ADVOCATE’S PERSPECTIVE: OK…WHAT NOW?

John Tote
Executive Director
Mental Health Association in N.C., Inc.

Welcome to another in the continuing series of an “Advocate’s Perspective,” presented by the Mental Health Association in N.C., Inc. (MHA/NC). This glance at issues affecting North Carolina’s public mental health, developmental disabilities, and substance abuse system is designed to invoke thought, discussion, and ultimately, solutions. This edition is being written in the early hours of Wednesday morning, November 5, 2008.

Moments ago, North Carolina , the United States , and indeed, the world witnessed incredible history being made. The son of a black man from Kenya and a white woman from Kansas , Barak Obama, is set to become the 44th President of the United States of America . Additionally, North Carolina has elected its first female Governor, Beverly Perdue. Historic? Without a doubt! A change in tone? Absolutely! Time to get to work? You bet! So, ok…what now?

In a few hours, many individuals called candidates just hours ago, will wake up with a hyphen and the word “elect” somewhere after their name, i.e. President-elect, Governor-elect, Senator-elect, etc. We have seen nasty, bruising campaigns. We have seen distortions and outright lies. We have seen “ungodly” personal attacks. We have heard promises, from vague to hopeful.

However, now these individuals with “elect” behind their names become like the dog that caught the car: You got it, now what are you going to do with it? Reaction from around the world regarding President-elect Obama has been swift and overwhelmingly positive. In North Carolina, a new page has been turned on the “good ole boys” network. But going from rhetoric to governing is never easy. Constraints are numerous for newly elected officials. Our forefathers did us a great service by injecting checks and balances throughout our political system. However, they also did us a disservice by injecting checks and balances within the system. It still takes Congress, and in North Carolina the General Assembly, to get laws passed and rule changes accomplished, which is how it should be. But often times the process can be bogged down or completely stopped because of this dynamic.

On this morning, and in the days ahead, there should be no talk of ‘political capitol’ or mandates won. While change and hope might buy a newly elected candidate a few extra days, it doesn’t pay the bills; it doesn’t get anybody a job; it doesn’t get us out of war; or end the financial crisis our state and nation finds itself in. However, it does give us a new opportunity and a different perspective from which to confront, and hopefully overcome these and other issues that we face.

One of those issues here in North Carolina is the true mess called our mental health system. After eight years of what can be kindly called marginal – some my say pathetic – leadership over our health & human service system in general, and our mental health system in particular, it is time that real change occurs within our reformed/transformed system.

Let’s be perfectly honest, “the good ole days” prior to reform weren’t always all that good. Our state’s public mental health, developmental disabilities and substance abuse system absolutely needed to be changed. We needed new leadership, new direction, and new priorities. However, most importantly, we needed sound policies to guide our financial decisions to serve more people, to serve those in the most need, and to do it with a system that was imminently accessible and person-centered. As we continue to meander in the wilderness of reform, new leadership at the administrative and legislative level must provide a realistic endpoint as to when we are finished “reforming” our system. We must have the picture of Oz at the end of whatever r oad this is that we are on. It is only then that we can take the steps, however small at times, to give our system the direction and the eventual outcome that is required and that our citizens deserve.

Change is not easy. Egos get in the way; political favors get in the way; and, sometimes, honest differences get in the way. It is time, however, that we get everything out of the way. It is time that we have a spark of ingenuity that turns into a raging wildfire – a system change of true reform and of forward thinking and vision not bogged down by bureaucracy and ineptitude.

Our new administration and General Assembly will, undoubtedly, feel their way for sometime before they are fully comfortable in their role. That is understandable. However, those in the MH/DD/SA system can no longer wait. After seven plus years of trust fund raiding, financial “realignment,” institutional failures, and community stumbling, the time has come for true progress and not simply the rhetoric of better days ahead. Those that have good programs and systems in place must be encouraged to continue down the path that they are taking, but those that do not can no longer be coddled, protected, or overlooked. Hope is real; change is needed; and the possibilities are endless. But unlike the past eight years, let’s turn the days, weeks, and m onths to come into something that we can all look back on with pride, dignity, and a sense of accomplishment for what we have done and gained within our state’s mental health, developmental disability, and substance abuse system.

So again I ask, ‘so…what now?’ We have all had our votes be counted. We have all had our say. So now all of us, regardless of who we voted for, must also do something else as well. We must continue to let our voices be heard; we must continue to keep those that have been elected responsive – hold them accountable and responsible – stand with them and lift them up to move us as a system, as a society, and as a state, where we want and need to be. That’s one advocate’s perspective.

Vote Early, Vote Often

Welcome to the last week of this seemingly endless campaign season, an extraordinary one for North Carolinians. Not least, for us at ncmentalhealthvote.org, is the prominence of mental health in the gubernatorial election.

Each candidate for governor has spoken often about mental health. We have a choice, and the race is close. You must decide and you must vote.

As it is non-partisan, ncmentalhealthvote.org endorses no one. What we do endorse is the need for change.

It will all change next Wednesday, when we will know who our next Governor will be.

And it all changes on January 1!

(And the title of this post? No, we do not endorse voter fraud - just an whimsical hommage to Chicago politics - the quote is attributed to Wm. Thompson, Mayor of Chicago 1915-1923 and 1931-1935.)

A Vision for Mental Health in NC

There's been talk about North Carolina needing a "vision" for mental health, after the last eight years.

One contribution ncmentalhealthvote.org has made has been to be a place where a clear vision has been articulated - it is a clinically-centered vision, where the needs of a person with mental illness is the central organizing principle for the mental health system, and everything derives from that.

So the places to start are in rebuilding the safety net where it has been tattered, and rebuilding the clinical workforce needed to take care of those in need.

The next Governor faces a daunting task, now compounded by the financial crisis that will certainly create a budget crisis for the state. In view of that, it is hard to imagine new funds flowing into the mental health/substance abuse system. The best we can hope for is to ward off budget cuts.

In view of that, the task for the first years of the next Administration will be to bolster the critical safety net services, and start the reorganization that will sustain the system when new funds become available.

