NCMentalHealthVote

ADVOCATE’S PERSPECTIVE: OK…WHAT NOW?

2008-11-14T05:53:00.000-08:00

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

2008-10-30T06:30:00.000-07:00

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

2008-10-18T04:13:00.000-07:00

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

2008-10-15T07:30:00.000-07:00

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

2008-10-13T05:24:00.000-07:00

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

2008-09-18T06:16:00.000-07:00

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

2008-07-13T10:51:00.000-07:00

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

2008-07-13T10:42:00.000-07:00

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

2008-07-10T06:49:00.000-07:00

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

2008-06-28T06:13:00.000-07:00

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

2008-06-28T06:04:00.000-07:00

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

2008-06-06T08:47:00.000-07:00

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?

2008-05-26T13:11:00.000-07:00

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

2008-05-14T16:26:00.000-07:00

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 mentalhealth policy attempts to provide maximally effective servicesin the context of limited resources, promulgate clear servicestandards in the context of scientific uncertainty, and workto harmonize frequently conflicting needs and objectives ofmultiple stakeholders (patients, families, providers, otherpayers, general citizenry, and so forth).. . .

Choosing which servicesto provide in a public mental health system is always a matterof balancing clinical effectiveness, cost, and political will.Political will has never been sufficient to support the fullcost of all that we believe to be clinically effective, andtherefore 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

2008-03-02T11:15:00.000-08:00

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

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)

2008-03-01T05:22:00.000-08:00

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

2008-03-01T05:20:00.000-08:00

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

2008-03-01T05:10:00.000-08:00

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.

Dan Barkin, N&O 3/1: Series touches a nerve

2008-03-01T05:00:00.000-08:00

Our stories this week on the problems of the state's mental-health system tapped into an intense public policy debate that has been going on since the state decide to "reform" the system earlier this decade.

That's my conclusion after looking at the forum at share.triangle.com/mentaldisorder.

You get the feeling from reading the remarkably detailed posts that we stepped into a vast hall full of people who have been arguing vociferously about the mental-health system: State and local government employees, mental-health providers, families, academics. It is a debate that doesn't typically get as much attention, say, as school reassignment. And if you aren't steeped in the details of the system, you may need a glossary to keep up.

What has struck me about the forum is the length and the thought that has gone into the posts, which had drawn more than 5,900 views from people who clicked on them as of Friday afternoon. One of the headlines on a post was the poignant "I can't take it anymore," written by the mother of an ADHD and bipolar son. On my desk, I have a stack of the posts, printed out. Some of the comments run for several pages. Here are some of the points that have been made.

* There's too much red tape in the system. Forms and more forms. One provider says one form has changed five times, and each time it changes, 400 employees need to be trained in how to fill it out.

* State mental hospitals are unsafe places to work, according to front-line employees. As the state has come under increasing pressure to reduce the incidence of patient injuries, some workers say that their safety is a secondary concern.

* The state hasn't provided enough training for service providers.

* North Carolina should look at states that do a good job of providing mental health services and copy their practices.

* As bad as things might be for the mentally ill in urban areas, those in rural areas have a harder time getting access to services.

Some of the most useful insights in fixing the system come from parents, siblings and children of the mentally ill, because they live with the challenges of caring for a loved one.

A number of the most compelling posts in the forum come from moms and dads detailing how the system has let their children down, how their kids bounced in and out of short stays in institutions and, in one case, wound up on the streets. One woman worries that her daughter, who has attempted suicide, will not live to see 30.

These are painful -- but incredibly informative -- to read. One suggestion that was made: Anyone in a senior policymaking position (like a governor, lawmaker, Cabinet secretary) should get involved with a family trying to get services for a suicidal spouse, or an anorexic child, or a schizophrenic sibling. See firsthand what that experience is like, and then design a system that would make sense for these cases.

It is traditional in a column such as this to say something like, "This forum would make useful reading for candidates running in this year's election." And it would.

I am realistic enough to know, however, that seldom do candidates see much political upside in vowing to provide better services to the mentally ill. Typically, you'll see candidates promising to fill more prisons.

Now, no one who knows me would ever say that I am soft on crime. But I was impressed by one point made in the forum: It is wiser to provide good mental- health services early on so we can avoid having to keep building costly correctional facilities for the many prisoners who are mentally ill.

That strikes me as something a smart politician could run on.

dan.barkin@newsobserver.com or (919) 829-4562

Jail Diversion Programs for the Mentally Ill Saves Money and Improves Care

2008-02-28T04:59:00.000-08:00

Joseph Coletti’s latest John Locke Foundation Spotlight paper on jail diversion programs in thirty seconds:
Sheriffs could provide some impetus for county governments to take a more active role in rebuilding the state’s mental health safety net. If done right, jail diversion programs can improve public and officer safety, provide care for those with chronic mental illness, and save taxpayers money. Doing it right depends on a strong system of community-based care, which means more county involvement and less reliance on Medicaid. Intervening earlier saves more money and has greater potential to help the person with an illness.

Carolina Journal provides a summary here. The report itself is here.

Candidates Stake Out Opinions on MHDDSDA

2008-02-27T05:52:00.000-08:00

February 25 is a red letter day. I spent the day at The Coalition (formerly Coalition 2001) Candidates' Forum, and for the first time, listened to 10 candidates for Governor and Lt. Governor talk as if our public system is a campaign issue!

Yes, there was some awkwardness in tackling the details of the public MHDDSA system--candidates have not had to talk about our system to get elected before. Yesterday, in front of a packed room of advocates, consumers, and family members, these candidates came to recognize that this issue is indeed an important campaign issue. The Coalition Candidates' Forum and NCMentalHealthVOTE.org are proof that business as usual is over.

Some quotable quotes:

Bill Graham: "Failure is not an option."

Pat Smathers: "The system must have adequate funding."

Dennis Neilson: "The system is in free fall."

Beverly Perdue: "Expand the medical home concept to include mental health services as well." And "I know many like privatization but we have to have a public safety net."

Richard Moore: "We must rebuild the safety net so we don't turn to the criminal justice system. Failure always seems to get fixed by a $26,000 a year bed (in a prison)." And "The biggest problem is that there is no accountability. You should hold your next governor accountable!"

Robin Huffman

Executive Director,

NC Psychiatric Association

NC Mental Health Spending: from <$1 bil in 2006 to $1.53 bil in 2007

2008-02-26T07:00:00.000-08:00

Take a look at the "Print Graphics" on the N&O Website. They have one graphic showing that total MH spending in NC went from under $1 billion in 2006 to $1.53 billion in 2007. So we ARE spending the hundreds of millions of dollars that, if spent wisely, could get us out of this mess!

