Delays in Psychiatric Care: New Hampshire’s Robust Response

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New Hampshire’s mental health system, like many other states, has faced numerous challenges throughout the years. Discussions, news updates, and most recently lawsuits have targeted emergency department (ED) boarding, or the holding of patients awaiting involuntary psychiatric admission to an inpatient unit.^1,2 Lawsuits increased concerns regarding patient rights violations, excessive time of emergency room holds, violations of due process, and lack of resources within the mental health system.^1-5 The issues associated with ED boarding and lack of due process alone are serious and significant.^1,2 However, maintaining a narrow view without broadening the lens to view the challenges across the continuum diminishes the breadth and complexity of problems impacting care.^6,7

Challenges within the system are complicated by an increasing demand for psychiatric services and a decrease in available resources. These factors create access issues for patients in need of psychiatric treatment across the continuum of care and for providers trying to facilitate and provide treatment. A dwindling number of inpatient beds, inadequate number of mental health specialists, lack of community resources, and lack of affordable and available independent and supervised housing are all part of overwhelming care challenges for patients and clinicians.^4,5

Some individuals in need of psychiatric care are unwilling or unable to consent to the treatment needed to maintain safety or reduce psychiatric symptomatology.^8,9 New Hampshire statutes regarding involuntary hospitalization and treatment outline the path to care for these patients.^9,10 New Hampshire statutes have evolved over the years, with an increasing focus on due process following the passage of Revised Statute Annotated (RSA) Chapter 135-B in 1973, which extensively revised the involuntary admission process and allowed for increased judicial review. Further adjustments and improvements were initiated in 1986 with the passage of the current RSA 135-C, which further delineated the careful balance between the need for treatment and preservation of an individual’s civil liberties.^10,11

RSA 135-C guides processes for involuntary hospitalizations in New Hampshire.¹⁰ These processes follow systematic steps that include assessment of behaviors and level of dangerousness limited to the 40 days before filing the petition for involuntary hospitalization. The petitioner for an involuntary emergency admission (IEA) could be a lay witness observing the proposed patient’s behavior and may initiate the process. However, a clinician who is approved to do so must certify that criterion for an IEA—including dangerousness or inability to function due to psychiatric illness— is met before submission to the circuit court for a hearing to be scheduled. A list of certifying clinicians who are either approved by a designated receiving facility (DRF) for involuntary psychiatric patients or a community mental health program (CMHP) to conduct the evaluation of the patient and approve the petition is maintained and updated. For years, under the IEA process, a patient would be quickly transferred and admitted to a DRF in New Hampshire where a probable cause hearing for the IEA admission would then be held.¹⁰ Until recently, this probable cause hearing would take place within 3 days of the patient’s admission to the psychiatric unit or hospital (not including Saturdays and Sundays) in the DRF’s respective Circuit Court-District Division, regardless of how long the patient was held in the ED.^10,12

This process prevailed as the pathway for patients in need of involuntary emergency admission for many years, but it was imperfect and without flexibility in relation to the changing dynamics of the state's mental health system. As the problem of ED boarding worsened, with increasing numbers of patients staying in the ED for longer periods of time, concerns mounted related to compliance with RSA 135-C:29 (“Upon completion of an involuntary emergency admission certificate under RSA 135-C:28, a law enforcement officer shall… take custody of the person to be admitted and shall immediately deliver such person to the receiving facility identified in the certificate.”).¹²

Since 2011, the immediate delivery to a DRF has not been possible in most situations due to limited availability of DRF beds in the state.⁹ The pattern of extended ED holds without a timely hearing within 3 days elicited concern for patient rights, leading to lawsuits being filed in multiple court systems. ¹³

State of Change: Jane Doe vs the State of New Hampshire

On February 1, 2021, the American Civil Liberties Union (ACLU) of New Hampshire filed an appeal to the New Hampshire Supreme Court on behalf of an IEA admittee, Jane Doe, requesting clarification on the timing of holding probable cause hearings. Historically, probable cause hearings were held within 3 days (not including Sundays and holidays) of admission to a DRF. Patients awaiting admission to a DRF sometimes waited for weeks without a probable cause hearing, leading to due process concerns. The New Hampshire Supreme Court addressed this issue when it held that, "The plain language of RSA 135-C:31, I, entitles the person to a probable cause hearing within 3 days 'after an involuntary emergency admission, not including Sundays and holidays.' Therefore, the time for a probable cause hearing is triggered by the completion of a certificate, not by the person's delivery to a designated receiving facility."⁷