As a start toward that, the NC Psychiatric Association is proposing draft legislation to revise the mental health law. We hope to assemble a wide coalition in support. It is important that we who are at the epicenter of the mental health crisis strive to set the agenda for the next session of the General Assembly.

Pinehurst, 12/10/08: Mental Health Policy for the Next Administration

December 10 - NC Council of Community Programs Conference, Pinehurst

The changes in the state's mental health system during the Easley Administration have been profound. The next Administration, taking office in January, faces problems -- and decisions -- of unprecedented scope and complexity. This presentation provides an analysis of the current state of public mental health policy, a discussion of proposals for the next Governor and legislature, and an opportunity to hear from the next Governor/staff members

What Are The Data, Outcomes, and Organizational Needs for Mental Health
- Brian Sheitman, MD (Clinical Professor of Psychiatry, UNC)

Restoring Mental Health Services in Rural North Carolina
- Sy Saeed, MD (Professor and Chair of Psychiatry, ECU)

The PBH Waiver - is it ready for wider application?
- Craig Hummel, MD (Medical Director, PBH)

A Clinical Vision for Public Mental Health
- John Wagnitz, MD (Medical Director, Sandhills LME; Assoc. Consulting Professor of Psychiatry, Duke; Chair, NCPA Community & Public Psychiatry Committee; Past President, NCPA)

Revising the Mental Health Law and other Policy Options
- Harold Carmel, MD (Consulting Professor of Psychiatry, Duke; Past President, NCPA)

Perspective from the Next Administration - (Governor-Elect or staff members, invited)

Akland Report from NAMI-Wake

This is worth a careful read, as it provides a snapshot of what is known about LME operations, especially ACT Team development, at this time. Very compelling, as well, is its account of its careful survey of the 100 NC Sheriffs and how they experience the effects of mental health "reform."

http://www.nami-wake.org/

Dix to move to CRH in October

Indicators are very strong - including an announcement at a CRH Department Heads' meeting this week - that DMH will try to move Dix to CRH in October.

Of course, one of the reasons for building CRH was to consolidate two hospitals into one, to save the costs of operating two different hospitals. When the dust settles, DMH will have patients at three different sites, since patients will continue to be at the old JUH and at Dix, as well as at CRH.

Mayor McCrory has made clear that he wants this decision left to the next Administration. Lt. Gov. Perdue wants the move to wait until CRH meets accreditation standards. Understandably, the lame duck administration wants to finish as much of its agenda as it can before December 31. The question is how many of the options the next Governor might want to have on the table will be taken off the table by the outgoing administration.

Budget Act MH language

The 2008 Budget Act was unprecedented, in terms of the length and detail of the instructions to DHHS, DMA and DMH. The Overall DHHS Budget was cut $185.3 million, mostly due to the DMA (Medicaid) cut of $210.8 million, which itself was mostly due to the Community Services overspending debacle. DMH’s budget was increased by $21.35 million. (Language covered in the accompanying post is not duplicated here)

http://www.ncga.state.nc.us/sesssions/2007/budget/2008/conferencecommitteereport.pdf , especially pp 68 et seq

MENTAL HEALTH CHANGES

SECTION 10.15.(b) Of the funds appropriated for substance abuse services to the Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, for the 2007-2008 and 2008-2009 fiscal years, the sum of at least eight million dollars ($8,000,000) shall be allocated for regionally purchased locally hosted substance abuse services. These funds shall be used to support LMEs in establishing additional regionally purchased and locally hosted substance abuse programs. Funds appropriated shall be for the purpose of developing and enhancing the American Society of Addiction Medicine (ASAM) continuum of care at the community level.

SECTION 10.15.(c) The Department shall encourage the conversion of the remaining non-single-stream LMEs to single-stream funding as soon as possible.. . .

SECTION 10.15.(d) The Department of Health and Human Services shall simplify the current State Integrated Payment and Reporting System (IPRS) to encourage more providers to serve State-paid clients. This effort shall include working with LMEs to develop billing codes for relevant activities currently lacking such codes.

SECTION 10.15.(e) The Department of Health and Human Services shall consult with LMEs and service providers to determine why there have been under- and over-expenditure of State service dollars by LMEs and shall take the action necessary to address the problem.. . .

SECTION 10.15.(f) The Department shall perform a services gap analysis of the Mental Health, Developmental Disabilities, and Substance Abuse Services System. The Department of Health and Human Services shall involve LMEs in performing the gap analysis. The Department shall not contract with an independent entity to perform the gap analysis. The Department shall report the results of its analysis. . . not later than January 1, 2010.

SECTION 10.15.(g) Notwithstanding any other provision of law to the contrary, the Secretary of Health and Human Services shall not transfer patients from John Umstead Hospital or Dorothea Dix Hospital to Central Regional Hospital unless and until the Secretary provides a written report to the Governor, based on the Secretary's findings, that on the day of its opening and thereafter, Central Regional Hospital will be operated in a manner that provides a safe and secure environment for its patients and staff. On or after the date the Secretary has provided the written report to the Governor, the Secretary may transfer patients from John Umstead Hospital to Central Regional Hospital. On and after the date of the transfer of John Umstead patients, the Secretary may commence the transfer of patients from Dorothea Dix Hospital but only if the following conditions are met:

(1) At the time of commencing transfer of Dorothea Dix patients the Secretary has determined that an inspection of Central Regional Hospital indicates no findings of noncompliance with conditions of participation from the Centers for Medicare and Medicaid Services (CMS), and

(2) The Secretary finds that Central Regional Hospital is in compliance with Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards for accreditation.

SECTION 10.15.(h) In order to temporarily address high admissions to adult acute unit beds in the State psychiatric hospitals, the Secretary of the Department of Health and Human Services may, notwithstanding G.S. 122C-181 and G.S. 122C-112.1(a)(30), open and operate on a temporary basis up to 60 beds at the Central Regional Hospital Wake Unit on the Dorothea Dix Campus and may maintain the Wake Unit on the Dix Campus until beds become available in the system.. . .

SECTION 10.15.(v) The Department of Health and Human Services shall ensure that veterans and their families comprise one of the target populations for mental health, developmental disabilities, and substance abuse services in order that this population is eligible for existing funding.

