scaling back of staff at Broughton Hospital in Morganton, there are no longer enough professionals to watch over mentally ill individuals. As a result, patients from the western part of the state must compete for a limited number of beds — and until one is freed up, they have no choice but to wait. And wait. And wait ...

“It’s a complex problem, but the bottom line is, there’s more demand for hospital beds in our region than there are hospital beds that exist to treat people with mental illness,” explains Tom McDevitt, area director for Smoky Mountain Center for Mental Health, a local management entity that is in charge of placing patients at hospitals around the state.

Some of the crowd going into Broughton could be alleviated if there was another, closer, place to take patients. But in the seven counties west of Asheville, “there are absolutely zero psychiatric beds available,” McDevitt says.

That wasn’t always the case. Fourteen years ago, Smoky Mountain Center operated the Amelia psychiatric ward on the third floor of Angel hospital in Franklin.

“The irony was that it closed down because there wasn’t enough demand for it. A 23-bed unit had gone down to four (patients) a day,” McDevitt said. “Fourteen years later, we’ve come full circle and the state hospitals are full and we don’t have those community resources.”

Mental health professionals didn’t foresee the circumstances that have been dealt to them in recent years. The number of patients increased, state hospitals suffered staff cutbacks, and the focus moved to outpatient, rather than inpatient, care — causing psychiatric wards in hospitals statewide to shut down in favor of moving care to outside sources, like outpatient therapy.

It hasn’t been easy to get hospitals to step back up to the plate. Operating a psychiatric ward often comes as a loss to the hospital. This is because a majority of mentally ill who need treatment — some 80 percent — are indigent, meaning they don’t have insurance at all. Funding for indigents is severely lacking at a state level, and hospitals must pick up that shortfall at a cost to them.

But now there may be a solution that would keep hospitals from losing money. A $1.2 million grant is being awarded to four community hospitals in North Carolina to allow them to open a psychiatric ward. One of those hospitals is Haywood Regional Medical Center, set to open a 16-bed facility in July.

David Rice, CEO of HRMC, played a crucial role in the idea for the $1.2 million grants. A year and a half ago, Rice (who is now the chair) and other members of the North Carolina Hospital Association came together to try and figure out a fix to the growing mental health crisis.

“Fifteen hospital administrators came to the table and started discussing this concern, that the mental healthcare system was not working well at all,” Rice says.

Rice and others agreed that a solution should be a state-driven process and sent letters to the state seeking help. Frequent turnover in the Department of Health and Human Services meant that response time was slow. Finally, Secretary Dempsey Benson was selected to head up the department.

“He admitted the mental health system is broken. Finally, somebody admitted we needed someone in the government working on the system,” Rice said.

State Sen. Martin Nesbitt (D-Asheville) was the only state legislator to come forward with a plan.

The plan was this — take an organization intimately involved in the mental health care system, like Smoky Mountain Center, that could bring experience and expertise in dealing with the issue to the table. Pair them with a local hospital — in this case, HRMC — that could provide the bed space. Give them 18 months and $1.2 million and see if the two can provide a solution.

HRMC stepped up to take on the challenge for several reasons. For one, Rice thought it was important for him as chair of the board to set an example.

“I felt if I’m going to talk about it as chairman of the board, it would certainly be important to take a leadership role,” Rice remembers.

HRMC also had the space. A sixth floor restorative care unit had recently closed due to lack of demand.

The hospital had another crucial factor — a strong working relationship with Smoky Mountain Center. That’s not always the case in other communities with the local mental health management entity.

“A lot of those organizations do not function well throughout the state. Some failed and one went belly up financially, but we maintained a good relationship with Smoky Mountain and felt we could make the model work,” Rice says.

Rice figured the psychiatric unit had a better chance of succeeding if partnered with an organization with experience in mental health care.

“The structure in these LME’s (local management entity) already exists. I just personally felt it would create a very high risk to start from scratch with no background in mental health services,” he said. “You partner with somebody that knows the business.”

The HRMC hospital board was apprehensive. They didn’t want the facility to lose money on the endeavor — a danger hospitals face in mental health care.

“The board asked many, many questions, because this is a difficult service line for a hospital, for a number of reasons. The funding process in the past had been so poor that it’s very difficult to develop a functioning financial model,” said Rice.

