Mental health

A lack of psychiatric beds in Western North Carolina and statewide means that patients sometimes require monitoring for extended periods in local hospitals.

On May 7, a psychiatric patient was transported from Watauga Medical Center in Boone to Central Regional Hospital in Butner, just north of Durham. In Central, the patient would be able to receive treatment for his psychiatric condition, and such transports are fairly normal.

What wasn’t normal is that the patient, who won’t be identified, was in Watauga Medical for weeks before his transport, waiting for a bed in a psychiatric unit to open up.

Due to the wait, the burden fell mostly on the Watauga County Sheriff’s Office to monitor the patient 24 hours a day until he was transferred to another hospital.

“There were a couple times in there where it was hospital police,” said Watauga County Sheriff Len Hagaman. “We were there for the most of it.”

According to Stephanie Greer, director of Behavioral Health Services for ARHS, the patient was in Watauga Medical Center for 20 days. Watauga County Sheriff’s Office Major Kelly Redmon said the patient was originally brought to the area by his caretaker to RHA Health Services in Deep Gap, but Redmon said he was admitted to the hospital after attacking several patients.

“When patients have complicating conditions like this patient suffered from, it requires high levels of state resources that are often unavailable immediately,” Greer said. “The delay in his transfer was specifically due to having to wait for bed availability at Central Regional Hospital.”

In North Carolina, local law enforcement agencies are specifically charged with transporting and seeking bed space for involuntary psychiatric patients after a court official makes a determination to commit them.

“Once we receive the paperwork, we have to line up a bed,” Hagaman said.

The involuntary commitment process in North Carolina is for mental health patients who are determined to be a risk to themselves or others, or who are in a deteriorating mental state.

Due to a lack of psychiatric bed options, Hagaman said his office will look all over the state. The trouble of finding a psychiatric bed for mental health patients is an issue that is prevalent across Western North Carolina.

Craig Martin is the chief medical officer of Vaya Health, which is a licensed managed care organization that covers 23 counties in Western North Carolina. Vaya is one of several MCOs that receive state funding to help provide services at reduced costs, including mental health services.

“Absolutely there’s currently a shortage,” Martin said. “We’re probably in the bottom quartile in not only the state but the nation.”

Locally, the only option available within a 40-mile radius is Cannon Memorial Hospital in Linville, which is part of the Appalachian Regional Healthcare System.

“Each year Cannon Memorial Hospital’s 10-bed behavioral health unit receives over 5,000 referrals, but we are only able to admit approximately 500 patients,” said Greer. “While all of those referrals are not from the High Country exclusively, it clearly paints a picture of a gap across the state of North Carolina relative to inpatient psychiatric / behavioral health care.”

Hagaman said that once an individual in an emergency department is designated for the involuntary commitment process, law enforcement usually turns them over to hospital police. A rating system is used based on a physical and mental assessment where low risk patients are looked over by hospital staff, high risk patients by hospital police and very high risk by the local police.

“We get a couple of people (annually) for very high risk,” Hagaman said.

Hagaman said the individual who was held at Watauga Medical for 20 days and roughly four weeks in WCSO care was “very combative.” Greer said that there were six reported assaults at Watauga Medical by the patient, but couldn’t speak on other assaults prior to the patient’s arrival. Redmon didn’t have records of reported assaults at RHA Health Services, although he said the number of incidents there was more than they could handle.

Not all psychiatric patients wait as long as four weeks, but the waits do affect the other emergency aspects of the hospital.

“A delay in accessing behavioral health treatment creates longer wait times in emergency departments for psychiatric and non-psychiatric patients alike,” Greer said. “The average length of stay or wait time to find appropriate treatment options for behavioral health patients is 16 hours at Watauga Medical Center and 18 hours at Cannon Memorial Hospital.”

Once a bed is found, typically WCSO is transporting the patients. Hagaman said that in 2018, around 50,000 miles were driven out of Watauga County for transport, sometimes all the way to Craven County on the coast. Around half that number was for standard inmate transport and the other half for psychiatric patients, involuntary and voluntary, Hagaman said.

Helping find psychiatric beds for mental health patients takes a community effort. In Watauga County, a mental health task force exists between WCSO, the department of social services, Daymark Mental Health Services, Vaya Health, local police departments, ARHS Police and individuals from local counseling centers and medical staff.

“It’s a whole myriad of folk whose goal is to reduce the time they are in the emergency room or emergency department because it takes a lot of resources to watching someone for 24 hours for two to three days,” Hagaman said.

Hagaman credits Greer for putting together the task force, which has met on a monthly basis for the past three years after starting roughly five years ago. The meetings are to share statistics and better improve lines of communication between agencies.

“Watauga County is very fortunate that we have this task force,” Hagaman said. “There’s a lot of struggle elsewhere. This task force irons out the issues and the benefit is that we usually find a bed earlier so the patient is getting help quicker.”

Prior to the partnership, Hagaman said that “everyone was blaming everyone else.” The need arose from a commitment of a special needs child, who waited weeks before law enforcement was able to find a bed. Hagaman said the total officer time with the child was 4,000 hours.

“To have someone sit there for 12 hours, they’re off the road for that time,” Hagaman said. “Its takes an officer that could be answering calls.”

“We, the county, had to take care of this,” Hagaman added.

So far, the task force has been effective, Hagaman said, noting an “absolute decrease” in time it takes to find a bed for a patient, but did note that there’s been a rise of involuntary commitments over the last few years.

“For (patients in the involuntary commitment process), we have a very good relationship and partnership with Blowing Rock Police, (Appalachian State University) Police, (Appalachian Regional Healthcare System) Police and Boone Police.”

Going forward, the number of mental health patients is on the rise while the funding is lacking.

“We don’t treat people with mental illnesses in our hospitals the same way,” Martin said. “If you have a heart attack, would you wait seven days for service?”

Martin says the problem is connected directly to a lack of funding for state mandates.

“Legislation was passed to require each county has a crisis intervention plan, but no funding was attached to that legislation, so no money for law enforcement to hire an officer, or for hospitals to treat the people, that’s the challenge,” Martin said. “The need is there, but the funding to provide that need is not there.”

“The mental health system is definitely broken, but we’re better off in Watauga,” Hagaman said. “The patient is getting much more quick treatment than they did in the past and that’s the bottom line.”

One positive going forward is that regionally, the number of psychiatric beds is growing. Cannon Memorial Hospital in Linville, part of ARHS, is adding 27 psychiatric beds to its 10 existing beds with an anticipated completion by 2021.

Martin noted psychiatric beds are being added in Caldwell, Alexander and Buncombe counties over the next year, but he believes Medicaid expansion would help uninsured patients be able to find a psychiatric bed quicker.

“People who have Medicare or Medicaid usually don’t have problems (finding psychiatric beds); people who don’t have insurance have more problems,” Martin said.

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