When a new hospital opens in a small town, doctors, nurses and staff are often treated like long lost cousins at a family reunion. Townsfolk welcome them, take pride in their arrival and anticipate a long and close relationship.
How would that scenario play out if the first name of the hospital were “mental” and not “medical”? What if “mental” were softened to the more descriptive, “behavioral health”? Would there be the same pride, anticipation and welcoming handshake? Yes, if the town were Davidson. No, if it were Huntersville.
Old Devils Die Hard
In 2007, Carolinas HealthCare Systems (CHS) spent $24 million to demolish the old Huntersville Oaks nursing home and rebuild a modern 168-bed facility for the elderly who needed special care.
Four years later they unveiled a plan for a section of the new Huntersville Oaks property. CHS wanted to rezone the site for an all-private rooms, single story in-patient and out-patient behavioral health center. Zoning would change from neighborhood residential to campus-institutional.
After a contentious public meeting in January 2012 that focused on public safety and traffic, the town planning board approved the CHS application on its merits. Neighborhood opposition solidified at the Huntersville town commissioners meeting in February 2012 and commissioners voted 4 to 2 against the rezoning plan. Even a 16-foot perimeter wall for the in-patient center failed to convince the skeptics.
The real cause for the no vote is as old as civilization itself—the stigma attached to those who don’t fit in. For over 3,500 years, odd behavior—hearing voices, unrelenting sadness, paranoia—was attributed to evil spirits or demonic possession. It’s hard to imagine a more fear-provoking mark of shame, the classic definition of stigma. Psychiatrists and psychologists know better now, but old devils die hard.
“I think that was a substantial reason why elected officials chose not to support building it there,” says Tom Gettelman, Ph.D., the clinical psychologist appointed to administer the new facility. “Some neighbors chose not to understand that providing an acute mental health facility actually enhances the safety of a community.”
Ever the psychotherapist, Gettelman reframed the experience. “In the end,” he says, “Huntersville allowed Davidson to embrace us.”
Davidson wasted little time moving from hello to embrace. Two months after the Huntersville plan failed, Davidson Mayor John Woods approached CHS. “We appreciate the great need for mental health facilities in our community,” Mayor Woods was quoted as saying. The very mission of the town of Davidson encourages a healthy lifestyle in a healthy environment. A behavioral health hospital fit perfectly with the community’s goals for itself.
To add a bear hug to the embrace, one of the goals of the Davidson town board of commissioners is to enhance the physical, mental and emotional well-being of its citizens. “Commissioners use that health lens with all of their projects,” says Gettelman.
The 23-acre site offered to CHS did not need rezoning nor was it in an established neighborhood. Six months before Mayor Woods visited with CHS officials, the Davidson town board had rezoned the area to allow for flex campus development, a designation that fit the new behavioral health center to a T. The purchase price of the property was not made public, but the price tag on the Davidson center was $36 million, three million dollars more than the Huntersville campus plan.
Davidson was not the only town in northern Mecklenburg County to step forward, but it was the most enthusiastic. “Davidson has been amazing,” says Gettelman. “From day one, across the board, from elected officials, the chief of police, the entire community has embraced what we want to bring. The walk matches the talk.”
What CHS wants to bring are jobs, a new staffing model and help to those suffering the perverse effects of drug abuse and mood disorders.
New Davidson Facility
For Davidson’s 66-bed, 67,000 square foot in-patient hospital, Gettelman wants to employ 45 psych nurses, 55 psych technicians, 18 master’s level therapists, four recreation therapists, three peer specialists, two pharmacy techs, and six psychiatrists. That’s more therapists and fewer nurses than is typical of behavioral health hospitals. But it is how they work together that makes Davidson different.
He also wants to divide the new hospital into three 22-bed units. Each unit has its own therapy team that works seven consecutive days and then has seven days off. The result? “Very cohesive and consistent teams on every unit,” says Gettelman. Since the length of stay at Davidson’s inpatient hospital is expected to be from five to eight days, it’s possible that a single team would manage a patient’s progress from admission to discharge.
This type of staffing model is unique among behavioral health hospitals in the United States. In medical hospitals the model has been around since 1996 and goes by the name “hospitalist.” A hospitalist is a physician responsible for coordinating a patient’s care during their time in the hospital. Although patients often complain that their personal physician or surgeon has not come to see them, hospitalists have achieved greater consistency of care, shortened lengths of stay, eliminated on-call MDs, enhanced patient safety and minimized handoff problems between shifts and departments.
Since few patients in a short term “mental” hospital like Davidson have a family psychiatrist, Gettelman’s model has no obvious disadvantages. Psychiatrists—medical doctors trained in psychopharmacology and behavior disorders and employed by CHS—will be Davidson’s hospitalists.
Treatment at a Loss
Carolina HealthCare Systems is gambling on the long-term benefits of its behavioral health care centers. Topping the short benefit list is a reduction in emergency department visits by those needing psychiatric care. In a report released in April 2013, a North Carolina joint legislative committee found that the majority of individuals admitted to a psychiatric inpatient unit or to a hospital are referred through an emergency department. The average length of stay for those in crisis was nearly 16 hours.
