NHCBHA Position Paper April 2019
As the 2020-2021 NH State budget moves to the Senate, there are differing opinions about which mental health system services and programs are the highest priority items, in which order they need to be addressed, and how they will move the new 10-Year Mental Health Plan forward. Whatever decisions are made regarding these issues, the NH Community Behavioral Health Association (CBHA) urges policymakers to keep in mind that they will be built upon the foundation of the community mental health system, which serves tens of thousands of NH citizens each year. Without a strong foundation, we can’t stand up any new programs.
CBHA maintains that the State should commit to do the responsible thing and make sure that all aspects of the 10-Year Mental Health Plan are addressed, especially because, on any given day in the Granite State, there are between 30 and 70 people waiting in hospital emergency departments for inpatient care. Large numbers of people waiting for care is a symptom of a system that is in need of resources on both the community and the inpatient sides of the equation. The 10-Year Plan is careful to describe a continuum of care of many parts, a system that meets the needs of Granite Staters regardless of insurance, geography or indeed the acuity of their illness. The 10-Year Plan, while not perfect has, as they say, ‘something for everyone’. That is the hallmark of an initiative which is inclusive and mindful of all interested parties.
Mental illness is a disease, not a choice or a lifestyle. Like other diseases, mental illness has a pathway to recovery. The arc of that recovery is different for all; but for all it is possible. Indeed, the Centers for Disease Control and Prevention recognize that recovery rates for people with mental illness are better than for other chronic diseases such as diabetes. Having established that we are working with people who have a disease, it is important to ensure that we have every level of care available to those citizens.
If we consider another disease model, for example, conditions of the heart, it would be absurd to suggest that people in acute phases of their illness do not need a period of hospitalization. That inpatient stay must be as short as possible given the medical necessity and every effort is taken to restore the person’s health to a state where it is possible to return to their community.
It is exactly the case with mental illness. Some people need hospitalization and some people need longer term stays due to the refractory nature of their illness or troubling actions precipitated by the disease.
In order to solve this problem, building adult inpatient capacity at NH Hospital must be part of that solution. This can be done by following the blueprint of the 10-Year Plan and moving the children to a more appropriate setting and creating 48 new adult beds at the state hospital after appropriate renovations. In the meantime, the State should capitalize the funds for a much-needed Forensic Unit, which adds to the continuum of care necessary for this disease, and create a realistic plan for the building and staffing of this new unit over the next 2 years.
If we do this and pay attention to ensuring that the community system is adequately funded with rates that can sustain the critical work of the Community Mental Health Centers, we will have fulfilled the promise of the 10-Year Plan and we will be able to look all stakeholders in the eye and say, ‘We did what was needed for the people of New Hampshire’.
Peter Evers, CEO of Riverbend Community Mental Health, Inc., and President of the NH Community Behavioral Health Association – April, 2019.
Statement of Policy
CBHA urges New Hampshire’s executive branch and legislative leaders to adopt the following approach with regard to funding the 10-Year Mental Health Plan and addressing the hospital emergency department boarding crisis. These are issues that can be successfully addressed, but not if the budget process repeats the mistakes of past years when new programs were underfunded (e.g., the failure in getting responses to the mobile crisis RPP in 2018; the need to reduce fidelity of ACT teams in 2017; and the abandonment of underfunded housing programs in 2016 and 2019.)
1. Workforce investments/Medicaid rate reimbursement increases: There is ample evidence that current Medicaid rates are not sufficient to support the existing mental health system and that the access to care that NH citizens are lawfully entitled to is being impacted. The small amount of stabilization funds found in the Governor’s proposed budget and in the House version of the budget will not address the need for current services let alone any new programs. UNLESS MEDICAID RATES ARE IMPROVED NONE OF THE ELEMENTS BELOW CAN BE STOOD UP.
2. Appropriate funds to stand up 24 additional Designated Receiving Facility (DRF) beds at up to 3 regional hospitals: Currently addressed in SB 11 and funded in the House version of HB 1.
3. Re-locate the children’s behavioral health hospital, fund the rehabilitation needs for this transfer, and appropriate adequate funds to care for this population:
- The authority to move forward with this policy is included in HB 2, but there are not yet adequate funds to pay for the capital costs of the new program. The $5 million included in HB 1 will likely be short of the need, by $2 to $3 million.
- Adequate Medicaid funding needs to be newly appropriated to fund the operational costs of the new children’s facility. HB 1 fails to address the obvious need.
4. Reconstruct the existing children’s unit at NH Hospital to accommodate 48 adult beds:
- $1 million is included in the House version of HB 1.
- It is unclear if sufficient funding has been appropriated in HB 1 to care for this population at NH Hospital.
5. Fund 4 additional mobile crisis unit flexible teams, including sufficient coverage for statewide children’s mobile crisis:
- The House version of HB 2 includes $2 million for children’s mobile crisis units and $3 million for adult mobile crisis units, for the biennium.
- Current and future needs must be funded. We are already underfunded in this area and need adequate funding for existing mobile crisis units.
6. Begin the process to transfer individuals out of the existing Secure Psychiatric Unit (SPU) at the NH Prison:
- CBHA strongly supports transferring those individuals who have not been found guilty of crimes out of the SPU to a more appropriate setting.
- The Governor proposed one-time spending of $26 million to build a new forensic hospital to replace the SPU. While it is accepted that a new facility is needed for those currently inappropriately housed at the NH Prison, the proposal lacked sufficient detail and did not address future operating costs.
- HB 2 and HB 726 create a commission to address this policy and a floor amendment to HB 2 added $1.2 million to fund the study. We recommend requiring this commission to report by December of 2020.
- Appropriate $2 million in the capital budget for engineering and planning a new facility in 2021.
- Fund the facility through traditional capital budget processes in 2021.
- Amend the existing study commission language in HB 2/HB 726 to require that a plan is developed to pay for the operating costs of the new facility and ensure that the planning also includes the goal of strengthening community placements, to avoid over-building of the new facility.
- Fund meaningful case management for the purpose of evaluating and stepping down levels of care for some of the existing SPU population with the goal of relocating as many of the current population to more suitable facilities as soon as practical.
This position paper was supported by the NH Community Behavioral Health Association (NHCBHA), Concord, New Hampshire, a section 501(c)(3) organization, established by the ten community mental health centers in New Hampshire for the purposes of advocating for the priorities of NHCBHA members, eliminate the stigma related to mental health, provide high quality and effective systems of care, and raise awareness of overall health care and prevention and treatment of mental illness. However, the views expressed in this study are solely those of the author and are not intended to represent the views of the NHCBHA.