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Ken Norton on Psychiatric Boarding and New Hampshire’s Crisis Redesign

Psychiatric Boarding and New Hampshire's Crisis Redesign

Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at​

In the early 1990s, New Hampshire was rated number one in the country for community mental health programs. Peggy Straw, the founder of NAMI New Hampshire, responded by saying to the press that wasn’t much of an accomplishment, considering the status of mental healthcare in the United States at the time. Her objective was to improve the quality of life of people experiencing mental illness, and there was a significant chasm between where the state and nation were versus where they needed to be. The gap, says Ken Norton, LICSW, executive director of NAMI New Hampshire, continued over the next 10-15 years. “Funding for services was going downhill, so the state put together a mental health commission to create a 10-year mental health plan, which was issued in 2008.” The strategy included numerous healthcare system reforms but, unfortunately, was released at the same time as the Great Recession, and “the plan went nowhere.” 

In 2011, the United States Department of Justice (DOJ) wrote a letter to the New Hampshire Department of Justice, expressing concern with the high rates of hospitalization and rehospitalization, and the dearth of full continuum community-based services in the state, citing violations of the Americans with Disabilities Act (ADA) Olmstead provisions. The legislature in the state ignored the letter and shortly after that, at the beginning of 2012, legal advocates filed a federal class action suit against New Hampshire for the violations, and the federal DOJ joined the lawsuit (Amanda D., et al. v. Hassan, et al.; United States v. New Hampshire). 

Spike in Psychiatric Boarding

Interestingly, emergency department (ED) psychiatric boarding—people in mental health crises languishing in hallways or other ED spaces while awaiting treatment—was not mentioned in the suit. “At the time of the initial filing, it didn’t really exist. By 2013, psychiatric boarding had become a crisis.” Norton met with the new governor at the time, Maggie Hassan, on her first day in office. On the following Monday, NAMI held a press conference jointly with roughly 15 other organizations, including hospitals, law enforcement, mental health providers, and medical associations, bringing attention to the issue, describing psychiatric boarding as a legal, medical, ethical, and economic problem plaguing the system. Norton says the dire situation arose from the absence of funding for solutions identified in the 2008 10-year plan as well as a reduction in adult state hospital beds. 

Due to the 2011 recession, the children’s unit at New Hampshire State Hospital (NHH) was closed because of reduced funding and moved to the adult hospital, with children having single rooms. The hospital took 48 adult beds and turned them into 24 children’s beds. “The Department of Health and Human Services said, ‘The only way we can achieve these cuts is to do this,’ never thinking that the legislature would agree to it. The legislature said, ‘Do it.’” The children’s unit needed upgrading and facility improvements, and the legislature said there wasn’t money to make changes, but then, in 2013, it approved $3 million to renovate the building and turn it into state offices. “Mental health just wasn’t a priority for them.” 

There was also a reduction in private psychiatric hospital beds, and they began seeing an overflow at the EDs, resulting in psychiatric boarding. Norton highlights that there were also legal challenges. “When someone meets the criteria for involuntary emergency admission, state law dictates that the person shall immediately be transported to a designated receiving facility.” He says long delays are problematic medically because the sooner a person in a mental health crisis is treated, the better they get. “Not just the quicker they get better, but, truly, the better they get.” Ethically, it puts ED staff in a tenuous position of doing harm to people and places hospitals in a challenging legal situation because they didn’t have the authority to hold. “We don’t treat people experiencing any other illness this way. It also has economic implications because, short of the intensive care unit, it’s the most expensive area of the hospital. There are more effective treatments and services that don’t carry the same financial burden.” 

The number of psychiatric boarding cases continued to spike from there. For example, in 2017, the highest number of people waiting for beds at NHH was 71 adults (August 2017) and 27 children (May 2017). Norton says some people were waiting for more than three weeks in the ED. Depending on the ED, people are sometimes placed in a separate pod, an observation room, or strapped to gurneys in the hallways. Not only was psychiatric boarding clogging up the hospital system, but people weren’t getting due process under the law: a hearing within 72 hours. “The language said, ‘Upon admission to the designated receiving facility, a person should have a hearing within 72 hours.’ Someone, somewhere, interpreted that to mean the hearing clock didn’t start until the person was admitted.”

