CABHA–One Year Later

by Richard Edwards

Last week, I presented to the Mental Health Subcommittee at the NC Legislature on the Critical Access Behavioral Healthcare Agency (CABHA) implementation. We had been asked by Benchmarks NC, an advocacy organization to which my employer belongs, to speak on our experience with implementing the Critical Access Behavioral Healthcare Agency model over the past twelve months.

You can view my presentation here, but the main points are these: we have found the CABHA model to be very effective in our organization; but woefully underfunded; and that the transition to a CABHA-based provider community is far from over.

In terms of cost, the primary costs of the CABHA model are the personnel costs of the Medical Director and Clinical Director, for which there has been no additional funding. That’s significant given that these are likely two of the highest paid positions in any mental health organization. But now that we’ve been at this for over a year, it is impossible for me to imagine going back to having physicians without a Medical Director, or not having the support of our Clinical Director in responding to a crisis or developing support plans for the individuals we serve. Their impact has just been too valuable, even if we decided not to be a CABHA in the future.

The challenge this presents for our agency and others is that CABHA is a one-way street, in a way. If your Medical Director and Clinical Director are really doing their jobs, they become linchpins in the organization, and there’s no way to get around how much benefit they bring. That said, if the state doesn’t do more to support the CABHAs, the sustainability of the CABHA model is in doubt, begging the question–if CABHA is a one-way street, where does it dead-end?

Beth Melcher, from the NC Department of Health & Human Services, spoke to the subcommittee first and told the members, plainly, there are too many CABHAs (approaching 200). You can see the full list here. There are certainly more than anyone anticipated, but does that mean there are too many? Maybe, maybe not–but the truth is, there are more CABHAs than will survive. Here’s one reason why…Community Support Team.

Currently on the list are 71 CABHAs providing Community Support Team (CST), which is a service for adults with mental health and/or substance abuse issues. That is fully a third of the total, and CST has not only had additional training requirements put on it in the past six months, but has actually had hours available cut from 15 hrs/week (maximum) to 3 hrs/week (on average), and has had a rate cut on top of all these changes. Agencies are exiting CST as quickly as they can, because the rate simply cannot support the service. But these 71 CABHA agencies are providing CST, and will continue to provide CST, because they have to demonstrate a continuum of services–meaining, a variety of enhanced mental health or substance abuse services–meaning, they are a on a one-way street.

Without CST, they lose their CABHA status. With CST, the whole agency could go under. And without significant changes in the way the state supports CABHAs, we will continue to see rapid attrition of providers as reality sets in.

So while we have turned a corner in the mental health system, we are not, to mix a metaphor, out of the woods.  My angle is that CABHA is the right direction, but without additional support, it could mean another dead end.

But that’s just my angle–what are your thoughts?

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