Two solutions to that problem have emerged—telepsychiatry and psychiatric emergency departments. Through Skype and a high definition telephone/video connection, CHS emergency department personnel can have a person in crisis interviewed by a psychiatrist at the Behavioral Health Center—Randolph 24/7.
This innovation has two benefits, says Gettelman: “The psychiatrist can determine the level of care needed and often discharge the person to home.” If the person needs to be admitted and is waiting for a bed, the psychiatrist can start the medical treatment. This often involves psychotropic drugs for which psychiatrists are medical experts.
Dr. John Santopietro, CHS’s new chief clinical officer for behavioral health services, sees another long term benefit to treating behavioral problems first. “The cost of treating diabetes is 60 percent more when treating diabetes and depression,” he was quoted as saying. “Control depression first and it makes diabetes easier to manage. Leave depression untreated and the chances are very good, says Santopietro, that the person will be readmitted to the hospital.”
The same may be says about gun-related tragedies like Sandy Hook Elementary School. Left untreated, the demons that drove Adam Lanza, Seung-Hui Cho, and others to murder continue to disrupt lives and increase the likelihood of more atrocities. Gettelman says he cannot guarantee that Davidson or Randolph will prevent another Sandy Hook, but treatment lowers the risk. “If you treat people for heart disease can you guarantee they will not have a heart attack?”
There are long term business implications to what Gettelman is doing at Davidson. Absenteeism, poor productivity, bad attitude and workplace violence may be crisis-induced or the psychological consequences of chronic and untreated depression. These business costs are estimated to be two to three times higher than what it would take to treat these problems at a facility like Davidson or Randolph.
In the short term, behavioral health is hardly a money maker. “Psychiatric facilities don’t make money,” says Gettelman. “CHS expects to lose $3 to $5 million a year at Davidson,” he adds.
The reasons go back 50 years. In the 1960s, states began deinstitutionalizing their long-term “mental” patients. New drugs, new federal laws and new ideas regarding humane care provided the stimulus for change. Local communities were expected to absorb the now released patients with some help from the federal government and no help from the states.
The beds at the Davidson hospital are state beds that were transferred to CHS from Broughton, the state mental hospital in Morganton. While North Carolina is willing to make the transfer, they are not willing to provide any financial support to private businesses like CHS to build community-based in-patient units.
Communities and businesses willing to take that risk and build or retrofit existing hospital units for psychiatric patients soon discover that insurance reimbursement for those patients does not cover costs. “You can have a billion dollars of insurance coverage,” says Gettelman, “but an insurance company can deny coverage because in their mind, inpatient care is not medically necessary.”
The sad facts are that community mental health needs private businesses to build and staff local or regional clinics, but at a financial loss.
Crossing the Divide
While it is the inpatient program that draws most of the attention, Davidson’s outpatient clinic is where many inpatients are referred after discharge. Outpatient services provides the support, medication management, counseling and eventual dismissal after inpatient’s quick stabilization. The outpatient staff is not a seven days on/seven days off team like the inpatient side, but there is one element that glues them together: “Everyone is trained in the methodology of cognitive behavior therapy,” says Gettelman.
This form of therapy has become one of the most widely used therapy approaches in the United States. It rests on the assumption that faulty cognitions—maladaptive beliefs, unrealistic expectations and distorted ways of thinking—are the cause of abnormal behavior. The therapist’s job is to explore and reinterpret thinking errors like “I’ll never get a job,” “The boss invited me to lunch, so I guess I’m going to be fired,” and “Every time I try to have fun it turns into a nightmare.”
Complimenting cognition is a strong behavioral component. The therapist is a teacher, role play leader and social skills trainer. The goal is for patients to unlearn inappropriate cognitions and behaviors and replace them with those that are effective and normal.
Cognitive behavior therapy fits perfectly with the environment Gettelman is attempting to build at Davidson. It reduces the stigma attached to treatment—everyone has unacceptable and strange thoughts—and is respectful of the ways we arrive at our faulty thinking. There is no probing the unconscious or the first five years of life. The emphasis is on thinking and doing in the here and now.
After Davidson is built and operating, what’s next for Carolinas HealthCare Systems? Possibly its most influential and difficult task lies ahead. Gettelman says it is the integration of behavioral health with primary medical care. Only an organization with “HealthCare” and “System” in its name could pull off this much needed paradigm shift.
Dr. Santopietro provides the context for integration: “Up to 70 percent of primary care medical appointments are for issues related to psychosocial concerns. This is especially true for children.” Leaflets concerning depression could be distributed during a child’s annual physical, counselors could be employed by family physicians and pediatricians could link to psychiatrists via telepsychiatry for on-the-spot consultations.
Medicine first put a toe in the waters of behavioral health in the 19th century when the cause of a disease then called “general paralysis of the insane” was discovered. For years the hallucinations, delusions, personality changes and mood swings associated with this disorder were thought to be purely mental and out of reach for traditional medicine. When it was learned that these symptoms were the later stages of syphilis, medicine and behavioral health found at least one common bond.
Over the years, other connections were made, more recently in the area of depression. Others remain to be discovered and implemented.
“There is no health without behavioral health” is more than a mantra or cliché. The two seemingly disparate fields are joined at the brain, not the hip. Integration may be the long-awaited cure for the stigma associated with mental illness and the key to greater behavioral health.