In 2023, the N.H, Department of Health and Human Services launched Mission Zero, promising to eliminate emergency department boarding — the practice of holding admitted patients in the ER while they wait for an inpatient bed to become available — by March of this year. Because of those practices, patients requiring care for mental illness often go to hospitals, with their experience resulting in hours, days and even weeks awaiting an inpatient bed. Have New Hampshire hospitals been able to fulfill this tall order of eliminating boarding? To discuss that are Lisa Madden, president and CEO of Riverbend Community Mental Health and vice president of behavioral health for Concord Hospital, and Susan Stearns, executive director of NAMI New Hampshire, the National Alliance on Mental Illness.
This article has been edited for length and clarity.
By Rosemary Ford and Caitlin Agnew
Melanie Plenda:
Lisa, to start us off, could you please tell us who is affected by emergency department boarding?
Lisa Madden:
What we have historically encountered is folks that are in the midst of a psychiatric crisis who come to the emergency department looking for some acute level of help. There haven’t been sufficient resources in the community to serve them, so they've been waiting in the ED for extended periods of time.
This had to do with not having sufficient number of beds to be able to meet the demand, but it also had to do with making sure we had the right community support programs to try to have places where people could go after they received the acute level of care they needed in the hospital and could be supported in the community. These are folks that are really dealing with an acute crisis and need a higher level of care, as would anyone else going to an emergency room for a medical condition that needed that level.
Melanie Plenda:
Susan, one of the reasons people go to NAMI NH is to get support, including support for ED boarding. As someone who has heard personal stories related to boarding, what are people going through in these situations?
Susan Stearns:
There are 26 critical access hospitals across the state, so I will give you a sense, but it isn't specific to any one hospital, and it's going to vary slightly from hospital to hospital.
The really common themes we hear are individuals who are considered to be at some risk to themselves or others, are there involuntarily so they're not able to leave, unlike you or I. They report having their personal belongings for safety removed from them. The very lucky ones have a television in the room where they're waiting, usually behind Plexiglass, but that isn't standard. I've heard from folks who tell stories of how a security guard actually proved to be their lifeline during an extended stay in the emergency department, because that security guard talked to them about movies that they liked in common. So we hear a lot of these real challenging stories.
Another really common theme is the inability to choose, like when you might take a shower and practice your own basic hygiene — things that most of us don't think about when we think about someone who may be spending an excessive time waiting in an emergency department. These are folks who have really very limited things to pay attention to. We do hear from parents of kiddos who report restraints being used sometimes, and we certainly hear about that from adults as well. So these are experiences no one would want to go through. And I would say that our hospitals would agree — these are not experiences anyone wants to go through or watch your loved one go through, and that's why we’ve had so many folks being willing to try and make New Hampshire a real leader in reducing and eliminating this problem.
Melanie Plenda:
Lisa, as president and CEO of Riverbend Community Mental Health, can you please tell us more about what community mental health centers and certified community behavioral health clinics offer in New Hampshire?
Lisa Madden:
Community mental health centers are designated centers within regions of the state, and the catchment areas are designed by the state. I can speak to Concord, which is Region 4. We have nine other designated areas throughout New Hampshire. We provide the state-supported services for people who are acutely ill, for young people or adults — and that means people who are living with severe and persistent mental illness or severe emotional disturbance.
Our system of care is comprehensive. So not only are we able to do therapy, be it individual, group, family, couples, work, but we are also able to provide extensive case management and community support services, often referred to as functional support services. That's where folks can actually go into the community with the folks we work with and help them achieve the goals they need to be able to stay living in the community.
For young people, it means we're heavily involved in schools. We also have services for adults in which we help them get some employment through our supported employment program, and we have lots of different group activities to try and help people learn how to successfully manage their symptoms and stay in the community.
We have everything from education and teaching people about mental illness all the way up to residential programming, where we, in fact, are part of the network of support for people who need to live in structured housing, and all the treatment in between.
Melanie Plenda:
If people don't need as much help as what is offered at a hospital, a community mental health center or a certified community behavioral health clinic, what is available to them, Susan?
