Crisis is a word—like perseverance—that gets used a lot by policy makers, politicians and advocates when human suffering reaches a boiling point. In NH, the mental health crisis has been boiling for years, and for those suffering with problems relating to their mental health, perseverance—however hopeful sounding the word may be—can be a form of torture.
The mental health crisis in NH began long before the pandemic hit in March 2020, according to experts, and despite some recent investment in mental health services, the crisis continues. There are 221,000 adults in NH suffering from a mental health condition—five times the population of Concord—according to NAMI NH. Increasing suicide rates for young people, lack of access to care and lack of funding to increase the number of clinicians in the state all remain issues of deep concern for policy makers and professionals in the field.
Susan Stearns, executive director for NAMI NH, says the pandemic brought the crisis into focus in a new way because it was a “collective traumatizing event” that forced conversations about wellbeing and mental health into the open and “exacerbated what was already happening for people.”
While years of hard work remain to address the state’s approach and response to mental health, Stearns sees a glimmer of hope on the horizon. She believes the state is experiencing a time of system transformation.
“In a certain sense we’re lucky to be doing this work at this time,” Stearns says, citing Medicaid reimbursement expansion, recent programmatic changes, such as NH Rapid Response—the state’s crisis support system, as well as the state’s Mission Zero plan that aims to eliminate hospital emergency department psychiatric boarding by 2025. “We’re experiencing a true transformation of our systems. I think in 10 years we will look back and be able to say we’ve transformed our entire mental health system.”
But transformation involves addressing the complex reasons for the ongoing mental health crisis, finding help for those who need it as quickly as possible and seeking ways to prevent it from ravaging people’s everyday lives, mental health experts agree. “There are still a lot of areas of need that we need to do a lot of work on,” Stearns says.
A Supply and Demand Problem
One glaring area of need across the state is a lack of mental health professionals, making it difficult for patients to access mental health services. Roland Lamy, executive director of the NH Community Behavioral Health Association (NHCBHA), which has 3,000 full-time employees at 10 centers across the state—including one of the the largest, Riverbend in Manchester— says demand for services across the state is “greater than our supply of providers.” He explains that, as of May, NHCBHA had 348 clinical vacancies across its 10 centers. “This includes everything from folks with bachelor’s degrees—which would include social workers— to MD’s. The total number, aside from these clinical folks, is 392. This is our main issue because it can delay care and create access problems,” Lamy says.
According to NAMI, 92,510 people in NH, or 6.6% of the state’s population, live in a community that does not have enough mental health professionals.
Brad Kreick, CEO for SolutionHealth in Bedford, an integrated health care system that includes Southern NH Health in Nashua and Elliot Health System in Manchester and employs close to 7,000 people, says the access problem applies to both inpatient and outpatient settings. “We have a fundamental access problem,” he says. “The outpatient access crisis is every bit as significant as the inpatient crisis. We have a fundamental supply and demand problem.”
New 144-Bed Behavioral Health Hospital
SolutionHealth is stepping up to address the access issue, recently reaching an agreement with the state to operate a new $60 million, 144-bed behavioral health hospital in NH for at least 10 years.
Like hospitals across the state, SolutionHealth’s facilities have experienced the strain caused by boarding patients in emergency rooms until there is a more appropriate setting that can treat them. “We continue to see long-term boarding of patients in our emergency rooms—rooms that are not equipped for long-term care needs—due to the lack of hospital beds and facilities that are properly equipped and staffed to care for patients in need of specialized services,” Greg Baxter, president and CEO of Elliot Health System noted in a June 30 announcement about the new behavioral health hospital.
The new hospital is due to open in 2024 and will be a joint venture between SolutionHealth and Acadia Healthcare, a national provider of behavioral healthcare services, with the NH Department of Health and Human Services contributing $15 million in state funding to defray capital costs for the construction. The agreement with the state calls for a minimum of 70% occupancy in the first two years and then 80% for the remaining eight years.
