Terri Clyde’s grandson John is 12 years old, but cognitively he’s five. Clyde gained custody of John, who has fetal alcohol syndrome and a traumatic brain injury, when he was an infant. By age three, he experienced auditory and visual hallucinations. Voices told him to harm himself; imaginary bugs flew down from the ceiling and crawled around his skin, and blood oozed from his sneakers.
After four hospitalizations at the state hospital, John was admitted to Spaulding Youth Center, a residential program for kids with disabilities. Last December, after three years, he came back to Clyde’s home in Merrimack and is attending a private school.
To manage his anti-psychotic medications, John visits an advanced practice registered nurse (APRN) at Harbor Care Health and Wellness Center in Nashua who consults by phone with a psychiatrist at Dartmouth-Hitchcock in Lebanon. The APRN prefers that he visit a psychiatrist in person, as does Clyde, but she cannot find one locally, especially one willing to accept his two insurances, one of which is Medicaid.
That’s not unusual, says Ben Garber, a child psychologist and family law consultant in Nashua. He says the average waiting period for a psychiatrist in NH is about six weeks. For a child, “twice that.”
More than half of all psychiatrists are over the age of 55 and many of them will retire soon, leaving further gaps in the system, according to the American Psychiatric Association (APA).
A Critical Shortage
The shortage of psychiatrists and other master’s level clinicians has many implications. It limits care for underserved individuals like John and his family. And in the wake of an epidemic of heroin and opioid abuse, it is also creating havoc for NH community mental health centers and hospitals that can’t keep up with heightened demand.
In July, insufficient staffing pressed the Cheshire Medical Center/Dartmouth-Hitchcock Keene to eliminate its 18-bed inpatient psychiatric facility, which had room for six adolescents. The decision wasn’t sudden or easy, says Don Caruso, CEO/president and chief medical officer. Three years ago, two psychiatrists retired. Since then, a shrinking pool of per-diem staff filled in shifts, commanding 1.5 times the standard rate. Potential salaried candidates, because of a lifestyle choice, didn’t want to cover evenings and weekends, a requirement at acute care facilities.
To bridge the treatment gap for mentally ill patients, Caruso says a consultative liaison service, which includes an APRN, assesses patients in the emergency department. The service also coordinates with Monadnock Family Services (MFS), one of the state’s 10 community mental health centers, to help evaluate and place at-risk patients who are a threat to themselves or others.
High-risk patients wait in one of the hospital’s four so-called safe rooms until the APRN finds them a psychiatric bed at either the NH Hospital for involuntary admissions or another facility. Unfortunately, Caruso says some patients have waited up to two weeks.
At the end of May, between 20 and 60 patients crowded NH’s emergency department rooms or hallways, waiting for a psychiatric bed, according to the National Alliance for the Mentally Ill-NH (NAMI-NH). Many of them were children.
A Mixed History
The shutdown of Cheshire Medical Center’s inpatient psychiatric unit comes on the heel of other scale backs at the state hospital, including the closure of the Anna Philbrook Center for children in Concord in 2010.
Devra Cohen, a child and adolescent psychiatrist in Nashua, says that since the Philbrook Center closed, young children with dangerous psychotic symptoms linger in pediatric wards for prolonged periods, with no access to treatment, at an incredible expense, and with patient sitters who stay with the children to ensure they remain safe. “The costs are shifted to the taxpayers,” she says.
In 2010, the NH Hospital had 189 psychiatric beds for potentially dangerous patients who are admitted involuntarily. By 2016, that number slipped to 158, a net loss of 31. Why the reductions? A report by the Treatment Advocacy Center, a national nonprofit dedicated to eliminating barriers to the timely and effective treatment of severe mental illness, describes a movement against warehousing mentally ill patients in large facilities. On the surface, this trend makes sense: patients fare better receiving services in their own communities rather than at institutions.
But community services in NH, which include support for employment and housing, are falling through the cracks, says Ken Norton, executive director of NAMI-NH.
Norton says the state’s weak mental health delivery system is a far cry from the late 80s when state lawmakers sanctioned budgets that allowed people with chronic or severe mental illness to receive care close to home.
In that era, NH was recognized as a leader in providing services in community settings. But NH’s stake as an exemplary model for treating the mentally ill ended in the 90s after the economy dipped.
By the 2008 recession, lawmakers turned off the spigots for funding critical residential programs that offered therapy and social services. They also slashed jobs at the NH Department of Health and Human Services (DHHS). As a result, institutionalization climbed. In fact, from 1989 to 2010, annual admissions to NH Hospital increased by 150 percent from approximately 900 to about 2,300.
Negligence ran so amok that in 2012, the Disability Rights Center, representing six plaintiffs, sued the state for violating the Americans with Disabilities Act as well as other laws requiring people to receive care in the communities where they live. The complaint stated that without such services, “many class members are repeatedly and needlessly readmitted to NH Hospital, or forced into other inappropriate settings, such as hospital emergency rooms, homeless shelters, and jails.”
