That one night turned into eight more before a bed became available and the youth was transported to Broughton, a state psychiatric hospital in Morganton.
Although the thought of a juvenile in need of psychiatric services left languishing for more than a week in a local emergency room seems exceptional, it’s not. Across Western North Carolina, unequipped hospitals are being overrun by an increasing load of patients in need of emergency mental health services while the state resources available are rapidly disappearing.
“By default, the ER department becomes the repository for some of these individuals for days at a time,” said Jim Bross, president and CEO of Angel Medical Center. “This is not specific to Macon County; this is not specific to Franklin — the hospital leadership around the region is all sharing a similar experience.”
Because most local hospitals like Angel Medical Center are not staffed with psychiatrists or personnel to provide mental health care, Bross said providing an initial assessment and then making the patients comfortable until they can be transported to another facility is the best they can do.
At Angel Medical Center, which is prohibited from turning away patients because of its nonprofit status, it’s not uncommon to have four or five such patients at a time in the 13-bed emergency ward awaiting transport to a psychiatric facility. Meanwhile, the medical staff has to split its time between the usual emergencies such as heart attacks and car accidents and these mental health patients.
“In many cases, they consume significant resources from the ER,” Bross said. “It’s not the best place for them, not at all.”
And the strain in resources is not only felt in the health care sector. If mental health patients are involuntarily committed by a local judge — usually referred by a friend or relative who has safety concerns for that person — law enforcement becomes involved. Those patients usually pose a threat of suicide or violence, and substance abuse is often involved.
Then, sheriff’s deputies or detention guards are responsible for picking the patient up, taking them to the local emergency room, standing bedside around the clock, providing transportation when an opening appears in a psychiatric facility, and later picking that patient up at the end of the commitment.
Swain County Sheriff Curtis Cochran said the matter has become a big problem for his small staff. And the situation is impossible to anticipate.
“We may have weeks where we don’t have any, and then a week where we have one everyday,” Cochran said.
Andy Shields, chief deputy for the Macon County sheriff, has watched the number of man-hours he loses to the process climb during recent years. In 2012, the office saw a 43 percent jump in the number of involuntary commitment transports it had to make. In 2011, the department dealt with an almost 100 percent spike compared to 2010.
“It’s not very long before you run out of resources to deal with the issue,” Shields said. “Each year, the issue gets worse.”
The transport can be as close as a mental health care facility in Haywood County, or as far away as Wilmington, a more than six-hour drive to the coast. Last year, Macon officers drove more than 42,000 miles on just under 200 transports. Those transports took up nearly 6,000 hours between driving on the road and trading off shifts in the hospital with the patient.
The average wait time for a patient to find a bed in a local mental health facility — such as the Balsam Center in Haywood County — can be a matter of hours. However, as the severity of the patient’s need increases, so does the amount of time spent waiting for an appropriate hospital to have a vacancy.
Shields said committed patients who are violent, suicidal, juveniles, elderly or have serious medical complications will wait a long time in the emergency room with a guard by their side. If several of these factors are present, the situation becomes particularly difficult for the patient and law enforcement. Last year in Macon County, the process for one violent juvenile lasted more than 300 hours.
“If you view mental health as an issue that requires immediate assistance, and you don’t get it, how would you fare?” Shields said. “Can you imagine the despair and anguish?”
Moreover, the two primary overnight mental health hospitals in the area — the Balsam Center and Haywood Regional Medical Center — only provide adult care. The closest facility for children is in Asheville.
Having children sent so far from their families to recover from a mental health episode is not an ideal situation, said Doug Trantham, clinical director at the Balsam Center. And, that’s if they’re lucky enough to be admitted to the hospital in Asheville, which is often at capacity.
“Children and adolescents need to be served near their families,” he said. “For inpatients, minors are one of the most difficult to deal with.”
Trantham works for Appalachian Community Services, which contracts as the service provider for the Smoky Mountain Center. The Smoky Mountain Center is a quasi-governmental agency that is the designated mental heath care provider in the region. ACS has walk-in mental health clinics in six of the seven western counties, a patient center in Haywood — which is a level of care below a psychiatric hospital — and an on-call mobile crisis team for mental health emergencies.
Most mental health patients in the region are not involuntarily committed but rather seek help, said Trantham. These patients can be treated in an outpatient setting or during a short stay at the Balsam Center to detox or receive other care. One of the most effective ways to prevent the overload of mental health patients taxing local hospitals and law enforcement is through services, identifying and treating mental health problems before they escalate and end up as a visit to the ER, he said.
But if that fails, it’s the children, people with mental retardation, elderly with diabetes or violent patients that fall through the cracks.
“As bad as it is for certain people, it doesn’t mean that nothing in the system is working,” Trantham said. “But some things, frankly, are not working at all; they don’t even exist.”
And Trantham fears that if public funding for mental health does not rise to meet the level of need, the gaps in the system will become even more apparent. About nine out of 10 patients treated at the Balsam Center are without health insurance or Medicaid, so treatment at private mental health hospitals is usually not an option.
Meanwhile, the ACS clinic in Sylva was closed due to funding reductions, and many experienced staff members have been lost during recent years. Also, services like case management to help patients navigate the care network were eliminated last July. Trantham said the situation has been exacerbated by the fragmentation of services, split up among different providers contracting with Smoky Mountain Center.
“Now, more of those people are going into crisis,” Trantham said.
The Smoky Mountain Center operates on a mix of federal, state and local funds. It took a $3 million hit last year from the state, said Brian Ingraham, CEO of the Smoky Mountain Center. It was the latest in a series of recent reductions, he said. In the meantime, a struggling economy and higher unemployment have added further stress to local households and possibly put some people a bit closer to the edge.
“As the money shrinks, the group of people needing that funding does not shrink,” Ingraham said. “That’s simple math.”
Community mental health services available
Despite statewide funding cuts and lack of access to inpatient services, outpatient services are available in all counties including mobile crisis management, clinical assessment, medication management, and evidenced based group and individual therapy. Individuals should to contact Smoky Mountain Center at 800.849.6127 or Appalachian Community Services at 888.315.2880 if they, or someone they know, is in need of mental health services. A mental health professional will assist the caller in accessing services.
Mental health in the seven western counties by the numbers
Involuntary commitments initiated
Calls to the mobile crisis mental health line
2011: 3,945 calls
2012: 4,464 calls
Patients seeking mental health services in 2012 by age
*Source: Cases handled by Appalachian Community Services