SECTION 10.15.(w) The Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, shall develop a service authorization process that requires a comprehensive clinical assessment to be completed by a licensed clinician prior to service delivery, except where this requirement would impede access to crisis or other emergency services. The Department shall require that the licensed professional that signs a medical order for behavioral health services must indicate on the order whether the licensed professional (i) has had direct contact with the consumer, and (ii) has reviewed the consumer's assessment. The Department shall report the failure of a licensed professional to comply with this requirement to the licensed professional's occupational licensing board.. . .

SECTION 10.15.(x) The Department of Health and Human Services shall develop a plan to return the service authorization, utilization review, and utilization management functions to LMEs for all clients. Not later than February 1, 2009, the Department shall report on the development of the plan. . . Not later than July 1, 2009, utilization review, utilization management, and service authorization for publicly funded mental health, developmental disabilities, and substance abuse services shall be returned to LMEs representing in total at least thirty percent (30%) of the State's population. An LME must be accredited for national accreditation under behavioral health care standards by a national accrediting entity approved by the Secretary and must demonstrate readiness to meet all requirements of the existing vendor contract with the Department for such services in order to provide service authorization, utilization review, and utilization management to Medicaid recipients in the LME catchment area.. . . The Department shall not contract with an outside vendor for service authorization, utilization review, or utilization management functions, or otherwise obligate the State for these functions beyond September 30, 2009. The Department shall require LMEs to include in their service authorization, utilization management, and utilization review a review of assessments, as well as person-centered plans and random or triggered audits of services and assessments. The Department may also develop and implement a plan to return plan authorization for CAP-MR/DD slots to LMEs.

SECTION 10.15.(y) The Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, shall study Medicaid waivers, including 1915(b) and (c) waivers, for all LMEs. In cases where Medicaid waivers are not appropriate for an LME, the Department shall identify and recommend strategies to increase LME flexibility to provide case management, assessment, limit provider networks, or other innovative approach for managing care. Not later than March 1, 2009, the Department shall report its findings and recommendations. . .

SECTION 10.15.(aa) The Secretary of the Department of Health and Human Services shall not take any action prior to January 1, 2010, that would result in the merger or consolidation of LMEs operating on January 1, 2008, or that would establish consortia or regional arrangements for the same purpose, except that: (1) LMEs that do not meet the catchment area requirements of G.S. 122C-115 as of January 1, 2008, may initiate, continue, or implement the LMEs' merger or consolidation plans to overcome noncompliance with G.S. 122C-115, and

(2) The Guilford Center for Behavioral Health and Disability Services, the Smoky Mountain Center, and the Mecklenburg County Area Mental Health, Developmental Disability and Substance Abuse Authority may continue with or implement the proposed administrative service organization under development as of March 1, 2008, for merger or consolidation of any combination of these entities.

SECTION 10.15.(bb) If the Secretary of the Department of Health and Human Services desires to merge LMEs, the Secretary shall develop a detailed plan for General Assembly review on its recommendation to merge, consolidate, or establish regional arrangements or consortia of LMEs. In developing the plan, the Secretary shall consult with LMEs to obtain input on the feasibility and effectiveness of potential mergers and the time frame needed to fully implement the mergers, regional arrangements, or consortia at the local level. The Secretary shall provide the plan. . . not later than March 1, 2009.

IMPROVE AND STRENGTHEN FISCAL OVERSIGHT OF COMMUNITY SUPPORT SERVICES

SECTION 10.15A.(a) Not later than June 30, 2008, the Department of Health and Human Services, Division of Medical Assistance, shall submit to the Centers for Medicare and Medicaid Services, revised service definitions for two Medicaid billable services: (i) community support–adults, and (ii) community support-children/adolescents. The revised definitions shall focus on rehabilitative services and be developed to ensure that community support services are provided as efficiently and effectively as possible to minimize overexpenditures in community support services in the 2008-2009 fiscal year and thereafter.

SECTION 10.15A.(b) In order to ensure accountability for services provided and funds expended for community services, the Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, shall develop a tiered rate structure to replace the blended rate currently used for community support services. Under the new tiered structure, services that are necessary but do not require the skill, education, or knowledge of a qualified professional should not be paid at the same rate as services provided by qualified skilled professionals. The Department shall not implement the tiered rate structure until 15 days after it has notified the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services. The Department shall report on the development of the structure to the Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services not later than October 1, 2008.

SECTION 10.15A.(i) Sections 10.49(ee)(5) and (6) of S.L. 2007-323 read as rewritten:

"(5) All community support services are subject to prior approval after the initial assessment and development of a person-centered plan has been completed;approval.

(6) Providers are limited to four hours of community support for adults and eight hours of community support for children to develop the person-centered plan. Those hours shall be provided only by a qualified professional. Providers that determine that additional hours are needed must seek and obtain prior approval. If additional hours are authorized, the LME may participate in the development of the person-centered plan as part of its care coordination and quality management function as defined in G.S. 122C-115.4. After the tiered rates required under Subsection (b) of this section have been implemented, not less than fifty percent (50%) of community support services must be delivered by qualified professionals."

SECTION 10.15A.(j) The Department of Health and Human Services, Division of Medical Assistance, shall adopt a policy reducing the maximum allowable hours for community support services to eight hours per week. This subsection does not apply to community support services offered under a Medicaid managed care, capitated at-risk waiver.

Budget Act Conference Report

The 2008 Budget Act was unprecedented in recent memory in its attention to mental health issues.