There's another graphic showing that government auditors found that only 11.4% of recipients got clinically necessary treatment in the right amount. 36.1% got clinically unnecessary treatment. 52.5% got clinically necessary treatment, but inappropriate duration or intensity.

From the N&O: only 5% of MH money spent on services proven to help people with serious mental illness

2008-02-25T19:05:00.000-08:00

To clarify: what this graphic tells us is that from April 2006 through January 2008, North Carolina spent $1.42 BILLION on community support -- and only $77.4 million on critical services, which are evidence-based practices likely to avoid hospitalization. This, from the leadership that promised "the right treatment, in the right amounts, to the right people"!

N&O Executive Editor: Easley Must Lead (2/24)

2008-02-24T07:05:00.000-08:00

After reading our series that starts today and ends next Sunday, you will see that the state has wasted at least $400 million as it changed the way it treats the mentally ill.

You also will learn that the most seriously ill are getting less care than they did before the "reform."

The person ultimately responsible for managing this initiative -- Gov. Mike Easley -- now says his administration opposed the 2001 changes enacted by the legislature. Yet there is little proof that anyone representing Easley opposed the changes.

Easley has tried to distance himself from the issue. He clearly doesn't want to engage. But he doesn't have a choice. There's too much at stake -- in taxpayer money and human cost.

Simply put, Easley needs to lead.

One burden of leadership: Sometimes you have to deal with issues you'd rather ignore. Some issues are popular with voters. This is not one of them. No one gets elected governor saying he will deliver good care to the mentally ill at a reasonable price to taxpayers.

In a December news conference, Easley said the state was merely the banker, supplying the money for companies to provide services to the mentally ill.

Easley is wrong. His administration set the rules for the new program. It set the reimbursement rates. It had the responsibility to set and enforce standards.

I'd like to be able to tell you Easley's further thoughts on the subject. But he declined repeated attempts by The N&O's Pat Stith to discuss it.

Stith, one of the best investigative reporters in the country, has studied the state's mental health system for six months. Few people understand it as well. That might make Easley nervous.

The governor couldn't make the time to talk with Stith. But he did find the time recently to appear on the public TV show, "The Woodwright's Shop."

Easley and host Roy Underhill worked on a walnut table together. It's good -- I guess -- that we have a well-adjusted governor who enjoys his free time so much.

But there are 10 months left in his last term. There are plenty of projects on the state's workbench.

Easley has appointed Dempsey Benton, Raleigh's former city manager, to lead the state agency in charge of mental health.

Benton is an old pro -- a skilled, capable public manager, although he has little experience in delivering social services.

But Benton is digging in. Easley should too. As chief executive, he should be able to ask Benton hard questions about what the goals are, how the state is going to meet the goals and how it's going to measure success.

Anyone who works with wood knows you measure twice and cut once. When it comes to mental health reform, Easley missed on the first cut.

We'll see if he has the skill -- and the will -- to get it right on the second cut.

John Drescher, Executive Editor

john.drescher@newsobserver.com or (919) 829-4515.

N&O Op Ed: Mark Sullivan: Our shredded safety net

2008-02-24T07:00:00.000-08:00

Our shredded safety net: NC's MH 'reform' a recipe for tragedy

Mark Sullivan 2/24/08

CARRBORO - Eight years into mental health reform, North Carolina has thus far dodged a bullet. Much of the postmortem on the origins and unfolding of the reform effort has been done. But how much worse can things get, and what will it take to bring about real and meaningful change? If recent developments do not mark a turning point in reform, the turning point will be marked by tragedy on a massive scale.

Consider that after all of this time, just three of 24 Local Management Entities (the organizations charged with ensuring needed services are available) in North Carolina are meeting minimum standards for routine care. Just 45 percent are meeting minimum standards for urgent care. How bad must things get before we are willing to rethink the fundamental assumptions that the new system was founded on?

North Carolina ranks near the bottom in the nation in per capita funding for mental health care at $16.80, compared with the national average of $91.12. Yet our problem is much bigger and more complex than underfunding.

After the first six months of the fiscal year, the Division of Mental Health, Substance Abuse and Developmental Disabilities reported that only 30 percent of mental health funds and 20 percent of substance abuse funds that had been budgeted had been expended.

On the surface it might look like the system is overfunded, but what these numbers signal is that needed services are not being provided because they are unavailable.

A core problem with the new system is that it was built upon a fundamentally flawed assumption; that the private sector will always outperform anything run publicly. It is a wildly popular notion, and a key reason why this particular plan was able to gain support in North Carolina.

The private sector is far superior in many arenas, but not necessarily when it comes to protecting the poorest and most vulnerable members of society. Private providers pick and choose which services they will provide, based on what will best meet the needs of the agency, as opposed to public entities whose first responsibility is to meet the needs of the citizenry. Departments of social service, child protective services and health departments are county run -- why not mental health?

In Orange, Person and Chatham counties, Caring Family Network, the agency designated as the Comprehensive Service Agency (CSA) in our area, has determined that it could not financially sustain service provisions and will cease offering services effective March 12. CSAs are designated to provide psychiatry, psychotherapy, crisis services, substance abuse counseling and community support. They are meant to replace our old public "safety net" clinics to ensure that a basic level of service is available to the community.

THE NEW SAFETY NET IS THE CRIMINAL JUSTICE SYSTEM.

We know what happens when people who need psychiatric care do not receive it. Most suffer quietly, some lose their jobs, are engulfed by addiction, lose their housing, fill hospital emergency departments, crowd jails and prisons or take their own lives.

But Wendell Williamson, the UNC law student who opened fire on Franklin Street on Jan. 26, 1995 with a military rifle, killing two and injuring two, tells another story. Alvaro Castillo, who allegedly killed his father and fired eight shots at Orange High School in 2006, made a convincing argument for the importance of mental health treatment. Most recently, Steven P. Kazmierczak made his case at Northern Illinois University.

Calling up these names risks reinforcing some stigmatizing stereotypes about people with mental illnesses. When people hear of mental health disorders, they too frequently conjure up images of the most severe, least common cases. They do not think of someone like me, though I represent a more common picture of someone with a mental disorder.

Only a small fraction of people who experience mental health disorders present a danger to others. But when one considers the scale at which our system is failing, it is clear that a new tragedy is only a matter of time; it's a statistical certainty.