Lawsuit Settlement Expands Crisis Services

With support from Governor Hassan, in December of 2013, the DOJ and private plaintiffs entered into a settlement agreement with New Hampshire that expanded crisis services. It included:

  1. The development of three mobile crisis teams in the Interstate-93 corridor, the population center for the state—Manchester, Concord, and Nashua,
  2. The development of assertive community treatment (ACT) teams to integrate psychiatric and medical treatment at each of the 10 community mental health centers,
  3. Increase in supported housing, 
  4. And an increase in supported employment.

The changes came with a hefty price tag, and experts assumed that as implementation occurred, the number of psychiatric boarding cases would go down. They didn’t. “The staff of NHH were beside themselves at that amount of ED boarding that was happening. This wasn’t good for anyone.” In January 2017, Chris Sununu became Governor of New Hampshire. Norton said it brought new attention to the issue. “Governor Sununu went to an ED, without the press in tow, to see firsthand what was going on. He spoke to patients, staff, and families, and gained a determination to address the issue.” Consequently, Norton says, there were increased legislative efforts during that session, including the governor personally testifying on a bill to increase designated receiving facility capacity in the state, which was passed and funded, and to add a mobile crisis team. “A request for proposal (RFP) went out, and no one applied because of diminished capacity. Medicaid rates had not gone up in the state since 2002, and providers were tired of taking it on the chin and providing services that weren’t adequately reimbursed. They were also fearful of the future of the Affordable Care Act.” 

At the time, New Hampshire was in the middle of an addiction/opioid crisis and experiencing staggering opioid deaths per capita. Overburdened, psychiatric boarding continued to rise at the EDs across that state. “What we discovered is that the backdoor was as problematic as the front door: people were at the state hospital who no longer needed that level of care, but they couldn’t get out.” He says this is in part because there weren’t sufficient step up and step down services like partial hospital programs or crisis respite that could mitigate hospitalization or allow someone to more slowly transition back into the community, and with a booming economy, there was a severe shortage of affordable housing. 

In 2018, New Hampshire renewed Medicaid expansion, extending it through 2023, and legislation called for developing a new 10-year mental health plan that broadened numerous crisis services, such as more designated receiving facility beds, developing a forensic hospital, and increasing mobile crisis teams. “We, at NAMI New Hampshire, continued behind the scenes, pushing for a statewide mobile crisis.” At the time, lawmakers were more focused on children than adults, triggering legislation for a statewide pediatric mobile crisis, which is being developed, but, Norton says, “They now realize that it needs to be a mobile crisis for everyone.” The plan also included a walk-in psychiatric facility, which opened in Concord, where NHH is located. “People were coming to the ED at Concord Hospital more than any other in the state for psychiatric issues.” 

In addition to statewide mobile crisis for children, the 2019 legislative session also increased Medicaid reimbursement rates and funding for an additional walk-in crisis stabilization unit and a plan to transfer children from NHH to a private facility and reopen those beds for adults.  

The psychiatric boarding numbers have decreased considerably; in December, they reached single digits for adults. Due to COVID-19, Governor Sununu declared a state of emergency in New Hampshire on March 13th, closing schools. Thirteen days later, he issued a statewide stay-at-home order until May 4th. The hospital’s highest number of adults or children waiting at one time for beds at NHH was more elevated in March—42 adults and 16 children—than in January or February, but they occurred before March 13th. The virus accelerated plans to transfer all children to a private facility, which was completed by March 20th. Over the next week, NHH began admitting people from EDs to the former children’s unit, bringing the boarding numbers down considerably. The highest psychiatric boarding numbers for April are strikingly lower: 22 for adults and 0 for children

Even the highest numbers in 2020 are far lower than the 71 adults and 27 children from the peak in 2017. Norton says this is because of the previously mentioned measures as well as in-home Wraparound services for children/youth and their families, called the FAST Forward program, which stands for Families and Systems Together. “Because of this support, the children’s census has been down at the hospital, decreasing the numbers by a dozen on any given day. The increase in community support for children decreased the demand on NHH, allowing it to split the psychiatric unit in half, with children on one side and 18-21-year-olds on the other. The division went away mid-March when adults began to be admitted. The state has also aggressively pursued developing better community placements and step down services, resulting from the lawsuit settlement agreement. “There is more from the last legislative session that needs to be operationalized, and once that has occurred, we will likely see psychiatric boarding continue to decrease.”