Circuit courts have begun holding hearings for psychiatric holds in emergency room departments, a change New Hampshire hospitals have long fought against. However, in order to ensure patients are receiving mental health care, hospitals acknowledge it may be a necessary evil for the time being.

Lawyers and emergency rooms are not an ideal combination, said Riverbend CEO Lisa Madden, who also oversees mental health care at Concord Hospital.

“We’ve got traumas coming in. We’ve got injured children. We’ve got COVID patients,” she said. “It is not where those hearings should be occurring.”

Up until last year, Granite Staters deemed to be in mental health crisis often waited days or weeks in the emergency rooms for a bed at a psychiatric facility to open up without an opportunity to challenge the involuntary admission. That practice was deemed unlawful last May when the New Hampshire Supreme Court sided with a plaintiff, identified by the pseudonym Jane Doe, who said she was involuntarily held in an emergency department for 17 days before she received a probable cause hearing.

The court determined that the state either had to offer court hearings within three days of the patient being admitted, or discharge them.

Circuit Court Administrative Judge David King said over the last year, many petitions for involuntary emergency admissions have been dismissed solely because the state didn’t have the resources to get a hearing before the three-day time limit ran out, a practice King calls “Doe dismissals.”

That meant that people who may have posed a threat to themselves or others were released without receiving psychiatric help.

“If the three days have expired and there’s no new, dangerous act, we really didn’t have a choice but to dismiss the petition,” he said. “We’ve got a person who’s potentially in a mental health crisis who needs help, and the only response we’re giving them is we’re dismissing the petition because you can’t meet the deadline.”

Since shifting to the new system, in which patients virtually attend probable cause hearings from the emergency room, only two of 190 IEAs have been dismissed due to logistical problems, King said.

“This seemed to be the only way that we could meet that 72-hour deadline with any regularity,” King said. “The success has been beyond what I would have expected.”

Madden said Concord Hospital has been able to provide about 25 hearings to date in the emergency room.

“It still remains the truth that we don’t really want to have legal proceedings happening in the middle of an ED, but that is the expectation right now,” she said. “So that’s what we’re making sure we do for the patients so that they have a due process.”

Last week, the Joint Legislative Fiscal Committee voted to spend $2 million to expand emergency room hearings even further. The funding would create a centralized filing system and fund the salaries of circuit court judges, staff and counsel for patients subject to an involuntary emergency admission.

Melissa St. Cyr, the chief legal officer for the Department of Health, said holding hearings in the hospital is a temporary fix that the department hopes to phase out as fundamental problems with mental health capacity are addressed.

“It’s not the best environment for someone to receive a probable cause hearing, but it’s certainly still a good environment,” she said.

Published: 1/30/2022 9:01:33 AM

There is always room for improvement in everything we do. Being open to constructive criticism is a must if you are to improve on your product or service. Think of the progress made in technology year over year.

Improvements were driven by the customer experience, needs and interests. However, inspiring to do better every day should not negate the accomplishments made over time. Our successes need to be honored and celebrated as well.

Much has been said over the past several months about the interactions between those living with mental illness and law enforcement. We have heard about the catastrophic outcomes including the loss of life for the person living with mental illness and/or addiction, as well as the pronounced trauma experienced by the law enforcement professionals involved.

These situations are tragic and deserve a careful examination of the circumstances and the facts. The hope is that we could develop ways to avoid negative outcomes in the future.

At the same time, it is important to recognize the progress made to support those living with mental illness not only during times of crisis but also when living successful, fulfilling lives in the community.

For many years, 51°”Íű Mental Health has worked closely with Concord’s first responders. Riverbend’s board of directors has been fortunate to have retired NH Commissioner of Safety John Barthelmes, Chief of Concord Police Department Brad Osgood, and Deputy Chief of Administration for the Concord Fire Department John Chisholm. All three are integral members of a diverse board addressing several key strategic initiatives including integrated approaches to treating people in crisis.

We are also grateful for the leadership of Chief Osgood and that of Commissioner of Safety Robert Quinn. They have dedicated countless hours to training their teams on signs and symptoms of mental illness and de-escalation techniques when working with people in psychiatric crisis.

In addition, Commissioner Quinn was recently honored for his work in supporting his troopers in managing daily stress, burnout, and critical incident debriefing and post-traumatic stress.

Mobile Crisis Response Team has been active in Concord for six years. In the past three years, Riverbend alone has responded to 11,904 calls to assist someone in a psychiatric crisis. The Mobile Crisis team has been deployed to community locations 1,017 times. Of these calls, 69 were referrals from the police department. Working together we have reduced the need to use force to manage a situation.

The other nine community mental health centers in New Hampshire are engaged in similar processes. With the January 1st implementation of the Rapid Response Access Point and Rapid Response teams, all of New Hampshire now has access to mobile crisis services.

Although a high percentage of incarcerated people are also living with mental illness, the vast majority of people living with mental illness are not involved in the criminal justice system. They are not violent, they are not dangerous.

