The Hippo


Jun 2, 2020








New Hampshire Hospital. Photo by Ryan Lessard.

Mental health system holes
State analyzes behavioral health infrastructure

By Ryan Lessard

The state is behind in meeting its obligations after a lack of mental health services reached crisis levels and a $30 million settlement was agreed on in an effort to resolve it, but experts and officials disagree on whether the health department’s organizational structure and staffing shortages are to blame.

Flat tires
For New Hampshire Health and Human Services Commissioner Nick Toumpas, the mental health system is like a car.
“You can have a car but if I have a car with no wheels, it can’t move. I can have the greatest motor in it, I can have the greatest transmission ... [but] if all the components don’t work in harmony, the system is not going to work,” Toumpas said.
For years, there have been several components to the state’s mental health mobile, such as New Hampshire Hospital for acute institutional care, a network of community mental health centers, inpatient psychiatric facilities and supported housing. But in recent years, the car has had a flat tire.
“There’s clearly a number of different factors that have impacted the overall mental health system in the state,” Toumpas said. “One of the most significant pieces of it is the loss of bed capacity in the community.”
Several factors led to the bed shortage, but when a 24-bed unit at NHH closed a few years back, Toumpas said, that led to to a greater number of admissions at the Lakeview Neurorehabilitation Center in Effingham, which may have exacerbated the poor conditions there.
“There’s more that have been referred there than before we closed that unit,” Toumpas said.
He said because the system is so reliant on each component functioning together, when one fails, it runs into issues like waiting lists to get into NHH.
According to an independent report released June 30 on the mental health system’s progress on complying with the terms of a $30 million settlement, the waitlist to get into NHH has been an average of 22.3 each month. There was also a high readmission rate reported; about 18 percent of the admissions (223 people) were returning patients who left within 180 days. More than 90 percent of them left within 90 days.
And the administrator of Glencliff, a long-term institution for elders with mental illness, told the Hippo the waitlist for entry was at 18 as of late June.
The independent report also said the state had failed to meet its benchmarks for developing housing support, mobile crisis teams, 24/7 access to clinicians and more. But while the state is moving slowly, it is moving and in the right direction according to Toumpas.
Still, there are those who point to the staffing issues at DHHS itself as another flat tire.
Ken Norton, the director of the National Alliance of Mental Health in New Hampshire, remembers when DHHS’s Bureau of Behavioral Health was a crown jewel in the state’s mental health system.
“It used to be a ‘Division of Mental Health’ and it was downgraded to a bureau,” Norton said. “The Division of Mental Health used to include oversight of New Hampshire Hospital. It no longer includes that oversight.”
Toumpas believes this took place around 2004 or 2005.
Norton said the system used to be an example for other states.
“New Hampshire was really a leader. Don Shumway was the head of the division for many years. There was a full-time medical director for many years. It’s now a part-time medical director position. That full-time medical director had a lot of stature nationally and a lot of vision,” Norton said. “People were coming from all over the country to see what we were doing in New Hampshire. New Hampshire was rated, at one point, number one nationally in the early 1990s, in terms of services.”
Norton said this was partly due to the construction of NHH with psychiatric expertise from Dartmouth. But he said the originally conceived model of having a small, central mental health hospital with satellite receiving facilities in local hospitals and elsewhere was never fully realized.
“The old guard’s vision was all about community-based care,” Norton said.
And while Norton says most state officials still subscribe to community-based care, budget cuts and unfilled positions resulted in a greater emphasis on institutional care, one of the major complaints in the lawsuit.
“Those services have been cut and eroded during the past decade. As a result, we ended up with higher numbers of people being incarcerated, higher rates of homelessness, higher rates of people waiting in emergency departments for beds,” Norton said.
He said this is partly due to the state of the Bureau of Behavioral Health.
“The bureau’s currently missing key leadership positions and ... the bureau administrator has been in an interim capacity for close to 20 months,” Norton said.
There are vacancies in the positions for director of consumer and family affairs, a person to coordinate compliance with federal disabilities regulations, and the children’s director left in the spring to work at Lakeview. And BBH interim administrator Geoff Souther will be transitioning to become the chief operations officer at NHH.
“The word on the street was people who would’ve been well qualified for that position didn’t apply because ... the salary wasn’t commensurate with what was being required of that position,” Norton said.
Toumpas disagrees.
“To be sure, salary has one element of it, but I would not put everything on the salary structure the state has,” Toumpas said.
He said a shortage of qualified people in the marketplace played a bigger role in failing to fill the administrator position and others. And he said that’s true for the whole health department.
“The department has gone from 3,300 authorized positions down to around 2,900 authorized positions. And of those 2,900 authorized positions, we have about 350 vacancies,” Toumpas said.
Norton said people are stretched thin as a result, within the BBH and the department as a whole.
“People are doing multiple positions within the department. I’ve learned that up to 1,000 positions have been reduced, eliminated or vacated within the last maybe eight years within the department,” Norton said. “At some point, that impacts on caseloads, it impacts on ability to move projects forward, it impacts on accountability for programs, it impacts on vision and it impacts on retention of employees.”
Toumpas recognizes the need for a workforce development and retention strategy, but he says the reorganization of the BBH from a division had no impact on its effectiveness.
Toumpas says the solution to the system’s breakdown is not looking to the past. Instead, it’s an opportunity to incorporate some modern upgrades.
“We’ve lost some of these components and now with the evidence and the data that’s emerging ... it creates an opportunity for us to step back and reexamine the system for the next decade, for the next 20 years, or for the next quarter century,” Toumpas said.
Toumpas said he’s redesigning the department by placing the policy and strategy responsibilities for mental health, substance abuse and long-term services for the elderly and disabled under a single leader. 
As seen in the August 6, 2015 issue of the Hippo.

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