Here is language on Mental Health from the Conference Report on the Continuation, Capital and Expansion Budgets FY 08-09 http://www.ncga.state.nc.us/sessions/2007/budget/2008/conferencecommitteebudgetreport.pdf

R = Recurring Funds; NR = Non-Recurring [one-time] funds; all figures in millions

o New Local Psychiatric Inpatient Capacity - $8.12 R - the State-paid share of new local psychiatric inpatient capacity (beds/bed days).

o Clinical Staffing Ratios at Psychiatric Hospitals - $7.28 R - for 107 positions at the State's psychiatric hospitals: 7 psychiatrists, 1 Medical MD, 40 RNs, 34 LPNs, 25 Health Care Techs

o Walk-In Crisis and Immediate Psychiatric Aftercare $4.46 R; $1.65 NR - funding to Local Management Entities (LMEs) for walk-in crisis and immediate psychiatric aftercare. Also provides funding for the purchase of telepsychiatry equipment - to support 30 psychiatrists and related support staff. Of these funds, $1,650,000 shall be used for telepsychiatry equipment to be owned by the LMEs and shall be distributed across the State according to need determined by the Department.

o Mobile Crisis Intervention Teams - $4.655 R; $1.1 NR - operating subsidies to 30 mobile crisis teams state-wide. Also provides start-up funding for 11 crisis teams to bring the total number of teams state-wide to 30.

o Recruitment and Workforce Development: $1.27 R - for recruitment and workforce development initiatives at State facilities, including psychiatrist loan repayment, increased recruitment efforts, and expansion of the Psychiatry Nurse Practitioner scholarship program. Funding for each item is as follows: Psychiatrist Loan Repayment Program in Office of Rural Health - $868,519; Expansion of Recruitment and Advertising Funding for Difficult-to-Recruit Positions - $277,000; Psychiatric Nurse Practitioner Scholarship Program at UNC School of Nursing - $125,000; Additionally, $500,000 NR is included for sign-on bonuses for hard-to recruit Registered Nurse positions at the State's psychiatric institutions in the Statewide Reserves Section of this report.

o Dorothea Dix Hospital Overflow Unit $5,212,166 NR; 96.85 positions - for the Dorothea Dix Hospital Overflow Unit, a 60-bed unit to remain open on the Dorothea Dix campus after the opening of the new Central Regional Hospital. Total requirements for this item are $10,731,103 with $4,767,760 in receipts from Wake County and $751,177 in Medicaid receipts. The 60-bed unit will be staffed with a total of 174.75 FTEs, of which 77.9 will be funded by Wake County receipts and 96.85 are funded by State appropriation and Medicaid receipts. Position classifications & number of FTEs for all 174.75 positions: Physician III-B (psychiatrists) (7.75) – 1 Physician IV-B (psychiatrist supervisor) ; 0.5 Physician III-A (medical MD); 1 Psychiatric Unit Administrator II; 1.5 Senior Psychologist; 3 Physician Extender II; 1 Nurse Supervisor B; 37 RNs; Nurse B (4); 66 Health Care Technicians; 6.5 Clinical Social Worker; 1 Social Work Supervisor; ; 1 Pharmacy Technician; 1 Clinical Dietitian I; 1.5 Occupational Therapist I; 2.5 Therapeutic Recreational Specialist I; 9 Rehabilitation Therapists; 0.5 Advocate I; 1 Word Processor IV; 1 Personnel Technician III (1); 4 Office Assistant IV; 1 Utilization Review Nurse; 1 Patient Relations Representative V(usually, this is for the admitting office); 1.5 Medical Records Assistant IV; 1 Floor Maintenance Assistant; 8.5 Housekeeper; 1 Kitchen Manager; 1 Food Services Supervisor; 3 Cook I; 6 Food Services Assistant; 1 Diet Clerk

o Clinical and Operational Enhancements of State Facilities $1.8 R; $0.05 NR; 19.00 positions - to improve training and supervision of direct care staff, for monitoring of State facilities, for pharmacy management, and for information technology and accounting positions: Clinical Nurse Specialists (2 at each of the three psychiatric hospitals and one at each Alcohol and Drug Abuse Treatment Center); 9 Nurse Cs; State-Operated Services Compliance Team: 4 Mental Health Program Manager IIs; 1 Mental Health Program Manager I (1) - $57,666; Clinical Policy Section: 1 Pharmacy Manager III ; 1 HEARTS Training Coordinator; DHHS Controller's Office: 1 , Accounting Technician IV, 1 Accounting Technician III; Longleaf Neuro-Medical Center; 1 Technology Support Technician;

o Resident Furnishings $0.61 R; $1.02 NR in receipts for replacing resident furnishings in poor condition in State mental health facilities.

o Realignment of Mental Health Trust Fund Funding for Housing Initiative - realignment [cut from this line] $2.0 NR - Realigns unallocated funding from the Mental Health Trust Fund to the Housing Trust Fund to continue the MH/DD/SA Housing Initiative.

o Continuing the MH/DD/SA Housing Initiative - Housing Trust Fund 7.0 NR - Provides $7,000,000 in non-recurring funding ($2,000,000 of which is realigned from the Mental Health Trust Fund) for the financing of additional independent- and supportive-living apartments for people with disabilities. The apartments shall be affordable to those with incomes at the Supplemental Security Income (SSI) level. The funds for this item are located in the Housing Finance Agency section of this report.

o Continuing the MH/DD/SA Housing Initiative - Operating Cost Subsidy - $1.0 R - Provides funding for operating cost subsidies for independent- and supportive-living apartments for individuals with disabilities. The apartments shall be affordable to those with incomes at the SSI level.

o Julian F. Keith ADATC Pharmacy $0.47 R; 4.00 positions - Provides funding for four positions to create a pharmacy program at the Julian F. Keith Alcohol and Drug Abuse Treatment Center (ADATC) to serve the expanded acute treatment beds. The Substance Abuse Prevention and Treatment Block Grant includes $70,000 for one-time start-up costs associated with the pharmacy. Position classifications, number of FTEs: 1 Pharmacy Manager I; 1 Clinical Pharmacist; 2 Pharmacy Technician

o Early Intervention for Autism $1.875 R - Provides funding for services for children ages 0-10 with autism (i.e., autism early intervention), as follows: $625,000 to the Autism Society of NC for training and collaboration with model programs and community agencies to increase availability of autism early intervention services. $1,250,000 for DHHS to contract directly for three model programs of early intervention services.

o Supportive Services for HUD 811 Projects $0.13 R; $0.155 R - Provides funding for on-going operations and start-up expenses to support 6 two-bedroom and 19 one-bedroom apartments financed through the United States Department of Housing and Urban Development.

o Program Service Funding for Group Homes $0.2 R - Provides funding for on-going program service funding for two group homes under development by the Mental Health Association in N.C., Inc.

o Traumatic Brain Injury Services $1.0 R - Provides funding for the provision of traumatic brain injury (TBI) services.