In May 2021, the New Hampshire Supreme Court upheld the rights of IEA patients to have probable cause hearings within 3 days of detention, not within 3 days of admission to a designated receiving facility. After this ruling, the executive, legislative, and judicial branches worked on developing a plan to address the Supreme Court’s decision. There was work on legislation addressing the need to increase DRF bed availability. The judicial branch developed a system for holding probable cause hearings within 3 days of IEA petition being certified even if the patient was still in the ED, with most of these hearings held telephonically.⁷ These changes alleviated due process issues, but many issues remain unresolved, and psychiatric patients could still be stranded for days in the ED.

Beyond the Inpatient Bed Shortage

The challenges within the state’s mental health system, even the issues related to ED boarding, extend far beyond inpatient bed shortages.⁴ For years, with boarding on the rise and waitlists sustained, inpatient bed availability was seen as the main problem needing resolution. Although additional psychiatric inpatient beds could lessen time spent by patients in the ED, this alone will not resolve the challenges of the mental health system. Additional inpatient beds are likely to yield only a temporary fix to a complex problem.

Admissions from the EDs are not the only through-ways impaired in this complex continuum of care. Patients are delayed in EDs, but many patients remain stuck in inpatient units, delayed in treatment and discharge due to a variety of factors. Involuntary admission to a DRF does not automatically lead to involuntary treatment. Individuals involuntarily hospitalized can refuse psychiatric treatment unless a determination is made that there is an imminent risk of danger to themselves or others, at which point emergency treatment can be initiated over a patient’s objection using a personal safety emergency or exploring additional legal channels. Delays in treatment and psychiatric stabilization add to patients languishing in a hospital setting without active or optimal psychiatric care.

Patients admitted on an IEA in New Hampshire are hospitalized against their will; however, they cannot be treated against their will without emergent need or additional legal steps. Many of these patients will have a petition for an involuntary commitment order placed during the 10 day IEA period (not including Saturdays or Sundays). This petition requests a hearing to obtain a probate judge’s order allowing for a longer period of involuntary inpatient hospitalization if their psychiatric symptoms during the initial 10 day period have not stabilized. An involuntary commitment hearing needs to be set within 15 days (excluding Saturdays, Sundays, and legal holidays) from the receipt of the petition at the Probate Court per NHRSA 135-C:37.¹⁰ Patients may wait up to 3 weeks for this hearing. Even if an involuntary commitment is ordered by the Probate Court, treatment is not started without the patient’s consent unless there are emergency circumstances that necessitate use of medication to prevent imminent harm to self or others resulting in a personal safety emergency, or if additional legal channels are explored. Circumstances may be present that allow for a psychiatric provider to request a 45-day period of emergency treatment authorization for a patient who has already received an order for involuntary commitment by the probate court.¹⁴ This is requested under state rule He-M 306and a hearing officer from the administrative appeals unit of the Department of Health and Human Services (DHHS) presides over the hearing and offers a ruling.¹⁴ Only 2 emergency treatment authorizations can be ordered during an inpatient admission, as outlined in the NH He-M 306 rules, and there is a clear set of criteria that must be met for this option to be considered and ordered.¹⁴ Given these outlined timelines, it may be at least 5 weeks before an admitted patient refusing care can be treated with scheduled medication.^10,14

If the patient is substantially lacking in their capacity to make decisions, manage affairs, and is at risk of harm to person or estate, a petition to apply for guardianship may be completed as a safeguard when no less restrictive alternative is available. Guardianship resources are substantially depleted in this state. If there is not a family member who is able to be nominated to assume this role, then patients and team members may wait weeks or months for a public guardian to be appointed by the probate court judge. If awarded, guardians may give informed consent for care over the patient’s objection.

