RANDOLPH, Vt. (AP) - It's no secret that both New Hampshire and Vermont lack a sufficient number of beds for people suffering mental health crises, forcing emergency rooms at local hospitals to serve as holding stations while patients wait for a bed to open up in an appropriate facility.
With New Hampshire down to 168 beds at New Hampshire Hospital and Vermont's 45 beds spread across the state psychiatric hospital, Brattleboro Retreat and Rutland Regional Medical Center, those emergency room stays can be lengthy.
It's also well known that people experiencing mental health crises do not receive the care they need while they're waiting, because local hospitals generally don't have staff members trained in mental health care.
Less well known, however, is the impact this ad hoc arrangement has on the hospitals.
A person in mental health crisis who has been involuntarily admitted to a hospital and forced to wait for transfer to appropriate treatment can create any number of problems, including endangering staff, creating financial burdens for the hospital, undermining morale of hospital employees and diverting resources from other patients' care.
Both states are taking steps to address the chronic shortage of beds, but neither expects the problem to disappear soon. In the meantime, the issue is very much on hospital administrators' radar.
"If you're at the state level and at the regional level, you're hearing about the cost of health care," said Barbara Quealy, chief operating officer at Gifford Medical Center in Randolph. "This is a piece of it, especially with such limited resources."
Patients who are involuntarily admitted to hospitals while in the throes of a mental health crisis might arrive at the emergency room in private cars, by ambulance, with a police escort or from another section of the hospital. The vast majority pose no threat, but a small number do become violent.
In late May, an aggressive patient with a mental illness in the emergency department of Valley Regional Hospital in Claremont kicked a staff member.
In another instance, a different patient in crisis caused several thousands of dollars' worth of damage to the hospital's emergency department while staff cowered nearby.
Though the injuries have so far been relatively minor kicks, bites and bruises Valley Regional's chief executive Peter Wright said he worries it could be worse.
"I'm afraid that we are just playing statistics," he said. "Is this going to be the time that someone really gets hurt?"
Such patients often demand a high degree of attention and security while they are waiting sometimes weeks for involuntary inpatient beds elsewhere.
"I have a lot of people afraid to come to work," Wright said. And, he added, "Let's not forget that the person is in crisis."
Valley Regional saw about 48 patients experiencing such crises between April 2016 and April of this year, Wright said.
At Gifford, just two nurses typically work in the emergency department at one time. If a mental health patient requires one-on-one care, the nursing staff is reduced by 50 percent, said Dr. Scott Rodi, director of Gifford's emergency department.
Or, if they call in an additional nurse, they're increasing their nursing staff by 50 percent, he said.
Other staffing costs for hospitals include training to prepare staff to de-escalate situations when patients become violent this may involve a mental health patient in distress, a person with dementia or someone struggling with substance abuse. Valley Regional and Gifford recently have begun offering Crisis Prevention Institute training to all staff members.
And time in training is time away from patient care, Wright said.
At one such training, in May, Patricia Hall, a registered nurse and director of Valley Regional's clinical practice and education, instructed about a dozen participants in methods of avoiding injury when patients become violent.
"As much as is possible, keep yourself between people and the door," Hall said. That way, "(you) don't have to walk by them to get out."
During the active portion of the training, Hall instructed those standing on one side of the room to "attack" those on the other and asked the "victims" to "respond the way you are really going to respond if someone takes a swing at you."
"Be aware of your joints. They are a weak point," Hall said.
She also advised participants to choose their clothing carefully, warning against high heels and recommending layers that might be easily removed if grabbed by a patient.
When a mental health patient becomes violent, both Valley Regional and Gifford rely on a private security firm and local law enforcement to help keep patients and staff members safe.
Valley Regional uses security services provided by Hunter North Associates, a company based in Spofford, N.H., or officers from the Claremont Police Department, Wright said.
Paying the Claremont police for detail duty is billed at time and a half, he said. The police officers earn the money, he noted, but the hospital isn't reimbursed for the added cost.
Valley Regional pays between $20,000 and $30,000 in additional security costs annually, Wright said. That does not include times when the hospital's regular security team is summoned from other tasks to attend to a mental health patient in the emergency room, he said.
"It is difficult to quantify those dollars," he said.
