Many people go to the emergency room with behavioral health issues, but not all need psychiatric hospitalization. One Winston-Salem organization is stepping up to provide interim support for people leaving the ER who are still struggling.
By Taylor Knopf
When Mamadou Kasse drives for Uber or Lyft around Winston-Salem, he sometimes gets requests to pick up patients discharged from a hospital emergency department.
Those pick up requests come from the hospital, which pays for the rides, he said. With Uber or Lyft, each ride request includes an address for the passenger’s destination.
When Kasse picks up the patients, they often say they don’t live at or don’t feel comfortable going to the address provided. Sometimes it’s because they are homeless, he said. Kasse also works as a mental health peer support specialist and he makes conversation with riders to try to understand what they are going through.
The last such patient Kasse picked up from Atrium Health Wake Forest Baptist hospital was a woman struggling with substance use issues who asked Kasse to drive her to a different emergency department.
For many people in mental or emotional distress, the only thing they know to do is to go to the emergency room. But some patients do not meet criteria — such as being a danger to themselves or others — for admission to in-patient psychiatric hospitalization. So they end up discharged within a few hours without having their issue resolved.
The problem is that even though they might not need hospitalization, the patients often remain in distress and in need of support, said Laurie Coker. She founded and runs GreenTree Peer Center, a nonclinical mental health service in Winston-Salem staffed by people with their own stories of mental health struggles and recovery. These peer support specialists are often the key to helping people understand their mental illness and find recovery.
“We have all these people going into crisis, the system is so broken, and they aren’t getting connected to the next steps to help,” she said.
Coker decided to do something to help the people falling into this gap. Earlier this year, GreenTree opened “the Refuge,” a small house staffed by peer support specialists where people leaving the ER in distress can come free of charge for up to 24 hours. There they receive support from people who can relate to what they’re going through.
Since March, GreenTree has hosted more than 45 people in this new space across the street from the peer center, which is open for classes, socialization and support on weekday afternoons.
How it works
During nearly every hospital shift, there is a behavioral health patient who could benefit from GreenTree’s peer support, said Meagan Hunt, medical director of the adult emergency department at Atrium Health Wake Forest Baptist.
There is already a shortage of psychiatric inpatient beds available, both locally and across the state. Therefore, patients with active thoughts of harming themselves or those who are acutely psychotic will be prioritized for those beds, Hunt explained. However, there are many community members living with “chronic baseline delusions and hallucinations,” as well as “anxiety and depression every day” who could benefit from peer support to help prevent escalation to a crisis point, she said.
“[GreenTree peer support] is a resource that definitely bridges the gap for some of our patients who don’t necessarily meet criteria for inpatient hospitalization and still need support to be able to safely return to their communities,” she said.
“Whether it’s just to address the fact that the patient may suffer from homelessness or substance abuse and needs a space where they can both rest and have a moment of humanity, with access to a peer supporter rather than just pure clinical resources,” Hunt said. “As in many of these cases, pure clinical resources don’t really address everything that the patient needs to address to be able to succeed.”
Hunt emphasized that emergency departments are true community safety nets and that it’s helpful that GreenTree’s Refuge house is also available 24/7.
“We’re the only place that will never turn you away,” Hunt said of the ER. “We see plenty of people who were turned away from shelters and all the places that I think the world envisions as a safety net. That is always true of folks leaving emergency departments, that there’s not a place in the world that’s reserved for them. And that’s not because they don’t deserve one, it’s because that’s sort of the way it is.”
GreenTree’s mission is to be that place for people who are in distress with no other place to go.
If a patient is interested in going to GreenTree’s Refuge, hospital staff will call the 24/7 Refuge line (336-429-4086) and a GreenTree peer support specialist will meet the patient at the emergency room and escort them to the Refuge house.
“We felt if we could do this brief, up to 24-hour support, then we can help them get where they want to go,” Coker said. “More than half the people are homeless, and by being able to stay, regroup and clean up, we’ve been able to help them contact natural supports — family members or friends — who welcomed folks to their homes.
“We’ve been able to deliver folks to places besides the shelter even if they were homeless,” she said.
GreenTree’s Refuge is simply a small two-bedroom home where a guest can heat up a prepared meal in the kitchen or hang out and talk with a peer support specialist on the couch. They can wash their clothes, take a shower, lay down and get a good rest, or reflect in the plant-filled sunroom.
“We’re able to empower that person to feel comfortable enough to reach out to people in their lives,” Coker said. “They are tidied up and more grounded emotionally than they were when they left the emergency department.”
As a former psychiatric nurse diagnosed with her own mood disorder, Coker understands and can relate to the experiences of those who come to GreenTree for support. This work is also deeply personal for Coker whose son struggled with mental illness and died by suicide in 2009.