Once a patient is stabilized for discharge to the community or a less restrictive setting, there are still barriers to this transition.⁴ Many patients cannot be discharged even after they have been stabilized due to a lack of resources allowing for adequate bridging to community care. There are deficits in staffing, financial, and physical support at community mental health centers, where the most vulnerable and at-risk individuals receive treatment. Housing options remain a consistent concern, with significant limitations of affordable apartments, waitlists for beds in transitional and supported housing, and limited options for long-term care beds. A barrier to most appropriate referrals to transitional housing may present when patients have active charges, even nonfelonious charges in the criminal justice system that have not been resolved. Homeless shelters and rooming houses are often without openings. Historically, patients ready for discharge were prioritized first in the Division of Mental Health Bridge Subsidy Program, a program assisting those diagnosed with serious mental illness or serious mental illness with co-occurring substance abuse issues to secure affordable housing by bridging rent payments.¹⁵ However, over the past few years, challenges in securing housing options in a timely manner have persisted even for patients with active Bridge vouchers.

Co-occurring diagnoses create additional challenges, as resources outside of the mental health system are necessary to provide adequate treatment and support for patients with comorbid substance use disorders, intellectual and developmental disabilities, brain injuries, and significant medical issues requiring specialized care. The bridging and combining of services across sectors of care is difficult and there are often limitations in the other divisions of care. These frequently encountered factors lead to an increasing number of patients with delays in their transition to the community. In recent reviews, the number of patients who could be discharged from the state’s psychiatric hospital if appropriate resources were available exceeded the number waiting for admission.¹⁶

This broken system impacts patients, families, community members, and the staff and teams that support this vulnerable patient population. Although there are dedicated frontline staff, supportive and innovative leaders, clinically astute providers, and advocates across the care continuum, barriers to effective and efficient care remain. There are significant and persisting social, economic, and resource factors, further complicating and impacting the limitations of the mental health system.¹⁷ Some of these factors are homelessness, lack of community resources, and access to support systems to promote stability and independence.^4,9,16,17 There are negative financial effects on hospital and community care systems, with reduced and fragmented reimbursement for psychiatric services further impacted by extended hospital stays.¹⁷ The system remains plagued by substantial staffing shortages across a variety of disciplines necessary for care.^2,17 The deficits increase workforce dissatisfaction, staff burnout, and an increased risk of injury and workplace violence.²

New Hampshire’s Response: Mission Zero

The depth and breadth of system issues in New Hampshire called for a comprehensive, solution-focused response. New Hampshire responded with a robust plan to promote changes across the care continuum to improve the system, strengthen the resources, and better support the lives of those suffering from mental illness and the structure that supports them.⁹ This response, named Mission Zero, is a multi-tiered, dynamic plan to address variables impacting efficient and effective care across the mental health continuum and mitigate inappropriate and excessive emergency room use and ED boarding.^18,19 Mission Zero is outlined by 3 areas of focus.

1. Front door issues: This focus area addresses variables associated with the lack of ability for individuals to receive timely services in the community to meet their psychosocial/psychiatric needs and/or crisis. The goal is to reduce the burden on emergency departments and determine what less intensive levels of care can be provided in the community.^18,19

2. Inpatient supply and coordination issues: Addressing system deficits, fragmentation, and availability of inpatient beds, preventing those with acute needs from being readily transferred to appropriate inpatient beds.^18,19

3. Back door issues: Focusing on issues related to excessive stays that are not medically necessary and the associated factors impacting the ability to safely and effectively discharge and transfer patients to lesser levels of care in the community.^18,19

This state-wide strategic plan has seen success in decreasing the number of patients and time spent waiting for psychiatric beds. The goal of 0 patients in the queue waiting for involuntary emergency admission in New Hampshire was met on December 6, 2024, for the first time in years.²⁰ However, meeting this goal has not been sustained. Mission Zero continues to stimulate hope and progress with support and initiatives across the care continuum from leaders, key stakeholders, and dedicated advocates. Collaboration across disciplines and agencies targets action for improving integrated behavioral health services. The project continues to expand across systems and will hopefully link additional adjacent care divisions that are instrumental in supporting the most vulnerable patients to more holistically meet the needs of the individuals served.

Dr Sorrell is an advanced practice psychiatric nurse, an Attending Provider, for Dartmouth Health in Concord, New Hampshire. Dr deNesnera is a psychiatrist for Dartmouth Health, retired CMO of New Hampshire Hospital. Ms Fournier is a double boarded advanced practice nurse, Chief Advanced Practice Provider Officer for Dartmouth Health.

The preparation of this report was financed under a contract with the State of New Hampshire Department of Health and Human Services, with funds provided in part by the State of New Hampshire.

