ADVOCATE’S PERSPECTIVE: OK…WHAT NOW?

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

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

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

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

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

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

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

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

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

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

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

Vote Early, Vote Often

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

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

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

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

And it all changes on January 1!

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

A Vision for Mental Health in NC

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

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

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

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

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

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

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

December 10 - NC Council of Community Programs Conference, Pinehurst

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

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

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

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

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

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

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

Akland Report from NAMI-Wake

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

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

Dix to move to CRH in October

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

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

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

Budget Act MH language

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

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

MENTAL HEALTH CHANGES

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

IMPROVE AND STRENGTHEN FISCAL OVERSIGHT OF COMMUNITY SUPPORT SERVICES

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

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

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

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

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

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