Perdue & McCrory on budget bill change on state hospitals

North Carolina's candidates for governor issued dueling statements Wednesday in response to a last-minute change in the state budget approved Wednesday that will make it easier for the administration of Gov. Mike Easley to open a new mental hospital in Butner and close Dorothea Dix Hospital in Raleigh.

The campaign of Lt. Gov. Beverly Perdue, the Democratic candidate, sent an e-mail statement Wednesday morning.

"I strongly disagree with the budget provision that allows patients to be transferred to Central Regional Hospital before Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (JCAHO) standards are met," said the statement attributed to Perdue. "Secretary Benton should not authorize transfer until Central Regional meets those standards -- the long-term safety and care of both patients and staff must not be compromised."

The campaign of Republican candidate Pat McCrory issued a statement reaffirming his opposition to closing Dix.

"In another secret back room meeting, the political establishment in Raleigh has arrogantly dismissed the welfare of mental health patients and decreed through the budget that the state does not have to comply with the same regulations it places on everyone else," said McCrory, who is mayor of Charlotte. He said Perdue, the presiding officer of the Senate, should have stopped the change in the budget.

(from the News and Observer, 7/10/08, http://www.newsobserver.com/2771/story/1136633.html )

Bev Perdue on mental health

From her website - 4/18/08 - http://bevperdue.com/release_details.asp?id=1070

We need to get serious about the goal of quality health care for all North Carolinians – and that must include mental health care.

Thousands of our fellow citizens struggle everyday with mental health concerns. North Carolinians who face mental illness, developmental disabilities, and substance abuse issues as well as their families deserve our staunch support in dealing with their challenges.

My background in health care tells me that it makes no sense to separate mental from physical health care. The best research confirms that many patients have mixed mental and physical health issues. Thus I am proud that my plan for expanding health care coverage to all children and more low-wage working parents has been praised by such leading advocates as Adam Searing of the North Carolina Health Access Coalition for containing "the most significant changes in health care access in North Carolina in, quite literally, decades." To read more, go to bevperdue.com/healthcare.

Specifically in the mental health arena, my priorities include the following:

1) Extend Community Care model to mental health

North Carolina's Medicaid program has recently moved to the forefront in emphasizing the importance of a "medical home" for the primary care of adults and children. Our Community Care of North Carolina has developed a very cost-effective and quality-driven model of statewide case management through health care community networks. As Governor, I will extend this kind of collaboration and community network to the delivery of mental health services. Every person served by the mental health system should have the benefit of strong and effective case management to maximize treatment and service plans. In my view, the concept of a medical home should play a major role in helping to revitalize our badly tattered mental health system, for Medicaid recipients and others served by the system as well.

As North Carolina's next Governor, I also want to establish the national model for an integrated approach to behavioral and primary health services for patients with mental health, development disability, and substance abuse problems. One of my top goals will be to break down the barriers to the coordination of mental and physical health care.

2) Establish a “safety net” for those in need

We must also develop a basic safety-net which those in need of mental health services will have available to them. These core elements will provide a strong foundation for a true community-based system of care. Today there are just too many opportunities for people in need to fall between the cracks.

The quality and degree of care cannot be dictated by zip code. That is why I will take such immediate steps as expansion of the Office of Rural Health's loan forgiveness initiative to place more mental health professionals in the rural parts of North Carolina where they are desperately needed. This kind of state incentive can make a huge difference in the choices young students and professionals make when they are considering careers in mental health. As chair of our state's Health and Wellness Trust Fund, I have already developed an innovative loan assistance initiative to help our rural hospitals modernize and provide more up-to-date services across the board. Modernizing hospitals as well as attracting new health care providers will represent significant boosts to economic development in our small towns and surrounding rural areas, while at the same time enhancing the level of care for some of our most vulnerable citizens.

I know that we cannot neglect the need for strong in-patient services. To the extent possible, these services should also be community-based, close to home, family, and other resources. But the state cannot walk away from its obligations. If needed services are absent in a local area due to a lack of private providers, we must work to put them into place through public facilities.

3) Overhaul system to focus on outcomes

The state's overall approach to planning and implementation in mental health care must also be overhauled. We need a fundamental shift to a focus on outcomes – setting high program and service standards and then clearly stating what results we can and should expect while setting up the conditions most likely to achieve the best possible outcome for each person.

One way we can foster the highest quality services is to actively promote the best practices in the field. My vision is for the state to develop centers of excellence within our colleges and universities to advance evidence-based models and continue to build capacity for high-quality services across the state. Through these evidence-based models we can point the way to more effective and efficient services. We can also better support the ongoing training and development of our professionals who work in the fields of mental illness, developmental disabilities, and substance abuse services.

I know that changing mental health care in North Carolina is something far more easily said than done. Yet we cannot stop until we have a system that achieves access to high-quality mental health, developmental disability, and substance abuse services for all North Carolinians. We certainly need better funding. Our low standing in the National Alliance on Mental Illness' rankings of expenditures per capita is inexcusable. But funding is only one piece of this puzzle. We must work on many fronts to achieve the changes and improvements we need.

Many people, both professionals and volunteer advocates all across this state, are working their hardest every day to improve our system. The scale, complexity, and rapidity of change that they have endured over the past few years have been daunting but they are committed and determined. Our state needs the benefit of multiple perspectives as we work through the serious issues now facing our system. We will need to adopt a disciplined approach to maximizing system improvements. And we must make sure that government officials and the mental health community listen to and learn from one another.

As North Carolina's next governor, I will be directly involved in meeting our mental health challenges. I understand that our efforts will need sound leadership, accountability, policies, and coordination throughout state government and the system of services for mental health, developmental disabilities, and substance abuse. We all know someone – a family member, a friend, a co-worker – who is dealing with the challenges of mental health concerns. These are deeply personal issues for all of us. And they are critical issues for building a better North Carolina as well. I pledge to be the leader our state needs to establish a system of high-quality services that yields the best possible outcomes for those it serves.