References

1. Moon J. Arguments heard in lawsuit alleging lack of due process for N.H. mental health patients. April 2, 2020. Accessed January 29, 2025. https://www.nhpr.org/post/arguments-heard-lawsuit-alleging-lack-due-process-nh-mental-health-patients

2. O’Neill CP. NH hospitals seek court redress for boarding of psych involuntary emergency admits. March 3, 2023. Accessed January 29, 2025. https://www.nepsy.com/articles/leading-stories/nh-hospitals-seek-court-redress-for-boarding-of-psych-involuntary-emergency-admits/

3. Nordstrom K, Berlin JS, Nash SS, et al. Boarding of mentally ill patients in emergency departments: American Psychiatric Association resource document. Focus (Am Psychiatr Publ). 2023;21(1):74-79.

4. Abid Z, Meltzer AC, Lazar D, et al. Psychiatric boarding in U. S. eds: A multifactorial problem that requires multidisicplinary solutions. June 2014. Accessed January 29, 2025. https://hsrc.himmelfarb.gwu.edu/sphhs_policy_chcq/1/

5. Nolan JM, Fee C, Cooper BA, et al. Psychiatric boarding incidence, duration, and associated factors in United States emergency departments. J Emerg Nurs. 2015;41(1):57-64.

6. Ramer H. Pandemic hurts then helps psychiatric boarding crisis in NH. August 8, 2020. Accessed January 19, 2025. https://www.usnews.com/news/best-states/new-hampshire/articles/2020-08-08/pandemic-helps-then-hurts-psychiatric-boarding-crisis-in-nh

7. Jarvis T. New centralized involuntary emergency admissions process for mental health facilities is already delivering significant results. July 19, 2022. Accessed January 29, 2025. https://www.nhbar.org/new-centralized-involuntary-emergency-admissions-process-for-mental-health-facilities-is-already-delivering-significant-results/

8. Clarke A, Glick ID. The crisis in psychiatric hospital care: changing the model to continuous, integrative behavioral health care. Psychiatr Serv. 2020;71(2):165-169.

9. Sorrell S. Improving transitions in care: focus on the revocation of conditional discharge process in New Hampshire. 2020. Accessed January 29, 2025. https://scholars.unh.edu/scholarly_projects/41/

10. New Hampshire Revised Statutes. Title x public health: chapter 135-c New Hampshire mental health services system. Accessed January 29, 2025. https://gc.nh.gov/rsa/html/X/135-C/135-C-mrg.htm

11. de Nesnera A, Baldwin H. Commitment to treatment and care: the history of new hampshire’s mental health commitment law. New Hampshire Bar Journal. 54(2):24-29.

12. de Nesnera A,Vidaver RM. New Hampshire's commitment law: treatment implications. New Hampshire Bar Journal. 2007;48(2):68-73.

13. Ramer H. Court rules against state in emergency room boarding. May 11, 2021. Accessed February, 5, 2025. https://apnews.com/article/courts-health-c1c86bf135aae086b499233e94b2bfe6

14. New Hampshire Code of Administrative Rules. HeM-306. Accessed January 29, 2025. https://gc.nh.gov/rules/state_agencies/he-m.html

15. New Hampshire Code of Administrative Rules. He-M 406. Accessed January 29, 2025. https://gc.nh.gov/rules/state_agencies/he-m400.html

16. Towfighi M. How NH housing crisis is impacting availability of beds at psychiatric hospitals. April 2023. Accessed January 29, 2025. https://www.concordmonitor.com/Transitional-housing-NH-Hospital-50468441

17. Timmins A. ‘System is broken’: NH mental health centers seek $30M to add workers, bolster treatment. February 3, 2023. Accessed January 30, 2025. NH mental health centers in crisis seek help: ‘System is broken’

18. Mission zero. New Hampshire Department of Health and Human Services. Accessed January 29, 2025. https://www.dhhs.nh.gov/programs-services/mental-health/mission-zero 

19. NH Department of Health and Human Services. Mission zero: mobilizing collective action toward an adaptive leap. September 1, 2023. Accessed Januaary 29, 2025. https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/documents2/mission-zero-presenation.pdf

20. Mission Zero: no adults waiting in emergency departments for psychiatric placement. Press release. December 6, 2024. Accessed January 29, 2025.https://www.dhhs.nh.gov/news-and-media/mission-zero-no-adults-waiting-emergency-departments-psychiatric-placement