SolutionHealth currently has 65 inpatient behavioral health beds between its Manchester and Nashua campuses. “We’re really excited about the investment we’re making,” says Kreick. “Right now, it’s a matter of not enough beds and not enough employees. And, we’re making a really significant investment in building out that inpatient infrastructure.”
Geography Determines Who has Access to Care
While the new hospital will help alleviate the stress on emergency rooms in southern NH, access to mental health care providers is a statewide problem. And the severity of the crisis varies in different parts of NH. Data collected by the University of Wisconsin Population Health Institute shows that two of NH’s most rural countries have the lowest ratio of mental health providers in the state with one provider per 450 residents in Coos County and 460 residents per provider in Sullivan County.
“These data suggest geography may be a significant barrier to accessing mental health services for many New Hampshire residents,” says Phil Sletten, research director at the NH Fiscal Policy Institute.
While the disparities are less in central and southern NH, larger population centers are still feeling the strain of the shortage of mental health professionals. There was approximately one mental-health-services provider for every 190 people in Belknap and Grafton counties in 2022, and 210 people per provider in Merrimack County but relatively fewer providers in the state’s most populous counties (280 residents per provider in Hillsborough County and 350 residents per provider in Rockingham County).
The data is concerning as patients may face more significant delays in accessing mental health services depending on where they live. Delays in accessing mental health care can lead to the deterioration of a person’s condition and often come when a person is initially seeking mental health services as waiting lists are long. “How long does it take for you to get your first appointment? That’s where the delays are really happening,” Lamy says. “Access is a major issue, but I want to be clear, if people have an emergent issue or a patient is discharged from a hospital in an acute psychiatric condition, they’re going to be seen right away.”
One solution aimed at supplying more clinicians was taken up by the NH legislature two years ago. HB 143, signed into law in 2021, requires the Board of Mental Health Practice to adopt rule changes allowing a wide range of mental health workers to receive conditional licenses that allow them to work in NH. As of this writing those changes have yet to take effect. In August, however, the licensing board announced it is taking action to begin implementing the regulations found in the bill following pressure from Gov. Chris Sununu.
Lamy, whose association was involved in developing the initial legislation, says it can take more than nine months to recruit and hire non-domestic clinicians due to existing licensing requirements. “It shouldn’t take us as long as it does to get them approved,” he says. “The Board is responsible to people in our state. We’ve seen the state do things with the nursing community where there’s more reciprocity; why isn’t this true of the mental health work force, which is equally as stretched with limited resources?”
Gov. Chris Sununu issued the Board of Mental Health Practice an ultimatum, directing it to file a rulemaking proposal that implements HB 143 no later than Sept. 1. “If the Board is unwilling or incapable of fulfilling their responsibilities, I will take necessary steps pursuant to RSA 4: 1 to ensure that the Board is comprised of individuals who are so capable,” Sununu said in a statement issued in late July.
Medicaid Expansion and State Investment in Mental Health
Sletten says the recent reauthorization of the Medicaid expansion will likely help more people access care in the future. “Medicaid expansion, also known as the Granite Advantage Health Care Program in New Hampshire and enabled by the federal Patient Protection and Affordable Care Act, has helped many New Hampshire residents access mental health services,” he says. In fiscal year 2022, 29,941 people received mental health medication treatments through the Medicaid expansion. The Medicaid expansion also helped 11,456 people access mental health outpatient services during this time. Sletten points out these two groups are not mutually exclusive.
The 2024-2025 state budget includes $134 million in state general funds for Medicaid and waiver program rate increases. This is the largest infusion of state funds in history. It includes $12 million in general funds each year for a 3% rate increase for all Medicaid providers, except hospitals. “Had the program been allowed to expire, access to mental health services statewide would have likely been curtailed, particularly for residents with low incomes,” Sletten says.
Lamy says the NH House and Senate and the Governor’s office highlighted the need to invest in outpatient mental health care this year, and additional investments in the mental health workforce were recently approved in the annual budget. “That will go a long way,” he says. “The next issue that we have, the crux of the matter really, will be trying to invest in pipeline management. How do we get professionals interested in this field? How do we educate them here locally or regionally? And then how do we retain them?”
