Part 3 of N&O Series "Mental Disorder: The Failure of Reform"
Published: Feb 28, 2008 04:52 AM Modified: Feb 28, 2008 04:56 AM
Serious mental therapy fades
Reforms aimed to scale back the role of state mental hospitals. Now people with severe needs are left without care
Lynn Bonner, Staff Writer
Johnnie P. Yarborough, a Raleigh crack addict with bipolar disorder, was admitted to Dorothea Dix Hospital 14 times in 2006 for short-term stays that did nothing to improve his mental health.
His frequent hospital admissions came despite a new state goal of reducing mental patients' reliance on hospitals in favor of outpatient care. Under the new philosophy, he should have been helped in a treatment center -- and someone at Dix would have helped get him there.
But each time, he stayed at Dix a day or two, maybe three, before he was discharged to the street or to a homeless shelter.
He'd show up again, asking to be locked up. Doctors said he needed long-term drug treatment, but social workers couldn't help him find any.
North Carolina's 2001 mental-health reforms aimed to make its mental hospitals places of last resort and to have as many people as possible seek treatment near their homes.
But that new network of local help, provided by private companies seeking profits, is dominated by a service called community support, which sometimes is as basic as escorting someone to the mall.
People needing more serious care are often left to fend for themselves
-- or have had to enter one of the overwhelmed state facilities that nearly everybody wanted to close or reduce in size.
Signs that reform has failed:
* Spending on community support has consumed 90 percent of community mental-health spending. Only 4.9 percent has been spent on more intensive outpatient therapy.
* Spending on traditional therapy offered by licensed counselors declined
12.4 percent between 2005 and 2007. State officials wanted to de-emphasize office-based treatment, but doctors and counselors say it's generally more effective than the community programs that replaced it.
* State psychiatric hospital admissions have increased, and more patients have used the hospitals for short stays, which stabilize patients in crisis but have less therapeutic value. In the 12 months ending in June, 8,805 patients, more than half of all patients discharged from state hospitals, stayed a week or less. Six years ago, less than a third of those discharged, 4,881, stayed a week or less.
* Mental-health admissions to hospital emergency rooms increased 6 percent this past July, August and September compared with the previous three months, according to a state report. Another study last year cited "anecdotal reports" that more people with mental illness, unable to get adequate treatment, are going to jail.
* The state Department of Correction said in August that over the past five years, there has been a "steady increase" in the number of inmates with severe and persistent mental disorders.
State Sen. Martin Nesbitt Jr., an Asheville Democrat who has been involved in writing mental-health laws for four years, said the 2001 restructuring was seriously flawed.
"I don't think the initial package had the thought that it needed," he said.
"The details weren't there. And some of the assumptions that they made on how it would progress were faulty by their very nature."
In again, out again
Yarborough, 47, was a regular at Dorothea Dix Hospital. The Louisburg native was addicted to crack cocaine and had been diagnosed at different times with major depression and a mood disorder.
Since 1994, Yarborough has been in state mental hospitals and drug treatment centers 33 times, sometimes getting help but never getting well. He spent nine years bouncing among relatives' homes, homeless shelters, jail, halfway houses and drug treatment. In 2006, the frequency of his hospital admissions increased.
He would show up on his own at Dix or Holly Hill, a private hospital in Raleigh where he had been treated previously, asking to get in.
Holly Hill usually sent him to Dix, where he would stay for a few days before being sent away.
During a one-day stay in September 2006, he told Dix staff that he wanted to go to a drug treatment program in Charlotte. The program took only Mecklenburg residents, but a hospital social worker gave him the program's telephone number and a bus schedule for the Queen City.
He didn't go. Back at Dix a month later, Yarborough fought his planned release.
"I knew it that it was only a matter of time that my depression and addiction combined together with the number of drugs that I was doing, that I was going to end up killing someone or being killed," Yarborough said, "and I was afraid."
Hospital social workers did make appointments for him at one treatment center and set up a meeting with county drug counselors, but Yarborough often failed to show up. He also met three times with a psychiatrist who worked for Wake County.
He was on his own to get to all his appointments.
A common theme
This is a fairly common theme. People with mental illness aren't easy to work with, and they need help to schedule and attend appointments and encouragement to take their medication. The new network of caregivers finds it difficult to spend enough time with many of them.
Laura White, team leader for the state psychiatric hospitals, said it's difficult for hospitals to develop detailed community-care plans for people admitted for short stays, many of them substance abusers.