The formula is simple: Take a population of 9,061,032 North Carolinians, of which approximately 356,000 adults have serious mental illnesses and 192,000 children have serious emotional disturbances. Next, systematically restrict access (either intentionally or unintentionally) to treatment for those who need it. The result equals tragedy on a massive scale.

We will never be able to prevent every tragedy, even with an excellent mental health system. But by restricting access to care for 550,000 of our most deserving and needy residents, we are stacking the odds against ourselves.

Health and Human Services Secretary Dempsey Benton has been called upon to salvage the system. He is by all accounts a capable administrator, and he has taken steps that show he means business. But with less than a year left in Gov. Mike Easley's administration, Benton will have to be a miracle worker to provide leadership that amounts to something more than too little, too late.

County officials have a rare opportunity to step in and do something that is fiscally responsible, morally right and politically popular. Will they stand by and wait for the state, the Local Management Entities or a private provider to replace the safety net while the system is in free fall? If so we may be in for a very hard landing.

(Mark Sullivan is executive director of the Mental Health Association in Orange County.)

Requiem for a DMH Director

2008-02-23T09:05:00.000-08:00

Michael Moseley resigned as DMH Director yesterday, two days before the start of a Raleigh News & Observer investigative series on “Mental Disorder: The Failure of Mental Health Reform.” It is hard to believe that the timing is mere coincidence. As the video trailer for the series (http://videos.newsobserver.com/index.php?a=player&id=1730241) says, “Hundreds of millions of dollars wasted. . . Dozens of avoidable deaths. . . Six months of News & Observer investigation.” For a DMH Director to stay in the job at this moment, there would have to be confidence that his record could withstand the scrutiny sure to come in the next week.

Mike Moseley was appointed DMH Director by a DHHS Secretary who was stubborn, self-righteous, and determined to keep control of mental health policy. In mental health, there is no evidence she tolerated independent thinking and professional integrity.

Mike was always courteous and pleasant. But he was a careerist and no one could accuse him of being a hard-driving, effective leader. Always loyal to the party line, he was reluctant to accept evidence that things were not going well. He did what it took to keep his job. And when Secretary Benton, an honorable and able man, took control of DMH’s State Operated Services from Moseley, he signaled his attitude toward Moseley’s leadership on issues that matter.

Moseley leaves behind a discredited DMH leadership. It will be hard to fill this position in the last year of a gubernatorial term. We should continue to support Secretary Benton as he fills this position, and in his efforts to do what he can to improve mental health and substance abuse care in North Carolina.

We need to hear from you!

2008-02-20T16:52:00.000-08:00

The news so far in 2008 indicates that North Carolina’s mental health system steadily continues to crumble around us. In January, Wilson Medical Center announced it was closing its psychiatric beds. Last week, the Board of Trustees of Beaufort Community Hospital in Washington voted to close its 18 bed psychiatric unit, further depriving North Carolinians of psychiatric hospital beds in the community and putting more stress on our already overcrowded state hospitals. Two days ago, Partnership for a Drug-Free NC announced it was closing its mental health clinics in Mount Airy, Yadkinville, Statesville, and Mooresville, leaving the psychiatric care of 265,000 people in limbo.

In my own backyard, Caring Family Networks is closing its clinics at the end of the month in Orange-Person-Chatam Counties, leaving 1,500 patients without care.

The recent closing of mental health clinics and of psychiatric hospital beds in the community is the latest in a long list of private companies and community hospitals psychiatric units failing to survive in the “reformed” mental health care system of North Carolina. More closures are brewing on the horizon. The message cannot be more clear - the reform of North Carolina’s public mental health system has failed.

But I think we all that by now. I personally believe that we need to establish publicly run Safety Net Clinics or Clinical Homes that will provide a stable and consistent setting for mental health care. These Clinical Homes will be run by the county or the LME and funded with county and state money. They will not close down because they can’t make money. Most of the people that the system serves are indigent. North Carolina ranks 43^rd in the country in per capita spending on mental illness. It is no longer reasonable to think that private companies can break even or turn a profit while offering decent, quality care in a system with very little money.

We are all seeing the consequences of the failure of North Carolina’s Mental Health system. I’m asking people in Orange–Person-Chatam Counties to tell us what is happening - how is this closure is affecting you? If this has happened to you in other parts of the state, let us hear from you as well. Whether you are a patient, a provider, or anyone else we need to hear from you. Post a comment on this blog. Write a letter to the editor of your local paper. Call your elected official. Let our current and future leaders in state government really understand how this broken system is hurting people.

Minutes 2/5/08 HOSPITAL MANAGEMENT AND OPERATIONS WORKGROUP

2008-02-18T14:15:00.000-08:00

MINUTES

HOSPITAL MANAGEMENT AND OPERATIONS WORKGROUP

ADAMS BLDG, ROOM 264

Tuesday, February 5, 2008

ATTENDANCE:

Dr. David Rubinow, Mike Pedneau, Dr. Stephen Oxley, Cliff Hood, Peter Mumma, Iris Rubin, Rickye Collie, Mike Hennike, Laura White, Dr. Jack St. Clair, Deby Dihoff, Dr. John Esse, David Womble, Laura Thomas, Carmen Vincent, Dr. Donald Baucom, Pamela Graham, Dr. Michael Zarzar, Dr. Patsy Christian, Barbara Whitaker, Kathryn Davis, Walker Wilson,

