Uneven Efforts​ series.)Claremont — Mandy Dube was first..." /> Uneven Efforts​ series.)Claremont — Mandy Dube was first...">
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Falling Through the Gaps; Community Mental Health Care Continues to Be Vulnerable



Valley News Staff Writer
Friday, April 22, 2016

(Editor’s Note: This article was published July 26, 2015. It’s part of the Uneven Efforts​ series.)

Claremont — Mandy Dube was first hospitalized for mental illness when she was 12 years old. Over the next decade she was diagnosed with serious mental illnesses including bipolar disorder, admitted to New Hampshire Hospital 20 times and received inpatient psychiatric care at four local hospitals.

But it was during her 18-month stay in a small group home in Claremont that she thrived and managed to end, for a time, the self-mutilating behavior that was a dangerous symptom of her illness.

Then about five years ago, around the time of her 21st birthday, Dube moved into her own apartment in Claremont.

In other circumstances, that move might have marked a welcome rite of passage: exciting, difficult, rewarding and a source of future memories and stories.

But for Dube, the prospect of independent living was more of a cause for concern than celebration. To live successfully on her own, Dube required medical care and support services — the type of services that had been available in the eight-bed group home, which was operated by West Central Behavioral Health. There, Dube became more independent and stopped the self-cutting that she resorted to in order to tame suicidal impulses.

But funding reductions prompted West Central to close the home in August 2010. That reduced the availability of support services even as Dube prepared to move into her own apartment.

Soon, she resumed cutting herself. Her condition worsened. Within two months, Dube had been hospitalized. Eventually, she moved back into the basement of her family’s home in Newport.

For Dube and tens of thousands of other residents of New Hampshire and Vermont, serious mental illness is a fact of life. For some, gaps and weaknesses in mental health care can be life-threatening. Sometimes those gaps and weaknesses result from budget cuts that seem to make sense from a distance, especially to legislators not vulnerable to the perils being created. Sometimes the flaws are more systemic and longstanding, such as the crowding in general hospital emergency rooms that results when patients with acute mental illness are forced to wait for psychiatric care to become available.

As reported earlier in this series, each of the Twin States has attempted to address such shortfalls recently by updating the legal framework that spells out its obligations to deliver mental health care.

In New Hampshire, the state’s duties were written into a settlement agreement that resolved a 2012 lawsuit that alleged that the state was violating the civil rights of some of the seriously mentally ill. Dube was a plaintiff in that class action lawsuit.

Vermont’s commitment to deliver adequate mental health care became law as Act 79, which passed the Legislature and was signed by Gov. Peter Shumlin in 2012.

The settlement agreement and Act 79 both embody an approach that sees more and better services at the community level — including beds for less-intensive psychiatric care, supported housing, job training and support, and crisis and non-crisis care teams — as the best way to ease psychiatric care bottlenecks. The reasoning behind this approach: Good care in clinics and in communities can provide relief to some of the mentally ill who would otherwise be sent to higher-level psychiatric facilities. Also, better community services can provide a place to send patients well enough to be released from state mental hospitals but still in need of care.

But deinstitutionalization — the decades-long drive to offer community-based care when appropriate — has rarely delivered on its promises. Too often the right answers of today have been erased by the budget cuts of tomorrow. Such disappointments have occurred with such regularity that critics have even raised the cry, “Bring back the asylum,” as a provocative way to argue that deinstitutionalization went too far and that humane institutions would be preferable to the prisons, jails or homelessness that have become the de facto refuge for too many people with serious mental illness.

Caregiver Merry-Go-Round

Clinics and other services in communities are supposed to be the main venue for mental health care in both New Hampshire and Vermont. Most of those services are provided by nonprofit mental health care organizations — dubbed “designated agencies” in Vermont, “community mental health centers” in New Hampshire.

Community nonprofits depend mostly on the federal-state Medicaid program to pay their employees and cover other expenses. “Medicaid is the primary payer for mental health in every state,” said Sita Diehl, state and policy advocacy director for the National Alliance on Mental Illness.

That leaves community facilities and services like the group home where Dube lived until August 2010 vulnerable to state budget decisions. Compounding that problem, low Medicaid reimbursement rates make it difficult for community providers to recruit, retain and reward caregivers and support staff. Yet cuts may attract little notice beyond a small circle of affected agencies, patients and families.

For example, in its last budget year Vermont realized $5.6 million in savings through a mid-year decision to drop a plan to increase by 1.6 percent the rates at which Medicaid reimburses providers.

New Hampshire has little room to cut. In 2012, the Kaiser Family Foundation ranked the Granite State’s Medicaid reimbursement rate eighth lowest among all the states.

Despite chronic financial weaknesses, community services are expected to fill a gap in care created by the loss of inpatient psychiatric beds in the Twin States. Inpatient psychiatric beds in New Hampshire decreased 27 percent from 526 beds in 2005 to 384 beds in 2013, according to a state review of mental health care needs published in January 2014. Vermont currently has 188 inpatient and crisis beds, according to D epartment of Mental Health reports.