"Our hospitals aren't the best place for some of these folks," she said.
Yarborough said he didn't get better until he accepted that he has bipolar disorder -- a diagnosis from years ago -- and understood how he used crack to ward off his depression.
He has been sober for a year and is living at the Raleigh Rescue Mission, a nonprofit that ministers to the homeless and addicted. He had been there before and went back on his own.
Through the mission, he has found help from a mentor and a doctor, and he's working at a construction job.
The 2001 law that changed the mental-health system was designed to allow North Carolina to take better care of people such as Yarborough.
It took local governments out of the treatment business and made them responsible for monitoring private companies that offer counseling, education and other services.
The aim was to increase variety, let patients choose their counselors and limit office-bound counseling sessions in favor of serving clients in their homes, in homeless shelters, schools and other everyday settings.
As they handed work to private companies, most county and regional mental-health offices stopped offering psychiatric appointments and day treatment. Hundreds of companies rushed in to offer community support, for which they could charge up to $61 an hour and have employees with high school diplomas or GEDs do most of the work.
Many counties never found enough private companies to offer a variety of serious treatments, leaving some regions with little more than the most basic services.
Patients lose services
"We became a private-driven system all of a sudden," said Debra G.
Dihoff, executive director of the National Alliance on Mental Illness in North Carolina. "We're reaping the consequences of it now."
The 2001 law focused on how the local mental-health offices were to do their jobs and who had authority over them. The law says little or nothing about what kinds of needs the area programs should meet, how much money they would need and where they would get it.
In the changes, patients lost access to therapists and the other professional services that community mental-health offices offered.
Some mentally ill patients who had stable relationships with doctors and therapists under the old system ended up relying on charity.
Nancy Pace was one of them. Pace, 49, who lives outside Hendersonville, about 20 miles south of Asheville, has bipolar disorder and attention deficit disorder. She has depended on the state to pay for her care.
When the changes from the 2001 law were implemented, Pace's services ended.
She bounced from office to office. She decided to see doctors at a free clinic in Hendersonville. They checked to make sure she had the proper medication for about a year. The clinic recently referred Pace to a private provider, but she was reluctant.
"Some of the other agencies, if you don't need and you don't feel like you want community support and case management, they don't want to serve you,"
Local office directors say they need: teams of doctors, nurses and therapists who will work with severely mentally ill adults; places for emergency mental-health treatment; psychiatrists; and drug detox.
Patients have lost places such as a clubhouse in Jacksonville where they could socialize with others and perform simple tasks.
Jessica Stone, who has paranoid schizophrenia, once belonged there.
Her father, Jim Stone, said being around others helped his daughter realize when her symptoms were getting worse.
But the clubhouse is gone, a victim of the reforms. Stone, 32, now relies on community support to navigate life outside hospitals. She gets 15 hours a week with a worker who helps her adjust to community life.
Community support may not be exactly what his daughter needs, Jim Stone said, but it's the only service available.
"It didn't take long to get rid of all these services," he said, "and nothing has come to take their place."
Money goes unspent
The system is so tangled that even as patients struggle, local mental- health offices often fail to spend all the money the state gave them to treat patients.
Medicaid, federal insurance for the poor and disabled, is considered an entitlement, so if a resident qualifies for care and can find it, it's covered. With patients who rely on state payments, getting care is more complicated.
To get state money for treatment, the providers get permission from the county or regional office where the patient lives. Providers say it takes too long for the local offices to approve treatment and pay for it.
People looking for care can get pinched for two reasons:
* Because state money is limited, the local mental-health offices ration care. For example, a doctor may recommend six therapy sessions for a patient, but the local office may approve three.
Last week, the local office that covers New Hanover and two other counties said state-paid patients who do not need urgent care will be put on a waiting list. The region is running out of state money.
* Also, in some areas, there aren't enough service providers. Last year,
$18.5 million in state money for mental-health programs went unspent, along with $3.8 million for substance abuse. Nearly $10 million in federal money for substance abuse was left over, as was $2.5 million for mental health.
Regional mental-health offices spent about 85 percent of their treatment money last year.
"We were spending out the wazoo on Medicaid, but we had a lot of state money that was going unspent," said Leza Wainwright, deputy director of the Division of Mental Health, Developmental Disabilities and Substance Abuse Services.
Legislators who had fought for more state money for mental health were baffled that local offices were giving it back.
"We realized we've got a pretty severe shortage of providers in a whole lot of the state that we've now got to rebuild," said Nesbitt, the Asheville senator.
