A Vision for Mental Health in NC

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

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

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

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

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

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

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

December 10 - NC Council of Community Programs Conference, Pinehurst

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

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

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

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

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

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

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

Akland Report from NAMI-Wake

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

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

Dix to move to CRH in October

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

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

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

Budget Act MH language

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

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

MENTAL HEALTH CHANGES

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

IMPROVE AND STRENGTHEN FISCAL OVERSIGHT OF COMMUNITY SUPPORT SERVICES

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

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

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

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

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

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

Budget Act Conference Report

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Perdue & McCrory on budget bill change on state hospitals

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

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

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

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

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

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