Another positive development, Stearns says, was the state’s decision in July to not challenge a federal court order giving the state until May 2024 to stop holding people for emergency psychiatric care in emergency rooms for days and weeks. “Hospitals have agreed to forgo claims and legal fees as well,” Stearns says. “It’s a pretty aggressive deadline to manage this by May next year, but the budget signed into law contains unprecedented investments in our mental health system and Medicaid reimbursement rates should help with workforce issues [that] community health centers are facing along with the array of services they provide.”
The Impact of COVID on Youth
While COVID exacerbated mental health challenges for people of all ages, youth and young adults have seen a rise in anxiety and depression as well as suicide, Stearns says. “We’ve seen the numbers increase over the past few years with mental health issues and certainly suicidal ideation,” Stearns says, adding that according to data from 2021, suicide is now the leading cause of death for 10-to-14-year-olds in NH. “As long as I’ve done this work, it’s been rote in citing the data that suicide is the second leading cause of death for Granite Staters aged 10 to 34. Now I’m having to reframe that because for these youngest kiddos, it became the leading cause of death.”
Stearns says significant work and investment is happening in the children’s system including the state purchasing Hampstead Hospital for $15 million last year to provide mental health services to children. The state “is expanding that to include a residential treatment facility, a level of care the state hasn’t had,” she says. “So, there are really good things happening in our state.” Stearns adds that while the system is stressed, it is important that people not feel deterred from seeking the care they need.
She says she has been inspired by the youth and young adults she encounters. “They are very open about supporting each other, and I think they are going to push us and lead the way,” Stearns says, explaining they are forcing people in positions of power to listen. “They’re having conversations in the public eye today,” she says. “I think back to our founders of NAMI over 40 years ago, and this level of openness is an opportunity they could’ve only dreamt of.”
Access and the Need for Equity in Health Care
Reducing the wait times for people to access mental health services is vital. Dr. Holly Mintz, chief medical officer of Ambulatory Services for Elliot Medical Group, who has spent most of her career as a pediatrician, points out that patients with other medical issues would not tolerate the long waits endured by those with mental health issues to receive preventative care and treatment.
“When a patient calls to be seen for a health issue, it’s usually been going on for quite a while, and the need for access is really important,” Mintz says, noting that wait times for intakes for mental health services “can be anywhere between 60 days to nine months. If somebody has a pain, they don’t wait nine months or 60 days. We do what we need to do to get people in.”
Another issue that limits access is that most therapy practices will only provide care to those with insurance, Mintz says. “We’re working on that also to make sure there’s equity and access for care,” she says, adding that depression screenings, which started about 10 years ago, while helpful, are only effective if there are resources to treat the patient. “The challenge is, again, there’s an inequity there because people who have the ability to pay are more successful in finding care.”
The issue of equity when it comes to mental health intersects with other social problems, Stearns says. “The housing situation in New Hampshire has a profound effect on people with mental illness,” she says. “This is not simply because they can’t find safe and affordable housing. It’s also difficult finding housing for the providers who want to move new providers into the state. We also still see far too many people in our state [with mental health issues] getting involved in the criminal
justice system.”
Stearns says the NH Judicial Branch is doing “great work making sure mental illness is addressed,” including holding a Mental Health Summit in June. “People with mental illness intersect with the justice system at multiple points, perhaps because of symptoms they have, they have committed crimes, probate commitments, guardianships, there’s a whole host of legal reasons people intersect with that system, and we need to be responsive to their needs.”
Stearns is optimistic about the investments the state is making in mental health, and NH is moving in the right direction. However, there is still much work that needs to be done, she says. “This budget has significant investments, and that’s great, but it’s up to all of us to make sure policy makers in the future continue to invest in this system,” she says. “Thirty years ago, New Hampshire had what was considered one of the best systems in the country. We know where lack of investment or disinvestment can land us, and here we are. We need to ensure that these investments continue long term. We can’t afford to allow our system to reach this level of disarray.”
Current Issue - May 2024