Mental patients get stuck in ERs

RALEIGH -- Across North Carolina, mental patients are routinely languishing for days in emergency rooms ill-equipped to care for them, waiting for a bed to open at one of four state-run psychiatric hospitals.

Often, they pass the time handcuffed or sedated. Law-enforcement officers assigned to guard patients whose illness makes them prone to violent outbursts have occasionally resorted to using Tasers to shock them into submission.

Lanier Cansler, the state's secretary of health and human services, plans to ease the strain by paying private hospitals with taxpayer money to admit and treat more mental patients, especially those who don't qualify for Medicaid.

But a survey the department conducted of nine community hospitals raises questions about whether many medical facilities, especially those in rural areas, are capable of taking on that responsibility.

North Carolina tried to reform its mental health system in 2001 by downsizing state hospitals and paying private, for-profit companies to care for people in outpatient clinics.

Nine years later, the reform has had the opposite of its intended effect. Programs that were supposed to save taxpayers money wasted more than $635million, according to a recent legislative audit. Meanwhile, demand for state hospital beds has soared.

In the first eight months of this year, the state hospitals placed more than 3,700 patients seeking help on waiting lists because of the lack of available beds, according to the Department of Health and Human Services.

Despite the crisis, the state budget Gov. Bev Perdue signed in August cut $155million from the state's mental health system, resulting in the loss of 354 jobs at state hospitals.

At Cansler's urging, $12million was allocated to pay for adding about 100 psychiatric beds at community hospitals - an average of one bed per county.

The money will go to pay for small units of eight to 10 beds each in a handful of medical hospitals across the state. The secretary hopes more money for the initiative will be available in the future, as the economy improves.

"We're returning to really what was the original intent of reform," said Cansler, a former Republican legislator who was a deputy secretary of health and human services when the flawed initiative was implemented. "It's all built around doing as much as we can in our local communities, instead of depending upon our state facilities."

About half of all people admitted to such state-run facilities as Dorothea Dix Hospital in Raleigh stay seven days or less. If they can be treated close to home in local hospitals, Cansler said, the state hospitals would be left to focus on patients who need long-term, more intensive care.

The secretary said he recognizes, however, that it will take far more than the 100 beds funded to ease the crush of patients seeking admission to state hospitals. And there are questions about whether hospitals in parts of the state where the need is greatest will participate.

Many of North Carolina's small community hospitals far from urban centers don't have access to psychiatrists or other professionals trained to help people with mental illness, especially those who might become violent, according to the health and human services survey.

Emergency room staffs at two of the nine hospitals reported multiple incidents of law officers Tasering disruptive patients in the last year.

All the hospitals surveyed, including Raleigh's Wake Med, reported an increase in the number of psychiatric patients over the past six months, a trend attributed to the weakened economy and shrinking options among the very outpatient treatment programs that were supposed to ease the demand on hospitals under the reform plan.

And when those at the community hospitals contact the government-run facilities for assistance, they said, they are too often faced with rude state workers who use bureaucratic procedures purposely to delay admissions, according to the survey report.

Urgent phone messages are sometimes not returned for as long as 12 hours, and it is impossible to get someone admitted to a state facility during nights or weekends, when the need is often most acute.

"Without exception, they report that the single biggest problem they face in the emergency departments is procuring appropriate psychiatric care promptly," the report says. "They expressed confusion and dismay that it would be totally unacceptable for individuals with acute medical problems to languish in the [emergency department] for days, but that is a common practice for psychiatric patients awaiting care."

The hospitals reported good experiences transferring patients to the few government-funded beds in private facilities that are now available, mostly in the western part of the state.

'Crazy' cuts

The report, obtained by The News & Observer and The Charlotte Observer through a public records request, is far more frank and unvarnished than is typical for a government-produced document. Michael Lancaster, the chief of clinical policy for the state mental health system, described it as raw data intended for use by an internal workgroup. "It wasn't supposed to go anywhere," Lancaster said Friday.

The report also provides recommendations for what the state can do to help, such as assigning a single staff member to work on admitting patients who have been waiting in an emergency room for more than three days. Those recommendations, as well as a one-page summary of the problems found by the survey, will eventually be presented to senior DHHS administrators, Lancaster said.

Rep. Verla Insko, a Chapel Hill Democrat and co-chairwoman of the legislative oversight committee for mental health, said the survey identified problems that must be addressed if the system is to work. She said that she has heard of patients waiting in emergency rooms as long as 10 days and that the deep cuts to community services in this year's state budget are "crazy."

"We should act quickly to ensure prompt and courteous communications between agencies and give priority at our state institutions to the most severely ill or violent patients," she said. "The overuse of emergency departments will go on as long as we fail to provide adequate services."

Ann Akland, president of the Wake County chapter of the National Alliance on Mental Illness, said she was horrified to hear that patients suffering psychotic episodes are being Tasered in emergency rooms.

"If this were happening to animals, people would be outraged," she said. "The state hospitals are understaffed, underfunded and demoralized. Now the state is trying to pass the ball to communities even more ill-prepared."

Treating patients who suffer from severe and persistent mental illness is not profitable. They often don't have private insurance. Though some qualify for Medicaid, many are indigent. As a result, most community hospitals stopped providing psychiatric services in the past 20 years.

"We're working with the state to address the bed shortage issue," said Stephanie Strickland, spokeswoman for the N.C. Hospital Association. "But a lot of our smaller hospitals just don't have psychiatric caregivers at their facilities. Maybe they used to years ago, but they don't have the resources now. The infrastructure is not there."

Cansler said he wants to rebuild enough local capacity to implement a policy of patients being admitted to a state facility only if they first spent a week in a community hospital.

"Some hospitals, once they see we'll pay for it, are willing," Cansler said. "Some hospitals are resistant. They know they had the beds before and they lost money. I think given a little help, most of them are going to step up to the plate."

Empty beds

Bill Atkinson, president and CEO of WakeMed, was noncommittal when asked whether his hospital would start admitting mental patients.

Atkinson pointed out that Holly Hill Hospital, a psychiatric hospital in Raleigh adjacent to WakeMed, just built an expansion with the help of Wake County. Many of those beds have been empty, he said, because of "arcane" state rules limiting what types of patients the private hospital can admit.

Cansler said working with such private facilities to clear bureaucratic roadblocks will be essential to easing the capacity crunch.

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