Tier 5: Acute Psychiatric Care

The most intensive level of services within the NH Children’s System of Care, Tier 5 services include short-term hospitalization and intensive residential treatment designed to stabilize and treat a child or youth ages 0–21 who is experiencing an acute mental health or substance use concern that cannot wait and cannot be addressed by Level 4 residential treatment providers. Tier 5 may also include Transitional Residential Enhanced Care Coordination (TRECC) to help the child youth and family to have a smoother transition to post-hospitalization services and supports.

The emergency room staff in many hospitals have training and experience in treating youth and adults with acute mental health or substance misuse episodes. Still, it often becomes a holding place until a psychiatric bed opens. The best first step for any child or youth experiencing a significant and concerning behavioral, mental, or substance use issue is to contact the Rapid Response Access point: Call/Text 833-710-6477. The staff at the Access Point are trained to help assess a situation and will quickly link the child/youth and family to the right service. Call 911 immediately if anyone is unconscious, seriously injured, or if there is a weapon or other serious safety threat.

Why Do We Need Tier 5 Services?

The number of children and youth seeking inpatient psychiatric care for a mental health emergency has increased since 2020 due, in great part, to the effects of the COVID-19 pandemic, such as isolation and school closures. Between January 2022 and May 2023, there were over 4,500 calls to the NH Rapid Response helpline seeking help for a child or youth. National surveys show that an average of 14-20% of children and youth have a mental health or substance use concern, and many experience psychiatric emergencies each year for conditions such as serious suicide attempts, anxiety, depression, and symptoms related to substance use. Many go to their local hospital emergency rooms for help, especially if they are not already connected to treatment or care coordination. Tier 5 services are essential to the New Hampshire Children’s System of Care to provide short-term, inpatient treatment to children and youth experiencing a significant emergency due to a mental health or substance use episode. 

Who Is Tier 5 For?

Tier 5 services provide immediate safety, physical and mental health assessment and monitoring, medication when indicated, and treatment for children and youth ages 0–21 who are experiencing a serious and concerning psychiatric emergency.

When a child or youth experiences a severe and scary psychiatric episode, they can be “dysregulated” or seem out of control regarding their behaviors or emotions. This can include instances of threatening or following through to harm themselves or others, extremely aggressive behavior, extreme lack of interest or lack of responsiveness to the point where the child’s physical health is at risk, talk of seeing things or hearing voices that don’t make sense or are not real, or a serious drug or alcohol overdose, among others.

What Can I Expect if I Receive Tier 5 Services?

Tier 5 care is designed to be short-term hospital level treatment. Your child will typically be transported by ambulance if they are going into a psychiatric hospital. There will be an intake where the staff will ask you questions about your child and your family’s medical and psychiatric history. The staff will let you know which articles of clothing can stay and which you need to take home. You should ask a lot of questions and make sure you know how to contact the staff, as well as the rules for connecting with and visiting your child. The ward where your child or youth is staying will most likely be locked and you may not be allowed in for the privacy of all the patients, but there will be a visiting room. There are medical staff (nurses and psychiatrists), and social services staff (such as social workers). It’s important to note that the purpose of an inpatient stay is to stabilize your child enough so they can be discharged to a lower level of care. The process begins with a diagnosis, and then a daily routine that will include treatment guided by a treatment plan. Visiting hours may be limited as well. You should be part of a process that includes talking about discharge planning and process.

Read a more detailed description of what to expect

Who Provides Tier 5 Services?

  • Rapid Response Teams
  • Hospital Emergency Departments

The emergency room staff in many hospitals have training and experience treating youth and adults who are having an acute mental health or substance misuse episode, but the emergency room setting is not designed to help you find a longer-term solution. If you or your child is experiencing an acute mental health or substance misuse episode, the best way to start is to call or text the Rapid Response Access point for guidance: Call/Text 833-710-6477.

Hampstead Hospital: One of the primary providers of Tier 5 acute inpatient psychiatric treatment for children and youth under age 18 in New Hampshire is Hampstead Hospital. Hampstead Hospital has individualized behavioral programming based on both cognitive functioning and psychiatric need. There are two distinct treatment programs: the Acute Psychiatric Unit and the Intensive Behavioral Unit.

New Hampshire Hospital: NH Hospital provides inpatient psychiatric services to adults ages 18 and above.

Care coordination and guidance can be an important service for a child, youth, or family that is in Tier 5 care. Care coordination can help smooth the transition back into the community, link to community-based or other services, or into a lower level of care. Tier 5 care coordination may be provided by your insurance carrier, and can also be provided by Transitional Residential Enhanced Care Coordination (TRECC) through the Bureau for Children’s Behavioral Health at the NH Department of Health and Human Services.

How Can I Learn More about Tier 5 Providers in My Community?