‘Where their souls feel safe’
After leaving the ER and receiving peer support through the Refuge house, people are invited to participate in the classes, activities and fellowship that take place at GreenTree’s Peer Center, located directly across the street.
Some of the classes offered include Art for Wellness, Guided Meditation, and Dual Recovery Support for those dealing with substance use and mental health issues. Coker has seen that GreenTree’s peer support has been successful at keeping people connected in the community.
“We rarely have participants go to the hospital, and these are people who are most frequently hospitalized,” Coker told NC Health News earlier this year. She noted that GreenTree served 150 people in 2019, only four of whom ended up hospitalized.
The peer center is located inside a church-owned building (also called GreenTree), which allows the peers to use the space. The church pastor, Tim Gross, understands and embraces the mission of peer support for mental health recovery.
“Doing pastoral counseling, you deal with a lot of issues that overlap with mental illness and just throwing drugs at it isn’t a solution. It helps, but it doesn’t fix the problems,” Gross said.
“It’s just caring about people,” he added. “I think almost all of us know someone who either fits the description of mental illness or has a criminal background, and they’re trying to change their lives.”
Gross has built connections with peer center participants through the years. While cleaning the church building this summer, Gross said he often finds little pieces of gravel from the parking lot, sometimes with little notes underneath. Immediately, he recognized who they were from and that they were harmless.
Coker said the note author has a hard time expressing herself, but that the little pieces of paper she leaves behind tell stories.
“She creates these notes and she only gives them to you once she feels you can be trusted, and she feels this place can be trusted,” Coker said. “She’ll pick up different little rocks as paperweights and leave them outside or inside.”
Gross said this woman had been stopping by and leaving notes at the church even when the peer center was closed.
“That’s the place we want to be, a place where their souls feel safe. For us, we happen to be believers and Christians,” Coker said, gesturing to herself and the pastor. “Is that not part of our calling?”
GreenTree’s reach doesn’t stop at the peer center or the Refuge house. Peer support specialists have also started going into the community,engaging with people struggling with chronic mental illness who are in their homes and cut off from most people.
“We know people who are so isolated and have been for so long, they are nervous about getting out,” Coker said. “But we’re worried about their well-being.”
Kasse, the Uber driver and peer support specialist, has formed a relationship with one man who was first admitted to a psychiatric hospital as a kid. He’s been on psychiatric medications for years and has been part of various behavioral health programs, but nothing has truly worked for him.
After meeting in the man’s home, Kasse invited him out for coffee. Later, the man decided to come to several classes at GreenTree. He calls Kasse regularly just to check in.
“Doing this job makes me feel part of a community,” Kasse said, noting that he immigrated to the U.S. from Senegal. “This gives me a sense of pride and reminds me that I’m human. We have to be there for one another.”
Finding the funding
There has been a lot of interest in GreenTree’s Refuge house and the 24/7 peer support.
Local law enforcement agencies have sent representatives to see the house. Coker said the officers requested handouts with information about the Refuge, including photos, to show people they encounter who might benefit from a stay there.
“I very much see [GreenTree] as a hopeful option and resource,” said Hunt, the ER medical director at Atrium Health Wake Forest Baptist.
“And I hope that the organization continues to receive the funding they need to grow where they’re able to partner with our team as well as others,” she added, “because it really does serve a need that I’m not certain is served in any other context for some of the patients that we have.”
Leaders at Novant Health Forsyth Medical Center have also reached out to GreenTree with interest in referring patients for 24 hours of peer support.
Coker wants to be able to partner with more organizations, but GreenTree is a small nonprofit with limited human resources. Many of the staff work part time, and there’s currently little money for expansion
“Everybody in the community sees what’s going on here is good, they want to be able to use us, but they want to see more organizational support,” Coker said.
Even though GreenTree is in its ninth year, Coker said funders want to see more “long-term sustainability strategies in place.”
“Many funders see a lot of risk when they look at GreenTree because it’s so small,” she said. But to get to that long-term sustainability, the organization needs better funding.
A county-based grant funds the GreenTree Peer Center and the targeted community peer support it provides to isolated individuals. The new crisis peer support provided at the Refuge house is funded by a one-time grant from Cardinal Innovations, the behavioral health management organization that used to cover Forsyth County. In November, Forsyth’s mental health system will be moved to a new management entity, Partners Health Management, which Coker hopes will continue supporting GreenTree.
She’s also anxiously waiting to see what happens with mental health funding in the state budget, which is in final negotiations between the House and Senate. There is currently a proposal in the House version of the budget that would provide a one-time amount of $25 million to Forsyth and Mecklenburg Counties for mental health crisis services and hospital diversion.
“We anticipate that community partners will step forward to make [crisis peer support] part of the array of crisis services,” Coker said.
With additional funding, Coker said she dreams of expanding peer crisis support to youth and families because there are very few places to support parents and children together through mental health crisis situations.