Gifford also contracted with Hunter North this year to provide security services from 7 p.m. to 7 a.m. on weekdays and 24 hours a day on weekends, Quealy said.
"That's a huge investment," Quealy said, although she declined to provide details about the exact cost to Gifford.
Since Tropical Storm Irene destroyed the 54-bed Vermont State Hospital in Waterbury in 2011, Orange County Sheriff Bill Bohnyak and his deputies have often been called to assist with mental health patients at Gifford, he said.
"Almost every other week we're getting a phone call to go do one of these mental health 'sits,' whether it's at Gifford or somewhere else in Vermont," Bohnyak said. "If we have people available, we'll send them. If not, we have to call other county sheriffs."
Randolph police and the Vermont State Police also lend a hand when necessary, according to Gifford officials.
The sheriffs bill the state of Vermont $50 per hour per deputy, Bohnyak said. That covers time and a half for a deputy and the cost of a vehicle, he said. Two deputies per shift are required for a mental health sit, or six total for a 24-hour period.
The deputies are not just at the hospital for an eight-hour shift, he said. Instead, they're there until the patient leaves the emergency room.
"(It) could be days or weeks," he said.
Aside from the financial cost to cover the sheriffs' time, Bohnyak said, his biggest concern is the effect of violent patients on others in the emergency room.
"When we have these patients coming to an emergency room for help, they're not in control of themselves," he said. "Sometimes their behavior becomes very disruptive toward the staff."
There might be a small child with a fever nearby who is exposed to vulgar language by the patient in mental distress, Bohnyak said. He said he's also seen such patients smash telephones and tear televisions off walls in rooms in emergency wards.
"It's not their fault," he said. "They're going through a crisis in their life."
The presence of security at Gifford has helped some members of the staff to feel more safe, but it also has caused alarm among members of the community, officials there said.
Gifford sits on Route 12 just south of Randolph's downtown and its parking lot faces the road, so when a police car sits there for days, community members take notice, said Ashley Lincoln, Gifford's director of development.
Just that presence can make patients and community members tense, and when they need to seek care at the hospital some wonder, "what am I going into?" Lincoln said.
Within the hospital, the demand on limited resources can become acute.
Valley Regional has had to redirect ambulances to Dartmouth-Hitchcock Medical Center in Lebanon because the staff has been so overwhelmed with stabilizing the mentally ill, Wright said. In some cases, it can take eight to 10 people to hold down one patient in crisis, Wright said.
While staff members can handle one such patient, there have been times when they have been overwhelmed with four at once, Wright said.
It's at those times that Valley Regional has had to redirect ambulances, Wright said.
This is not something that Gifford has done, officials there said. Though they have had to call in extra staff, pay overtime and call in per diems to care for the up to three mental health patients they've had in the emergency room at one time, Gifford officials say they would not send other patients away.
"This is their community," said Jamie Cushman, the clinical nurse coordinator in Gifford's emergency department. "This is the right place to treat them."
Mental health patients who wait in Gifford's emergency department for an involuntary inpatient room elsewhere are often placed in the room that sits next to the nurses' station, which means that when such a patient is there and nurses need to attend to another patient or use the bathroom they must pass by two security guards and a patient who might be yelling, Rodi said.
"Ten days of this ... is exhausting for the whole staff and really demoralizing," Rodi said.
The stress has not caused people to leave their jobs, but it has affected employees' mental health, Cushman said.
For staff, the emotional toll is compounded by the knowledge that the patients aren't getting better, Quealy said.
"That's part of the frustration," she said. "They see these patients abandoned by the state system, almost."
In an emergency room, mental health patients lack access to the therapy, medications and the appropriate care they need to get healthy, Quealy said.
"They're just sitting there," Cushman agreed.
Working with difficult patients also takes a toll at Valley Regional, Wright said.
"This is a great job, but that can wear on you after a while," he said.
Staff members don't often get to see the results of their labors after a patient eventually receives the treatment he or she needs, but in at least one instance Quealy did.
"She sought me out, which surprised me," said Quealy, who had been involved in this patient's care. In a Dunkin' Donuts, the former patient "came and gave me a hug. She said, 'Gifford made me feel safe when no one else did and I will remember you people for the rest of my life.' "
Quealy said the woman "looked fabulous."