Staff writer Pat Stith and database editor David Raynor contributed to this report.
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Published: Feb 28, 2008 12:30 AM Modified: Feb 28, 2008 05:28 AM
Cycle of hospitalization, frustration
Johnnie P. Yarborough, 47, was admitted to state mental hospitals and drug and alcohol treatment centers 33 times between 1994 and 2006.
Nicholas Stratas, a Raleigh psychiatrist who reviewed Yarborough's state hospital records, said the cycle could have been broken at any time if community mental-health workers and hospital staff had collaborated to plan Yarborough's treatment after he left the hospital.
State records indicate that Wake County and hospital staff met to discuss Yarborough only once, in 1994.
Stratas, a former official in the state mental-health office, reviewed Yarborough's files for The News & Observer. He said Yarborough was telling doctors, " 'I need to be kept somewhere away from drugs.' But he is largely dealt with as a different event every time he appears at the door."
Police took Yarborough to Dorothea Dix Hospital in the early years after he threatened to kill family members or himself. After a while, he started showing up at Dix on his own.
In 2006, when Yarborough was admitted to Dix and state drug treatment in Butner 15 times, his records show no face-to-face meetings between Wake staff or private providers and the hospitals. While Yarborough was at Dix, doctors adjusted his medications, but his days there were little more than brief layovers between bouts of drinking and drug use.
Yarborough had to find his own way out of Butner after he left May 31, 2006.
He went to a bus station. He started using drugs again the day he left the treatment center. He returned to Dix 10 more times that year.
YARBOROUGH'S STATE HOSPITAL ADMISSIONS, 2006:
Admitted, discharged April 9. Cost for one day: $689
Admitted May 4, discharged May 8. Cost for four days: $2,756
Admitted May 10, discharged May 11. Cost for one day: $689
Admitted May 14, discharged May 16. Cost for two days: $1,378
R.J. Blackley alcohol and drug treatment center in Butner Admitted May 16, discharged May 31. Cost for 15 days: $11,400
Admitted June 20, discharged June 22. Cost for two days: $1,378
Admitted June 27, discharged June 28. Cost for one day: $689
Admitted June 28, discharged June 30. Cost for three days: $2,067
Admitted July 31, discharged Aug. 2. Cost for three days: $2,067
Admitted Sept. 7, discharged Sept. 8. Cost for one day: $689
Admitted Oct. 22, discharged Oct. 23. Cost for one day: $689
Admitted Oct. 23, discharged Oct. 25. Cost for two days: $1,378
Admitted Nov. 23, discharged Nov. 27. Cost for four days: $2,756
Admitted Nov. 28, discharged Nov. 29 Cost for one day: $689
Admitted Dec. 7, discharged Dec. 8. Cost for one day: $689
Cost of his 2006 treatment: $30,003
Cost of his state treatment since 1994: $90,046
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Patients in crisis can't get local help
What's available varies by county
Lynn Bonner, Staff Writer
To lift the weight from mental hospitals, state officials have pushed local mental-health administrators to build their crisis services. A county could use a local public hospital for patients who need short- term psychiatric treatment, or it could open a smaller clinic.
Crisis services have been slow to develop, although a number of counties have put them at or near the top of their list of needs.
Patients in Caswell County, for example, depend on a center in Yanceyville.
Their other option is to go to Rockingham or Alamance counties.
The region called Five County, which includes Vance, Franklin, Halifax, Warren and Granville counties, is looking for a company to help build and manage a 24-hour crisis center.
A mobile crisis team -- akin to a mental-health ambulance -- answers crisis calls in four of the five counties, and Halifax Regional Medical Center does some crisis work.
Many people in trouble end up in hospital emergency rooms.
The local office that covers Cleveland County wants a locked crisis and detox center there. Patients now go to a crisis center in Gaston County or a unit run by Kings Mountain Hospital in Cleveland County.
Rural areas don't provide enough customers to make it financially worthwhile to offer intensive or specialized therapy, said Yvonne Copeland, executive director of the trade group that represents local mental-health offices.
The amount the counties are willing to chip in for mental-health services determines what help is available, Copeland said.
County contributions to local mental-health budgets vary widely, from Mecklenburg's high of $42.9 million a year to a few hundred thousand a year for some rural areas.
Wake County has budgeted $10.6 million for mental health; Durham County,
$7.7 million; Johnston County, $1.7 million. Orange County budgeted $1.3 million as a contribution to its region, which includes Person and Chatham counties.
