A path forward for community-based mental health

New Hampshire once shone as a national model for success, and it can do so again


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In preparing a white paper describing how New Hampshire got to where it is today in addressing mental illness, we were struck by the consistent similarity of recommendations in the many plans and reports on the state’s mental health system over the past 35 years.

The 1982 Nardi-Wheelock Report, the 2008 10-Year Mental Health Plan, and all the other legislative and executive branch reports in between, incorporate some basic principles that remain relevant today:

 • Evidence-based intervention that emphasizes community tenure is preferable to keeping people with mental illnesses institutionalized with little or no expectation of recovery or return to society.

 • The arc of recovery to self-management, although different for each person, is possible for everyone.

 • The approach to mental health care should be person- centered, with individuals playing a full role in their treatment and recovery.

 • Individuals with mental illness should be given access to all the things that contribute to a full life, such as services pertinent to the phase and intensity of their illness, employment and housing.

There is no mystery about how to address this healthcare issue. We know what we should be doing. What has not been consistent is the will to make sustaining a top tier mental health system for New Hampshire a priority.

Like most crisis situations, the New Hampshire system of care for mental illness is not beleaguered because of just one big event; rather, changes in funding, philosophies, availability of workforce, the complexity of needs and legislative priorities and promises have created a “man-made crisis” that has had an extremely distressing effect on some of the most vulnerable people in our state.

Today, individuals experiencing a psychiatric emergency in our state are facing long waits in emergency departments in all 26 hospitals due to a lack of available beds at NH Hospital. The cost of a single night in a hospital emergency department is around $1,500. Some individuals wait for days, some for weeks.

House Bill 400, passed in June 2017, provides an opportunity for visionary leadership and a joint strategic plan with state officials, providers and members of our community, to look at all of the decisions and missed opportunities that have resulted in today’s predicament.

While first and foremost we believe that the entire mental health system of care must be funded fully, there are many things we can identify as small pieces of the solution, including:

1. Adequately reimbursing the CMHCs for the vital role they play. The Medicaid fee schedule for community mental health providers has seen no increase since 2006.

2. Increasing the income limit for Medicaid clients with spend-downs, which has not been adjusted since 1999.

3. Establishing a tuition assistance or loan forgiveness program; this is directly tied to employment at a CMHC.

4. Improving support for the implementation and sustainability of evidence-based practices.

5. Implementing licensure reciprocity for mental health and substance use treatment professionals that was signed into law this past spring.

6. Improving access to care in a timely manner.

7. Reinstating the moratorium for prior authorizations for medications prescribed by CMHC prescribers.

8. Adding and incentivizing the use of new technologies to improve care.

9. Creating urgent care centers for behavioral health clients.

10. Increasing funding for step-down crisis respite services.

11. Increasing funding for peer-based recovery support services.

12. Improving opportunities for hospitals and CMHCs to work together.

13. Re-releasing the RFP for an acute psychiatric residential treatment program to create more capacity.

14. Working closely with managed care organizations.

15. Adding more beds and community-based residential services.

New Hampshire already has a blueprint for success. The time when it shone as a model for community-based mental health care was when government and providers worked together, building conduits of communication which provided pathways to care. We can do that again. 

Jay Couture is executive director of Seacoast Mental Health Center in Portsmouth, and Peter Evers is executive director of Riverbend Community Mental Health Center in Concord. The white paper can be downloaded from the NH Community Behavioral Health Association’s website, nhcbha.org.

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