The state, in conjunction with the DHHS, settled the suit by the end of 2013, agreeing to spend $30 million on expanded mental health services. However, the commitments don’t extend to children.
Slow Improvements
Reviews are mixed as to whether the state is moving forward.
A few improvements show signs of hope. Franklin Hospital opened an acute in-patient psychiatric ward in 2013, where patients are admitted against their will. And in July of this year, a 10-bed crisis unit began accepting patients at NH Hospital, but only after a scarcity of psychiatric nursing applicants caused a yearlong delay.
These new beds may ease the strain on emergency department resources, but not likely any time soon. Emergency rooms continue to grapple with serving mentally ill patients. At St. Joseph’s in Nashua, social worker Jason Forbes describes a young man with paranoid schizophrenia who is repeatedly admitted to the NH Hospital and discharged, only to show up time and again in St. Joseph’s emergency room. “He’s been here multiple times in one month [of July],” says Forbes. Since he’s physically aggressive and sexually inappropriate, “one person has to hold him down, while another medicates him,” he explains. This goes on for hours, says Forbes, drawing staff members away from other urgent care patients.
More hospital beds won’t resolve the state’s demand for mental health services, says Norton, at least as long as funding and workforce deficits persist.
An overburdened system led to delays in creating what are called assertive community treatments and mobile crisis units through the community mental health centers. The state settlement requires these two provisions—but an expert reviewer who assesses the state’s progress says they continue to need improvement.
The assertive community treatment (ACT) teams, which include clinicians, social workers, vocational rehabilitation counselors and nurses, serve patients who may be homeless, or otherwise lack the cognition to show up to appointments. The ACT teams tend to offer more help than what traditional outpatient clinics can give. There are 12 ACT teams in NH: eight of the 10 community mental health centers have an ACT team, while Nashua and Manchester each have two.
The mobile crisis units act as first responders, diverting clients from landing in emergency rooms.
The true cost of staffing these ACT teams is about $1.5 million to meet federal requirements, says Peter Evers, CEO of Riverbend Community Health in Concord. That includes nurses, psychiatrists, social workers and specialists in substance abuse, as well as a program coordinator and an administrator. “They work together [to assist] 70 individuals who have very severe mental illness,” Evers says, explaining the money comes from the state and a federal 50 percent match.
Under the lawsuit agreement, the community mental health centers are committed to serving 1,500 patients. “But we only have slots for 830. We’re about $780,000 short of what we need in funding,” Evers says.
Riverbend was the first in the state to launch a mobile crisis unit. The second, in Manchester, was delayed for three months because of staffing challenges. It is due to open in October. A third is planned for July 2017 in Nashua.
Detailing the Shortage
Like many discussions about staff shortages, salaries are at the forefront. “Psychiatrists make a quarter of what surgeons do,” explains Evers. Riverbend compensates its six psychiatrists slightly above the average national salary of $186,000. But Evers says he’s always looking over his shoulder.
“We had about 140 vacancies across the community mental health system at the beginning of the summer,” says Norton, who says these positions are for more than psychiatrists. They include openings for mental health personnel who are on the day-to-day frontlines with clients.
Although beyond traditional retirement age, Riverbend’s Medical Director Osvaldo Evangelista, 66, says he gets 40 job offers a week in his personal email, about half that in his work email, and about five a week on his cell phone. “And this is not because I’m Sigmund Freud,” the psychiatrist says while laughing. “It happens to all of us.”
Evangelista says no other medical specialty has as acute a shortage as psychiatry. This became evident at NH Hospital when Dartmouth-Hitchcock took over staffing responsibilities in July from the Geisel School of Medicine at Dartmouth College. In a much-publicized labor dispute, 11 psychiatrists and psychiatric nurses severed their relationships with the hospital. Dartmouth-Hitchcock issued a public statement, saying that these were “disgruntled employees” who demanded “prevailing wage plus 30 percent, biannual cost of living adjustments … and other benefits not offered to any other Dartmouth-Hitchcock employee.”
Robert A. Greene, executive vice president and chief population health management officer for Dartmouth-Hitchcock, says that the organization is ramping up recruitment using national firms and hefty advertising. “And [the recruitment] won’t stop when the New Hampshire Hospital is fully staffed,” he says, adding that the hospital is committed to working on NH’s mental health issues.
But it won’t be easy. Lisa Mistler, a NH Hospital psychiatrist and president of the NH Psychiatric Society, says psychiatrists don’t command the high salaries—more than $350,000—that neurosurgeons, orthopedists and cardiologists earn because they’re not ordering revenue-producing procedures like X-rays, EKGs and surgeries. Still, psychiatrists leave medical school $200,000 in debt.
