Legislature is Right to Focus on Community Mental Health Services

New Hampshire is facing important choices about how to improve our mental health system. It has  seen troubled for years, leaving many without adequate care and triggering multiple lawsuits. Despite repeated recognition that a neglected community service system is the cause of increased demand for state hospital beds, the Governor is pushing the legislature to permanently expand hospital bed capacity to a level far beyond what current demand requires, even without accounting for gains that could be made with more humane and cost-effective community services. So far, the legislature has resisted the Governor’s effort, recognizing that we should avoid permanent hospital construction while we rebuild the community system.

The House Finance Committee just completed its budget work, declining to construct a second adult hospital, and more sensibly choosing to free up existing state hospital beds which can accommodate patients at the Secure Psychiatric Unit and waiting in emergency rooms. This would be accomplished by moving children to a more appropriate setting and moving patients ready for discharge from the state hospital into new housing in their communities. New local hospital beds would also be added. Initiatives to improve the community system also are proceeding through the legislative process. This is where we should focus our efforts and resources.

No one disputes that community services are badly weakened and need investment. Patients typically wait 4 to 6 weeks for a first appointment in community mental health centers, which struggle to operate with over 200 vacant clinical positions, 20% more than two years ago. This increases demand for hospital beds.

Resources needed for patients ready to leave the state hospital are also insufficient, wasting inpatient space. Between 50 and 70 beds are filled by people who could be discharged, but lack needed community supports. Those who do leave return at a 50% higher rate than the national average, another sign of a system that struggles to keep them healthy and stable.

Outside experts have repeatedly diagnosed the problem as one of inadequate community services, not inpatient capacity. A 2017 analysis commissioned by the state found that while our bed capacity was slightly above average for a state of our size, our community system was inadequate to avoid unnecessary hospitalizations. The US Department of Justice and the Disability Rights Center concluded that mental health patients were hospitalized due to insufficient community services, violating their civil rights. The state settled the resulting lawsuit, agreeing to improve the community system, but has yet to fully implement that agreement. The independent expert who monitors the agreement recently stated that “[m]uch remains to be accomplished to meet all the requirements” of the agreement and better performance by the state would reduce the demands on the state hospital.

The alarming numbers of adults and children waiting in emergency rooms for inpatient treatment is a tragedy that requires urgent attention. The impulse to dramatically increase bed capacity is understandable, but the Governor’s proposal misses the mark: First, it goes well beyond the need, creating many more beds than required to responsibly address the crisis, without considering reductions in demand that would result from improved community services. Second, new hospital construction is a permanent solution to a temporary problem. The community service  system could be restored in a relatively short time, resulting in fewer patients needing hospitalization, but a new 60-bed hospital would be a long-term commitment to an estimated $30 million per year operation, using scarce resources that should be devoted to keeping people living fulfilling lives in their communities. Third, as the community system struggles to find workers, the proposal would create large competing workforce demands, making it harder to restore community services.

The legislative effort is composed of sensible steps in the right direction, making an improved community system the focus by investing in housing, mobile crisis response, and reimbursement rate improvements for community service providers. These are proven to reduce hospital demand and help people transition successfully after hospitalization. Stable housing with supports from community service providers reduces the incidence of psychiatric emergencies. Crisis response and stabilization services focus on helping people in their communities, often making hospitalization unnecessary. Transitional housing eases the process of leaving the hospital so people can successfully reestablish a stable living situation and reduce the need to return.

The legislature is responsibly using this opportunity to rebuild New Hampshire’s mental health system by addressing short-term needs for inpatient capacity without losing sight of where long-term efforts must focus: community mental health services.

For more about our work in this area, visit our page on Mental Health