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0000017a-15d9-d736-a57f-17ff90890000A continuing series on The Exchange, featuring week-long looks at issues of importance to New Hampshire.New Hampshire's Workforce Challenges (Airing May 20-24, 2019)Mental Health In New Hampshire: The Patients, The Providers, The System (Aired in May, 2018)

In Depth: A Mixed Progress Report on N.H.'s Mental Health System

Dan Tuohy / NHPR

In the first of our four-day In-Depth series, The Exchange explored whether mental health care in New Hampshire has improved since the state agreed to invest more in the system  — part of a 2014 legal settlement. All agreed there's been progress. There's more help for people in crisis and more transitional housing.

But there's still plenty of room for improvement, including on permanent-housing arrrangements and reimbursement rates for struggling community mental health centers.  

(Interview highlights below (transcript excerpts have been lightly edited for clarity and length): 

Has the system improved?

Ken Norton, executive director of the N.H. chapter of the National Alliance on Mental Illness: When we're looking at the numbers of people waiting in emergency rooms and people kind of stacked up in crisis, the answer is, no. But in terms of the less visible -- the answer is definitely yes. Those are people receiving housing support through the mental-health settlement agreement; the mobile-crisis response in Concord, Manchester, and Nashua and other supports as well. I think that some of the steps that have been taken since the settlement agreement are definitely moving us in the right direction. 

Katja Fox, Director of the Division of Behavioral Health at DHHS: We need to look back a little bit further to 2008 when we had a recession hit and we had funding issues and an erosion of the system's infrastructure. Since that time we've had the opportunity -- and we really have an opportunity right now -- to invest in that infrastructure and to rebuild the system. And so we've been able to put in the community supports that are really needed, that we hope and know will make a difference in the future. It's happening now as a result of a lot of effort by a lot of people. 

"Under the leadership of Commissioner Myers from DHHS as well as our Governor and our legislature there is a commitment being demonstrated through funding." -Katja Fox

Andrew Milne, staff attorney for Disability Rights Center of New Hampshire:  For people at risk of unnecessary institutionalization, mobile crisis response has been a big benefit in three communities where it’s been implemented: a person in a mental health crisis can get help from a qualified professional either in person or by phone within an hour  to help defuse the crisis and avoid hospitalization. Teams can also refer folks to crisis apartments where they can stay for up to a week. And those are based in the community rather than the hospital. We’d love to see this go statewide.

Hundreds have received the benefit of expansion of supportive housing for people with mental illness, that's  money toward an apartment in the community. But there have been funding limitations and eligibility limitations. So there are still a lot of people who need this housing and aren’t able to receive it. The state has been expanding transitional housing, which is very different from permanent housing.

We have a close family member who was insitutionalized in the Concord State Hospital for a decade During that time, we tried very much to have him at least transitioned out to a more supportive community setting, a more integrated setting. That finally happened about five years ago, and it was as a direct or indirect result of the Disability Rights Center lawsuit that this dear family member was able to make that transition and start building some semblance of a normal life. It's not an easy path. It takes a long time but to have so many years essentially lost institutionalized was very painful for everyone involved. And I'm grateful that we made at least some progress. --Exchange listener, Dan.

Question from a listener:  The problems facing the mental health system aren't unsolvable. They just need to be made a priority by the legislature. What will it take to make that happen.

Katja Fox: I think under the leadership of Commissioner Myers from DHHS as well as our Governor and our legislature there is a commitment being demonstrated through funding. So we had funding through the budget and through HB 400 and the budget bill last year. There were serious dollars that were invested into the system, including housing supports, which are so important. We just had another session and there were additional investments in allowing us to be more flexible in the funding that we do have so that we can meet those needs.

How can the state attract more mental health workers when salary is still so low? What can inspire people to pursue the profession, given all the challenges?

Ken Norton: I've had just an amazing career. I've been in people's homes. I've been on maternity units. I've been in funeral homes. I've been in prison. I've been in jail. I've seen people at their worst. I've been to graduations. I've been involved in people's lives in a way that I wouldn't otherwise -- that has really helped me grow personally and help me with raising my family. And I've been able to, not get rich, but certainly lead a middle class lifestyle and be a much better person than I was before I got into the mental health field.

Katja Fox:  The student loan repayment program has been helping the state to recruit and retain qualified staff. Recent efforts by the legislature soon to be signed by Governor Sununu will invest another $700,000 into that program, so there is recognition that there needs to be a qualified workforce.  Once a person is placed and makes a commitment to stay with a particular program, they get repayment of their student debt over a period of time. 

Why are community mental health centers still reimbursed by the state at 2006 levels? 

Katja Fox: That is something that we are looking at. We're working very closely with the New Hampshire Community Behavioral Health Association and taking a look at those rates because we do know that the rates are set from 2006. We are working with our actuary to see what it would mean to make further investments. But yes very much so that's something that we need to do. When times were tough in 2008, it was one place where there was some leeway to be able to reduce rates and we need to get back and build those back up.

What is the role of private hospitals in improving New Hampshire's mental health system?

"There's simply a lack of capacity in the overall behavioral health system here in New Hampshire to treat patients with acute psychiatric crisis." - Steve Ahnen.

Steve Ahnen, President of the N.H. Hospital Association:  We still have people in waiting rooms. At the end of last week, there were 39 adults and three children in Emergency Departments around the state. The challenge is tremendous and hospitals are working very, very hard in collaboration with other community mental health centers and with others to try and make sure that patients who are waiting in the Emergency Departments are stabilized and that they're safe and that they are able to move as quickly as they can to the State Hospital. There's simply a lack of capacity in the overall behavioral health system here in New Hampshire to treat patients with acute psychiatric crisis. There are more private psychiatric beds today than in 2007. Reimbursement rates are often far less than the cost of providing the services. 

What is the state doing to address concerns about trasferring some patients with severe issues to the Secure Psychiatric Unit at the state prison?  

Katja Fox:  I think that's an area that is being debated and has been for years in the legislature. And I really think that that conversation is ongoing. I know that there was recent legislation that has to do with the Department of Corrections on that very issue, and so I think that's ongoing.

Ken Norton: Thirty years ago, it was in main building of New Hampshire Hospital.  There had been some incidents there. The legislature moved it to the prison. There was a lot of political pressure at time relative to the community not wanting it necessarily where it was on Pleasant Street.   There had been some incidents that had occurred there; there were a couple of high-profile escapes that resulted in tragedy. So it came under the auspices of the Dept. of Corrections. There was a gap  -- some people were not able to be managed at the hospital because of their safety or of staff. 

There's a new 10-year plan in the works now. What happened with the old 10-year plan?

Katja Fox: There were some pieces that we did not implement, including some of group housing. So we need a new plan because there have been many new models that have emerged -- like the mobile crisis unites, like the urgent care center for behavioral health. And those are the types of models and practices that we want to be able to implement in New Hampshire.

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