North Carolina has a long history of adopting simple, quick-fix solutions to complex problems facing the mental health system.
In 2001, in response to the Supreme Courts 1999 Olmstead decision, North Carolina began reducing its state psychiatric hospital capacity and shifting care to less restrictive local settings, without ensuring that adequate community-based services were in place.
In 2007, state psychiatric hospitals began placing patients on waitlists for admission in response to overcrowded treatment units and concerns for patient and staff safety. Although the waitlist policy helped hospitals manage admissions, it ended up shifting many of the people on waitlists to general hospital emergency departments, jails and prisons where persons with severe mental illness are greatly overrepresented and poorly served. Six years later, we still struggle with these problems.
Many people believe we need more state psychiatric hospitals to solve these problems, as suggested in recently proposed legislation (House Bill 981) calling for a new state psychiatric hospital to serve the southern region. Is this just another simple solution? A reasoned answer turns on three considerations.
• First, do we really need a new state psychiatric hospital or just more hospital beds? Planning and construction of a new hospital comes at great public expense. The Department of Health and Human Services recently estimated that it would cost $137 million in capital costs alone to build a hospital to serve the southern part of the state. A new hospital would be a costly, permanent and inflexible solution with no immediate effect on todays strained system. If bed shortage is the problem, unused capacity at existing or recently closed state psychiatric hospitals could relieve it. Alternatively, the new buildings set to replace Cherry and Broughton hospitals can be modified to accommodate additional patients.
• Second, do we really need state-operated beds or would local beds in existing general hospitals be more viable in the long run? State psychiatric hospitals with more than 16 beds are classified as Institutions of Mental Disease, making them ineligible for Medicaid reimbursements for patients aged 21 to 64 years, the majority of hospital users. This means the state would have to absorb all of the costs of inpatient care. By further expanding general hospital psychiatric capacity, Medicaid would pay for those inpatient costs, saving the state millions of dollars in future years.
• Third, do we need more beds or more community-based crisis and preventive services? North Carolina began its shift away from state hospitals for sensible medical and humane reasons. With modern methods, many psychiatric problems can be prevented, treated and managed more effectively in community-based mental health settings as opposed to institutions. Building more state hospitals is a 19th century solution that undermines progress and takes resources away from community care agencies. Lets get smart about what will be effective in resolving the current crises in mental health care.
A year invested in assessing these options would pay huge dividends. But state agencies have lacked the capacity to do this job well because of a culture of circling the wagons when challenges arise and because of the limited ability to gather and assess information to monitor how well mental health policies are being implemented.
Without first carefully analyzing the merits of alternative policy options and then constructing an early-warning information system to signal when chosen plans are going awry, millions of dollars can be spent pursuing mental health policies that just do not work.
Gov. Pat McCrorys new Innovation Center aims to fix the states limited information technology systems. The center could do a great service for the people of North Carolina by starting its work with the fragmented and siloed mental health system.
With leadership from the governor and legislature, along with a thorough re-make of how policies are chosen and monitored, North Carolina can avoid the simple, quick-fix solutions that have continually failed the many thousands of needy people who depend upon the public mental health system for care and support.
Elizabeth La, Michele Easter and Sean Sayers, who also contributed, are research fellows in the UNC Training Program in Health Services Research and the UNC-Duke Mental Health and Substance Abuse Systems and Services Fellowship Program.