Consider this. Riverbend serves over 7,000 people a year. 95% are living in the community. Most are employed either independently or through the Supported Employment Program. They attend outpatient services, pay taxes and have families and friends who love them. They deserve to be treated with kindness, compassion, dignity and respect, like every other person living with any other illness.

We all strive to do better every day. We will continue to work with our law enforcement and other first responder colleagues in a collaborative manner. We will continue to have high expectations of ourselves and the services we offer. People living with mental illness and/or addiction deserve nothing less.

(Lisa K. Madden, MSW, is the president & CEO of 51°”Íű Mental Health Center and the vice president of Behavioral Health for Concord Hospital.)

By Annmarie Timmins

The state’s 10 community mental health centers would be able to expand services significantly and offer statewide mobile crisis response under a contract going before the Executive Council Wednesday.

“This is really transformational and something I have not experienced in my 20 years,” said Brian Collins, executive director of Community Partners, which serves greater Dover, and president of the New Hampshire Community Behavioral Health Association. “I will tell you that we are on the precipice of something that is positive.”

The 10 contracts total $52.4 million and would give some centers nearly 50 percent more than what they get now from the state Department of Health and Human Services to serve low-income residents. In addition to a mobile crisis team, each center would add six supported housing beds, an employment counselor, and services for people who are deaf or hard of hearing. Some centers would also start integrating medical and mental health services for clients 18 to 35; develop mental health supports in schools; and one would add a small residential program for people dually diagnosed with severe mental illness and either a developmental disability or acquired brain disorder.

A few questions remain, however. The creation of statewide mobile crisis response teams, planned for in 2019 but never implemented, promises to make the greatest impact by connecting providers with people in the moment, while they are still at home, before they go to an emergency room. DHHS officials have said the statewide mobile crisis response unit is one of their top priorities, but they have not yet been able to hire someone to run the call center, which is expected to resolve 70 percent to 80 percent of calls over the phone. At its last meeting, the Executive Council tabled the department’s proposed $9.3 million contract with Beacon Health Optics of Boston to run the center over concerns that Beacon is seeking payment up front. Councilors have asked the department to revisit the terms with the company.

Second, hiring staff to provide these expanded services will also be a challenge. Many of the state’s 10 centers already have 25 to 40 clinical staff vacancies. William Rider, CEO of the Mental Health Center of Greater Manchester, said staffing shortages led his agency to add the supported housing beds to an existing facility rather than build a new one because doing so would allow the center to use existing staff for at least some of the additional work. The increased contacts that will go before the Council Wednesday are part of DHHS’s larger effort to expand treatment to help people manage their illness in their own communities and avoid crisis visits to emergency rooms. In May, DHHS also significantly increased its rates to hospitals and long-term care facilities in exchange for an additional 50 in-patient psychiatric treatment beds. As those beds have become available, the number of adults waiting days in emergency rooms for treatment has dropped, from 42 in mid-May to two on Monday. The number of children, however, has hovered between 20 to 25 since then.

“Over the last several years, Gov. Chris Sununu and the state Legislature have made significant investments to support the state’s 10-Year Mental Health Plan and Children’s System of Care,” said DHHS spokeswoman Kathy Remillard. “This comprehensive approach to providing essential mental health services and supports across the lifespan is in the process of being implemented to transform how the state addresses the behavioral health needs of individuals, families, and communities.”

Jay Couture, CEO and president of the Seacoast Mental Health Center, said the expanded contract will allow her center to not only add a mobile crisis unit but also expand its supported community housing program to 14 beds, allowing it to help more people who can live and work in the community with the support of a group home setting. Couture’s center already integrates primary and mental health care, a practice she said allows both types of practitioners to have a better understanding of their clients’ needs. The contract would allow the center to hire someone to coordinate the in-school counseling program, allowing the center to have a better understanding of students’ needs. “There’s a lot of good stuff in (the contracts) in terms of providing expanded services,” Couture said.

Rider, whose treatment center in Manchester would receive an additional $3.7 million in the proposed contract, said additional funding is critical to maintaining timely services for clients. The Manchester center is one of three in the state to already have a mobile crisis unit, a crucial service but also one that has cost the agency about $2 million since it started five years ago. This contract would be a chance for Collins and his team at Community Partners to create a mobile crisis response unit as well as bring on an employment counselor to work with clients who would like to work but need help finding the right job and navigating employment benefits and the Medicaid benefits they rely on for counseling. “We are excited about it and daunted by it,” he said. “It will require more clinicians, and there is still a clinician shortage in the state. This is not something that will be like turning on a light, but we are rolling up our sleeves and ready to get to work.”

We are living in uncertain times and dealing with long lists of unknowns right now – including when things will “go back to normal” and what “normal” looks like. The one thing we are certain of is that more individuals will be seeking mental health and substance use disorder service in the months ahead, and we will be here to ensure no one goes without treatment.