The Alabama Nurse - May 2022

Page 12 • Alabama Nurse May, June, July 2022
Crisis Care for Mental Health is Emerging in Alabama
Teena McGuinness, PhD, RN, FAAN
Thomas Insel, former director of the National Institute of Mental Health,
observed, “There are only two kinds of families in America: those who are
struggling with mental illness and those not struggling with mental illness
yet” (Insel, 2022, p. 30). This is another way of stating that mental illness is an
inconvenient fact of life for Americans and their families. Most families will
eventually be forced to address a mental health care crisis with a loved one. Sadly,
our system of care for persons with mental illness was not designed to be responsive
or even adequate for the current need of services.
Here are several harsh realities:
1. Our state, Alabama, ranks 50th out of 51 (including D.C.) states for statewide
access to mental health care.
2. There is an enormous unfilled need for hospital beds for the mentally ill.
Currently our country has fewer than 13 public hospital beds per 100,00 people.
This number meets only a quarter of the beds needed and is less than 5% of the
number of allotted beds in mid-1950s at which time our population was less
than half of what it is today.
3. Currently, only about 16% of persons with severe mental illness (disorders of
bipolar and schizophrenia) receive minimally acceptable treatment. Those not
receiving adequate treatment are incarcerated or in street camps or relegated to
custodial care where effective treatment is not administered.
4. Approximately half of US counties are without any dedicated psychiatrist.
These counties are overwhelmingly rural.
5. About 60% of psychiatrists will not accept Medicaid and 45% of psychiatrists
will not accept private insurance. Thus, in many locales, cash is the key to
access the services of psychiatrists (Satel, 2022). This is yet another barrier to
accessing crisis-preventing psychiatric services.
The truth is that most mental health crises today are initially handled by law
enforcement officers, much to the frustration of police whose primary mission lies
in public safety and have little, if any, training in coping with persons with mental
illness. In fact, persons in crisis may find themselves incarcerated or receiving
no psychiatric help at all, a situation which benefits neither the person nor the
justice system nor wider society. In Jefferson County Alabama approximately 240
people are taken to Jefferson County jails every month with mental illness and/or
substance use disorders, costing approximately $468,000* each month to house them
(*Source of statistic is Jefferson County Sheriff’s Department, 2022). Many of these
individuals could be helped outside the corrections system sparing their dignity and
saving tax dollars.
Historically, Alabama Code §22-51 and 52 established structure and procedures
for the Alabama Department of Mental Health (ADMH) but state funding is provided
year by year and may vary significantly contingent on funding source availability.
Minimum standards for mental health services (as established in Federal and State
Court cases such as Wyatt v. Stickney and Braggs v. Dunn) establish a legal basis
for mental health care but mental health care delivery system falls short by failing
to reliably and consistently diagnose and treat mental illness. One well established
reason for the persistent failure was the reduction in state psychiatric beds which
was never matched by the establishment of local community-based services.
The disappearance of institutional hospital beds without an adequate number of
community based replacement settings resulted in increasing levels of mental health
crises in our cities, towns and hospital emergency rooms. Management of these
mental health crises defaulted to local law enforcement and thus our corrections
system became de facto mental health treatment centers.
But there is promising news: a mental health crisis deserves a mental health
response (NAMI, 2022) and by July 2022, 988 (a new 3-digit number for suicide
crises and mental health) will be implemented. Alabama is moving toward this best
practice.
In addition, Alabama’s Crisis System of Care, supported by the Alabama
Department of Mental Health (ADMH), was developed in response to an obligation
to provide quality mental health care for all Alabamians who live with mental illness
and to response to suicidal crises. A new to Alabama concept, Crisis Care Centers,
will alleviate strains on local governments and establish links between community
organizations, psychiatric and medical services, and crisis services by reducing
arrests and opening space in local jails. In short, Crisis Care Centers will transform
delivery of mental health care in Alabama.
As of spring 2022, three Crisis Care Centers funded by the Alabama Department
of Mental Health are operating in Mobile, Montgomery, and Huntsville. In August
2022, the Region II Crisis Care Center (CCC) in Birmingham will begin offering
services to those who are experiencing psychiatric, behavioral and/or substance use
crises. Operating 24 hours a day, Birmingham’s CCC will include 48 beds consisting
of 32 temporary and 16 extended observation beds. The maximum length of stay will
be 23 hours for temporary observation which is adjustable based on need. Sixteen
extended observation beds will accommodate patients who need up to three days
of crisis care. Prescribers will staff the CCC to diagnose and provide care quickly
and effectively. A psychiatrist and psychiatric nurse practitioner will be available on
site on the day shift with a total of five psychiatric nurse practitioners staffing the
evening, overnight, and weekend shifts. Once the CCC is fully operational, walk-ins
will be welcome.
This CCC concept and design is intended to benefit several key groups:
1. Law enforcement officers and agencies will benefit with far shorter turnover
times at the CCC than at traditional emergency rooms; we anticipated that 15
minutes or less will be the norm for admitting a patient to a CCC. Formerly,
officers often had to wait for several hours in an emergency room until the
patient was admitted.
2. Individuals and family members will benefit due to the relatively quick
availability of crisis services delivered by mental health providers, an
appropriate response. Additionally, emergency departments, which are not
geared to treat people in a mental health crisis given the loud noises, busy pace,
and crowding, will not further traumatize people in crisis while seeking mental
health services.