For nearly a year, Jake Davis languished in jail, waiting for a bed in a state-run psychiatric hospital to get court-ordered mental health treatment.
Davis, 37 and diagnosed with bipolar and delusional disorder, was arrested and booked into the Watauga County Detention Center in Boone on Mother’s Day Weekend 2023 for nonviolent crimes. His mother, Jama Hinson, said he committed those crimes while in a state of psychosis. His mental status continued to be “off the chain” in the weeks that followed, she said.
But her son sat untreated for months in the detention center, waiting until October before a forensic evaluator declared him “incapable of proceeding.” The designation means someone is so mentally impaired that they can neither comprehend the court proceeding before them nor rationally work with an attorney to help in their defense. It also halts legal proceedings, putting one’s case at a standstill until their capacity is restored.
But it took nine months before Davis got a spot at Broughton Hospital in Morganton — in July 2024 — to start that capacity restoration treatment. During the wait, his mother told NC Health News his mental health continued to deteriorate.
Seeing her son locked away and spiraling without adequate mental health care took a toll.
“I never in a million years would have thought it would have taken so long,” she said. “It took probably five years off my life.”
Davis’ story isn’t an outlier. Capacity restoration services, which have historically only been provided in state psychiatric hospitals in North Carolina, aim to restore people’s ability to understand and continue trial proceedings. These services consist of mental health therapy, including medication, and education about the legal system.
An increasing number of criminal defendants are being declared incapable to proceed in North Carolina and wait an average of 173 days — nearly six months — before being admitted to one of three state psychiatric hospitals for capacity restoration treatment, according to the N.C. Department of Health and Human Services.
State health officials are working to reduce wait times by expanding options for capacity restoration outside of state hospitals. Just over $9 million has been allocated to stand up and support three detention-based and three community-based capacity restoration pilots.
Many of the programs are still finding their footing, but Robert Cochrane, DHHS’ statewide director of forensic services, said the new settings have great potential to serve people more quickly and more economically. Importantly, he said, they can relieve some of the load on the state’s overburdened psychiatric hospitals, shortening wait times for anyone else in crisis who needs a bed.
“It is a paradigm shift of sorts,” Cochrane said. “The alternative restoration sites — the community and the jail — are a huge part of deflecting from the hospitals those people who don’t need to go there, so that everybody can get care in a more expeditious manner.”
Limited beds
Beds in North Carolina’s state-run psychiatric hospitals are limited — with demand significantly outpacing available space. In addition to criminal defendants, like Davis, who wait months in jail for a state hospital bed for the treatment they need to be well enough to stand trial, hundreds of North Carolinians in crisis in the community wait weeks or even months in emergency rooms for beds to open in those same facilities.
North Carolina’s three state-run psychiatric hospitals — Cherry, Central Regional and Broughton — have a total bed capacity of 910. However, due to crippling staff shortages, only about 600 beds are in operation, a DHHS spokeswoman told NC Health News.
In recent years, a growing share of that limited bed space has been taken up by people involved in the criminal justice system who have been deemed incapable of proceeding. These patients made up 10 percent of the total annual admissions to the state’s psychiatric hospitals in fiscal year 2016; that number swelled to 28 percent of admissions in fiscal year 2024.
Nearly one-third of the patient population currently in state psychiatric hospitals are people deemed incapable to proceed, according to DHHS data provided to NC Health News on Feb. 7. This means these beds are unavailable for others who might be waiting in emergency departments.
Another 157 people are on the waitlist for a spot in a state hospital for capacity restoration services, according to data shared with NC Health News.
The beds generally do not turn over quickly because capacity restoration can be a slow process. DHHS said these patients stay 160 to 180 days on average. However, a spokeswoman noted that their restoration may be completed sooner but a person may still have to stay because they continue to meet involuntary commitment criteria or a judge orders that they remain at the facility.
