For a little more than a decade, UNC Health Care has provided care at WakeBrook, the mental health hospital in east Raleigh. Wake County owns the facility, but UNC has been the care provider. Earlier this year, UNC Health announced it will transition away from WakeBrook, a move advocates say will leave a hole in care for some of the most vulnerable patient populations in the area.
"If their needs are such that they really need a qualified psychiatrist, [or] really good psychiatric hospital beds, those aren't going to be available anymore," said Ann Akland, a past president of the National Alliance on Mental Illness (NAMI) Wake County and a longtime advocate for mental health services in and around Wake County. "I'm terribly concerned for the welfare of patients who have no insurance in particular, because there has to be a place for those people to go."
County health leaders say they are well prepared to absorb these patients, and say more new care options are just over the horizon.
The WakeBrook facility sees patients with substance use disorder and severe psychiatric diagnoses, including schizophrenia. It has crisis assessment services to treat people in active mental crisis, alcohol and substance use detox unit, and 28 licensed inpatient psychiatric beds where patients can sometimes stay for days while recovering from an episode.
Many WakeBrook patients rely on Medicaid or Medicare or do not have health insurance. Of the 485 patients who received service at WakeBrook in fiscal year 2022, just two had commercial insurance, according to UNC regulatory filings.
Because of this, their care is often filed as charity or uncompensated care from a business perspective. On Aug. 16, Wake County announced RI International would become the new provider of WakeBrook.
When UNC leaves WakeBrook, care for nearly all of these patients will fall to other providers. Much of that will fall to RI, but WakeMed Health and Hospitals will also absorb some of the patients. Despite the similar sounding names, WakeBrook, WakeMed, and Wake County are different entities and have no shared management or ownership.
"The needs around caring for those with mental health conditions will take all of the health providers in this community working together to develop and provide solutions," according to a statement released by WakeMed. "WakeMed will continue to collaborate with the County and other organizations on collective solutions that better support a healthier community."
From hospital-based to peer-led care
RI operates differently than UNC in a variety of ways, mainly that it is not an academic medical center and does not staff its facilities with as many medical doctors. It operates a more peer-led model with trained counselors, some of which have endured mental health episodes themselves, said Sean Schreiber, chief operating officer of Alliance Health, the managed care organization for publicly funded behavioral health care services in a six-county service area, including Wake.
"They're actually kind of the founder of something called the Living Room model, which builds a lot of peer supports, and really makes sure that when people come to a crisis facility, it's kind of a warm and welcoming experience to kind of help lessen the trauma," said Schreiber. "I think UNC being a health system and academic medical center, operated that campus a little bit more like they might operate a large health system. It was staffed very much like an emergency department may be staffed."
Schreiber said one noticeable difference to patients would be right at the front door, especially for an involuntary commitment.
"[Currently] you're greeted by a law enforcement agency who's taking custody of that individual," Schreiber said. "RI uses peers. So someone who's had lived experience; experienced mental health crisis themselves."
Another difference is simply in language. RI refers to the people it serves as "guests" instead of "patients" or “clients."
But some advocates worry that without hospital level care, it could leave certain patients without an option. Advocates like Akland say trained peer counselors can often provide good quality care, but some extreme cases require higher levels of care.
While RI does not staff its facilities with emergency room doctors who specialize in heart attacks or other physical injuries, it does staff with licensed psychiatrists as well as nurses with specialized psychiatry training, according to RI Chief Operating Officer Joy Brunson-Nsubuga. The RI model also seeks to work out partnerships with hospitals so they can bring patients in need of that kind of medical care to those emergency departments. In return, RI offers to take patients they can serve out of those EDs.
"RI prides itself in being that base and that diversion from jails, from EDs. Making sure that individuals get that level of care they need without going to a hospital level of care," Brunson-Nsubuga said.
Brunson-Nsubuga estimated that about 3% to 6% of RI's "guests" are taken to emergency rooms. She said it's likely that more patients would actually be diverted away from an ED to an RI facility than the other way around.
