RALEIGH — As darkness fell on a Friday evening over downtown Raleigh, Michael Lyons, a paramedic supervisor for Wake County Emergency Medical Services, slowly approached the tall, lanky man who was swaying back and forth in a gentle rhythm.
In answer to Lyons questions, the man, wearing a red shirt that dwarfed his thin frame, said he was bipolar, schizophrenic and homeless. He was looking for help because he did not think his prescribed medication was working.
In the past, paramedics would have taken the man to the closest hospital emergency room most likely the nearby WakeMed Health and Hospitals, one of the largest centers in the region. But instead, under a test program, paramedics ushered him through the doors of Holly Hill Hospital, a commercial psychiatric facility.
He doesnt have a medical complaint, hes just a mental health patient living on the street who is looking for some help, said Lyons, pulling his van back into traffic. The good news is that hes not going to an ER. Thats saving the hospital money and getting the patient to the most appropriate place for him, he added.
The experiment in Raleigh is being closely watched by other cities desperate to find a way to help mentally ill patients without admitting them to emergency rooms, where the cost of treatment is high and unnecessary.
While there is evidence that other types of health care costs might be declining slightly, the cost of emergency room care for the mentally ill shows no sign of ebbing.
Nationally, more than 6.4 million visits to emergency rooms in 2010, or about 5 percent of total visits, involved patients whose primary diagnosis was a mental health condition or substance abuse. That is up 28 percent from just four years earlier, according to the latest figures available from the Agency for Healthcare Research and Quality in Rockville, Md.
By one federal estimate, spending by general hospitals to care for these patients is expected to nearly double to $38.5 billion in 2014, from $20.3 billion in 2003.
The problem has been building for decades as mental health systems have been largely decentralized, pushing oversight and responsibility for psychiatric care into overwhelmed communities and, often, to hospitals like WakeMed.
In North Carolina, the problem is becoming particularly acute. A recent study said that the number of mental patients entering emergency rooms in the state was double the nations average in 2010.
More than 10 years after overhauling its own state mental health system, North Carolina is grappling with the consequences of a lost number of beds and a reduction in funding amid a growing outcry that the states mentally ill need more help.
In Raleigh, where the Dorothea Dix Hospital a state psychiatric institution that served the area for more than 150 years was closed in 2012, mentally ill patients began trickling into hospital emergency rooms.
Hospitals, which cannot legally turn away any patient seeking care, say the influx of psychiatric patients is straining already busy ERs and creating dangerous conditions.
Now, we are seeing some of the most acute, the most aggressive and the most chronic mental health patients, and were holding them longer, said Janice Frohman, the director of WakeMeds emergency department.
The effects of the upheaval in care of the mentally ill is playing out vividly at WakeMed. A private, nonprofit organization with 884 beds, WakeMed is struggling to find a way to meet the needs of increasing numbers of mentally ill patients while also controlling costs.
Hospital officials, along with their counterparts at the county and state level, support the pilot program but say it is one small step toward meeting a much bigger challenge.
WakeMed has treated an average of 314 patients a month whose primary diagnosis is some form of psychosis. That is up a third from two years ago.
The hospital now employs 14 behavioral health specialists and four patient service assistants who spend hours contacting care facilities in the hopes of finding an empty bed.
As the states mental health system became more fragmented, community leaders in Wake County have been trying to better coordinate care for patients who use the bulk of resources.
They are focusing on the high users individuals who repeatedly call 911 or show up at emergency rooms.
There is the elderly man suffering from chronic pain who has been transported by ambulance to Raleigh emergency rooms 120 times in the last two years. A female patient with a history of mental illness called 911 nine times in June alone.
A little more than three years ago, Dr. Brent Myers, an emergency room physician, noticed that increasingly at the start of his shift more than half the beds were already full of patients needing mental health care, rather than physical care.
The head of Wake County Emergency Medical Services, Myers was also among a handful of paramedics in the county who are trying to expand the role of first responders. Seeing an opportunity to both accomplish that goal and help reduce the number of patients flowing into the hospital emergency room, he persuaded county and state officials to agree to an experiment.
Shortly thereafter, a group of Wake County paramedics began to be trained to perform mental health exams on patients in the field who are judged not to be in need of emergency medical care. By asking a series of questions, the paramedics are then able to evaluate a patients mental condition.
While giving a patient the option of going to a local emergency room if they prefer, they also offer the choice of being taken to another facility that might be better suited to provide the kind of care they need.
Last year, more than half of the 450 patients identified with mental illness asked to go somewhere other than the emergency room.
Myers sees it as the start for connecting other types of patients with alternatives to hospital emergency rooms.
Our next big step is to get into the community in a big way, Myers said. Thats where were headed.