Increased demand for services
The number of people being referred by the courts for capacity evaluation every year is ballooning, taxing an already strained system further.
Last year, over 2,600 capacity evaluations were completed, according to DHHS data provided to NC Health News. It’s a 33 percent increase in evaluations over the past five years — without an increase in resources.
DHHS’ Robert Cochrane said staff turnover has added to the challenge. Seven of nine state forensic evaluators at Central Regional Hospital responsible for conducting evaluations left their jobs last year. The state is still working to fill these roles, he said, but even before the turnover, the team was struggling to keep up with the pace of referrals from courts.
Approximately 60 percent of individuals evaluated in 2024 — over 1,500 people — were deemed incapable of proceeding to trial and needed capacity restoration services.
North Carolina isn’t alone in struggling to meet the demand for capacity restoration services. Across the country, court orders for capacity restoration services are increasing much faster than states can provide them, contributing to what experts have deemed a national “competency crisis.”
“It just becomes more and more challenging as those referrals go up, as our staffing needs increase,” Cochrane said.
“It’s not going away,” he continued. “We can’t incarcerate and hospitalize this problem away. It’s been building for decades … so we’re having to really think creatively and do things differently, or else we’re just gonna dig ourselves deeper and deeper into a hole.”
Everyone doesn’t need a hospital
The state’s strained psychiatric hospitals can’t meet all the demand for capacity restoration services. However, even if they could, Cochrane said that many people don’t necessarily need the level of care offered in a hospital setting. But until recently, there hadn’t been any other options.
North Carolina is now turning to new settings for capacity restoration that can keep someone closer to home and be more cost-effective. DHHS has allocated $7.2 million to support three programs in local detention centers — funds that came from state lawmakers’ $835 million investment in behavioral health included in the 2023 state budget. Three community-based pilots are also supported by a two-year, $1.9 million federal mental health block grant.
NC Department of Health and Human Services
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via NC Health News
The programs required time to sort through a maze of logistics and contracts before care at the new sites could start. But as of Feb. 19, 54 people have received detention-based capacity restoration, and 16 have been served by the community programs, according to DHHS.
Rachel Crumpler
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NC Health News
Cochrane said that the jail and community programs provide nearly identical services to what someone receives in a state psychiatric hospital, including individual therapy, group therapy, education sessions on the legal system and medication management.
While the care is similar, the costs associated with each capacity restoration setting are much different. DHHS told NC Health News it costs approximately $1,200 a day to provide capacity restoration in a state psychiatric hospital, compared to $400 for detention-based restoration. Community program costs have yet to be determined but are expected to be far less than the hospital.
Read Monday’s story to learn how jails are playing a role in reducing how long mentally ill detainees spend in their custody by providing capacity restoration inside their facilities.
Community-based restoration
Outpatient community-based capacity treatment is available in Mecklenburg, Cumberland and Wake counties for people who have been charged with misdemeanors or nonviolent felonies and have been deemed by a court to be safe to be out on bond. DHHS started setting up these programs in 2023.
Sherif Soliman, medical director of the community-based capacity restoration program operated by Atrium Health in Mecklenburg, said treatment in the community is effective and people can benefit from remaining around their supports. It can also be less destabilizing as people can stay in their homes, jobs and relationships.
“I don’t think it’s ideal to have people waiting in jail for months at a time while waiting for a state hospital bed when they could be served in the community,” Soliman said. “From an ethical and humanitarian point of view, you want to reduce incarceration and hospitalization to the minimum possible.”
Community-based programs aren’t concerned just with restoring a person’s capacity, they are also focused on fostering long-term treatment engagement that helps lessen future interactions with the criminal justice system. Staff, such as peer support specialists and case managers, work on providing wrap-around support to participants, including helping them enroll in Medicaid benefits or find a physical health care provider.