"You find good services in areas where there are good local contributions,"
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Published: Feb 28, 2008 12:30 AM Modified: Feb 28, 2008 02:44 AM
System stymies care for alcohol, drug abuse Lynn Bonner, Staff Writer
Alcoholism or drug addiction may not fit the classic definition of mental illness. But there's a direct link: More than 20 percent of the patients admitted to state mental hospitals last year were dependent on alcohol or drugs.
Funding to treat financially dependent addicts before they end up in mental institutions is scarce. Medicaid generally will not pay the bills. Adults who seek treatment frequently don't qualify for the federal insurance for the poor and disabled.
That leaves the companies dependent on state money that county and regional mental-health offices control.
The procedures required to get that money are arduous and can result in companies' doing work they don't get paid for.
"You can provide all the services you want, they won't all be paid,"
said Trish Hussey, executive director of Freedom House Recovery Center in Chapel Hill.
Freedom House offers treatment for substance abuse and operates crisis centers and halfway houses. Big mental-health providers don't want to offer substance-abuse treatments, she said, because they are a financial drain.
State officials know there's a problem. It shows up in the state psychiatric
hospitals: Last year, they admitted more drug addicts than schizophrenics.
About two years ago, legislators pumped more money into drug treatment. But
$13.8 million in state and federal money for substance- abuse care went unspent. Local mental-health officials say they can't find enough providers offering drug and alcohol treatment. Those in the business say the money that's available is too hard to get.
"We know now this system is not working in this state," said Bert Wood, president and chief executive officer of Partnership for a Drug- Free North Carolina.
Wood's agency runs substance-abuse treatment services in 17 counties and mental-health services in nine.
"Instead of screening people in," he said, "we're screening people out."
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Published: Feb 28, 2008 12:30 AM Modified: Feb 28, 2008 02:44 AM
Opting out of federal rules, Piedmont pays for better care Lynn Bonner, Staff Writer
In the free-for-all that erupted when the private market came to dominate mental-health care in North Carolina, only one region had direct control over how its public system would look.
Piedmont Behavioral Healthcare, the office covering Cabarrus, Davidson, Rowan, Stanly and Union counties, sets its own rates and decides which companies will be paid with government money.
Piedmont, a local government agency, has federal permission to pay for services in a different way. The region receives a set Medicaid payment each year, and local officials decide how to spend it.
The arrangement keeps a grip on spending and builds strong companies, said Pam Shipman, Piedmont's deputy area director.
Piedmont relies on only four companies to provide most of its community support. Some other regions have 10 times as many community support companies.
"We set our own rules," said Craig Hummel, Piedmont's medical director.
"That allows us to shape our own network."
No other region has asked for the same powers.
From March 2006 until the end of last year, Piedmont spent a significantly larger share of its money than other areas for intensive services versus basic community support. Its overall spending on intensive outpatient services is lower than that of some regions because it spends more on clinical care.
With savings from its Medicaid budget, Piedmont pays for programs for people with mental illnesses and addictions that it wouldn't have otherwise. The region is starting a program for mentally ill children who need to leave their homes for a short time but do not need hospital care.
A report done for the state last year said the quality of care has stayed the same or improved since the region set its own rules.
Piedmont can use Medicaid money to help people with mental illnesses find and keep jobs. The office decided to increase its payments for psychiatric services.
"You can't have a mental-health system if you don't have psychiatry,"
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Published: Feb 28, 2008 12:30 AM Modified: Feb 28, 2008 02:44 AM
What's happening in Wake?
Michael Biesecker, Staff Writer
Wake County is working to build a $21 million mental-health crisis center and substance-abuse detox unit, which is expected to open in 2010.
It is hoped the new center will blunt the impact of the pending closure of Dorothea Dix Hospital, the state mental institution in Raleigh. Dix was originally set to close last year, but problems with the construction of a new state hospital in Butner have delayed Dix's demise until at least May 1.
Wake has also contracted with Holly Hill Hospital in Raleigh to admit indigent patients whom the private facility previously would have turned away. In cooperation with the county, Holly Hill plans to add space for 44 beds to make up for some of the capacity lost when Dix closes.
The addition at Holly Hill won't be ready until at least 2009. To help cover the gap, Wake and state officials are close to an agreement that would keep one ward at Dix open temporarily.
County commissioners have approved paying the state up to $5.3 million to help defray about half the annual cost for 60 psychiatric beds that would serve adult patients.