Patti Henke

ITEM	RECOMMENDATIONS/ CONCLUSIONS/ACTION	FOLLOW-UP
Welcome and Introductions	Mike Pedneau welcomed the group and requested everyone introduce themselves. He asked that any revisions to the minutes from the last meeting be given to him outside the meeting.	N/A
Central Regional Hospital Staff Model	Dr. Patsy Christian and Dr. Steve Oxley provided information on the CRH Staffing Model in a power point presentation. This same program had been shared previously with Secretary Hooker Odom and Central Region Hospital Steering Committee. Copies of the presentation will be provided with the minutes. The presentation included information on benchmarks from other state hospitals nationally and in North Carolina. There are very few states with psychiatric hospitals that admit the volume of acute patients as North Carolina, so comparison data is limited. One expectation during the development of the model was that the consolidation of DDH and JUH would result in savings that could be transferred to the community which limited the number of staff that could be included in the staffing plan. The staffing ratios are consistent with the current ratios at the 4 state hospitals. Specifics of the staffing plan include: formula for HCTs based on current staffing for DDH & JUH as bench mark and does not include positions for 1 to 1 coverage. Nursing staffing including RN, LPN and HCTs do not have enough positions to allow for time in training without the use of overtime. Dr. Oxley indicated that the number of psychiatrists for CRH is based on the number of admissions rather than census. Dr. Christian was asked if there were areas that CRH will be short staffed and she indicated that there is not staff dedicated to the treatment mall, which may make coverage of the 120 daily groups difficult. Dr. Rubinow asked if CRH staffing model is adequate to meet regulatory requirements. Dr. Oxley answered that, in his opinion, it is not. Several members of the group concurred that the staffing presented was inadequate and had potential risk and liability implications. Discussion followed that staffing at the hospitals has not increased commensurate with the increased volume and high acuity of patients. Dr. Christian discussed recruiting activities for CRH including job fairs and billboards (first time this has been done by state operated facilities). Recruitment of nurses is expected to be the biggest challenge. Attracting enough male HCTs is also problematic. CRH is currently expecting to have 5 – 6 vacancies for psychiatrists. The staffing model for CRH is intended to be replicated at Cherry and Broughton Hospitals once the new facilities are constructed. Dr. St. Clair and Dr. Esse both indicated that Cherry and Broughton Hospitals have many of the same staffing issues that Dr. Oxley and Dr. Christian discussed. Both Cherry and Broughton also have significant challenges recruiting psychiatrists.	Staff to the Workgroup to provide requested data (also see next section)
Metrics	Several members of the workgroup requested data related to staffing and hospital operations. The following was requested: restraint rates, patient injury rates, 30 day readmission rates, temporary employees – number and cost, vacancy rates, nursing staffing by hospital x discipline x unit x shift for Oct. 2007, lost work days, turnover rates for RN, LPN, HCT, SW, Psychologists, Psychiatrists, staff and patient satisfaction survey results, education levels of current nursing staff, discharge destination data, diversion and delay data, admission/discharge rules, facility/LME contract, denial rates, percent of patients seen within 7 days of discharge, percent of discharge planning that was done jointly between hospital and LME, number of CON and operational psychiatric inpatient hospital beds in the community.	Staff to the Workgroup to provide requested data
Centralized and Standardized Policies	Laura White handed out a list of Corporate Policies that are in place, being developed or to be reviewed. In addition to the policies, Governing Body Reports will be standardized across the hospitals. An example of a draft Corporate Policy, State and Federal Death Reporting, was also handed out. Each hospital has participated in the development of the Corporate Policies or will have the ability to provide input prior to finalization. Corporate Policies are based on philosophical underpinnings, regulatory requirements and existing DMH/DD/SAS policy. Each hospital then develops an operation procedure detailing how the Corporate Policy is carried out. Some policies apply to all state operated facilities, not just hospitals. Mike Pedneau asked for volunteers to review the draft Corporate Policies.	M. Peadneau and other interested workgroup members will review policies and provide feedback.
Accreditation Issues	Iris Rubin handed out and discussed the report North Carolina State Hospitals Regulatory Report Summary. The report lists deficiencies identified by DHSR/CMS, JC and USDOJ. The report does not contain information about Plans of Correction and steps that have already been implemented to address the deficiencies.
Next Meeting	February 19, 2008 at 1:00 p.m.

There being no further business, the meeting was adjourned at 3:05 p.m.

Minutes 1/22/08 HOSPITAL MANAGEMENT AND OPERATIONS WORKGROUP

2008-02-18T14:11:00.000-08:00

MINUTES

HOSPITAL MANAGEMENT AND OPERATIONS WORKGROUP

ADAMS BLDG, ROOM 264

Tuesday, January 22, 2008

ATTENDANCE:

Dempsey Benton, Dr. David Rubinow, Mike Pednau, Dr. Stephen Oxley, Cliff Hood, Peter Mumma, Iris Rubin, Rickye Collie, Mike Hennike, Dr. Jim Osberg, Laura White, Dr. Jack St. Clair, Debbie Dihoff, Ranota Hall, Dr. Tony Lindsey, David Womble, Art Robarge, Laura Thomas, Carmen Vincent, Dr. Donald Baucom, Pamela Graham, Kathryn Davis, Walker Wilson, Dr. Ranota Hall