“Our profession involves primarily listening to people, evaluating them clinically and prescribing medications as well as doing psychotherapies of various kinds,” says Mistler. “These activities are not reimbursed at the same rates as other health care providers procedures.”
Low pay is a deterrent, but Maria Oquendo, president of the American Psychiatric Association cites another disincentive: Psychiatry carries a stigma because the “illnesses we treat have long been seen as a sign of weakness or moral failing, particularly given the lack of biomarkers.”
That notion, however, is slowly changing, says Oquendo, as research since the 1970s bears out the connections between biology and brain functions. “As we become more biologically oriented, people view psychiatry with equal footing in the house of medicine.”
While there has been a minor uptick in medical students choosing psychiatric residencies, the United States trails at least nine other countries in psychiatrists per capita, per the Organization for Economic Cooperation and Development. When considering that one in five Americans experiences a mental health issue in a given year, the struggle to bring young talent into the fold looms even larger.
Rural Areas Hit Harder
The dearth of psychiatrists and other mental health care staff is not simply a challenge for NH. It’s a national plight. And the pipeline for a psychiatric workforce is even more tenuous in rural regions.
About two years ago, Northern Human Services, which provides mental health care for Coos, Carroll and northern Grafton counties, had six full-time psychiatrists. But then one doctor left to establish a private practice, a second joined him, and a third retired and now works for the agency part-time.
Eric Johnson, the agency’s CEO, is hiring another full-time psychiatrist, but the search has lasted for seven months.
And the latest statistics don’t forge optimism: While the total number of physicians rose by 45 percent from 1995 to 2013, the number of psychiatrists inched up only 12 percent, according to the American Medical Association.
The odds of hiring a good match are particularly grim for the North Country, which offers mountain views and low crime, but lower than average pay. With any luck, Johnson says he can lure doctors with previous ties to the area.
“We try really hard not to have a waiting list for people with severe mental illnesses,” says Johnson. “But it’s a struggle,” he adds, particularly in sparsely populated towns like Berlin.
Help may be on the way in the form of a student loan repayment program, which reimburses psychiatrists for up to $75,000 as long as they work a minimum of three years in medically underserved areas. In the last eight years, only three psychiatrists took the bait, according to the DHHS, taking jobs in Berlin, Colebrook, Groveton, Franklin, and Littleton.
For now, Johnson relies on a small but valuable corps of nurse practitioners licensed to prescribe psychotropic medications. The agency, which covers a large expanse of the North Country, also leverages telepsychiatry so doctors in one office can consult with patients in another community.
Fixing the System
Dr. Robert Feder runs a private practice in Manchester. He is 65, and in January cut back his patient load as a phase-in to retirement. While he admits many of his cohorts are of a similar generation, he insists the paucity of private psychiatrists is not a function of age, but of a wonky insurance system.
Feder is a board member of the NH Psychiatry Association, and represents the state at the APA assembly. He doesn’t mince words when referring to the health insurance industry. “Psychiatry has always been the first target of insurance companies to reduce the services they cover and amount of money they pay,” he says. “They know the population is vulnerable, and they know patients won’t raise the ruckus the same way they would for cancer or heart disease treatments.”
Most private practices don’t have the machinery to handle billing, which leaves psychiatrists like Feder on their own to process claims. Feder says he spends about 25 to 30 percent of his time on insurance bureaucracy, with a large chunk devoted to defending authorizations for medications or inpatient admissions. To simplify paperwork, he accepts only two types of insurance and limits insurance patients versus self pay to 80 percent of his practice, a number he is trying to reduce.
While the Affordable Care Act mandated coverage for mental health and substance abuse treatments on par with other medical conditions, the requirement is a work in progress, and Feder says the law is not enforced.
NH Initiatives
Several endeavors are underway to address staffing issues in NH. The DHHS received a $150 million waiver from the federal Centers for Medicare and Medicaid Services in January to transform NH’s behavioral health delivery system.
The Building Capacity for Transformation waiver includes projects to recruit, train and retain staff on the front lines of behavioral health care, including both mental health and substance use disorder counselors.
The waiver allows seven integrated delivery networks (IDNs) of regional providers to collaborate on clinical management and population health. All seven IDNs will use funding to develop capacity needs, and, by October, will submit project plans.
In April, Gov. Maggie Hassan created the Commission on Health Care Workforce to recommend ways to expand the pool of qualified health care workers. Hassan also signed a bill that month to simplify the licensing process for alcohol and drug abuse counselors moving here from other states.
In June, the Executive Council approved an $870,000 contract with Bi-State Primary Care Association in Bow to recruit primary care, oral health, behavioral health and substance use disorder professionals to NH.
The Affordable Care Act gives millions of more people access to mental health coverage. Yet finding counselors and other mental health professionals remains a challenge. Under the state’s initiatives, experts hope that bigger salaries and a better integration of holistic care will help. Meanwhile, the demands are growing at alarming rates.
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