CHARLOTTE, N.C. (Anna Douglas | The Charlotte Observer) - A 25-year-old Gaston County woman who is addicted to heroin waited two days in a hospital's emergency department, in a psychiatric observation room with no bed.
She needed help for her drug addiction, her family says, but local treatment centers were full.
"They don't have any place to put them. They're so packed," says the woman's grandmother.
Instead, the woman was taken to an emergency room by police last month, under a judge's order to involuntarily commit her. The woman's family says she had threatened to kill herself and they've been concerned about her health and behavior after learning she's been using heroin for several years.
The ER, according to the family, was the only option.
A growing opioid and heroin epidemic has escalated a problem that health care professionals have been raising concerns about for years: North Carolina has inadequate services for people with mental and behavioral health diseases.
Doctors in North Carolina confirm there's an increasing demand for help and patients are turning to emergency rooms – an expensive and ineffective place for treatment.
Often, patients wait days – a process called "boarding." Hospitals say it takes a toll on their budgets and leaves fewer beds available for other people who need the emergency room.
Most ERs can't provide full substance abuse or psychiatric health treatment. Instead, they can assess patients and offer some medical care – then work to transfer patients to specialized treatment centers.
But, when the treatment centers are full, hospitals end up keeping patients inside emergency room departments.
Recently, the North Carolina Hospital Association reported 30 to 80 percent of emergency beds are used for boarding. The result is higher costs for all patients and delays for patients who are in a mental or behavioral health crisis.
For privacy reasons, the Observer is not publishing the name of the Gaston County patient or her grandmother.
Her family says they grew concerned in the past year about changes in the woman's behavior. Then, they learned she had started using heroin while she was in college in western North Carolina a few years ago. After graduating from college, she got a job but she stayed hooked on heroin, her grandmother said.
Heroin is an opioid, a class of drugs that now kills more people in North Carolina each year than car wrecks.
This family's experience of a long stay inside an ER and difficulty finding a treatment bed is a common one in North Carolina.
After calling state and local lawmakers to complain about bed shortage, the 70-year-old grandmother called the Observer in late June as her granddaughter waited inside CaroMont Hospital's emergency psychiatric unit in Gastonia.
There, two rooms, separated by gender, house three recliners each for patients. There's no medical equipment inside and no other furniture, except for an encased television with no wires exposed. Patients may use a wireless phone and are supervised by hospital staff at a nursing station.
This is where the young woman stayed for 48 hours, her grandmother said. Hospitals are required to accept patients in mental health or drug abuse crisis and perform psychiatric evaluation.
CaroMont Hospital's average patient boarding time is four days – the same as the state's average for adults who are waiting for a transfer to one of North Carolina's three state-run psychiatric hospitals. For a transfer to a taxpayer-supported treatment center, the average statewide wait is 2.5 days.
"We will have patients present to our (emergency department) because they have nowhere else to go," said Dr. Tom Davis, chief medical officer for CaroMont.
"It is truly a public health crisis and it is really complicated ... Our society in general has not funded or put an emphasis on helping to treat and manage mental health problems."
CaroMont's ER sees nearly 90,000 patients a year. When mental and behavioral patients at the ER don't have acute physical medical problems, they can wait in rooms called psychiatric suites.
Davis and other hospital officials said they couldn't talk about the specific case of any patient. When boarding, the hospital prioritizes the patient's safety and medical needs, he said. And, if a patient needs follow-up care but not inpatient treatment, hospitals discharge them with a treatment plan.
Wait times in Charlotte
Patient boarding and gaps in health care services for mental and behavioral health patients are problems nationwide.
But North Carolina, compared to other states, sees nearly twice the rate of psychiatric patients who resort to the ER each year, says Martha Whitecotton, senior vice president for behavioral health services at Carolinas HealthCare System in Charlotte. Carolinas has an emergency room that exclusively serves patients in behavioral health crisis and it's often full.
On average, the boarding time at a Carolinas HealthCare emergency room or another facility in the system is about 17 hours.
"But we definitely have patients who are there much longer," Whitecotton said, including children and geriatric patients because of fewer beds for those populations.