Pat McCrory on mental health, Dix

N&O letter 6/27/08 Keep Dix open http://www.newsobserver.com/print/friday/opinion/story/1122013.html

I agree wholeheartedly with your June 24 editorial on the need to keep Dorothea Dix hospital open. Earlier this month, I held a news conference in Raleigh calling on the General Assembly to keep Dix open for another year. On Monday, June 23, I wrote Gov. Mike Easley, Lt. Gov. Beverly Perdue, Sen. Marc Basnight and House Speaker Joe Hackney urging them to personally intercede in this matter.

With the problems surrounding mental health escalating, the current administration appears to be implementing changes without proper planning. As a result, hundreds of millions of dollars are being misspent, poor medical treatment is being given to mental health patient, and concerns are rising for the safety of patients and staff in state mental facilities.

It is unacceptable that a nurse was beaten at Dix last week due to inadequate supervision of patients. It would be grossly irresponsible to close the hospital without making the necessary preparations for handling patients in a secure environment.

Dix hospital must be kept open and properly staffed for another year. This will give the next governor a chance to evaluate its closing and recommend the best way to address the growing scandal in mental health programs.

Pat McCrory

Charlotte

http://www.newsobserver.com/print/friday/city_state/story/1122070.html
Under the Dome N&O 6/27/08 :

Dix hospital

Pat McCrory has called for Dorothea Dix hospital to remain open for another year.

In a letter sent this week to Gov. Mike Easley, Lt. Gov. Beverly Perdue and other top Democratic leaders, the Republican gubernatorial nominee urged them to keep the Raleigh mental hospital staffed until the next governor could implement mental health reforms.

"I believe that the present problems are not a result of the legislatively passed reforms to provide local care for mental health patients," he wrote. "The scandal is a result of poor planning and implementation of the reforms. The next governor should be given the opportunity to bring new leadership to this area."

In the letter, McCrory says that the recent beating of a nurse at Dix shows there are continuing problems with the state's mental health care system.

From the McCrory website: http://www.patmccrory.com/docs/articles/McCrory-Calls-on-Administration-to-Keep-Dorothea-Dix-Open.html

McCrory Calls on Administration to Keep Dorothea Dix Open
‘Next governor should be given opportunity to bring new leadership to mental health’

Charlotte, N.C. – Mayor Pat McCrory today [June 23, 2008] wrote to Gov. Mike Easley, Lt. Gov. Beverly Perdue, Senate President Pro Tem Marc Basnight and House Speaker Joe Hackney to urge them to keep Dorothea Dix Hospital open and adequately staffed for another year. McCrory argued this would give the state’s next governor the opportunity to implement necessary mental health reforms. Below is the text of his letter:

“With problems surrounding mental health reform escalating, the administration appears to be implementing changes without proper planning. As a result, hundreds of millions of dollars are being misspent, poor medical treatment is being given to mental health patients, and concerns are rising for the safety of patients and staff in state mental facilities.

“It was reported on June 21 that a patient beat a nurse in the forensics unit of Dorothea Dix Hospital. It is unacceptable to inadequately supervise patients who are among the most violent being treated at Dix. Closing Dix without adequately preparing for handling forensics patients in a secure hospital environment is dangerous for patients, health care workers, and the public.

“I’m writing to ask you to keep Dorothea Dix hospital open and properly staffed for another year. This will give the next governor a chance to evaluate its closing and recommend the best way to address the growing scandal in mental health programs.

“During a June 2 news conference in front of the Legislative Building, I called on the legislature to keep Dix open for another year. I am now calling on you to personally intercede on behalf of the patients, staff, and the public. I understand that a version of the budget has passed the House and the Senate and is now before a joint conference committee to reconcile the two versions. However, inaction during this session could result in tying the hands of the next governor.

“This past week the Wake County Chapter of the National Alliance on Mental Illness, the N.C. Sheriff Alliance, the N.C. Public Service Workers Union, and a Dix psychologist wrote the legislature requesting Dix be kept open for another year. On Friday, hospital workers again marched on the office of the Secretary of Health and Human Services seeking a delay in the closure.

“I believe that the present problems are not a result of the legislatively passed reforms to provide local care for mental health patients. The scandal is a result of poor planning and implementation of the reforms. The next governor should be given the opportunity to bring new leadership to this area.”

From McCrory Website: "Policy Statement: Health Care"

http://www.patmccrory.com/docs/issues/Policy-Statement-Health-Care.html

Reform failed reform.
The current mess of our mental health system can be traced back to the “reform” measures backed by Governor Easley in 2001. Unfortunately, these “reforms” have wasted millions of taxpayer dollars, decreased community care, and left our mental health system without accountability. We need to establish citizen councils to review contracts and certify nonprofits; stop closing hospitals and reducing the state’s number of beds available to mental health patients; work with providers and Local Management Entities (LME’s) to meet the needs of local communities for short term care; provide new leadership to help citizens with developmental disabilities, substance abuse, and mental illness to lead productive lives in local communities; and establish clear priorities that will re-introduce accountability, allow interagency coordination, and bring care to those who need it.

Gubernatorial nominees weigh in on new state hospital

From the N&O, June 2:

Pat McCrory, the Republican candidate for governor, called on the state to keep Dix and Umstead open for a year to give the next governor a chance to bring in new leadership. "The hasty move to a new facility without adequate staffing and with design flaws only makes a bad situation worse," he said.

Lt. Gov. Beverly Perdue, Democratic candidate for governor, said the new hospital isn't ready to open, but she said she did not agree on imposing a deadline of a year.

"I don't believe one patient should be moved to Central Regional until we have adequate staffing and the safety issues are resolved," she said.

McCrory criticized the Department of Health and Human Services for not publicizing the results of work groups Benton appointed and said the work group report on the new hospital should be made public.

Can we prevent the debacle of opening the new hospital in June?

It's a safe bet that the opening of the new hospital will not go well. To recap: the new hospital is opening in June, no matter what - see the 5/24 N&O front-page story: http://www.newsobserver.com/2771/story/1083813.html . (One has to think such an imperative comes from the Governor.)

