A Broader View of the Mental Health System Crisis in NH

Recent press reports and opinion pieces regarding the mental health system in New Hampshire have focused on the shortage of psychiatric beds at NH Hospital and its impact on local hospital emergency rooms. Daily email updates from the Department of Health and Human Services starkly report the numbers of adults and children with a mental illness waiting each day for a bed, which have shown a steady increase year to year.

Governor Sununu and key legislators who witnessed the emergency room backup first-hand at Concord Hospital earlier this year were inspired to re-write and make more robust what was initially a modest proposal for a new Ten-Year Mental Health Plan – HB 400 – and add money to fund it in the state budget. At the same time, the NH Community Behavioral Health Association (CBHA), the organization that represents NH’s ten community mental health centers, was advocating for workforce funding in the budget, but our request was upstaged by the bed shortage and hospital ER situation.

There is no doubt that the investments made in and attention given to mental health this year by the Governor and the Legislature are positive steps forward; however, CBHA sees two inherent problems with this approach: one is that policymakers are reacting to an immediate crisis and not addressing the underlying structural weaknesses of the mental health system; another is that adding more psychiatric beds, ACT teams and mobile crisis units to the mix does not mean that services are going to be delivered if we don’t have the people to do the work.

Greatest Need is Workforce Development

Some basic investments in workforce development programs could encourage people to enter and stay in the mental healthcare field. The ten community mental health centers currently have over 170 openings statewide and the wait time for an appointment can run several weeks. Medicaid rates at the centers are at 2006 levels, which has a direct impact on the centers’ ability to attract and retain qualified staff. CBHA asked the House and Senate to fund rate increases for our clinical staff this year but the new services in HB 400 and the budget were seen as more critical.

Meanwhile, the centers compete for staff with hospitals, MCOs (the insurance companies which manage the state’s Medicaid managed care program), schools, FQHCs, and other healthcare providers, almost all of whom can offer higher salaries and benefits. The upshot is that people who need mental health services before they get to a crisis level and need hospitalization are not getting help when and where they need it. Adding more beds to the system will not take care of the root of the problem, which is a weak and underfunded community-based system. Increasing rates beyond the 2006 level is the simplest fix.

Another relatively easy fix to the workforce problem is to relieve the community mental health centers of some of the administrative burdens imposed by the State and the Medicaid managed care program. CBHA’s suggestions range from eliminating some paperwork burdens required of staff, to consolidating data, reporting requests, and audits. One of the most commonly voiced complaints in staff exit interviews relates to the oppressive burden of paperwork.  An example CBHA outlined for the Governor’s office, following his request for a list of administrative rules that could be eliminated, shows that staff at one community mental health center must complete and sign 56,300 documents per year. These documents are in addition to the documentation for intake, therapy, and psychiatry services that clinical staff must also complete.

Simply put, a rate increase for community mental health centers and some relief from the administrative rules that unnecessarily burden our staff could make a significant difference in solving the workforce problem. And that in turn could help reduce the number of people who wind up at the other end of the system: needing a psychiatric bed at NH Hospital and sitting in a hospital ER while they wait for one.

There was much progress for mental health made in 2017, but we need to do more. The State and the community mental health centers worked together in 2008 to develop the original Ten-Year Mental Health Plan, which was celebrated for its vision but never fully realized because of inadequate funding. CBHA is glad to participate in the new Ten-Year Plan directed by HB 400, which we hope will lead to a more structurally sound and adequately funded mental health system for the future.  Let’s get to work and start making a better mental health system for New Hampshire.

Suellen M. Griffin, MSN, is President of the NH Community Behavioral Health Association and President and CEO of West Central Behavioral Health in Lebanon. Ms. Griffin is also an active member of the Public Health Council of the Upper Valley’s Advisory Council.

Lebanon Police Department’s Crisis Intervention Team

Article first published in The Lebanon Times, Summer 2017 issue. Reprinted with permission.

Lt. Matthew Isham

The Lebanon Police Department’s Crisis Intervention Team (CIT) is a community partnership with mental health professionals, hospitals, and other local agencies. Lebanon police officers who participated in the training received 40 hours of specialized instruction in dealing with behavioral health crises due to mental illness. After completing the training, the officers are better prepared to recognize signs of mental illness and safely de-escalate situations with individuals in crisis. Based on a national model started in Memphis, the program defines mental illness as a medical issue rather than a criminal problem and encourages treatment rather than incarceration. This model for community policing brings together law enforcement, mental health providers, hospital emergency departments and individuals with mental illness and their families to improve responses to people in crisis.

