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Mental health leaders hope study into violent hospital outbursts will highlight problems

New Hampshire Union Leader

November 10. 2013 8:56PM

State mental health system leaders say they hope the state investigation into violent outbursts by patients forced to wait days for a bed in the state psychiatric hospital will focus attention on problems with the way mental health services are delivered in the state.

Gov. Maggie Hassan last week ordered a review of the circumstances that led to violent altercations with staff by patients at Elliot Hospital who were being held in the hospital’s emergency department for transfer to New Hampshire State hospital.

A retired Supreme Court justice, a senior assistant attorney general and the associate medical director at New Hampshire State were named to conduct the sentinel review, a term used to describe an investigation into a negative outcome in the health care system.

The study will focus on two episodes at Elliot Hospital in Manchester over the past several month. In July, a Manchester man who had been at Elliot waiting for a bed at New Hampshire State allegedly assaulted two nursing staff members. In October, a man was involved in an altercation with guards, also while awaiting transfer to the psychiatric facility.

“We see it as a problem, to make people have to wait to get into the hospital,” said Ken Snow, vice president of community relations at the Mental Health Center of Manchester, which provides community-based mental health services.

Snow, and some others involved in the mental health system say there are two components to the problem. A lack of available beds in psychiatric facilities means that patients under a court order for involuntary commitment must often wait in community or acute care hospitals for a bed in a psychiatric unit.

But he said community-based centers, such as the Manchester facility, are limited in the help they provide when a patient comes under severe stress, and the situation becomes worse, building to the point of crisis.

“If we could intervene earlier, there would be fewer people reaching the critical point,” Snow said.

Mental health workers told the New Hampshire Union Leader there have been other violent episodes around the state that have not received the attention of the Elliot incidents.

While the review ordered by Hassan is centered on the specific altercations at Elliot, mental health agency executives say they expect the panel to consider the broader issues that are blamed for those incidents.

“This will give us an opportunity to look at it from a system-wide approach and maybe understand what we can do system-wide given that viewpoint,” said Robert McLeod, chief executive officer of New Hampshire State Hospital.

The need to keep mental patients who are under state commitment orders waiting for a psychiatric bed is called a crisis by mental health treatment advocates.

“(Recently,) we had 30 people who were involuntarily committed waiting for mental health services at the state hospital; seven of them were children,” said Shawn LaFrance, executive director of the Foundation for Healthy Communities, a Concord-based organization that works to improve health care in the state.

The group published a report earlier this year documenting a reduction of about 140 beds in New Hampshire for psychiatric patients since 2005.

When all the available beds are full, the wait for admission begins when the commitment order is signed. The person ordered committed must wait in the emergency department of a hospital such as Elliot.

Sometimes, the wait continues for days.

“We would never tolerate that if these were cardiac patients who came in, or orthopedic patients,” Snow said. “If you came in with a compound leg fracture and someone said we don’t have any operating rooms or beds so we have to put you in a room and in two or three days we’ll operate, there would be a huge public outcry.”

Some involved in the system say there is a need for a balanced approach to treatment, to help patients before their problems build and they need emergency or court-ordered inpatient care.

“Whenever things get to the point where you have to do more emergency care, which is more resource-intensive, that draws energy and dollars away from more preventative care that focuses on rehabilitation and recovery,” said William Rider, executive vice president of the Manchester Mental Health Center.

Others say the problem is also seen at the other end of commitment, when patients remain hospitalized because there are few alternatives.

“There are those who are not discharged because there is not enough space in other places for them to go to,” said LaFrance. “People who work with these folks and their families realize that it’s not all just adding new beds, although there is clearly a need for that.”

More hospital beds for inpatient psychiatric care are being added, and funding for state mental health programs was increased in the current state budget.

New Hampshire State added 10 beds earlier this year, and is working to create a holding area in its admissions area to take some of the patients who might otherwise wait in emergency departments at hospitals that don’t have the resources of the state psychiatric hospital to deal with patients experiencing a mental health crisis.

In addition, Franklin Hospital has added 10 beds for mental heath patients and McLeod says other community hospitals have considered adding psychiatric beds.

But, he agrees that the state needs to balance creation of more inpatient space with restoring community treatment to levels that existed several years sgo so that fewer hospital admissions are needed.

“The real effort should be to keep them out of an inpatient setting to begin with,” McLeod said.

He expects the sentinel study team created by Hassan will see its mission as finding the underlying cause for the incidents at Elliot.

“There are greater factors than what went on in those incidents,” he said. “I know, in attending the kick-off meeting, that these individuals will be looking at anything that could be relevant.”

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