“Financial models drive care,” agreed Sheila Price, chief nursing executive for WestCare.

 

New beds at HRMC

Finally, the hospital board agreed to the project. Smoky Mountain Center is hoping the 16-bed facility will help divert a majority of indigent patients that would have otherwise been headed to Broughton — all but the most severe cases. Smoky Mountain has the responsibility of paying for the indigent patients.

“The goal is to divert 70 percent of the people from Broughton, with Smoky Mountain agreeing to be a funding source for that,” says Doug Trantham, director of clinical services for Smoky Mountain.

“We feel once these units are opened and fully staffed and operating, 75 to 80 percent of the people that are leaving our area will be able to receive hospital care locally and with no delay,” McDevitt said.

Keeping care close to home is a crucial part of treating a mental illness, says Rice.

“Often these patients need the support of their family and when you send them off to Broughton and the Raleigh area, that relationship is interrupted and most of those families can’t afford to drive that distance. They can’t be there when they’re needed,” Rice explained.

The project isn’t without obstacles. A major hindrance to successful psychiatric units is staffing. Psychiatric care providers are hard to come by anywhere, and it’s even more difficult to find them in the rural mountain region, where pay is lower.

Trantham said the facility will need “at least a couple of psychiatrists to run the unit and in the neighborhood of 10 psychiatric nurses for the program.”

“It’s going to be tough, but we didn’t think we could staff the Balsam Center either,” he said. The Balsam Center for Hope and Recovery is a limited psychiatric care facility in Haywood County and the only such place in the region to take patients.

McDevitt said that if staffing was easier, a psychiatric facility would have already opened.

“I think we’d have a psychiatric unit out of Murphy if it were a matter that we were able to recruit in that rural area. That hospital was willing to be a solution for years, but you need to deal with the reality of the workforce you have,” he said.

McDevitt said he thinks HRMC likely has the best chance in the region of attracting staff because of its proximity to the Asheville and Buncombe County area.

 

Relieving the pressure

Those involved in the project are hopeful.

“We think this is going to be the most profound step of fixing mental health reform that has taken place,” said McDevitt.

“I think this model has more merit than anything we’ve looked at before,” Rice agreed.

Trantham admits that though the psychiatric facility isn’t the final solution to the mental health care crisis, at least it’s a start.

“It’s a giant leap forward. It’s not a total solution, but it’s certainly a big step,” he said.

If the project is successful, it could serve as a model across the state, and in turn serve as a larger step toward solving the crisis.

“What we’re doing is a demonstration that can be part of the solution. If other community hospitals in other regions in the West would emulate what we’re doing, eventually they would really be able to downsize Broughton and they would move care closer to the community where it needs to be,” McDevitt said.

The facility should at the very least help meet the needs of the western part of the state.

“The 16-bed unit, based on our analysis, will be more than enough capacity to meet our needs and we’ll be able to take some referrals from the east to keep it busy,” Trantham said.

“We think we could do more with more money and more facilities, but we think these two facilities are going to take care of most all of our needs,” McDevitt agreed.

Not everyone agrees that the psychiatric facility will sufficiently meet the needs of WNC. Haywood County Sheriff Tom Alexander voiced his doubts.

“If every county in the 12-county area (where patients will be drawn from) does one (patient) a day, which some do and some don’t, it will be filled in one day. What happens the second day if you do another one?” Alexander asked.

“Anything will help,” he admitted — “it can’t do anything but help, and I think everybody is trying to be proactive about it and ease the problem for everybody, but Raleigh is going to have to do something else,” he said.

 

Patients needed

The continuation beyond 18 months of HRMC’s program is contingent upon being able to divert the number of patients that would have gone to Broughton to the psychiatric facility. That being said, Rice is optimistic in Sen. Nesbitt’s willingness to be flexible in the first year of the program.

“I think Sen. Nesbitt’s willingness to let us alter and massage this program as we go is very important, knowing we probably don’t have the perfect model but that the state is willing to work with us,” he said. “I think we’ll go a long way to solving the problem over the next year or two.”

When asked, hypothetically, what would be the next step if the program failed to meet criteria, Rice grew serious. Failure isn’t an option, he said.

“We cannot allow that to happen. We’ve got to make this work.”

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