Much has changed since the 1980s, when New Hampshire was among the first states to provide treatment and services for the mentally ill in a community rather than institutional settings. The development of medications, together with improvements in diagnosis and treatment, promised patients more complete and autonomous lives in their communities among family and friends while reducing the need for confinement and supervision.
“Capacity is the overriding issue,” said Roland Lamy, executive director of the NH Community Behavioral Health Association. Inpatient services are not sufficient to treat the numbers of mentally ill experiencing crises who require them. Outpatient and support services at the community level are not sufficient to stem the numbers requiring inpatient care. And housing, employment and other support services are not sufficient to ensure inpatients can be safely returned to the community in a timely manner.
New Hampshire Hospital, which once housed over 2,500 residents, was downsized and restructured as an acute care facility with 168 beds designated for those in crisis. They are admitted involuntarily and require immediate inpatient care. The hospital now serves some 2,000 patients a year.
Ten regional community mental health centers (CMHCs), private nonprofit agencies, have contracted with the state to provide a variety of publicly funded outpatient services, along with 24/7 emergency services, intended to spare patients from crises requiring inpatient care. The centers serve between 45,000 and 50,000 patients annually.
The system was also designed to include 10 regional designated receiving facilities (DRFs) or inpatient psychiatric units within hospitals or other institutions. Their number has varied over time as hospitals have closed and opened psychiatric units and now stands at four — in Portsmouth, Franklin and two in Manchester.
“It was a great plan,” Lamy said, “but it was never realized.”
An inventory taken by the Human Services Research Institute in 2017 counted 458 psychiatric beds, 168 involuntary beds at New Hampshire Hospital and 238 voluntary inpatient beds among 13 community hospitals. Another 28 beds have been added since the report was completed.
Lamy said that for want of sufficient and stable funding, the infrastructure of community-based clinical and support services has neither been developed nor sustained as originally intended.
The National Alliance for Mental Illness New Hampshire (NAMI-NH) reported that the number of mentally ill involuntarily held in hospital emergency rooms awaiting admission to New Hampshire Hospital or a DRF has risen by 350 percent in the past three years.
According to DHHS, the average daily waiting list by month was 24 in the 2014 fiscal year, 25 in 2015 and 28 through June 2016, then rose to 40 between July 2016 and July 2017 before jumping to 50 between August 2017 and May 2018. Moreover, many inpatient stays have lengthened for lack of community-based resources, especially housing, hindering the process of returning patients to the community.
Last year, the American Civil Liberties Union filed a class action suit in federal court, charging that holding involuntarily committed patients in emergency rooms for more than 72 hours without a hearing before a judge, as required by state law, violates their constitutional right to due process. The NH Hospital Association quickly joined the suit.
For some years, patients deemed to pose a threat to themselves or others, but not charged with a crime, have been held in the Secure Psychiatric Unit at the state prison, for lack of secure facilities elsewhere. There they are mingled with inmates sentenced for criminal offenses.
In his inaugural address, Governor Sununu pledged to end the practice — unique among the 50 states — this year, and in his budget address called for construction of a forensic hospital.
Other similar patients are boarded at the Glencliff Home for the Elderly, including some individuals in their 40s and 50s.
Adding to the problem, as the labor market has tightened with the growing economy, financial restraints have contributed to severe staffing shortages at the community mental health centers.
Ken Norton, executive director of NAMI-NH, said that staffing shortages have left patients waiting “weeks, even months” for access to appointments and treatment, while Lamy placed workforce issues alongside capacity as the major challenges facing the centers.
In 2016, the NH Community Behavioral Health Association (NHCBA) began tracking employment at nine of the 10 centers. In November 2018, 217 — or 9 percent of the 2,433 budgeted positions at the 10 centers — were unfilled. And 186, or 86 percent, of them were clinical positions. The rolling turnover rate for the 10 centers in 2018 was 23 percent.
Compensation for clinical staff at the centers is less than the state mean wage for their profession and qualifications, hindering the retention and recruitment of personnel, especially psychiatrists.
In 2017, the NHCBHA reported that psychiatrists at its members’ sites earned 12 to 29 percent less, advanced registered nurse practitioners earned 5 to 11 percent less and therapists earned 35 to 57 percent less than the state mean compensation for the those professions.
These and other issues were addressed by two reports in 2008, which included recommendations to stanch the erosion and restore the health of the system. But, with the onset of the Great Recession and the opioid crisis, the recommendations were not implemented.
[This story was produced for The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information, visit collaborativenh.org.]