Opioid overdoses soar during pandemic
As the opioid crisis ripped through the United States, governments - including in North Carolina - put in measures aimed at lowering deaths. These measures had limited success with 2018 and 2019 recording fewer opioid overdose deaths than in 2017, a year that was at that time a record high.
But the pandemic washed away all those gains. Opioid overdose deaths increased 72% from 2019 to 2021.
Some advocates say licensed medical providers are needed now more than ever, as the animal tranquilizer xylazine makes its way into street drugs like heroin. Akland was also concerned about patients who cannot afford to pay. Holly Hill hospital sits just across the street from WakeBrook, but it is a for-profit hospital and more than 30% of its patients last fiscal year had commercial insurance, according to regulatory filings.
"When you have something that's like a medical model based, the cost is always going to be higher than some of the community based services," said Schreiber.
Wake County Chief Medical Officer Dr. Jose Cabanas said RI’s model more closely matches what the county needs and will allow the facility to treat more people. He based that off recommendations from a May report by Human Services Research Institute (HSRI) which assessed the county's behavioral health crisis service system. He lamented that there would be a gap in service during the transition from UNC to RI, but said the timing gives the county an "opportunity to align some things based on those recommendations from that report, and definitely RI hits those points."
Cabanas emphasized the move was not simply to save the county money, but to spend money in a better way. He said he hopes that offering care to more people will reduce the number of people who need high level crisis interventions.
Negotiations between UNC and Wake County soured
In February, Wake County Manager David Ellis and then UNC Health Chief Operating Officer Steve Burriss met to discuss the future of their relationship at WakeBrook. After that meeting, Burriss informed Ellis that UNC would no longer provide care, and would wind down services well into 2024. That set in motion months of negotiations that at one point seemed to near a resolution, but that ultimately ended contentiously and with UNC planning to wind down operations on Sept. 30, months earlier than initially proposed.
It is not entirely clear how talks between the county and UNC broke down. Through a Freedom of Information Act request, WUNC received emails from the county between Ellis and Burriss that seemed to show a 5-year extension had nearly been reached, only for it to fall apart days later. These emails paint only part of the picture, though, as the two leaders also held face to face meetings. Clearly, though, talks broke down quickly and irreconcilably.
"In all honesty, I am extremely disappointed not only in the outcome and I no longer believe UNC was negotiating with us in good faith," Ellis wrote in an email to the board of county commissioners and county senior staff. "First, they publicly mischaracterized their initial meeting with us, blaming the County for not wanting to enter into a long-term funding and operating agreement when they informed us they were pulling the plug due to financial considerations and once the County met their request they moved the goalposts."
WUNC filed a FOIA for emails from UNC Health on June 22, but had not received those emails by publication. In a written statement, UNC blamed the county for the breakdown.
"Our leaders were committed to negotiating a sustainable, long-term contract, but were unable to persuade Wake County officials, who were relying on inaccurate financial projections," according to the statement.
Burriss left UNC Health Care to become chief operating officer of Orlando Health. His first day was July 24.
Separately from WakeBrook, UNC Health has said it wants to shift to focus to adolescent and family mental health and formed a new partnership with N.C. Department of Health and Human Services to operate a psychiatric hospital for children and adolescents in Butner.
“UNC is working toward a new emphasis on behavioral health that is broader than our current work at the WakeBrook campus,” Burriss wrote to Ellis in the February letter.
More care options
Even though UNC Health will leave WakeBrook, the county has more care options for marginalized patients, and more services are on the way, according to county health leaders.
For one, WakeMed in February received regulatory approval to build a 150-bed psychiatric hospital in Garner. That hospital's planned opening date is not until 2026, but in June, The Hope Center for Youth and Family Crisis began treating people at its location in Fuquay-Varina. There's also the Wake Behavioral Urgent Care in south Raleigh and other facilities like Triangle Springs, Healing Transitions, and Morse Clinic.
The county has also equipped emergency services personnel with Narcan kits, which can reverse an opioid overdose, and started a nurse navigator program to better triage 911 calls.
Wake is one of the few North Carolina counties to already allocate funds from the landmark opioid settlement. These funds are aimed at helping some of the same patient populations treated at WakeBrook.