ITEM	RECOMMENDATIONS/ CONCLUSIONS/ACTION	FOLLOW-UP
Welcome and Introductions	The DHHS Secretary, Demsey Benton, welcomed everyone and introductions were made. Those in attendance for this meeting are listed above.	N/A
Housekeeping	A contact list was passed around for additions/corrections. Travel reimbursement was mentioned and Mr. Womble will send out information to committee members regarding the process. Mike Pednau is assigned as the Chair of the workgroup by the Secretary. The Secretary provided a memorandum dated January 17, 2008 regarding the workgroup and background information. Mike Hennike provided one page fact sheets on each of the facilities that included operating budgets, authorized positions, census, admissions and cost per patient per day. Laura White indicated there will be data updates on the facility web sites that will include survey review reports, weekly admission and discharge data, number of patients and days the hospitals have been delayed (to be updated monthly). Significant incidents will also be available with information that does not breach HIPAA confidentiality. Other information will be added as necessary or requested by the workgroup or DHHS.	N/A
Issues to be Divided into Subcommittees	Mike Pedneau brought up for discussion how many subcommittees there need to be to work on major tasks. Tasks include: Standardization of policies, deaths, use of fiscal budget, chemical restraints, forced medications, consistent access and bed availability, uniform standards for requirements of primary treatment positions, quality assurance for standards of accreditation, and corrections of deficiencies. In addition, review of patient safety, assessing long-term mission and role of facilities and populations to be served, hospital and community interface, admissions/discharge planning parameters, continuity of care, staff recruitment, turnover, and maintenance were mentioned as issues. Dr. Jack St. Clair suggested grouping issues to reduce the number of subgroups needed to brainstorm and strategize. It was suggested that separating out issues by short and long term objectives might be helpful.	Subcommittees to be determined.
Centralized and Standardized Policies	Dr. David Rubinow requested information about centralized policies/standards and data actuaries. Jim Osberg explained the JCAHO and CMS standards and the need for each hospital to be a stand alone facility. He also mentioned that corporate policies have been developed, but they allow for a wide degree of local autonomy. Dr. Jack St. Clair indicated there are quarterly governing body reports that are submitted to the Division of Mental Health, Developmental Disabilities, and Substance Abuses Services (DMH/DD/SAS). Samples can be provided to the group if interested. The Department of Justice (DOJ) has been an impetus for driving standardization of the hospitals. Each State psychiatric hospital must respond to its region independently due to demographics and community needs. Carmen Vincent suggested using the regulatory requirements (JCAHO, CMS, CRIPA) as the minimum of quality of care objectives.	State Operated Services to provide the workgroup with a list of corporate policies that are being developed or revised.
State Psychiatric Hospital(s) Mission	A question about the mission of the State psychiatric hospitals due to the status of community gaps, leaving the hospitals as the “safety net” for communities was raised. It was agreed that there are not enough resources in the communities and for the facilities, specifically related to special populations that have led to overpopulation and increases in volume of admissions. The MR/MI population which requires specific resources that are not always available and require additional services due to the risks associated with the needs of these individuals is an example. Factors mentioned: population growth in the state and growth of the populations in need, milieu of community based services, downsizing of State psychiatric hospital beds, loss of services due to privatization of community services, and loss of community psychiatric hospital unit beds. Some beds have been added to the Developmental Centers to handle people with MR and behavioral health needs, but they are limited. Lengths of stay affect census at all facilities. There is a huge need for respite beds to alleviate hospital census volume.	The mission of the State psychiatric hospitals to be discussed further.
Staffing Issues Discussion	Adequate staffing was mentioned as directly influencing standardization of practices. It was asked if any wasted funds could be redirected, and what would need to take place in the communities quickly to slow down admissions to state hospitals? Dr. St. Clair indicated that there are not enough qualified staff for patient care. Lapsed salary latitude allows for hiring temp agency nurses to fill staffing gaps. Positions have had to be cut due to legislation which has cut into lapsed salary latitude. Dr. Oxley indicated it is a complex issue and although John Umstead Hospital does not have as much of a psychiatrist shortage as Cherry Hospital, nursing staff fill the gaps. With lengths of stay being shorter, the first few days are more work and staff intensive, and with challenging patients with violent tendencies there are not enough staff to handle these patients. The State psychiatric hospitals do not enough staff to have one-to-one and two-to-one and must force staff to work overtime, creating burn-out and low morale. This can lead to poor customer service and reduced quality of care. Dr. Ranota Hall asked Dr. Oxley to discuss the issues of staff qualifications and the need for intensive care. Dr. Oxley indicated that Health Care Technicians (HTCs) often do not have the expertise and education to handle the most intensive need patients. Nursing staff must mentor HTCs and with their load of paperwork/documentation, supervision and mentoring come last. Dr. Rubinow asked if documentation requirements could be reduced. This probably has not been reviewed closely as far as what is actually required. The electronic medical record (EMR) can alleviate the documentation needs. EMR has been discussed as a need, but DHHS has a shortage of IT staff to make this happen. Other obstacles for this technology are challenging and slowing down progress. Dr. Oxley indicated that Central Regional Hospital (CRH) is about a year away from having this in place. Carmen indicated you cannot throw EMR technology at a broken process and there should still be review of where there are inefficiencies.	Staffing and career ladders to be discussed further in a staffing issues subcommittee.
	It was indicated there is high variability of survey/regulatory teams in requiring new or changed documentation and it is different among all the hospitals. This adds to the lack of standardization among the State psychiatric hospitals with documentation and quality. Carmen suggested developing an internal process to centralize recertification capability. Art Robarge indicated that reviewing other facility processes has facilitated streamlining problem areas at Broughton. It was asked if there are meetings already in place that can meet the needs of these identified objectives. Can these meetings be more proactive rather than reactive? Dr. Osberg indicated there are monthly State psychiatric hospital directors meetings and this would be a place to start. It was indicated that community relationship efforts with local hospitals, regional crisis systems and between Local Management Entities (LMEs) and the State psychiatric hospitals are important to include in discussions and that standardized staff competencies would be helpful to utilize for improving quality and practices. Rickye Collie indicated that salary ranges are not necessarily the issue because they are competitive in NC, but there are not enough FTEs to handle the population to be served. Dr. Oxley stated that it would be helpful to have a better pool of entry level staff. Staff are often assaulted, and at risk by patients. This can create a sense of lack of appreciation, and the pay scale does not compensate for the impact of the assaultive environment of the State psychiatric hospitals. Dr. Hall stated that continued training for maintaining competencies and enforcing it among HTCs and nurses is important to prevent turnover. HTCs have not had a significant career ladder, and this is something that should be studied.
Budget for Salaries	It was indicated that budget issues and flexibility of funds would be an important subject to resolve by this workgroup. Dr. Oxley mentioned the limits of raising salaries and that it actually requires an act of Congress to pass it as a law.	To be discussed further.
Other Items	A question was asked about what is used to measure success. Dr. St. Clair indicated Cherry Hospital uses a strategic plan for that hospital. Although there is some lack of control with outcomes of patients once they are discharged, there is more work that can be done while patients are in the hospital. It was asked if there were other states NC could emulate regarding practices and Iris Rubin indicated some states are doing well, but most do not take direct admissions. NC State psychiatric hospitals have a higher rate of acute admissions than most other states. Cliff Hood indicated there is difficulty in attracting male HCTs and should be considering in discussions. Mike Hennike suggested that SOS create a list of corporate policies already in place for the group. He also suggested that the group review the key positions that are in the DRH plan. Need to determine main issues to focus on and hone down groups needed to work on the issues. Jim Osberg suggested the compliance issues document that SOS has been working on should be shared with the group for consideration—which is focused on expansion. The group indicated they would like the summary of compliance issues and what has been accomplished thus far. Other data/information requested: Length of stay, admissions, discharges, and recidivism. SOS to provide to Mike Hennike and Mike Pedneau.	Along with determining mission, specific objectives for the State psychiatric hospitals to be determined regarding patient outcomes and measuring success. SOS to provide requested data to Mike Hennike and Mike Pedneau.
Next Steps	Mike Hennike indicated that the group may have to shore up and meet in small groups more often.	Mike Hennike and Mike Pedneau to determine specific subcommittees for the Workgroup to focus on.
Next Meeting	February 5, 2008 at 1:00 p.m. Subsequent meeting: February 19, 2008, same time

There being no further business, the meeting was adjourned at 3:05 p.m.

