Orr releases mental health plan

MENTAL HEALTH

Over six years into a massive reform of our mental health system, it is clear that the transition to community-based care has been terribly mismanaged. In the process, many of our most fragile citizens have been left without the care that is so critical to their well being and potentially their survival, and millions of tax payer dollars have been wasted on suspect community support services. The consequences of this mismanaged reform have been well documented. Multiple commentators and experts have offered various ideas about how to rescue the reform effort. What has been lacking is not expertise, but committed and engaged leadership from the Governor’s office.

Caring for our fellow citizens who are challenged with mental illness, developmental disabilities, and substance abuse problems is a moral imperative, and our system must consistently provide the highest quality care so that they may lead more productive, healthier and happier lives. We have the expertise needed to create a system that provides the care and services our citizens deserve at a cost we can afford. To develop this system, we must have leadership, the right concept of care, the appropriate resources, and a rigorous oversight process.

Challenge: bringing effective leadership to mental health reform
It is almost incomprehensible that our mental health reform has come to this point: millions of dollars spent; continuity of care lost for thousands; and overcrowded state hospitals that are often the first line of treatment while community care providers go out of business across the state. We cannot expect to turn around this tragically botched reform effort without a leader who truly cares and will bring focus and commitment to:

• Establish clear priorities: build a viable system that provides the right clinical home for publicly funded patients and delivers multi-discipline team care that is specific to client needs and includes psychiatric care when appropriate, and support services at sustainable costs;
• Recruit and retain top talent: we must have the most effective leaders we can get at the Department of Health and Human Services (DHHS) and the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (MH/DD/SAS);
• Provide the right management structure: we must review the structure of the Division of MH/DD/SAS to establish clear lines of responsibility and ensure we have the right functional and treatment area expertise. I am not convinced that we have adequate MH/DD/SAS expertise in the Division, or that we have experts in the right positions within the Division’s functional structure to develop and implement the best policy. We must act immediately to address this problem;
• Interagency coordination: MH/DD/SAS issues cross departmental lines and often involve the Public Schools, Department of Corrections, the Department of Crime Control and Public Safety. We must implement an ongoing interagency process to coordinate efforts to deliver care and services. This coordination is especially critical in dealing with services for children and young adults.

Challenge: determining the right concept of care:
While it is true, as one mental health expert recently told me, that the original idea of the mental health reform was valid, the state should not be the provider of funds, manager, accountability agent, and provider of MH/DD/SA services. Nonetheless, I am not convinced that we have the right concept of care, and believe we need to answer some important questions about roles and responsibilities to give us a clearer view of how to proceed:

• State versus local responsibilities: under the current reform, the state is responsible for long term institutional care through state facilities (four regional psychiatric hospitals, four developmental disabilities centers, and three substance abuse treatment centers). Ongoing care and support services are to be provided by community providers and managed by Local Management Entities (LMEs) that have no clinical employees and provide no direct services. Properly implemented, this division of labor would provide consumer choice and consistent care closer to home and at a lower cost. We have not met this intent consistently across the state, which indicates that we must:
o Provide clear and specific operating guidelines for the LMEs with the appropriate flexibility and funding to create provider networks;
o Give the LMEs the primary case management tasks with the requisite authority to be the funnel for all care and services. We currently have different case coordination systems in the 25 LMEs and we must have one state standard;
o Determine state versus local roles and responsibilities for providing the local safety net of 24/7 crisis response, and act immediately to address our acute care deficiencies.
• Public versus private provision of services: privatization was the other principle that drove the current reform, with the idea being that the private sector could deliver ongoing care cheaper and better than the state funded Area Mental Health Programs. Yet we have seen reports of one local provider after another going out of business. We must address this disconnect by:
o Determining if privatization is appropriate for all categories of care (MH/DD/SAS), and for the rural areas of the state. Many mental health experts assert that there may not be a viable business model for developmental disabilities service providers;
o Implementing a fair and efficient reimbursement process that pays for actual care.
• The pace of change and continuity of service: nearly all the mental health experts agree that the transformation of our mental health delivery system has happened too quickly. The reality is that we stripped the local mental health programs of their clinical capabilities before the LME-managed private providers were in place. The result has been an alarming gap in care in many areas of the state and a corresponding run on our state mental hospitals. We must put the state hospital downsizing effort on hold, while we address the shortage of beds across the state and focus the reform effort on fixing the community-based system.

Challenge: bringing the right resources to bear on mental health
While I am not sure what is more troubling, the recent News and Observer report that approximately $400 million have been wasted on medically unnecessary community support services, or the unwillingness of the Governor to take responsibility for the current mess, it is certain that we need a comprehensive review of mental health expenditures. Given that many reports claim that mental health delivery in North Carolina is seriously under funded, (NC per capita spending is 55% of the national average, with only seven states spending less), the next governor must bring all the stakeholders together to develop a long-range funding and resource plan. At minimum, that plan must include:
• Mental Health Trust Fund: if we decide to pursue a large scale privatization model, we must fully fund the Trust Fund to bring innovative service programs to the delivery of care and services;
• Medicaid: Medicaid payments provide approximately 75% of annual spending. We must work with the most recent federal service definitions and ensure Medicaid dollars are spent on the services that have the most impact on the people who need them the most;
• State Mental Health Budget: our annual budget for state spending must complement Medicaid supported services, provide adequate funds for state facilities, and fund Division administration. While it is probable that additional funds are necessary for service delivery, we must streamline and simplify the reimbursement process to make it possible for private providers to operate in the LMEs, and look for every opportunity to reduce the amount spent on administration;
• Long term supply of mental health care providers: the same shortages of healthcare professionals described in my healthcare policy apply to mental health. We must ensure that our university and community college systems are prepared to provide the increasing number of psychiatrists, mental health nurses, and allied professionals that our growing and aging population will demand.

Challenge: provide ongoing oversight
Six years down the road of mental health reform is too late to find out we are way off track. People whose lives depend on these services deserve better, and our tax payers deserve better. We must have a more rigorous and ongoing oversight process. Spending nearly $800,000 on an outside consultant to evaluate LME programs, as DHHS is currently doing, is exactly what a responsible and accountable government should not need to do.
• Service provider qualifications: the Division of MH/DD/SAS must provide a comprehensive and standardized vetting process, by treatment area, for LMEs to use to determine service provider suitability;
• Outcome-driven quality control: currently service providers are reimbursed based on the reports they submit. Reports don’t necessarily mean positive outcomes, and we must have a standard Quality Assurance system that pays for quality care, not quality report generation;
• Regular Financial Audits: with millions of dollars being paid monthly for services, it is inconceivable that DHHS does not have a recurring financial review process with a warning system to notify officials when costs spike.

Mental Health support for our Citizen Soldiers
There has been little attention paid to the impact the failed mental health reform may have on providing quality care for our redeployed North Carolina troops. We have the fourth highest number of returning guard and reserve service members, and the ultimate tragedy of this reform debacle would be for them to return to their counties and not be able to get the mental health care that they need.

These North Carolinians have made the ultimate commitment to our country and borne the sacrifices that come with answering the call of duty. Some of them will face the challenges of dealing with post traumatic stress, traumatic brain injury, and family readjustment issues. Most concerning, is that they are returning in large numbers to homes in rural counties, which is exactly where our mental health delivery system is struggling the most.

In implementing a plan to rescue mental health reform, we must ensure close coordination between DHHS and the North Carolina National Guard, with a specific emphasis on effective liaison with the LMEs. Our Citizen Soldiers truly do represent “Americans At Their Best,” and state government must be at its best in delivering community-based mental health resources where they are needed.