In the winter of 2017, Concord Hospital first sounded the alarm on the lack of available beds for mental health patients.
Those suffering from mental health-related conditions found themselves languishing in the hospital’s emergency department for weeks until a bed could open up. They spilled into hallways and treatment rooms, and the hospital converted space to make room. The overflow increased wait times for all emergency room patients.
The situation is still bad, hospital officials say. But a new strategy to focus on treatment while patients are in limbo has either decreased wait times or eliminated the need for a bed altogether.
“I think we’re in a better position,” said Peter Evers, vice president of behavioral health at Concord Hospital and CEO of Riverbend Community Mental Health.
Evers said the hospital is more experienced with dealing with the overflow of patients, and – with the number of available state beds unlikely to increase any time soon – is trying to adapt to the problem.
Other hospitals are working to meet the need, too. Elliot Hospital recently opened a new unit called the Psychiatric Evaluation Program specifically built to treat those who need immediate mental health care away from the emergency room.
“I don’t like to use the term boarding,” said Heidi St. Hilaire, clinical nurse manager at Elliot. “But I feel like if the patient is with us, they should start treatment.”
Close to the crisis Because of its proximity to New Hampshire Hospital, Evers said Concord Hospital is still the “epicenter” of the bed crisis. Emergency personnel from the state’s northern areas, where mental health resources are scarce, will often send patients past other hospitals down to the southern parts of the state, he said.
“People view us as a portal to New Hampshire Hospital,” he said. “That’s not the case.”
Last week, Concord Hospital had about 12 patients waiting in its emergency department; the week before that, it was 15. In May, the number of waiting patients hit 17 at one point, “not too far off the high water mark” of 22 patients, the number of patients waiting at Concord Hospital when the state hit a then-record high of 68 patients waiting for beds in February 2017.
“We’re rarely into single digits,” Evers said.
Overflow spaces that were once temporary have now been converted into full-time beds, Evers said. Including the Yellow Pod – the hospital’s mental health unit – Concord Hospital now has 10 beds designated for mental health patients.
Patients used to wait weeks in Concord Hospital’s emergency department to get a mental health bed, Evers said. He said the average time is now lower, around three to eight days, although patients with more complex needs can still end up waiting weeks for a bed.
But many patients no longer end up at New Hampshire Hospital; the hospital has become “much more careful” in its assessments of who needs to be involuntarily committed, Evers said.
They also rely heavily on Riverbend’s mobile crisis units, designed to provide support to those living with mental health illnesses where they are.
Evers called it “early directed care.”
“We’re identifying people we know and getting their case managers and therapists into the ED while they’re there,” he said.
By getting them in touch with their providers, Evers said patients can receive treatment – like a new medication or therapy – that gets them back into the community faster. Occasionally, they can arrange to get patients into one of Riverbend’s four voluntary, 24/7 observation apartments, where they can continue to receive treatment.
“It has an incredible effect on stabilizing people,” Evers said. “... It’s about not delaying treatment until we can find a bed. A person does not deserve to be waiting for services.”
Elliot Hospital is employing a similar strategy, St. Hilaire said. She estimated about eight to 10 patients are waiting in the emergency room at a given time. Their wait time for a bed can be anywhere from three days to three weeks.
The hospital tries to reroute people to their local resources first before committing them to wait for a state bed. If they know the patient, the Mental Health Center of Greater Manchester’s mobile crisis team is called in to start treatment.
It helps to know your community, both officials said. About a third of Concord Hospital’s patients are from Concord, according to a 2015 patient origin report from the New Hampshire Hospital Association, and the majority are from Merrimack County. About 44 percent of Elliot’s patients are from Manchester.
If Elliot patients need a more residential stay, they can be sent to the hospital’s general psych ward or the Cypress Center – an alternative to hospitalization run by the Mental Health Center of Greater Manchester. The hospital also has the Pathways Unit, a psychiatric intensive care unit separate from the PEP unit.
The PEP unit has six beds, two more than what the hospital had beforehand, soft walls, a shower and a separate room for family visits and small group sessions.
For patients who may be in limbo for a long time, such features can make a difference, St. Hilaire said.
“If you’re going to be waiting, having a shower right there is a big deal,” she said.
And Evers said diverting patients out of emergency departments, already a chaotic place, can stop them from getting worse.
“It’s not the place for those with emotional disturbances,” he said.
Cost of care Accommodating the patient overflow has financial consequences for hospitals.
A study by the Foundation for Healthy Communities, a nonprofit organization focused on improving health and health care in New Hampshire affiliated with the New Hampshire Hospital Association, last year found that 421 people were medically cleared to leave a hospital in a three-month period were unable to do so.
The study, called “Barriers to People Receiving the Right Care,” surveyed all 26 of the state’s acute care hospitals, including Concord Hospital and Elliot Hospital, from Jan. 1 to March 31, 2017. Those 421 people stayed a total of 5,794 additional patient days in an acute care setting than necessary. The average length of stay was 15 days.
Of the five biggest barriers to care found, the biggest was a lack of available skilled nursing home beds, according to the study; the second was other health/behavioral/psychiatric care needed. Overall, those barriers resulted in $17.1 million in additional, nonreimbursable acute care hospital expenditures for people with non-acute medical care needs.
“A person in an acute care hospital waiting to be transferred to the right care setting or discharged to their home, may not have the opportunity to achieve a greater level of independence and receive the type of support available in a less acute care setting that could maximize their well-being,” the study notes.
With more patients comes a need for more staffing. Evers said Concord Hospital has hired additional psychiatric staff, more LNAs and three extra security team members to staff their overflow areas.
And Elliot’s new PEP unit needed a total of six new nurses specialized in behavioral health to staff it around the clock, St. Hilaire said.
A state problem While the state is working to address the issue, an in-place solution may be far off.
There are currently 168 beds at New Hampshire Hospital, said Department of Health and Human Services spokesperson Jake Leon via email. The last time that number increased was in June 2016, when the Inpatient Stabilization Unit, a short-term, intensive psychiatric treatment for individuals living in community settings who are in the early stages of a mental health crisis, added 10 new beds.
But more beds have been lost in recent years due to budget cuts. Leon said the closure of the I Unit at N.H. Hospital in 2009 slashed 30 beds. Another 48 were lost in 2010 when the Anna Philbrook Center, which provided psychiatric care for children, closed.
Last year, Republican Gov. Chris Sununu signed House Bill 400, which directed DHHS to develop a 10-year plan for mental health services in the state that focused on principles of resiliency and recovery, evidence-based practice, effectiveness and efficiency, and to study the shortcomings of the state’s mental health systems.
The December report noted the number of boarding patients has been increasing; On Sept. 24, 2017, the state recorded 70 patients waiting. The greatest total number of individuals at one time was 72.
Overall, the number of inpatient beds in the state has actually increased in recent years, going from 430 to 458 in 2016-17, according to the report. However, “the wait list for beds has continued to increase,” the report notes.
The report is inconclusive as to whether the solution to better care for mental health patients is, in fact, more beds. It says the state’s roughly 11.9 beds per capital is adequate for its population and notes that barriers to discharge, like adequate housing or access to treatment, may be just as significant a problem.
“... Increasing capacity of outpatient services and supports, especially housing, is at least as important – and significantly more cost-effective – as increasing the number of inpatient beds,” the study says.
Evers and St. Hilaire think the solution is a mixture of both.
“It’s a complicated system,” St. Hilaire said. “If you build more beds, you end up filling them. I think community resources are essential.”