NC Crisis Services Workgroup Minutes 2/05/08

2008-02-15T13:22:00.000-08:00

Crisis Services Work Group

Meeting Notes

February 5, 2008

Dorothea Dix Campus, Adams Building, Room 264

Members Present: Secretary Dempsey Benton, Amy Blackwell, Wendy Webster, Sarah Wiltgen, David Rubinow, Jack Naftel, Ellen Holliman, Mike Watson, Foster Norman, Barbara Beatty, John Tote, Robin Huffman, Marvin Swartz, Brent Myers, Carl Britton-Watkins, Walker Wilson.

Members Absent: Tara Larson, Peter Mumma, Tony Lindsay, Patrice Roesler, Darlene Menscer.

Executive Support Team Present: Mike Hennike, Linda Povlich (by phone), Leza Wainwright, Stuart Berde, Mike Lancaster, Michael Vicario, Yvonne Copeland, Jack St. Clair.

Others Present: Barbara Whitaker, Katherine Davis, Martha Are, Paula Graham, Rebecca Troutman, Scarlette Gardner, Pam Shipman, David Jones, Billy West.

Decision Making Process

Decisions will be made by consensus as much as possible. We intend to present the Secretary with a list, and we will rank the list based on preferences expressed by the group. If someone has a dissenting opinion they will be able to write that up and it will also be submitted to the Secretary.

The process we will use to make our decisions is
1) define the issue
2) gather information
3) build a list of alternatives
4) evaluate the alternatives including ways to measure their effectiveness

Outputs

Recommendations for what the outputs should include are
- A list of short and long term alternatives for what an LME crisis program should look like, the resources needed including staffing requirements
- Clarification of which of these alternatives are budgetary requests from the legislature, recommendations for spending of current funding, and which are systemic changes that do not require funding
- An impact statement clarifying the impact if a recommendation is or isn’t adopted
- Strategies for evaluation
- Recommendations for follow up work this group will need to do

Secretary Benton clarified that the group should look at the state’s capacity for crisis and short term care. We need to understand how the state hospitals work and who they serve and how we fully operationalize the community component so we can see it on the ground.

LME Presentations

Piedmont LME presented on their crisis services, naming that most of the people they see in crisis are IPRS, not Medicaid funded. Their hospital ED’s have had a reduction in cases they see, down from an average of 8 a day to 1 a day. Piedmont has a DMH waiver and a Medicaid waiver that assists with their flexibility. The group received handouts that provide additional detail.

Sandhills LME presented on their crisis services strategies which have focused on reducing demand for crisis services, increasing crisis services capacity, and protecting the consumer’s safety and welfare. This LME also has a funding waiver from DMH that help with things like medication, transportation and housing assistance. The LME focuses quite a bit on consumers coming out of the hospitals, and has seen a significant switch from state hospitals to community hospitals, and overall hospital admissions have gone down. Handouts provide additional details on goals, 18 strategies and progress to date.

State Crisis Funds Expenditures

Leza Wainwright shared a spreadsheet that shows what has been spent during the first six months of the year, looking only at the $27.3M state dollars that are in the current budget and earmarked for crisis services. Other funds used for crisis services are not included in the spreadsheet. Some of these state funds were allocated by the general assembly using formulas, and others funds were put in at the discretion of the LMEs. The spreadsheet includes fee for services categories that are also eligible for Medicaid reimbursement, fee for services that aren’t eligible for Medicaid reimbursement, and reimbursements for expenses that aren’t fee for services. Some LMEs have not yet reported any spending in the fee for services categories. Beginning next year LMEs will also have to report how they spend their county funds.

Single stream funding waivers have been approved for 9 LMEs. Those funds were decategorized. The LME has one pot of money that is paid out in equal, monthly increments. Reports from these funds are not as specific about how the funds are used and their outcomes. Through Oct.1 of this year, it was a judgment call on the part of the division and the department about whether or not single stream funding waivers would be provided. The division/department approached LMEs known to be good at managing their dollars and that had been creative within the old funding stream system. Starting Oct. 1 there are published guidelines for past performance an LME must have demonstrated to apply for the single stream waiver. Since then, only Crossroads has applied and been approved.

Hospital Association & NC Council on Community Programs Report

The NCHA and NCCCP, along with several LMEs,
 have been meeting to establish a common plan for MH crisis
 services. The plan was presented in the form of a charter,
 and uses a methodology from an April 2007 DMH/DD/SAS
 document that projects need for 187 additional inpatient crisis
beds. The problem is that 50% of state psych hospital admissions
 have stays of 7 days or less, up from 30% only a few years ago.
 Our focus is on increasing community capacity by the number
 of beds needed to serve these short stay admissions.

We recommend that LMEs with high state hospital
utilization and limited community capacity be identified for
 projects that include financing of inpatient capacity and
 of related capital costs. The model would require
 sequential exhausting of all efforts identified in the
 plan. NCHA indicated that a rate higher than the
 Medicaid rate was proposed to help cover costs
 of higher acuity, medical co-morbidity and physician
 care. He also reminded the group that the plan
 differed from the need in the State Medical Facilities
 Plan as it specifically identifies need for funded beds
 to serve indigent patients that would otherwise be
 admitted to state hospitals. The group commented
that there are beds that are licensed, not utilized and
 possibly not practical to be counted as available beds.
 Additional details are provided in the project
 document distributed to the workgroup.

Survey Results

The survey document was distributed. Members are asked to review it and come prepared to make additional comments at the next meeting. Members can also continue to submit responses to Martha who will incorporate them into a revised document.

The next meeting

The group was asked to identify what additional information might be helpful to have at the next meeting. Ideas that the Executive Support Team will explore included

- Information on what each of the LMEs is doing with crisis services so we can compare services being offered.

- What does it cost to transfer someone from the community to a state hospital?

- Exploration of disproportionate share funding

- What do LMEs identify as the patient need and capacity? This is important for exploring the idea of clinical homes in the community.

- More information about licensed and in-use beds. Similarities and differences in admission criteria.

In our next meeting we’ll review the survey responses and begin listing alternatives.

NC Crisis Services Workgroup Minutes 1/22/08

2008-02-15T13:19:00.000-08:00

We are posting the minutes of DHHS Secretary Benton's Crisis Servives Workgoup. We'll try to get the minutes from the other workgroups. Let us know what you think.

