While the current mental health system could be diagnosed with a severe case of adjustment disorder,

changes could lead to better and broader approaches to treatment in the future.

Gail Hawkinson, who has worked in the mental health field locally for 35 years and is program director of New River Behavioral Healthcare, which is Watauga County’s designated public service provider.

Hawkinson said staffing shortages were plaguing the mental health service providers, with 90 licensed child psychiatrists in the state, many of them clustered around research and teaching hospitals.

New River previously was managed as a part of a five-county entity but this spring fell under Smoky Mountain Center, which covers 12 counties in western North Carolina. Under the arrangement, county and state funding go through Smoky Mountain while counties provide some support to their local provider. In Watauga County’s case, the county provides a building and New River provides services at the county jail.

Hawkinson said as a public provider, it is required to have around-the-clock services and to serve all indigent or Medicaid-eligible patients, while private providers can choose to only accept those who have private insurance or other means of direct payment.

“We see anybody that comes through the door who meets state criteria,” Hawkinson said. She acknowledged the use of interns had helped stretch the budget and provides broad training for the next generation of caregivers.

“If we can’t help them, we work with Smoky Mountain and find a way to get their needs met,” Hawkinson said. Increasingly, those needs include a connection with outside support groups such as those offered in the community or through churches.

Hawkinson laments the increased paperwork required under the revamped system and said Medicaid funding has been reduced for mental health services. A recent change in service definitions coincided with the reform movement to create a doubly whammy of transition, creating an added layer of accountability and bureaucracy in a field that has long been a poor candidate for a “one size fits all” strategy.

“This is a system that was already bogged down in accountability requirements,” Hawkinson said. “The accountability that’s devised is all paper and doesn’t really do anything.”

Changes have also led to more shuffling of patients, as hospitals increasingly find it not cost-effective to maintain psychiatric wards or beds. Sometimes treatment becomes a game of hot potato as the patient uses up funding limits and must change treatments or find new providers.

“Sometimes they can’t stay in the hospital long enough to get stable,” Hawkinson said. “This is related to problems in health care in general, and it’s bigger than just mental health. It affects the schools, the health department, the court system, the hospitals. There’s not enough money in the system to entice hospitals back into having (psychiatric) beds.”

New River serves as consultant in case where a patient with mental health issues is admitted or shows up in the emergency room. Sometimes that leads to a backlog of the entire system, as personnel from New River, the hospital, and, often, law enforcement must stay until a case is resolved or decision made, which sometimes can take up to 48 hours.

While mental and behavioral health services, as well as substance abuse treatment, gets little attention in legislative circles, it affects many people. About 4,550 people a year use New River’s services in Watauga County, and often they each have multiple contacts. The office fields 100 calls a week on a range of topics and information requests.

This workload is handled by 62 care staff, nine of them providing clerical duties for the outpatient service. Another six staff members serve those with development disabilities.

Nearly 40 percent of New River’s funding comes from Medicaid, making it more vulnerable to changes in the state budget and policies than most private service providers. Only two percent of its income is from private insurance and even less comes from clients who pay for their own treatment. Watauga County funds about four percent of New River’s budget.

Hawkinson said large providers need to be able to offer a broad range of services due to Medicaid changes, but it’s also difficult to hire staff certified in all those areas. She said even though reform measures took effect immediately and Medicaid billing changes were adopted in 2006, changes required some staff members to get two years of training toward certification. Hawkinson said once those certifications are complete, clients should benefit from broader services, including more field visits designed to meet the patient in an environment outside the traditional office visit. That could help close some of the gaps and create more integrated and coordinated approaches to treatment.

She acknowledges frustration but believes there’s a glimmer of better service once the transition is over. “If I wasn’t so invested in the mental health system, I would have run screaming three years ago,” she said.