Susan Stearns:
Our community mental health centers offer a broad array of services, but if someone's in a crisis, there’s the 988 crisis system and our Rapid Response System. That is a resource that is available for everyone and can provide you with access. So it's a critical resource.
We have crisis stabilization units in our state. Those are also available for folks who might need to not be alone but haven't reached that point where they really need to be under the supervision that you might see in an emergency department. We also have some places in our state where we have peer respite available that are run by peer support agencies. There are a number of alternatives for folks if they aren't meeting that level of acuity that they absolutely need to be in an emergency department.
We don't think it should be a one-size-fits-all model. There should be multiple ways to access the care you need. NAMI New Hampshire offers various support groups. Our peer support agencies are wonderful resources in the community. We want to make sure, again, that folks are able to access support they need, but absolutely get that clinical care that our community mental health centers and now certified community behavioral health clinics are truly the experts in providing.
Melanie Plenda:
Lisa, behavioral health doesn’t receive as much funding as other departments. Why, in your opinion, is that?
Lisa Madden:
I've been doing this for a really long time, and I wish I could answer that question. I mean, my passion is to give people access to health care that takes care of the whole person. My particular area of expertise tends to be within the behavioral health world, but I just think it's part of who you are. Why we don't get the same support, I think, still falls under people not understanding the full scope of the illnesses. There's certainly still some stigma. We're trying to work to educate people to understand medical conditions that require appropriate medical care. But you know, it's taken us a long time to be able to be seen and heard in a way that says this is an important element of whole person health, and we need to fund it appropriately and unfortunately.
Behavioral health is often one of the elements of treatment that's not adequately funded and is cut early in the process of cuts. I will say our state is very committed to our care and is very committed to the treatment of people with mental illness and addictions. Our work with the department has been very, very collaborative to try to find ways to keep people served, but I honestly don't know the answer why people won't fund us appropriately.
Melanie Plenda:
So, Susan, if someone is struggling, what should they do? What should their steps be?
Susan Stearns:
The best life skill is to be able to ask for help. Absolutely, there's not one of us who gets through this life without having been at a point in our lives where we have to ask for help. So I often tell parents, if your child is struggling, helping them reach out and access care is a really good life skill to have. So yes, absolutely, tell someone that you're struggling. Maybe you might pick the wrong person who doesn't know what to do with that, but try not to be shut down by that.
Also, if you have someone that you know, that you're concerned about — maybe it's a co-worker or a neighbor — ask them how they're doing. That communication is so critical. It doesn't mean you have to have a solution. I can tell you, if you're really concerned, anyone can call 988 so you can access assistance, so there's no reason to hesitate to engage in that conversation.
I would tell anyone who is even thinking about calling 988 to do it. As soon as you question if you're at a place where you should call 988 the answer is yes. You can also chat with them online, and you can text 988, so it's a really critical resource. But remember that you're not alone, that there are folks who are there to help, and that there are many folks who are walking this walk as well, and that treatment is available for most people.
Lisa Madden:
What Susan said is just so spot on, that nobody is alone, there are multiple avenues for support, and people exist in order to be able to offer guidance to recovery. That is why they’re there.
I’ll reflect a little bit on even my role as a parent. What I used to say to my son, and still say to my adult son anywhere along the line, is that when you feel like you don't have any choices or if there's any reasons to believe that, ask somebody who can help you see your choices. But never feel like you do not have choices, because you do, and you just might not see them that day, and someone else may be able to help you see them.
Melanie Plenda:
Thank you to Lisa Madden, president and CEO of Riverbend Community Mental Health and vice president of behavioral health for Concord Hospital, and Susan Stearns, executive director of NAMI New Hampshire. If you or someone you know is struggling, help is available 24/7. Call, text, or chat 988, the national suicide and crisis lifeline.
“The State We’re In” is a weekly digital public affairs show produced by NH PBS and The Marlin Fitzwater Center for Communication at Franklin Pierce University. It is shared with partners in the Granite State News Collaborative, of which both organizations are members. For more information, visit collaborativenh.org.