By Lynn Bonner
August 26, 2014
U.S. Rep. Tim Murphy, a Pennsylvania Republican and author of a bill to revamp mental health care, came to North Carolina on Tuesday, visiting a state suffering many of the ills his legislation is meant to remedy.
A sharp decline in state psychiatric hospital beds and a lack of meaningful community treatment after a state overhaul in 2001 left wreckage authorities are still trying to fix.
The state hospital beds that remain are usually full. Too many mentally ill people end up in hospital emergency rooms, where they wait, sometimes for days, for available beds.
U.S. Rep. Renee Ellmers, a Dunn Republican who supports Murphy’s bill and accompanied him to a meeting with News & Observer editors and reporters, said emergency rooms are trying to adapt to help mental health patients who may wait up to five days to get a bed: “That’s five days without care. And although those health care professionals are doing the best job they possibly can, they are not psychiatric doctors and nurses.”
The state is trying to figure out alternatives to emergency room care, with the state Department of Health and Human Services convening meetings to develop solutions.
Murphy’s bill is meant to address some of these deficiencies, also common in other states. The proposal was developed in response to the Sandy Hook Elementary School shootings in 2012, where a mentally ill 20-year-old killed 26 people, including 20 children.
Murphy wants to direct more of the money the federal government spends on mental health to care for seriously ill patients, encourage funding for treatment shown to produce good results, and make it easier for patients to receive the medicine that doctors prescribe.
‘A success story’
Murphy, a practicing psychologist, and Ellmers began the day with a telemedicine demonstration at Daymark Recovery Services in Raleigh, a company that provided mental health services to more than 4,000 people at its facilities around the state without doctors or nurses in the same room.
The state itself is investing in telemedicine as a way to address the shortage of psychiatrists available to consult with other doctors or treat patients. East Carolina University is administering a statewide telepsychiatry network, and more than two dozen hospitals are signed up to use it, with more to come.
“It really is a success story,” said Dave Richard, a DHHS deputy secretary.
Murphy’s bill would set up a $12 million, 4-year grant program to help 10 states develop telepsychiatry and doctor training programs for treating and referring children and young adults.
Mandatory treatment provision
But some of the bill’s prescribed remedies are controversial.
They include a requirement for states to have “assisted outpatient treatment” laws, which allow judges to order people into treatment, to be eligible for a source of federal community mental health treatment money. North Carolina is among the states with such laws that require some severely mentally ill patients to receive outpatient care. Opponents criticize these laws, which they say amount to coerced medical treatment.
Murphy said the laws cover a small percentage of severely mentally ill people who cycle in and out of jail and emergency rooms, yet refuse treatment.
Some people who are severely ill don’t believe they’re sick, he said.
“Why would we say, ‘We know you have a deteriorating brain disease, but we’re not going to help you until you kill someone?’ ” Murphy asked. “Why would we have that standard? It is a perverse and inhumane standard to have for people.”
Researchers at Duke University have reported that costs for patients in New York City declined 50 percent in the first year after assisted outpatient treatment began. Costs dropped more dramatically in five other New York counties studied.
A 1999 Duke study of outpatient commitment in North Carolina found that patients required to be in treatment had about 57 percent fewer hospital readmissions than similar patients who were not required to receive care.
The N.C. Department of Health and Human Services did not have current information on how many patients have been ordered to receive outpatient treatment or how much it costs.
‘Proactive intervention’ needed
Vicki Smith, executive director of Disability Rights North Carolina, said having adequate treatment is the central issue because judges can’t order people into treatment that doesn’t exist.
“We don’t have readily accessible mental health services for adults until they go into crisis,” she said. “Until the state does more proactive intervention, it won’t work.”
Murphy hopes to see movement on pieces of his bill this fall. He says the plan will save money, because fewer people will need mental health care in jails, prisons and hospital emergency rooms. But he wants to get proof of that, which is difficult.
The bill has bipartisan support, but Ellmers is the only representative from North Carolina who has signed on. Some Republican colleagues worry about the bill’s costs, Murphy acknowledged.
A Democrat from Arizona is sponsoring legislation that omits some of the controversial elements in Murphy’s proposal.
N.C. effort slowly takes hold
The state, through DHHS, has been working for months on its own plans for reducing emergency room use by people with mental illnesses.
An early effort was to develop a county-by-county directory of emergency mental health treatment services. Another project includes an education program to help young people. The regional mental health agencies are also actively strengthening their own crisis services, Richard said.
The plans have yet to show results, however. Hospital emergency department admissions have not dropped significantly, Richard said.
“It will take time to see big drops,” he said. “We haven’t seen any dramatic changes.”
Deby Dihoff, executive director of NAMI NC, said there was more the state could do. For one, mobile crisis teams that regional mental health offices pay for should operate properly, she said. The crisis teams are supposed to handle emergencies so that patients don’t have to go to the hospital, but too often teams end up taking people to emergency rooms, Dihoff said, resulting in charges for both the crisis team and hospital treatment.
Hospitals are required to report how many psychiatric beds they have available, but the policy is not enforced, Dihoff said. So hospital social workers spend hours calling around the state, she said, searching for places to send patients who are languishing in emergency rooms.
Dihoff said she was frustrated by the slow pace of progress of the state effort. “Let’s move things along a little more quickly,” she said.