And seeing her look so well was "a gift" one Quealy was glad to share with others involved in her care.
All hospitals are affected, small and large. At a June "No Health Without Mental Health" forum at Dartmouth-Hitchcock Medical Center in Lebanon, Dr. Alan Green, chairman of the department of psychiatry at Geisel School of Medicine, noted the emergency department wait time in his introductory remarks.
"Last night, there were 53 patients in the (New Hampshire) system waiting for beds," Green said.
That number included four at DHMC, he said. "They're stacking up here; they're stacking up everywhere," he said.
Annually, DHMC refers 150 such patients to involuntary inpatient beds elsewhere, primarily at New Hampshire Hospital, said Dr. Christine Finn, the director of crisis and consultation services at the medical center.
DHMC is better equipped than its smaller counterparts to handle these patients. There, the emergency department has four rooms that have been specially designed for mental health patients, three with features intended to reduce the risk of self-harm or harm to others, and a fourth quiet room, Finn said.
"We certainly did some good anticipatory work with the construction," she said.
That work, which was completed about three years ago and cost about $500,000, was prompted by hospitals in southern New Hampshire already seeing an increase in their mental health patient loads in emergency rooms, she said.
The tertiary care hospital also has psychiatrists and social workers on staff and its own security force, she said. DHMC has 21 inpatient adult voluntary beds, Finn said.
For mental health patients awaiting beds elsewhere, Dartmouth-Hitchcock has hired licensed nursing assistants to assist such patients with food and basic hygiene.
Because DHMC has psychiatrists available, they are able to begin treatment in the emergency room, Finn said. Some patients are then able to be admitted to voluntary placements or even to go home, she said.
"That is an important resource that many, many hospitals won't have," Finn said. It allows DHMC to "really start to manage these patients from a treatment perspective. Not just kind of hold them in a contained environment."
To assist smaller community hospitals with the care of mental health patients, Finn said, DHMC could provide telemedicine services. Making such expertise available would allow patients to begin treatment while they await transfer, she said.
Though DHMC has more resources than the smaller community hospitals, patients in the emergency room still don't receive the high level of care they need, Finn said.
"It's very distressing to feel like there's a very important patient need that isn't being met because of the lack of availability of resources," she said.
A contributing factor to the problem is that the two states have reduced the number of appropriate beds in recent years.
When Vermont made arrangements to replace the state hospital destroyed by Tropical Storm Irene in 2011, it designed a system with nine fewer beds. New Hampshire's diminished capacity stemmed from legislative efforts to cut costs during the recession, which resulted in the closure of about 40 beds at the state hospital over the past decade. In what may be the beginning of a trend reversal, New Hampshire Hospital opened a 10-bed unit last July.
Both states' problems are exacerbated by a nationwide push to care for such patients in less restrictive environments closer to home, which requires additional community supports such as access to housing and counseling services.
While providing and staffing more beds for mental health patients in crisis is the most obvious solution to address the long wait times in the emergency room, this is a problem that seems to defy simple answers.
While both states have taken steps to address these problems New Hampshire in response to a 2012 federal lawsuit and Vermont in response to the loss of its state hospital neither has sufficient community resources to help people transition from an intensive treatment facility back into their communities. They also lack sufficient supports to help people maintain good mental health and prevent recurring crises. Though treatment in an involuntary inpatient setting may relieve patients' immediate suffering, their illnesses often persist.
No official interviewed in either state could readily define what combination of community supports, additional inpatient beds and other resources would provide adequate capacity.
The community hospitals are making individual efforts.
In an effort to prevent crises that send people to the emergency room, Gifford officials say they are working to connect patients with mental health services when they come for primary care and are exploring grant funding to create separate rooms better suited to holding mental health patients.
But finding the approximately $1 million to cover the cost of converting the space isn't easy, Rodi said.
Rodi also is looking into using telemedicine to connect patients with psychiatric care while they are waiting, he said.
"People are working on this in different ways," he said. "Not sure (it's a) well-coordinated statewide effort."
Gifford officials have tried to make clear to state officials that the current situation is untenable, Quealy said. At times, she said members of the board have reached out to the Governor's Office.
