People with severe behavioral health disorders face enormous obstacles in attempting to live a normal life. They are often unable to maintain a job, and they tend to live alone, suffer from chronic medical conditions, and have issues with substance abuse. These issues are all compounded in rural areas, where transportation is limited and mental health services are not widely available. In this environment, patients are unlikely to receive centralized, coordinated, and long-term care for their illnesses from a single primary provider, or to develop the skills necessary to ensure that their treatment is effective. Instead, they go untreated until their symptoms escalate into a crisis that forces an emergency room visit.
Once inside the emergency room, patients may wait days for admission to a state psychiatric hospital—these delays generate enormous costs. Before their release from the psychiatric hospital, patients are usually given new prescriptions and instructions to visit with outpatient providers, but these new orders do not incorporate any prior treatment the patient may have been receiving and do not address the issues that forced the patient to go untreated in the first place.
The North Carolina Mobile Medication, the winning entry of the 2016 Better Government Competition, addresses this issue in a unique way. It focuses on two things: the cohesiveness and accessibility of care and skill-building in target populations.
The program begins either at discharge from a state psychiatric institution or by referral from care providers, law enforcement, or families. Trained registered nurses conduct a thorough assessment of all care a patient is receiving or has received, and reconciles prescriptions and care instructions. The nurse also helps the patient identify any barriers to following medical instructions, including cost, and ensures that the patient’s living environment is safe and healthy. If the patient cannot afford his medication, or if the home is an unsafe place to live, the nurse can assist the patient with finding solutions. Once the nurse has conducted his or her assessment, trained technicians begin the second phase of the program, which is focused on building patient skills.
At the beginning of the program, the technicians visit patients daily in their homes. During their short visits, they ensure that medical instructions are being followed, help the patient with any side effects, and prepare patients for upcoming medical appointments. The consistency of these visits mimics the routine of inpatient treatment and builds patient capacity to follow medical instructions consistently. Over time, daily visits taper, first to three times weekly, and eventually to once per week. Over time, this routine will evolve to just one weekly call as a check in, by which point the patient will have developed the skills necessary to keep appointments and follow medical instructions at home. Once they are receiving proper care for their illnesses, indicators like substance abuse-related incidents and law enforcement involvement decline as well.
In an ongoing three-year trial in rural areas of North Carolina, the program has achieved a 94 percent reduction in emergency room visits and similarly high reductions in state psychiatric hospital admissions and lengths of hospital stay. These results, if they can be reproduced on a larger scale, achieve cost savings by reducing the cost of avoidable emergency room visits for hospitals (and therefore for state and federal governments), and improve the lives of target populations by ensuring that they receive appropriate treatment for their illnesses.
Recent research has shown that this kind of intensive, at-home care is the most effective way of addressing health concerns in impoverished and isolated communities for individuals with behavioral health needs. Many home care programs, however, run into the same overriding issue: for the coordinated care necessary, many highly trained providers have to spend a great deal of time with each patient. Especially in rural areas with high travel times, this time translates to high costs. The North Carolina program achieves savings by delegating most of the time-intensive work to technicians, who are not as highly trained and therefore less costly to employ. They are in constant communication with a registered nurse at a central location, which allows them to draw on the nurse’s expertise when needed without requiring his or her presence in the field. This approach was pioneered in a similar program in Pennsylvania, and has been expanded on in North Carolina, where the program is sponsored by a local charitable trust.
Going forward, the initiative’s organizers would like to see the program’s expansion across the state of North Carolina and eventually to other states in the region. They would also like to advocate for a federal Medicare and Medicaid definition for the service they provide, so as to make it more accessible on a nationwide basis. This novel approach to providing care to vulnerable populations has the potential to achieve excellent results, lowering the human cost of mental illness while achieving significant savings for hospitals and government bodies.