In Charlotte, both Carolinas HealthCare System and Novant Health told the Observer they board up to 40 patients daily, with some fluctuation, including those who go to the ER in crisis, with mental health and substance abuse issues.
At Novant, the average boarding time varies by location – from 10 hours in Huntersville to close to 17 hours at Presbyterian Medical Center in Charlotte.
Many hospitals in the state – including Novant, Carolinas and CaroMont – are trying to cut down on the boarding wait times by using "telemedicine" services that include psychiatric consultations by phone and video.
Boarding costs soar
Each time boarding happens, hospitals stand to lose thousands of dollars.
"It's draining the system," said Julia Wacker, vice president for community and behavioral health with the North Carolina Hospital Foundation. "It's counterproductive in every way."
Nearly 80 percent of mental health and substance abuse patients in North Carolina are covered by Medicaid or don't have insurance, which means tax dollars pay for some of their costs and hospitals absorb the rest.
Hospitals lose money by the hour when they board uninsured and Medicaid or Medicare patients because expenses past the first day of their stay can't be fully reimbursed. Some experts estimate this type of boarding costs about $100 an hour, per patient.
These extended stays in the ER burden hospital budgets, and those costs are being shifted to other patients and payers.
Some doctors and health care administrators say boarding is happening at higher rates because North Carolina doesn't have enough treatment and psychiatric beds. Others say patients are turning to the ER because preventative care for mental health disease and drug addiction is too expensive or inaccessible. Data shows about half of the state's counties don't have enough psychiatric doctors.
The stakes are high, with nearly 1,100 opioid deaths annually in North Carolina – a death rate higher than murder rates in the state. That figure from 2015 is a 73 percent spike compared to opioid deaths in the state 10 years ago.
Over the same time period, the wait for treatment beds and the number of patients resorting to the emergency room for mental and behavioral health care has gone up fourfold, the hospital association reports.
North Carolina's Department of Health and Human Services is trying to alleviate the boarding problem and related opioid crisis on several fronts. This year, the department introduced new criteria for the groups that manage mental and behavioral health care, and it plans to impose penalties and fees if services aren't improved.
Adding beds would reduce some ER boarding but one research project performed in North Carolina suggests the state would need to effectively double the amount of beds it currently has to just ensure patients aren't waiting more than 24 hours in a hospital for a transfer – a potential solution that would take years to build out and millions of dollars not currently allocated.
Partners Behavioral Health Management is trying to reduce the problem of boarding at ER rooms, said Dr. Michael Forrester, a psychologist and the chief clinical officer. Partners operates in eight N.C. counties, including Gaston, Iredell and Catawba. It's one of seven regional entities that receive state and federal tax dollars to act as a managed care organization for mental and behavioral health needs.
These regional organizations have special care centers for patients who are in mental health or drug addiction crisis, as an alternative to the ER, as well as offering individualized outpatient treatment.
DHHS says many of its solutions for emergency room boarding are routed through Partners and the other regional organizations. One pilot program is running now in 13 N.C. counties, with the aim of diverting patients in behavioral health crisis away from ERs and on to specialty facilities.
A better approach to getting patients the right kind of health care outside of an ER is key, says Billy West, executive director at Daymark Recovery Services, a growing mental health and substance abuse treatment provider, with 32 clinics in North Carolina.
Whether a person is in a mental health crisis, involuntarily committed through court or is personally ready to start drug addiction treatment, West says, doctors and health care providers want to act quickly in that window of time to help a patient. Boarding delays access to long-term health solutions, West said, and may contribute to a dangerous and expensive cycle.
Some statewide statistics suggest this may be happening already.
More than one quarter of Medicaid patients who use an ER for mental and behavioral health issues return to an emergency room the same year with the same problems, North Carolina DHHS statistics show. Of those, nearly 13 percent were return ER visitors within a month's time.
In the young woman's case in Gastonia, her family worries she'll be one of these statistics. After being discharged last month, the woman followed up on outpatient treatment as prescribed by the hospital, says her grandmother, but more waiting may be in the future.
The local outpatient treatment facility she's enrolled in has some wait times for appointments the young woman will need, her grandmother told the Observer Tuesday.
"I'll do anything," says the grandmother, who adopted her granddaughter around her first birthday. "I want to get her good help now."