Sharing a Best Practice

Lieutenant Matt Isham started the trainings in Lebanon, and later worked with police forces in Hartford, Haverhill, Sullivan County, and the Vermont Forest Service to share the training across the area.

Crisis Intervention Team Depends on Partners

To implement the trainings, the Lebanon Police Department works in coordination with a diverse team of volunteers and professionals from Dartmouth-Hitchcock, West Central Behavioral Health, the National Alliance on Mental Illness (NAMI), the Public Health Council of the Upper Valley, and many more. Marjorie Matthews, a volunteer with NAMI New Hampshire says, “Matt is really the hero of this story. He saw the need, found the national Crisis Intervention Team model, and started the training here in Lebanon.”

The Right Thing to Do

The CIT program is focused on identifying, de-escalating, and diverting situations involving mental health crises. Once these situations are identified, the cases can be sent to the Mental Health Court in Grafton County through Halls of Hope. Lieutenant Matt Isham says, “It was the right thing to do. We have a lot of calls involving mental health issues or in crisis, so the more training we can get, the better for our officers.” Lieutenant Isham is especially grateful for the partnerships and collaborations that they have been able to create through the work with the Crisis Intervention Team. Both private and public entities provided training free of charge, and made a commitment to the intensive training. “It’s a total community and Upper Valley initiative that we started here in Lebanon and with the help of the Public Health Council,” Lieutenant Isham says. “The more officers have the knowledge, the more they will be able to help.”

Donna Stamper is a NAMI New Hampshire volunteer who has participated in six CIT trainings in the Upper Valley. She feels passionately about working with the Lebanon Police Department and other local law enforcement agencies to help address mental health issues in the community. She says that the key is to avoid the cycle of individuals going to jail instead of getting the help they need. Stamper says, “Lives can be saved by these diversion tactics.”

NH Opioid Addiction Prevention, E-Resources, and Support Website

Opiods were once thought harmless.In the spring of 2017, a group of Dartmouth students participated in a Neuroscience class, “Motivation, Drugs, and Addiction.” They were intrigued by the social ramifications of their classroom learnings. To explore their interests, they compiled a lot of useful information. The students then decided to share that information by designing a website. That site, NH Opioid Addiction Prevention, E-Resources, and Support (NHopes), is a collaborative effort between students at Dartmouth College, local researchers, and New Hampshire community organizations. All these partners seek to provide accessible scientific information regarding the current opioid epidemic in NH. NHopes is designed to be a welcoming, informative experience for those interested to explore and learn about the extent of the opioid crisis, how opioids act on the body, and about recovery and resource options.

The website uses info-graphics and simple explanations to explain who is affected by the opioid epidemic, what is happening in the epidemic, and why opioid use has exploded.

Samples of NH Opioid Website Content

Hotspot Study
Dr. Lisa Marsch and colleagues at the Dartmouth Center for Technology and Behavioral Health conducted a study in NH designed to understand what gave rise to the opioid crisis. She and her team interviewed 75 Fentanyl and heroin users and 36 emergency personnel from the fire, police, and medical departments. See more…

Carfentanil is an analog of fentanyl that is 100x as potent as fentanyl.

Carfentanil is an analog of fentanyl that is 100x as potent as fentanyl. Carfentanil has recently been reported in New Hampshire and has been attributed to 6 deaths so far in 2017. Carfentanil is lethal at small doses compared to both heroin and fentanyl (see image), and it is resistant to overdose reversal drugs.

A Social Impact Practicum

This site is made possible through the Social Impact Practicum (SIP) initiative at Dartmouth’s Center for Service. This program integrates community-driven opportunities for experiential learning into undergraduate courses at Dartmouth College. For more information, please contact Ashley Doolittle, Ph.D.

Partnering with Our Community

The Dartmouth students partnered with ALL Together to build this website. ALL Together is recognized as the Substance Misuse Prevention workgroup of the Public Health Council of the Upper Valley.  It is also nationally recognized as a Drug Free Communities Coalition.  ALL Together is supported by the New Hampshire Bureau of Drug and Alcohol Services, the New Hampshire Charitable Foundation, the Substance Abuse and Mental Health Services Administration (SAMHSA) and by Dartmouth-Hitchcock.