Two so-called designated agencies provide mental health and related care in Vermont’s Upper Valley communities. In Windsor County, Health Care and Rehabilitation Services has offices in White River Junction and Springfield. HCRS’ 720 employees provided care to 4,100 people and posted a $1.4 million loss and $46.8 million in revenue in the fiscal year that ended June 30, 2014, according to reports by the organization. Medicaid accounted for 89 percent of the $33 million in revenue that HCRS generated by providing client services.

In Orange County, the Clara Martin Center has offices in Randolph and Bradford. In fiscal 2014, the agency’s 215 employees provided more than 83,000 hours of services to 3,600 clients, and its revenue of $10.6 million exceeded expenses by $184,000, according to the organization’s annual report and tax filings.

In the New Hampshire portion of the Upper Valley, West Central Behavioral Health offers mental health and other care at facilities in Lebanon, Claremont and Newport. In fiscal 2014, West Central’s 187 employees cared for 3,100 adult, senior and child patients, and its revenue of $10 million exceeded expenses by $246,000, according to agency reports and tax filings. More than $7 million of West Central’s revenue came from Medicaid.

Responding to mental health crises and slogging through the daily grind of therapy, problem solving and support can be physically and emotionally demanding work. Many positions require extensive training. Some caregivers are required to be licensed as social workers, counselors, nurses or physicians.

Recruiting, retaining and paying competitive wages to professional and other employees is crucial to these agencies’ ability to do their work well. And often the money needed to do that is scarce.

Vermont Care Partners, an organization of designated agencies, recently conducted a salary survey of three job classifications in which designated agencies employ 2,400 caregivers. In those front-line jobs, community-level employees got paid hourly rates ranging from 23 percent to 32 percent less than state employees holding comparable positions.

Not surprisingly, turnover is rapid at the local organizations. For the 1,540 employees in psychiatric technician jobs with an average annualized salary a little over $26,000, the average length of service was only a little over four years.

“The pay issue is certainly real,” said Frank Reed, the interim commissioner of the Vermont Department of Mental Health. “It varies around the state.” Finding and keeping staff is especially challenging in the remote Northeast Kingdom and in southwestern Vermont, where local agencies face stiff salary competition from the Albany Medical Center and New York state, he said.

New Hampshire’s community mental health centers also experience high rates of turnover. They typically replace one out of five staff members each year, according to a recent report by the New Hampshire Community Behavioral Health Association. Budget pressures have resulted in positions being cut, salaries lagging behind those available elsewhere and benefits being trimmed, according to the association.

At West Central, the turnover rate in 2014 was 16 percent, according to Suellen Griffin, the agency’s executive director. That is “one of the lowest turnover rates in the state but it’s still a problem,” she said.

“We’re not the highest-paid people in the state,” Griffin said. West Central’s salaries may be “OK when you are just out of school” but after a couple of years, licensed and experienced caregivers often move on in search of better pay, she said. In the Upper Valley, they don’t have to move far. “We compete with the hospital and the college,” Griffin said, referring to the Dartmouth-Hitchcock medical complex and Dartmouth College. “Both of them pay more than we do.”

The turnover problem is statewide, according to Roland Lamy, executive director of the Community Behavioral Health Association. “Nearly all of our centers … are struggling with this phenomenon,” he said. “We’re competing on sort of an unfair playing field.”

Workforce problems aren’t unique to New Hampshire and Vermont, and won’t be easily resolved. A 2013 report by the U.S. Department of Health and Human Services on the labor market for substance abuse and mental health caregivers concluded that “the workforce is too few, aging into retirement, inadequately reimbursed; inadequately supported and trained, and facing significant changes affecting practice, credentialing, funding and ability to keep up with changes in practice models driven by changing science, technologies and systems.”

Patients are affected by agency staffing problems. Ginny Kirschner, a family support group leader for the National Alliance on Mental Illness Vermont chapter. said many case workers “are just people who want jobs.” She added: “They are not paid well so they turn over quickly.”

Diana Slade, an outpatient being treated at Health Care and Rehabilitation Services in Springfield, Vt., said the departure of an agency staff psychiatrist resulted in the interval between psychiatric appointments doubling. “They have people filling in and they’re looking for a psychiatric nurse to help fill in,” she said. “Instead of seeing a doctor every month, it’s every two months. That’s the problem.”

While staffing problems at community mental health providers will not be solved overnight, solutions are worth pursuing — especially in light of the successes that can be achieved by skilled and experienced caregivers with decent pay and resources to work with.

Consider Dube’s recent experience. After years of fighting mental illness, her life has improved with the help of a psychiatrist at West Central, who adjusted her medications to eliminate side effects, and of Daisy, a beagle-Rottweiler psychiatric support dog who senses the onset of one of Dube’s stress-induced seizures and then comforts her. Dube now lives in an apartment in downtown Claremont, where she is able to afford the rent with the help of a Section 8 housing voucher. She spends time helping administer a depression, self-harm and suicide support group on Facebook and plans to resume her studies to become a veterinary assistant. In a recent interview, Dube was upbeat: “Things are really going awesome.”