This looks like a debacle waiting to happen. It appears that the planning that should have gone into merging the two hospitals has not happened. (In my view, the last year should have been spent preparing for this month - developing a firm timeline of all the tasks that would need to be accomplished by Day One. There is little, if any evidence this has happened effectively.)

It appears that there will be serious staff shortages on Day One, suggesting that one-quarter of the beds cannot be safely opened.

It appears that the projected savings from running one hospital instead of two will be negated, as beds will be operating in not two, but three sites.

It appears that serious design flaws persist, including serious risks of patient death and escape.

It appears that the work of merging two hospital staffs, which at least involves reaching out to the staff of both hospitals, has not occurred.

I am sure there are more elements that will come to light in the days to come.

If the hospital opens as planned, there will be bad patient events. Is the Easley Administration ready for the firestorm that will come with, God forbid, the first patient or staff serious injury, or, God forbid, the first avoidable death?

At the very least, CMS, which is certainly monitoring the media activity, will come and visit; the odds are that CMS will not be amused and that CMS will send NC a letter alleging "immediate jeopardy" to patient safety.

The NC Psychiatric Association is opposing "moving to a new hospital until its building and staffing are sufficient to ensure a safe treatment environment for patients and staff." I am sure NCPA is not the only source of such opposition.

If the above is true, in my view, it is essential that the opening of the new hospital be delayed until it can be opened safely and that the Central Regional Hospital leadership, which is responsible for this, be replaced by competent leaders.

What a Good DMH Should Do

As we contemplate the next Administration, the following quote, which I came across in the May 2008 issue of Psychiatric Services, is worth considering:

Public mental health policy attempts to provide maximally effective services in the context of limited resources, promulgate clear service standards in the context of scientific uncertainty, and work to harmonize frequently conflicting needs and objectives of multiple stakeholders (patients, families, providers, other payers, general citizenry, and so forth).. . .

Choosing which services to provide in a public mental health system is always a matter of balancing clinical effectiveness, cost, and political will. Political will has never been sufficient to support the full cost of all that we believe to be clinically effective, and therefore difficult choices are always necessary.

(Joseph J. Parks, M.D., Alan Q. Radke, M.D. and Rajiv Tandon, M.D.: Impact of the CATIE Findings on State Mental Health Policy. Psychiatric Services 59:534-536, May 2008.)

This may be stating the obvious, but as we work to rebuild our shattered public mental health system, we will need to return to basic principles.

News & Observer on MH "reform": One week of articles, editorials, letters & Q comments

News & Observer investigative series on “Mental Disorder: The Failure of Mental Health Reform.”
http://www.newsobserver.com/news/health_science/mental_health/

Sunday, 3/2/08: "Patients die from neglect, restraint"

Patients die from poor care; families don't hear full story http://www.newsobserver.com/2771/story/976809.html

(also, links to documents on the Janella Wilson & Delores Franklin deaths can be found on this page)

"Law requires notice of deaths, but not all comply: Reports missing on 165 patients" http://www.newsobserver.com/2771/story/976645.html


Sunday Q section: "What do we do now?" http://www.newsobserver.com/2771/story/976757.html

DHHS Secretary Dempsey Benton http://www.newsobserver.com/news/q/story/976751.html

NCPA President Harold Carmel, MD http://www.newsobserver.com/news/q/story/976753.html

Disability Rights NC Exec. Director Vicki Smith http://www.newsobserver.com/news/q/story/976726.html

NC Med Soc. Immed. Past President Darlyne Menscer, MD http://www.newsobserver.com/news/q/story/976698.html

Joe Morrissey PhD (UNC), Marvin Swartz, MD (Duke) http://www.newsobserver.com/news/q/story/976719.html

Chief District Court Judge Joe Buckner (Orange/Chatham) http://www.newsobserver.com/news/q/story/976723.html

THE N&O's 82 questionable deaths:
Broughton: http://www.newsobserver.com/2771/story/974188.html
Caswell: http://www.newsobserver.com/2771/story/974225.html
Cherry: http://www.newsobserver.com/2771/story/974241.html
Dix: http://www.newsobserver.com/2771/story/974223.html
Longleaf (formerly Wilson Special Care): http://www.newsobserver.com/2771/story/974159.html
Murdoch: http://www.newsobserver.com/2771/story/974253.html
O’Berry: http://www.newsobserver.com/2771/story/974267.html
Umstead: http://www.newsobserver.com/2771/story/974233.html


LETTERS: http://www.newsobserver.com/news/q/story/976699.html


Saturday, 3/1/08: "Hospitals, nearly forgotten, teem with abuse"

Main story: "Caregivers abuse patients -- and usually get away with it" http://www.newsobserver.com/2789/story/975411.html

"Employees pile on, and a patient's leg is shattered" http://www.newsobserver.com/2771/story/975429.html

"Stress, short staffing take toll on workers"

http://www.newsobserver.com/2771/story/975426.html

"Employees of mental hospitals disciplined for abuse, neglect" http://www.newsobserver.com/2771/story/975424.html

"Crowded hospitals turn patients away: Outpatient care falls short of need" http://www.newsobserver.com/2771/story/975419.html

"Video cameras can deter abuse, advocates say" http://www.newsobserver.com/2771/story/975417.html

CLICK ON "EXPLORE ABUSE DATA" HERE: http://www.newsobserver.com/1181/story/958236.html

LETTERS:

http://www.newsobserver.com/opinion/letters/story/975236.html http://www.newsobserver.com/opinion/letters/story/975246.html http://www.newsobserver.com/opinion/letters/story/975239.html

http://www.newsobserver.com/opinion/letters/story/975240.html

http://www.newsobserver.com/opinion/letters/story/975237.html

http://www.newsobserver.com/opinion/letters/story/975241.html

http://www.newsobserver.com/opinion/letters/story/975238.html

Friday Editorial (2/29/08): Repairing 'reform' 'http://www.newsobserver.com/print/friday/opinion/story/973317.html


Thursday (2/28/08) : "With reforms, serious therapy fades"

http://www.newsobserver.com/front/story/971029.html

You can view spending, by county, here: http://www.newsobserver.com/1181/story/958236.html


Wednesday editorials (2/27/08):