Crisis Services Work Group

Meeting Notes

January 22, 2008

Dorothea Dix Campus, Adams Building, Room 264

Members Present: Secretary Dempsey Benton, Amy Blackwell, Wendy Webster, Sarah Wiltgen, David Rubinow, Jack Naftel, Tony Lindsey, Ellen Holliman, Mike Watson, Patrice Roesler, John Tote, Robin Huffman, Dr. Marvin Swartz, Carl Britton-Watkins, Peter Mumma, Mike Hennike, Mike Lancaster, Leza Wainwright, Mike Vicario, Yvonne Copeland, Tara Larson, Linda Povlich Stuart Berde, Walker Wilson, Jack St. Clair.

Members Absent: Foster Norman, Barbara Beatty, Brent Myers, Dr. Darlene Menscer

Others Present: Barbara Whitaker, Katherine Davis, Paula Graham

Secretary Benton opened the meeting with introductions and appreciation for everyone's participation. He challenged the Crisis Services Group to come up with the core components of a crisis service system and to determine the inpatient bed needs in the state. The expansion budget request is due Feb. 19 but he stated we probably had a 30 day grace period during which he wanted this group to have some recommendations for the Department.

Leza Wainwright presented several maps depicting the current picture of crisis services across NC which invited further discussion about crisis services functions, realistic expectations, response time, geographic accessibility, data needs, effectiveness of mobile crisis units, etc.
Discussion highlighted a number of concerns and needs. Many fell into the following themes:

1. Emphasis on work force development, training and retention
2. Bed inventory versus bed availability/need
3. How are crisis dollars being spent
4. Excessive paperwork and need for conformity in forms and processes
Suggested agenda items for next meetings include:

1. A review of the models being used at Southeastern, Piedmont, Smokey and Sandhills.

2. A presentation by Mike Vicario and Yvonne Copeland on the mobile crisis teams' report being presented to NCHA on January 29^th.

The group agreed to meeting on alternate Tuesday afternoons beginning February 5th. Please note for logistical purposes, the time has been changed to 3:15 p.m. to 5:00 p.m. This will enable the earlier group to vacate the conference room in time for our group to convene. It is imperative that everyone be prepared to begin our meeting at 3:15 to maximize our time together.

Notes from WUNC-TV's Governor Candidate Healthcare Forum

2008-02-10T13:04:00.000-08:00

WUNC-TV hosted a forum for gubernatorial candidates on Thursday, Feb 7. that focused on health care. I watched the forum on-line (http://www.unctv.org/gubernatorial/health.html) this weekend and I thought I’d summarize what the candidates said. Almost every candidate, Republican and Democratic, recognized that the mental health care system in North Carolina is a mess, which was great to see. For the most part, they touched on the important problems - lack of a safety net, lack of leadership, a wasteful bureaucracy, the need for more funding, the need for local hospitals to provide psychiatric beds, the need to give more control to local providers, and the costs being shifted to police and sheriff departments, courts and prisons. To varying degrees they offered plans to fix the system. Of course, two minutes in a debate does limit a candidate’s ability to provide details, and the devil is in the details. I hope that each candidate will continue to tell us how they will fix the system. But recognizing the problem is the first big step (I’m sounding like a psychiatrist!), and we have to glad that the candidates for governor have done that.

The question was: “The Department of Health and Human Services secretary wants to completely overhaul our state's mental health system, how should the state’s mental health system be structured?”

Beverly Perdue said that the MH system was in a “real challenging state”, that there were challenges in finding community care and institutional placement. She proposed using the Community Care model for Medicaid recipients in the mental health system, so that there would be a mental health clinical home – with a “cadre” of mental health care providers that will provide excellent care.

Richard Moore said that the mental health system is an illustration about “why people get so upset with government”, and that “no one wants to defend what has happened”. He stated it was a system that was “not serving anyone as well as it could” and is “wasting millions and millions of dollars”. He stressed that accountability and strong management was critical for improving the system.

Pat McCrory said that mental health was a “difficult issue” and noted that the recent addition of mental health coverage to medical insurance runs the risk of making insurance too expensive and driving more people to Medicaid. He stated that future mandates should be stopped. Noting “good trends” in the mental health system in Mecklenberg County, he stressed transferring control to the local level as opposed to the centralized bureaucracy.

Bob Orr pointed out that while the mental health system in Charlotte may be working, it was not working in the rest of the state and called it “an absolute disaster.” He noted the recent announcement that the major provider of psychiatric care in Orange-Person-Chatam counties was closing, and that there was no safety net. He stated that this closure was due to poor reimbursement. He also noted that the state was losing community psychiatrists and other care providers because of the chaos in the system. He stressed that a safety net should be provided offering quality care, and that money should be put back into the Mental Health Trust Fund. He also noted that the system should be ready to provide care to returning veterans.

Fred Smith said the mental health system was “in crisis”, that there had been a rush to implement mental health reform and that many “poor decisions” had been made. He noted that there is inconsistent care across the state and “in some cases, no care”. He offered a new strategic plan that gave clear responsibility to local providers and called on local hospitals to provide crisis services.

Bill Graham said that the mental health care system was a “disaster” and was “broken”. He noted that the failure of the mental health care system has caused people to end up in the courts, and has created a burden on the police. It also creates problems in families as well. He called for reimbursements to be restored to local providers and asked the Division of Mental health to stop “changing the rules every other week” so that providers could function.

An excellent link for MH/SA/DD news

2008-01-29T06:03:00.000-08:00

http://mentalhopenews.blogspot.com/

Membership on Secretary Benton's Working Groups

2008-01-29T05:14:00.000-08:00

The list of members of DHHS Secretary Benton's Facility Management Working Groups has been announced:

A. Central Hospital Construction Review Group
Dr. Marvin Swartz, Duke & member, Mental Health Commission
Mary Silverman First Health of Carolinas (Moore/Richmond)
Mary Beck and Eileen Spahl, UNC
Dr. Tony Lindsey, Vice Chair for Clinical Affairs, UNC Dept Psychiatry

B. Management and Operations Work Group
Peter Mumma, New Hanover Health Network
Laura Thomas, Carolinas Health Care – Mecklenburg
Carmen R. Vincent, University Health Systems of Eastern Carolina
Dr. David Rubinow, Chair, Department of Psychiatry, UNC
Dr. Tony Lindsey, Vice Chair for Clinical Affairs, UNC Dept Psychiatry
Eileen Spahl, Director, UNC Psychiatry Inpatient & Rehab Center
Mike Pedneau, Former Director of Dorothea Dix & DMHDDSAS
Mike Hennike, Former Section Head, State Operated Services
Dr. Ranota Hall, Former Clinical Director, JUH Child Psychiatry
Debbie Dihoff, NAMI
Dr. Michael Zarzar, Psychiatrist, Raleigh
Donald H. Baucom, Prof. Psychology, UNC & NC Psychol. Assoc.