Reluctant Gatekeepers

At other times, the results of mental health care can be far from awesome.

For example, despite some progress as a result of recent reforms, neither New Hampshire nor Vermont has completely eliminated another long-standing failure in their respective mental health system — the use of hospital emergency rooms as holding areas for patients in the throes of acute mental illness when psychiatric care is not immediately available.

Tracy Pike, a veteran nurse who manages the emergency room at Valley Regional Hospital in Claremont, recalled a pair of 14-year-old boys who waited there last year for psychiatric beds to open. “There was nothing we could do for them medically,” she said. Emergency room personnel fed them, allowed them to take showers and organized some activities. One boy waited for 14 days, the other for 17 days.

“When (the mentally ill) are held in an emergency room they are not getting any care,” said Kirschner, the support group leader. “And they can be there a week or two. And they are just sitting in a bed. And a lot of them are very psychotic.”

Emergency-room waits can also take a toll on staff. “People spit at us, punch us and kick us,” Pike said. “We have a lot of injuries,” including broken noses and fingers.

Yet every day, patients wait in Twin State emergency rooms for beds to open in facilities that offer high-level psychiatric care. A surge in psychiatric patients seeking crisis care in its emergency room prompted Springfield Hospital to contract for around-the-clock, on-site security and to create a psychiatric holding and isolation area.

Despite serious limitations in the services they can provide, emergency rooms remain critical connectors in the mental health networks in the Twin States, dealing with mental health issues even in hospitals that don’t have psychiatrists on staff. Care may instead come from emergency room doctors or mental health caregivers called in from nearby agencies.

Emergency-room care can be as simple as assessing, treating and referring to other caregivers patients who are newly experiencing severe mental illness or don’t know where else to turn.

Emergency rooms can also serve as gatekeepers to state-supported psychiatric hospitals, making initial diagnoses of patients who need high-level care and holding those patients while they wait for such care to become available.

In February, the New Hampshire Community Behavioral Health Association, an organization of community mental health centers, described queues of patients in emergency rooms waiting for care at New Hampshire Hospital “as a major symptom of the crisis” in the state’s mental health care.

In Vermont, the Department of Mental Health operates a statewide “electronic bed board” that tracks the availability of inpatient psychiatric care. Holding patients in an emergency room waiting for an open psychiatric bed is “disruptive to the emergency care setting and not a standard that the department regards as adequate for individuals requiring inpatient care,” DMH said in a January report.

Still, emergency-room waits remain a fact of life in both states.

During an interview in April, Robert MacLeod, the chief executive at New Hampshire Hospital in Concord, said that, as he spoke, seven patients waited in emergency rooms for space to open at his hospital, which, with 158 beds, is the state’s main facility for high-level mental health care. An eighth waited in a county jail.

MacLeod said that, on an average day in the second quarter of 2015, about 20 patients were waiting in emergency rooms for space at New Hampshire Hospital, which mainly treats patients considered threats to themselves or others. That average had dipped to a 21-month low of 14 in March 2014, then soared to 36 six months later.

Things are a little better in Vermont. During May, 25 patients ended up held in an emergency room while they waited for high-level inpatient psychiatric care. In late September, one patient at Rutland Regional Medical Center waited six days for a psychiatric bed. One frantic evening, seven more patients joined the line.

In March, a cumulative total of 18 patients waited in Vermont emergency rooms for psychiatric care to become available. That was the lowest total since the beginning of 2014. In June of 2014, a total of 33 patients ended up waiting in emergency rooms.

“The good news is that most of the wait times have been reduced so much that we’re not talking about long lengths of stay like we were before,” said Reed, the interim commissioner of the Vermont Department of Mental Health. “People are able to get into those beds much faster.”

In February 2014, the Vermont Medical Society Council passed a resolution urging hospitals with psychiatric beds to provide “sufficient capacity and overflow capacity to ensure that no acutely psychiatrically ill patient waits for a Level 1 Acute Involuntary bed at an emergency department or correctional facility for more than 24 hours.”

But some advocates have warned against seeking to solve that problem by adding beds in the big state psychiatric hospitals. Amy Messer, the lawyer who represented plaintiffs in the 2012 federal lawsuit alleging that New Hampshire was needlessly and illegally warehousing patients in its large psychiatric hospital, said that her state would do better to spend money instead to enhance and expand community mental health care services.

Tomorrow: Patients and families confront complexity and fragmentation in the search for mental health care, while legislators often find in such services clear, simple and not-too-visible targets for budget cutting.

Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229. This series is part of a project that is supported by a Health Care Performance Reporting Fellowship from the Association of Health Care Journalists and by The Commonwealth Fund.