"Mental errors. . . the system is in shambles": http://www.newsobserver.com/opinion/editorials/story/968292.html

"Blame to go around": http://www.newsobserver.com/opinion/editorials/story/968291.html


Tuesday (2/26/08): "The door opens and companies rush in"
Main story:
http://www.newsobserver.com/front/story/965714.html

Community support can help if done right:
http://www.newsobserver.com/2771/story/965581.html

State clamps down on claims:
http://www.newsobserver.com/2771/story/965568.html


Day 1 (Sunday, 2/24/08): "Reform wastes millions, fails mentally ill"
Main article:
http://www.newsobserver.com/2771/story/962049.html

Video: http://www.newsobserver.com/1181/story/958236.html

Fixing NC's Mental Health System: Public Comment Remarks to the Legislative Oversight Committee (LOC)

Submitted by: Debra G. Dihoff, MA, Executive Director, NAMI NC


The News & Observer has condensed the miseries of the last seven years of reform into a succinct five part series. The good thing is we can now admit what isn’t working and we can begin to do something about it. The assumption that complete privatization in the complicated health care arena would make things better and cheaper has been proven false.

Let’s seize the moment to move forward. I challenge you to adopt a goal- let’s be in the top ten states in the nation in mental health services, not 43rd in the nation in per capita spending.

How do we do this?

1.Leadership – We have an opportunity right now for new leadership to get a team, establish a goal, and get everyone moving in the same direction. Leadership must be clear on who does what.

2.Restore the public safety net- it’s time to fix what isn’t working. Put the service coordination, case management, linkage function back into the public sector. Data shows that discharges from our state hospitals have rising numbers of people going to shelters- there is no one to link them back to the community; we haven’t said whose job it is to do that, nor have we planned for a way to get paid. Let LMEs run community based walk in crisis facilities/clinics. Like Dr. McLellan said to you in October, require that providers also serve the non Medicaid people, and that they not be allowed to pick and choose.

3.Incentive the right treatments– Fund start up for the things we know work like ACTT teams, Multisystemic therapy (MST), intensive in home, psychoeducational programs that involve families in treatment, Supported Employment. Make rates that actually pay for the service. Give bonuses to providers who achieve outcomes like reduction of hospital days through receiving the right service mix in the first place. Realign hospital dollars to the local people to purchase care locally, which incentives the building of a local response system. Fund peer support services, using the Deficit Reduction Act provision, which gives jobs to people living with mental illness, who are effective, and at a cost less than half that of the community support rate.

4.Simplify getting the money out and get more money out NC still ranks 43rd per capita, we need more money in the right places. Since we’re in crisis mode, we need to cut through the red tape and get it out there quickly and easily. We need one IT system, one billing/authorization protocol. Let’s not spend 6 of l0 dollars on documentation rather than service delivery. We need to fund community inflationary needs. The legislature takes care of the psychiatric hospitals, and does excellent planning for their capital needs. Yet communities have enormous needs as well – where are those lists? Let’s provide ongoing inflationary increases where the system most needs stabilization- in the community

The people in North Carolina who are living with a mental illness are counting on their elected representatives to make the fixes that are necessary in statute when the session resumes May l3, 2008

Welcome to the new DMH co-directors

Yesterday, Secretary Benton announced his appointment of Mike Lancaster, MD and Leza Wainwright as co-directors of DMH. http://www.ncdhhs.gov/pressrel/2008/2008-2-29-new-management-mhddsas.htm

It would have been very hard for the Secretary to find someone from outside DMH to take the job (or jobs), in the last year of a gubernatorial administration. And, given the Secretary's efforts overall, which we must view positively, we want to support him even when he makes difficult decisions. At a time when many would desire new leadership for DMH, the new co-directors are closely identified with the failures of mental health "reform."

I think it is reasonable to point out that, in view of their record, the new co-directors have a certain burden of proof to meet. They have an opportunity here. They may signal that they view this as a new situation, with a new boss committed to change; that they are learning the lessons so forcefully publicized by the N&O this past week; and that like the Secretary they will include outsiders with different views in their decision-making. I think we would all welcome that.

Easley & the mentally ill: Easley Administration 2/27 response to criticism in Charlotte Observer

Easley and the mentally ill

Editorials implying governor didn't act are `flat wrong,' a top aide says

From Dan Gerlach, Gov. Mike Easley's senior policy adviser for fiscal affairs:

While editorials in your newspaper (Feb. 26, "Playing with lives") and others have been busy engaging in finger pointing to blame the current problems in our state's mental health system, rest assured that Gov. Mike Easley and his administration have been working to make sure it gets fixed.

It is clear that the rapid change in the mental health system led to problems, no doubt. But to insinuate that nothing has been done, or that these problems were ignored, is flat wrong. Regardless of what has happened in the past, we want to remain focused on solving problems for those in need of services. Consider the following:

• In 2006, Gov. Easley recommended, and the General Assembly supported, almost $100 million in additional funding to support the mental health system, including the replacement of lost federal funds for the developmentally disabled.

• This year, the governor ordered additional resources be made available to keep a state presence at Dix Hospital in conjunction with Wake County.

• Last year, the state Department of Health and Human Services and the administration recognized that some mental health community service providers were exploiting the system, inflating charges and wasting tax dollars. I informed the reporter in an interview that the governor demanded that the department take immediate action to audit the finances and practices of providers, adjust rates in cooperation with responsible providers, open fraud investigations, and toughen criteria for would-be providers and to screen inappropriate service requests. These changes started in early 2007, as soon as it became apparent that community support was open to abuse.

• In May 2007, Gov. Easley designated Dempsey Benton to be the state Secretary of Health and Human Services and specifically directed him to produce a set of proposals that will bring effectiveness and accountability to the state's mental health system. Secretary Benton has taken numerous steps to strengthen hospital oversight, involve independent experts and advocates, and increase accountability. The secretary's hard work has been uniformly welcomed.

Gov. Easley and Secretary Benton will soon recommend further initiatives to improve our mental health services for the General Assembly's consideration in May. More needs to be done.

Your editorial implies a lack of compassion and action for the mentally ill. This is false, as the above illustrations show.