“We want to be able to help them understand how beneficial treatment can be for them,” said Sarah Hallock, executive director of Cumberland County CommuniCare, the organization heading up the county’s community capacity restoration. “We want to be able to get them the help that they need by wrapping supports around them so that they can live better and so that they can feel better. It also translates into a safer community.”
However, the community-based programs are all struggling with low participant volume.
A main barrier is hesitancy by courts to order people to community programs for treatment, Cochrane said. The state’s statute about capacity evaluation and restoration does not explicitly authorize courts to order people to a jail or community restoration program, and he thinks that lack of clarity holds back referrals.
That’s why DHHS is pushing for the passage of legislation this year that will make these options clear.
“Until we get judges who see, ‘Oh yeah, I can do this. The statute says I can send them right to a community program.’ Until we get that, I think we’re going to continue to struggle,” Cochrane said.
Atrium’s Soliman said offering capacity restoration in multiple care settings also offers a step-down system that has never existed before.
“We can also serve as a continuing care facility for both Broughton and the Mecklenburg County Detention Center, and it has happened before where somebody’s in NC RISE and they’re suddenly granted bond, they can then continue their care in the community-based program until they’re restored,” Soliman said.
‘Real violation of rights’
A federal lawsuit filed in April by attorneys from the ACLU of North Carolina Legal Foundation, Disability Rights North Carolina and the private law firm Arnold & Porter is also putting pressure on the state to reduce wait times. The lawsuit alleges that DHHS is violating the constitutional rights of pre-trial detainees in North Carolina jails by failing to ensure timely evaluations and treatment for people who lack the capacity to understand the legal proceedings against them.
Susan Pollitt, an attorney at Disability Rights NC, said she’s fielded many calls from concerned family members who have watched their loved one languish for months in jail waiting for treatment.
“This continues to be a very live and real violation of rights that’s going on in our state,” Pollitt said.
“We hear about people who spend months and months in solitary confinement inside these jails without adequate mental health treatment, sometimes harming themselves and smearing feces,” she continued. “Their mental health deteriorates in jail, and we’ve heard over and over that once people do get to a hospital, their stay there and their treatment there is much longer than it might have been — or should have been — without months and months in a jail setting.”
In response to the lawsuit, attorneys representing DHHS filed a motion to dismiss the case in June 2024, arguing that many factors contributing to wait times are outside of the department’s control, and they do not have unilateral authority to solve the issues.
For example, persisting staff vacancies constrain how many people can be served, but the General Assembly sets the pay scale, which is not competitive with private hospital facilities. Additionally, many defendants charged with misdemeanors are not diverted from the criminal justice system — decisions that rest with the court and could reduce the demand for services.
DHHS outlined its efforts to reduce wait times, which they say are helping numbers trend down. They cite that the 157 on the waitlist for capacity restoration services is down from its peak of 213 in June 2023.
“Despite the limited control that DHHS has over the ITP system, DHHS is deeply committed to reducing ITP wait times,” the state’s June filing reads. “Reduced wait times require careful planning and close coordination among all state and county stakeholders, plus resources, and time.”
There have been no new legal filings since September, but the case is ongoing in federal court.
Deflecting from state hospitals
Cochrane said he believes these new programs and the increased focus on the problem will be effective in deflecting some patients from the state’s overburdened psychiatric hospitals and reducing wait times. That’s a positive for not only criminal defendants stuck waiting in jail, but also community members in crisis who wait weeks and months for scarce beds.
“We expect, once we can sort of get more and more buy-in and show people that these pilots are successful, it’s going to build upon itself, and we’ll ultimately get to a place where the state hospitals will serve those who are the most acutely ill,” Cochrane said.
He noted that state officials are closely evaluating the pilot programs, and if the results warrant, then the state legislature may have to make their temporary funding into something recurring.
But Cochrane’s hopeful about the impact.
“Numbers will be smaller, and people won’t have to wait as long to get [to a state hospital], because lots of other people are getting care in the jail and in the community.”
This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.