Upper Valley School Superintendents Summit

Upper Valley School Superintendents’ Summit Matches Students’ and Families Needs with Area Providers

On June 5, 2017, the Public Health Council of the Upper Valley and Dr. Joanne Roberts, Superintendent of the Lebanon School District, hosted a forum that brought together school personnel with health and human services providers. “Our schools in the Upper Valley provide great learning opportunities for our students. Our administrators and staff are talented, passionate and caring. One of the challenges we currently face is meeting students’ and families’ needs who struggle with poverty, housing insecurity, and are impacted by mental health issues and addiction. We need to mobilize all available resources to help support and serve our children and families,” said Dr. Roberts, to a crowd of over fifty people.

The idea for the Summit emerged from conversations between Dr. Roberts, and Alice Ely, Executive Director of the Public Health Council of the Upper Valley. Dr. Roberts described the challenges children and families are encountering. Ms. Ely offered to find the providers who could help address those issues. “We have so many great resources available here in the Upper Valley. However, sometimes the challenge for busy professionals is making connections to others who can help them better serve their constituents. That is one of the key roles the Public Health Council plays. I was thrilled to partner with Dr. Roberts to make this event happen,” says Ms. Ely.

A Service to Schools
At the Summit, 20 area providers shared brief descriptions of their services with over 25 school representatives from seven school districts. We used a round robin format to give each provider time to speak. Each round included time for questions and discussion. During a luncheon that followed, providers and school personnel were able to discuss future collaboration more informally. According to Jacqui Guillette, Superintendent of the Grantham School District, “This summit enabled staff from the Grantham School District to learn about providers and services available to support and help the Grantham students, families, and community. We feel better prepared to offer referrals or networking to these providers and services. This event was well worth the time we invested.”

Many of the providers at the Summit described the process as a very efficient way to let schools know how they can help. The Summit also served to many as a call for more collective action. As put by Heidi Postupack, Executive Director of Second Growth, “During the Summit, it became evident to us all that schools need support from every corner of the community including parent organizations, nonprofits, and faith-based organizations.”

Participants from Across the Region
The schools and districts whose staff attended the summit included: Grantham School District, Hartford Area Career and Technical Center, Hartford School District, Lebanon School District, Ledyard Charter School, Lyme School District, and the Mascoma Valley Regional School District.

Representatives from the following organizations attended to share information about their services and discuss partnership opportunities: Center for School Success, Child and Family Services, Clara Martin Center, Dartmouth-Hitchcock Pediatrics, Deer Creek PA, Good Beginnings of the Upper Valley, HALO Educational Services, HCRS, Lebanon Human Services, NAMI New Hampshire, Ottauquechee Health Foundation, Second Growth, TLC Family Resource Center, Twin Pines Housing Trust, Upper Valley Haven (Family Services and Children’s Support Programs), Vet Center, The Welcoming All Nationalities Network of the Upper Valley, West Central Behavioral Health, and WISE.

Ms. Ely hopes to use this summit format for future gatherings, between schools and providers and, potentially between other groups who would benefit from learning about each other. For the next School Superintendents Summit, planned for the spring of 2018, the Public Health Council expects to invite more school districts within our region.  She also welcomes ideas from the community about how such a format might be used to promote collaboration for better health.

PHC Seeks VISTA Volunteer

May 12, 2017 — The Public Health Council of the Upper Valley seeks a motivated VISTA Volunteer to serve as our PHC Partnership Coordinator for the next year. The Partnership Coordinator will develop an outreach and fundraising plan to build capacity in Vermont communities. The Partnership Coordinator will manage communications with and between the working groups of the Public Health Council. Finally, the volunteer will help promote the work of the Public Health Council in the region.

Benefits of the Position

The PHC works with community leaders and representatives from a diverse group of community sectors. Partners work together to create a more healthy, safe, supportive, and vital Upper Valley. The PHC encourages collaboration among organizations to deliver core public health services, establish public health priorities, and mobilize resources to achieve measurable outcomes. The proposed project will help the PHC build capacity to serve the needs of towns and organizations in the 22 Vermont communities recently added to our region. The project will strengthen our capacity to reduce health disparities and address social determinants of health across our entire region.

To do this work, our volunteer will interact with a diverse group of people from organizations across our region. All of these people are dedicated to improving community health and have lessons to teach. The volunteer will learn about the connections between health, health care, and the conditions in which people live. The position provides a wonderful opportunity for someone interested in a career in public health, community development, or community-based health services.

How to Apply

This position has been approved by the Corporation for National and Community Service. We are pleased to have a grant from the Couch Family Foundation to allow us to support this VISTA Volunteer position.

More details about the job description and instructions for applications are available at the Americorps website.