At Valley Regional, the Ladies Union Aid Society held a plant sale this spring to raise money for a $3,500 bed with restraints for the hospital's emergency room. The bed was installed in June.
Other physical improvements to Valley Regional's emergency room may be in the offing. Officials proposed converting the hospital's now-closed birthing unit into 10 designated receiving beds, but failed to secure the bulk of $1.5 million needed to do the renovations from the state, Wright said.
"(We) haven't totally taken it off the table," he said. But, it's "not at the top of our list."
Regarding the state legislation, Wright said, having beds in the community available to those who are transitioning out of the state hospital will be helpful.
"(We) need facilities in every corner of the state to help take low-acuity patients," he said. "(We) need a stepping stone."
Patients who are receiving care at the state hospital "don't just become well overnight," he said.
A law enacted by the Vermont Legislature this year, Act 82, outlines many of the things that may contribute to wait times for involuntary inpatient beds, including the state's failure to establish a 24-hour non-emergency help line and eight recovery beds, which were intended to help people transition from involuntary inpatient treatment back into their communities. The help line and recovery beds were required under Act 79, a 2012 law that aimed to address the state's mental health system following the loss of the state hospital in Irene, but have yet to come into existence.
Additional factors include a shortage of psychiatric care professionals, low wages and reimbursement rates for social service agencies, and a need to address other needs that may contribute to mental health disorders, such as housing, employment and food security, according to the text of the law.
Act 82, which was sponsored by the Senate Committee on Health and Welfare, also points to a need for more information to guide future policymaking.
The secretary of human services is called upon to provide the Legislature with an action plan and legislative proposals by Dec. 15 of this year.
"ER wait time is a symptom of all these factors highlighted in this bill," said Laurie Emerson, executive director of Vermont's chapter of the National Alliance on Mental Illness, a nonprofit organization that offers support, education and advocacy for those affected by mental illness.
Emerson said she is encouraged by Act 82.
"We are hopeful they are starting to look at the system as a whole," she said.
But, Vermont Sen. Dick McCormack, a Bethel Democrat who sits on the Health and Welfare Committee, did not mince words in his assessment of Act 82.
"I don't think we really accomplished much with it," he said.
McCormack said the Legislature was hamstrung by Gov. Phil Scott's desire not to increase spending and uncertainty about spending at the federal level.
"We know that the situation is not acceptable," he said.
If the money were available, McCormack said, he would legislate to establish more crisis beds.
"It's not rocket science," he said. "You would have more facilities with people who are trained to do this kind of work."
In New Hampshire, legislators passed a bill, HB 400, that in combination with the recently approved state budget, will add 20 beds for community-based inpatient care of involuntary psychiatric patients, according to Susan Paschell, the lobbyist for the New Hampshire Community Behavioral Health Association.
The budget also includes funds for transitional beds intended to help prepare patients to return to their communities 20 in fiscal year 2018 and 40 in fiscal year 2019. There also is money for a new mobile crisis unit, which provides care to those in crisis in the community or at home; peer crisis beds, which are staffed by people who have themselves struggled with mental illness; and wrap-around services for children with severe emotional disturbances.
"I'm very pleased overall," said Ken Norton, executive director of NAMI New Hampshire.
In particular, the community-based designated receiving beds will make a big difference in taking pressure off emergency rooms, and transitional beds will help those who have completed treatment at the state hospital but still need support, he said.
Even as the state has made progress, however, Norton said he has concerns about the way that proposed federal cuts to Medicaid would diminish access to mental health and substance abuse services.
"It's been really good news on the state level," Norton said, "scary news on the federal level."
Suellen Griffin, president of Lebanon-based West Central Behavioral Health, also said she is enthusiastic about the state's efforts and thinks that once the beds are up and appropriately staffed they will make a difference in emergency room wait times.
But, she noted, some of the money for these new initiatives was taken from workforce development programs intended to encourage people to enter and stay in the state's mental health care field.
"If they can staff it and build it, it will make a difference," she said.
Additionally, Griffin said, the state's efforts are targeted at addressing a crisis, but do not address broader structural issues with the way mental health care is provided, such as low reimbursement rates.
"The underlying problem still exists," she said.