Beyond the Stigma: Mobile response teams get results, but doubts about funding worry someBy SHAWNE K. WICKHAM
New Hampshire Sunday News
July 08. 2018 12:16AM
The patients come as young as 4; as old as 96.
By all measures, the state's three mobile crisis response teams are having the desired effect, reducing the number of people going to emergency rooms for mental health crises. There are MCRTs in Concord, Manchester and Nashua; each serves the surrounding communities.
In Manchester, the team operated by the Mental Health Center of Greater Manchester has seen more than 2,600 clients since it began 18 months ago. Most clients call the team's crisis line, but hundreds also have been referred by police, Safe Station, schools and medical providers.
And for the first time in nine years, there has been a drop in the number of clients evaluated by Mental Health Center clinicians in emergency rooms, according to Bill Rider, the center's president and CEO. Of all the clients evaluated by the MCRT since it started, there were just 151 hospitalizations.
The teams in Nashua and Concord are seeing similar success.
The data suggests the model is working. But Rider worries that without more stable funding, the important work the team does may be unsustainable.
"The good news is we're very busy; the good news is we have great response times. But that costs a lot of money," Rider said.
The idea, and the funding, for the teams were part of a 2013 comprehensive settlement agreement of a class action lawsuit filed against the state by the U.S. Department of Justice and Disability Rights Center. That action claimed that New Hampshire was failing to provide services to individuals with mental illnesses in the most appropriate integrated setting.
Among the expanded services the state agreed to provide were three mobile crisis teams that would serve clients in their homes and communities, along with "crisis apartments." The idea is to divert individuals from emergency rooms. Part of the mandate was to include both clinicians and peer counselors on the teams.
The peer counselors have "lived experience" with mental illness, substance use disorder, or both, plus training to help clients, Rider said. They provide not just a sympathetic ear but powerful proof that recovery is attainable, he said.
Lawmakers were so convinced that the program was worthwhile that last year they authorized creation of a fourth mobile crisis team. But when the state Department of Health and Human Services put out a request for proposals late last year, no agency bid on it.
Rider said he knows why.
When the teams were first created, he said, agencies had to estimate what it would cost. "We were essentially doing a live experiment," he said. "We were making our best guess that we could do this for a couple million dollars."
"Now, two years later, I can't look anybody else in the eye and tell them this isn't going to cost you money," he said.
Rider estimates the annual cost of running the 24/7 team is around $2 million; the state provides $1.3 million in general funds for each of the next two years, and they have to try to recoup the balance from Medicaid and insurance.
"So the biggest threat is ... that we will need to constantly look at the financing so that mobile crisis doesn't go the way of Serenity Place," he said, referring to the treatment center that was taken over by the state late last year.
Since the Concord team started in January 2016, it has served 4,386 clients, ranging in age from 4 to 87. Of those, 409 needed hospitalization, according to Peter Evers, vice president of behavioral health at Concord Hospital, and president and CEO at Riverbend Community Mental Health, which runs the Concord MCRT.
Evers said there are certainly times when a behavioral health patient needs to be seen in an emergency department.
But Evers said keeping someone in crisis in the hospital while they wait for an inpatient psychiatric bed to open up can have a negative effect. "The longer they stay here, the worse they're going to get," he said. "Being holed up somewhere you don't want to be for a long period of time is going to make things worse."
Ken Norton, executive director of NAMI (National Alliance on Mental Illness) New Hampshire, said the mobile teams are making a big difference in their communities.
And he expects a new law that takes effect July 1, allowing individuals to be discharged from an emergency room directly to an MCRT, will keep even more people out of hospitals or jail. "If a mobile crisis team goes to them, they're much more likely to end up with a disposition that doesn't result in hospitalization," he said.
Meanwhile, DHHS is trying again to expand crisis services, seeking proposals for either a fourth mobile crisis team or a behavioral health crisis treatment center. This time, they got three bids - including one from the Mental Health Center of Greater Manchester, Rider confirmed.
Jake Leon, spokesman for DHHS, said the idea is akin to an urgent care clinic. "The intent is that people can go to this urgent behavioral health care facility rather than go to an emergency department," he said.
Patients may still need to be referred to a higher level of care, but they can be treated more quickly, "and hopefully be returned back to the community with supports in place," Leon said.
Norton said NAMI prefers a statewide mobile crisis response model to a centralized crisis treatment center. He said the real goal is to incorporate behavioral health care into the overall health care system.
"I think one of the things that we are all seeing is having a segregated system of care for people with mental illness or substance use disorder isn't necessarily helpful," he said. "We need to do a better job at providing integrated care."
That's the approach taken by Harbor Homes, a federally qualified health center that offers a broad spectrum of services, including primary care, housing support and residential treatment for substance use disorder. The agency also runs the Nashua MCRT.
Melbourne Moran Jr., director of integrated care and population health for Harbor Homes, said the team's call volume was low at first but it has picked up in recent months. In May, they saw 145 clients, providing 109 face-to-face assessments and 985 services from counseling to case management.
In the year the team has been in existence, only 12 clients were hospitalized.
Moran said he expects the new law will result in a "big leap" in the number of clients referred to mobile crisis teams by doctors and psychiatrists.
Rider said providing immediate help to those in crisis can save money down the road. But the funding, including insurance reimbursement, remains a challenge, he said. "I think overall, on the macro level, it saves, but on the micro level ... we have not had enough experience to know the best way to fund it," he said.
Beyond the Stigma, sponsored by the New Hampshire Solutions Journalism Lab at the Nackey S. Loeb School of Communications, is funded by the New Hampshire Charitable Foundation, Dartmouth-Hitchcock Medical Center, NAMI New Hampshire and private individuals. Contact reporter Shawne K. Wickham at firstname.lastname@example.org.