Combining mental health beds, crisis services and a psychiatric Emergency Room in one region of South Carolina could create a model for the entire state, health leaders said.
The Department of Health and Human Services is heading up a task force that includes Medical University of South Carolina and other health care systems and state agencies. The group held its first meeting at the end of August and will meet again at the end of September, with monthly meetings to follow.
The initial focus is on creating a behavioral health care system in the Pee Dee region that includes new mental health hospital beds. The state averages one of those beds for every 2,600 people, but in the Pee Dee it is close to one for every 7,000, said HHS Director Robbie Kerr.
The department has $65 million in funding from the state Legislature for the effort but could also spend other one-time funds it has, in a partnership with MUSC and McLeod Health.
“It is one of the more under-resourced areas for inpatient beds in the state,” Kerr said. “So we’re going to remedy that and MUSC is working very closely with us in putting proposals in place that we will hopefully fund … very quickly to get that stood up.”
Where it will go in the area is still being determined. MUSC and McLeod are considering multiple sites in and around Florence.
The goal is to have a plan by January that could be presented to the governor and the Legislature, he said.
“I’d like to go into January saying, ‘You have spent your money wisely with us in the sense that we are bringing you plans for the legislature to see,'” Kerr said.
Model for mental health care
Planning and construction of inpatient beds will take the longest time, but a whole host of other details on the model are still being studied, said Dr. Patrick J. Cawley, CEO of MUSC Health System.
“Not everybody needs inpatient (treatment),” he said. “Some people will be fine in a crisis stabilization center. Some people will be fine with a quick stop in a psychiatric Emergency Room.”
The state has already identified a lack of crisis stabilization units, centers where patients can go for a short stay of intensive treatment, as a real need for South Carolina; the only such unit is in Charleston and it is currently operating at half-capacity. The S.C. Department of Mental Health has been working to establish others across the state, with talks in Columbia, Greenville and Anderson at various stages.
The Pee Dee model will also look at creating new units but with an eye toward connection, Kerr said.
“We’d like to build those and network them” with other mental health resources, like mobile crisis teams, he said.
The idea of a dedicated psychiatric Emergency Room is also a new concept that needs to be considered, Kerr said.
“Do we have dedicated Emergency Rooms for mental health and how do they handle referrals?” he said. “That is going to be the big focus of the committee initially.”
It is a problem MUSC is dealing with “every single day,” Cawley said. “I’m talking every single day, there are 20-30 patients boarding in our Emergency Room (waiting for a room), just in Charleston, with the majority of those patients (having) biobehavioral problems.”
It is happening all across South Carolina, he said.
“That’s happening in every single Emergency Room across the state, to one degree or the next,” Cawley said. Those hospitals are looking for solutions and the goal with the Pee Dee project is to try and put together something that will work for them, Kerr said.
“We’re kind of using the Pee Dee as our incubator for this,” he said. “Though the network we hope will be statewide, we’re going to test things in the Pee Dee, using them as a model, with the desire to roll things out hopefully very quickly into the state.”
It includes looking at important questions, such as whether the psychiatric ER needs to be next to the regular ER, where crisis stabilization locates, and where the clinics for outpatient care are in relation to the inpatient beds, Cawley said.
Connection is the key to the model and providing the right care at the right time, said Dr. David J. Cole, president of MUSC.
“It’s about access and continuity of care. Those are the first steps,” he said. It is one thing to have crisis stabilization but “it’s not acceptable, if you are in a crisis mode, to have an appointment to follow up with you in four months,” Cole said. “It just doesn’t work.”
It also means dealing with the opioid crisis and making sure that mental health services do not exclude drug and alcohol treatment, Kerr said. Some estimate that roughly half of all mental health patients also have a substance-use problem and vice versa, he said. But due to the way those services are currently structured, “we isolate and silo those treatments,” Kerr said. “We have got to figure out how to bring those services together in a (common) setting. That is one challenge we are going to be looking at very closely.”
That is currently a real problem for mental health providers, Cawley said.
“We run into this all of the time,” he said. “We have a patient, we refer them to a provider and they’ll say, ‘I don’t treat anybody with alcohol or substance abuse (issues).’ Or vice versa.”
Filling the gaps
Even as they are looking to revamp the system, the Palmetto State is facing a severe shortage of providers. As of Sept. 9, the state Community Mental Health Services division had 515 vacancies of mostly clinical positions, in part due to a lack of competitive salaries, said Deborah Blalock, deputy director of the division. While there may not be a quick and easy fix to that workforce issue, there are better ways to use the state’s existing resources, Cole said.
“We are creative in terms of changing the model” for care, he said. “We have huge strengths in terms of telehealth, which is making a huge impact in behavioral health delivery and leveraging what providers we have. I think it is more of a long-term commitment to training more providers, but changing the model for how care is provided will help the workforce match the need over time.”
State leaders recognize that and were ready to support it when asked to help fund workforce development last year, said Mark Sweatman, chief of governmental affairs for MUSC.
“From the legislative standpoint, I’ve never seen an issue have so much support, from the governor, Director Kerr, the legislative leadership, House and Senate, they are all on the same page,” he said. “They granted that in a heartbeat.”
From the hospital standpoint, there is a great interest in having a new model for how to respond to the current lack of crisis services, Cawley said.
“I don’t see this as an MUSC thing at all,” he said. “Other hospital systems are getting involved. There’s a lot of interest. I hear it through the hospital association.”
It also can’t fall on the state to lead it and fund it, Kerr said.
“If we try and handle this as a public initiative, it will fail,” he said. “It’s got to be an initiative across the board, for all providers.”
To do nothing is not an option for anyone now, Cole said.
“In my opinion, we’re on the front edge of a behavioral health crisis, tsunami, whatever term you want to use,” he said. “We have to address it. It affects our society at so many levels.”