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NH mental health report: More beds needed

New Hampshire Union Leader

February 26. 2013 6:55PM

A middle-aged man with schizophrenia arrived at a community hospital recently, and was quickly designated for involuntary admission to the New Hampshire State Hospital, but for three days he was kept in the local emergency room, where he was prone to violent outbursts, punched holes in a wall and required a 24-hour police detail.

A patient considered suicidal by doctors spent five days in a hospital emergency room waiting for a bed at the state hospital, with one doctor, one nurse and one technician assigned to her the entire time, at a cost of $26,000.

A 47-year-old man with a psychotic disorder waited so long for treatment that one of his family members went to the emergency service office and threatened to blow it up. The hospital went into high alert until local police resolved the situation.

Those are three of the emergency room horror stories that dot the pages of a newly released report on the state of mental health care in New Hampshire, which has lost 27 percent of its in-patient psychiatric beds in the past eight years.

In 2005, the New Hampshire State Hospital in Concord, in cooperation with other acute hospitals and community centers, provided 526 beds for in-patient mental health care, according to "HELP: People Seeking Mental Health Care in New Hampshire," a report commissioned by the Foundation for Healthy Communities (affiliated with the New Hampshire Hospital Association), and released on Feb. 21.

Today, that number is down to 384 beds, with only one acute care hospital (Elliot Hospital in Manchester), and one community center (The Cyprus Center in Manchester) participating, in addition to the state hospital. With few exceptions, acute care hospitals in the state have basically abandoned in-patient mental health care, mostly citing cost concerns. "The Medicaid reimbursements are so low, and the costs so high, that it just became cost-prohibitive," said John Clayton, spokesman for the New Hampshire Hospital Association.

The result is often chaos in emergency rooms, with as many as 30 mental health patients a day warehoused in emergency beds across the state, sometimes for days at a time, awaiting admission to a psychiatric facility, according to Nick Toumpas, commissioner of Health and Human Services.

"We are seeing upward of 30 people a day waiting to get into New Hampshire State Hospital, which means they are backed up at emergency rooms," he told Gov. Maggie Hassan and the Executive Council at their meeting on Feb. 20. "It is not an optimal situation for them or their families."

Emergency expansion

Toumpas appeared before the governor and council, along with Linda Hodgdon, commissioner of Administrative Services, to seek emergency approval for renovations at the state hospital to accommodate an additional 12 beds for acute mental health patients.

"It's not the be-all and end-all solution, but it is something that is absolutely essential at this time," Toumpas said.

The council granted informal approval for Toumpas and Hodgdon to proceed with renovation of the hospital's Acute Psychiatric Services wing, with a plan to vote on a formal proposal at the March 6 or March 20 meeting. Toumpas could not quote a price for the renovation, pending bids from contractors, but estimated it at a couple hundred thousand dollars. "As far as the staffing goes, we will find the dollars elsewhere in our budget for the balance of this fiscal year," he said.

The work will take about 60 days to complete, and demolition is already under way, Hodgdon said, citing a May 3 target date for completion.

Gov. Hassan endorsed the move, and said it is only the beginning. "We have a much more compelling challenge on our hands," she told the council, "which is to rebuild our community mental health system."

Of the 30 or so mental health patients backed up in emergency rooms each day, 10 are on average children. "When you talk about sedating or restraining children in emergency rooms, that certainly brings it home to me," she said.

The governor has money in her budget to create additional community-based crisis beds and housing support, and Toumpas is working with two acute hospitals in the state to become "designated receiving facilities," although he declined to identify them until an agreement is worked out.

New Hampshire once had a community-based mental health system that was cited as a national model, but over the years, the state experienced steady erosion in the number of community beds, due to reductions in funding for community-based mental health centers and what Toumpas called a "not in my backyard phenomenon when we try to place beds out in the community."

Key findings of report

The "HELP" report authors invited all 26 acute care hospitals in the state to cooperate in their study, and 15 agreed to provide data and anecdotal material from an eight-week period in the fourth quarter of 2012. In addition to charting the loss of mental health beds in recent years, the report contained other key findings, including:

-- Nearly one out of three people waited more than 24 hours in a hospital emergency department for mental health treatment. The average wait was 2.5 days.

-- The primary diagnosis for more than 20 percent of the patients was reported as suicidal, with about one-third reported for major depression.

-- More than 75 percent of the patients required constant observation while in the emergency department, and almost half required special security.

The report suggests that money saved by reductions in funding to community health centers and in-patient beds has only caused more money to be spent on personnel and security in emergency rooms, not to mention the resulting disruption and delays experienced by patients seeking medical care.

"Not supporting a strong mental health system can result in wasted expenditure that have no bearing on treating the problem," the report's authors wrote.

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