C. Crisis Services Group
Peter Mumma, New Hanover Health Network
Amy Blackwell, Wake Medical
Wendy Webster, Duke University Hospital
Sarah Wiltgen, Brynn Marr Hospital, Onslow
Dr. David Rubinow, Chair, Department of Psychiatry, UNC
Jack Naftel, Professor of Psychiatry, UNC
Dr. Tony Lindsey, Vice Chair for Clinical Affairs, UNC Dept Psychiatry
Ellen Holloman, Director, Durham Center
Mike Watson, Director, Sandhills Center
Foster Norman, Director, Five County-Vance-Granville
Barbara Beatty, County Commissioner, Catawba County
Patrice Reesler, Deputy Director, NCCCA
John Tote, NC Mental Health Association
Robin Huffman, NC Psychiatric Association
Dr. Marvin Swartz, Duke & member, Mental Health Commission
Dr. Brent Myers, NC College of Emergency Physicians
John Meads, Private Provider-1st Responder
Dr. Darlyne Menscer, NC Medical Society
Carl Britton-Watkins, State CFAC

What Would the Next Governor Do?

2008-01-26T03:40:00.000-08:00

What would you do about mental health and substance abuse if you were the next Governor?

This Website is based on the idea that mental health and substance abuse affects everyone. If you're reading this, you already know this and don't need to be convinced. But the politicians and policymakers do -- not that they don't have loved ones who suffer from mental illness or substance abuse, not that they don't have friends who do. But somehow this realization is divorced from their daily work of campaigning and policymaking. And they have learned that this blind spot is shared by the electorate at large.

This Website strives to change that. If enough people join us by saying their vote is strongly influenced by MH/SA issues, politicians will have to take notice.

Why is this important?

Because we have learned since 2001 that it is the attention or inattention of the Governor that determines what happens in MH/SA. And because of what the current administration has done, we now have a mess that will take a lot of work and a lot of money to fix.

It seems to me that as the enormity of the current crisis has become apparent, the state government has been limited in what it can do. And, all things considered, this is understandable. The General Assembly has been reluctant to invest new money in a situation where it seems appropriated money has not been fully spent and, apparently, fraud has come into play. The new DHHS Secretary, an able and honorable man, is doing the best he can with the situation he has inherited. I think everyone realizes that only a new Governor can bring the new start that is needed.

What I would say to the next Governor is this:

1. This is a big problem. Fixing it will not be cheap.

2. The first thing that needs to happen is to restore the safety net. This means that everyone in the state must have access to a full-service clinical home where assessment and treatment services are available.

3. For this to happen, policymakers must stop trying to make the clinical needs of sick people match the contortions required by multiple funding streams. The design of the mental health / substance abuse system must be based on clinical needs, with funding flows supporting that.

4. Substance abuse treatment capacity, including medical detox, needs to be expanded dramatically throughout the state. (This should be very attractive to politicians, given the high returns of money invested in substance abuse treatment -- in human terms, in mental health system terms, and in terms of reducing criminal behavior.)

5. The clinical home must be designed so that the clinical workforce can be restored. The current Administration's policy could not have been better designed if it had explicitly wanted to drive dedicated professionals out of public mental health. This needs to be reversed.

The next Governor needs to understand that the imperatives of privatization and the imperatives of a safety net are mutually exclusive. You cannot have a safety net in an unfettered "any willing provider" environment. You have to have a clinical home where patient care is coordinated and provided.

And, to repeat, it won't be cheap.

Is anyone who wants to be Governor able to do this?

Welcome to NCMentalHealthVote.org

2008-01-23T11:42:00.000-08:00

Thanks for your interest in NCMentalHealthVote.org. To get things started, I'm posting the remarks that I made at our formal announcement/press conference this morning in front of the State Legislative Building in Raleigh.

We really would like to hear from you - your experiences with North Carolina's mental health, substance abuse, and developmental disabilities system - good and bad - as well as your thoughts about how to improve things. The new DHHS Secretary Benton has made some very impressive first steps, but we all know the problems are so deep and pervasive that it will take years of committed leadership to bring real improvement to North Carolina's mental health system - hence our focus on the 2008 election and the next leaders of North Carolina.

My remarks:

I’m Dr. John Gilmore, a Professor of Psychiatry in the School of Medicine at the University of North Carolina at Chapel Hill, where I am Director of the UNC Schizophrenia Treatment and Evaluation Program. I’m also Chair of the Legislative Committee of the North Carolina Psychiatric Association.

I’m here to announce the creation of NCMental HealthVote.org, a project intended to raise awareness of the enormous problems facing the mental health system in North Carolina. We hope that this effort will help make mental health care in North Carolina an issue that each candidate will address during the upcoming election, one that each candidate will offer solutions for.

Through our website, bumperstickers, advertisements, and other activities, we hope to help educate the candidates and voters about the critical issues that need to be dealt with. NCMental HealthVote.org is non-partisan and is endorsing quality mental health care for the citizens of NC – not specific political candidates or parties.

The mental health care system in North Carolina has undergone a so-called “reform” over the past several years, one that has included the privatization of the public mental health system and the downsizing of state psychiatric hospital beds. This reform has left a system in chaos.

The evidence of the system’s failure comes every day as North Carolina’s citizens are falling through the cracks, unable to find a psychiatrist or other provider who will take care of them. We wait, sometimes for days, in emergency rooms because there are not enough psychiatric hospital beds in the community or in our state hospitals. There is no safety net and we are all paying the price.

When psychiatrists stand up and speak out, you know things are really bad. As a group, we’d rather sit back, listen, observe, and quietly do our job. But things are really bad, and we are speaking out. We do believe that once the citizens of North Carolina and our elected leaders understand what the problems are, they will want to fix them. Mental illness is very common, and we all know someone, a family member or friend – even ourselves - who has had to deal with a mental illness.

NCMentalHealthVote.org was developed by the N.C. Psychiatric Association, and has been joined by other partners, including the National Alliance for the Mentally Ill in North Carolina, the Mental Health Association of North Carolina, the Foundation of Hope, and many other organizations and individuals. Today, NCMentalHealthVote.org is starting a constructive, non-partisan discussion that will stop the ongoing failures and create something all North Carolinians deserve - a decent mental health care system that works.