Rural programs help spread mental health care from door to door

Aug. 16--At the height of her panic attacks, Mildred Fuller lay with her baby on the floor, hands pinned beneath her body and hearing voices. She was paralyzed by anxiety after giving birth to her fourth child 16 years ago.

She had seen a news segment about a Durham woman who hurt her own children, and she was afraid she might do the same. Realizing she needed help, Fuller checked herself into a hospital.

Now, after years of work and medication, Fuller has a handle on her anxiety. It's been five years since her last panic attack. The problem now is she can't keep her prescriptions straight. A pharmacist who noticed that Fuller was coming in for medications not yet due to be re-filled referred her to a new program.

The Mobile Medication Program, run by the behavioral healthcare provider Daymark Recovery Services and coordinated by the N.C. Hospital Association, ensures that people at risk of psychiatric hospitalizations understand and stay on track with their medications.

The program is run by a team of three -- one nurse and two technicians. They travel from home to home in Vance County, and specialize in helping people with mental illness with their medications.

In place since early April, it's an attempt to peel through the layers that complicate treatment of mental illness, such as self-medication and substance abuse, poverty, incarceration and hospitalizations.

Julia Wacker, who oversees the program for the NCHA, knows that the mental healthcare system in North Carolina is fragmented. She sees the program as a needed response to a lack of resources in the state.

"Any county in North Carolina could justify a need for something like this," Wacker said.

Missing link

Chronic mental illness is expensive to treat, said Allen Smart, vice president of the Kate B. Reynolds Charitable Trust. Programs in Vance and Nash County were each granted $1.2 million, spread out over three years.

Within the healthcare sector, Kate B. Reynolds awards about 75 grants per year, about a third of which are focused on mental health, Smart said.

Mobile Medication's model is exciting, he said, because it cheaply addresses a missing link in healthcare. Providers don't typically provide support to keep people on their medications, Smart said. The program sets itself apart by addressing only medication adherence.

Ideally, clients are enrolled for about three months. Participation is voluntary.

"It was responding to a gap in the system," Smart said of the program.

Thava Mahadevan, director of operations for the UNC Center for Excellence in Community Mental Health, said Mobile Medication is likely the first program of its kind to focus solely on medication adherence. The NC Alliance for Effective Care Transitions does in-home visits, he said, but addresses patients' other health concerns as well.

Without their medications, people experiencing mental illness can become unstable, Smart said. That often leads to a hospital or jail.

Mobile Medication is, in part, a response to a lack of psychiatric beds. North Carolina cut 700 psychiatric beds between 2005 and 2010, according to the Treatment Advocacy Center. Donna Perry, a Daymark nurse who oversees the program, said the Maria Parham hospital in Henderson constantly has eight to ten patients waiting for a psychiatric bed.

Generic forms of drugs often change in size, shape and color, which is often a source of confusion for people diagnosed with mental illness, Wacker said.

The fact that most mental illnesses coincide with some other medical diagnosis further complicates the situation, Wacker added, leaving people to struggle with multiple prescriptions and complicated drug interactions.

How it works

Lipitor, Celexa, Gabapentin. Glyburide, Lasix and Metformin represent about half of the medications Robert Neal needs to remember to take.

Neal, who has struggled with depression and substance abuse in the past, is typical of clients in the program. Of the 32 people currently enrolled, psychiatric illness and poverty are among the common denominators.

A hip surgery in 2009 cost Neal his job as a housekeeping supervisor for a nursing facility. Without a job and hindered by his physical disability, Neal became depressed. Alcohol was his self-selected medication.

Neal is recovering well from his alcoholism. Now, transportation is his greatest obstacle. Every day, Stephanie Timberlake, one of the two technicians along with Church, drives 20 minutes outside of Henderson to meet Neal at his house. There, they discuss each of his 11 prescription drugs, going over what they do and when to take them.

"If you take one at 5 o'clock when you eat dinner," Timberlake prompts Neal about his painkiller, "when are you going to take another?"

"Before breakfast?" It's a guess.

"Before you go to bed tonight," Timberlake corrects him. "Don't double up on 'em."

Neal is polite, always answering with a "yes ma'am" and a deferential nod to Timberlake's directives. He has been on the program since May, and it's getting easier to keep everything straight. Soon, he might be one of the program's first success stories.

I keep my mind focused on my program. If it weren't for them, I'd be in trouble.

Robert Neal, Vance County

"I keep my mind focused on my program," Neal said. "If it weren't for them, I'd be in trouble."

The program keeps costs low by employing technicians, rather than certified nurses, to do home visits. In Vance County, the team brought on a "peer support specialist" -- someone who has battled with their own mental health -- to work on the Mobile Medication team. Wacker said results have shown people respond well to people who can relate.

Michael Church, the peer support specialist for the team, has lived in Henderson for 30 years. Before the Mobile Medication Team was created, Church worked in a local crisis center, where he witnessed first-hand the severity of the mental health problem in Vance County. He said he doesn't know why Henderson copes with so many cases of mental illness.

"What is unique to Vance," Wacker said, "is the scale and the breadth of the problem."

Vance County in need

Vance County, north of Raleigh on the Virginia border, is the third-poorest county in North Carolina according to the U.S. Census Bureau. The State Bureau of Investigation reports the county has a crime index more than twice the state average.

Jerry Earnhardt, a regional director for Daymark, said a tool to measure the severity of mental illness in a region is the number of injectable medicines, used for serious thought disorders, given each week.

Compared to about 20 per week in Randolph County and 15 per week in Harnett County, Earnhardt said Daymark administers as many as 100 shots per week in Vance. Despite the challenges -- Earnhardt pointed to a lack of public services and transportation in Henderson -- coordinators are confident the program will be effective.

Mobile Medication is modeled after a similar program in Pennsylvania by the same name, that reportedly reduced hospitalization costs in the area by $1.3 million in its first year.

Kate B. Reynolds set a goal of 100 people enrolled in the program by the end of the year, and Wacker is managing a similar program that is in its first weeks in Nash County, also funded by the charitable trust.

"I am excited about it," Earnhardt said. "If we are able to do it well, it will show benefits and it will show success."

Weaning off the program

Hopefully, Mildred Fuller will be able to cope without the Mobile Medication team soon. She lives in a tidy Henderson apartment with her bird Early Berly and her dog Lola. Her walls are decorated with art made by her kids. She muses about being a grandmother soon.

The team has watched Fuller steadily improve. Perry, the program's certified nurse, is bursting with pride. She said even the apartment, which was dark and messy when the team first started with Fuller, seems brighter.

Wacker said the program isn't successful if the clients remain on the program forever. The Mobile Medication Team is meant to educate its participants on how to be independent, despite their challenges.

Fuller isn't sure when she'll be able to handle her seven prescriptions by herself. She still doesn't feel confident enough, but the finish line is in sight, and she's proud of the progress she's made.

"Not quite yet," she said. "But almost there."

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