Archive for May, 2011

May 19, 2011

According to the Evidence: Implementing EBPs

by Richard Edwards

Today I sat in on a work session with the NC Practice Improvement Collaborative–a small group dedicated to the implementation and dissemination of evidence-based practices for human services in NC.

The main speaker for the morning was Dr. Dean Fixsen, from The National Implementation Research Network, a renowned speaker on practice implementation in organizations and state systems. He made several interesting points about change leadership and quality improvement, but I was especially interested in his research on the amount of time it takes to implement evidence based practices in an organization.

Two to four years, he said.

Admittedly, two to four years can go by in a flash (where have you gone, 2009?), but in the human service field, when new services go live with perhaps a 90-day hold harmless period, have we ever had two years to get something right? It seems to me that if we’re going to be about bringing science to service, we have to also be about the science of bringing science to service. And how do we fund that in a fee-for-service system?

Dr. Beth Melcher from DHHS was also present and spoke briefly about evidence based practices and their role within the new 1915b/c combo waivers, set to roll out in 2013. Her stance is that–in contrast to the opinion of some that the state is abandoning CABHAs (was she looking at me?)–the waiver environment will actually make EBP implementation easier, because of the flexible funding available through savings generated (if a 1915b/c waiver site or managed care organization saves money, it gets to put that money back into services at its discretion). That’s a fair point–and although I’m not convinced that’s really why NC is going down this road so quickly–it could make that 2 to 4 year start up period for a new EBP more manageable.

My angle is that this kind of flexible funding is essential to an innovative healthcare system that brings evidence-based practices to the people who will benefit most, in the shortest period of time. Otherwise, we run a substantial risk of just being another 2 to 4 years older, and perhaps not a day wiser.

But that’s just my angle. What are your thoughts?

May 12, 2011

Hey, Remember CABHAs? Nah, Me Neither…

by Richard Edwards

It was just January of this year, 2011, that DHHS Secretary Cansler made the announcement that “the era of mental health reform is over”. A new service model–Critical Access Behavioral Healthcare Agencies (CABHAs)–would put mental health and substance abuse services on a firm foundation, finally, after years of turmoil and substandard services for people in need.

CABHAs would, through the substantial investments they make through the addition of key personnel–a Medical Director and a Clinical Director, as well as a Quality Improvement/Training Director–provide a clinically sound provider community to NC’s citizens. Of course, this would cost money, so CABHAs would be the only providers allowed to bill the new Targeted Case Management service.  TCM would offset the costs encumbered by the CABHAs and provide stability to a fragile provider community that has been hit by repeated service rate reductions in the past two years. As of this writing, there are just over 200 CABHAs operating in NC, and while that’s a much larger number than was anticipated, it also represents a significant winnowing of the provider field. Becoming a CABHA clearly had raised the bar beyond what many were able to achieve.

CABHAs were the future. Until they weren’t.

In April of 2011, the state announced the rollout of statewide 1915b/c Medicaid waivers similar to the Cardinal Innovations plan being operated by Piedmont Behavioral Healthcare since 2005. A 1915b/c waiver, in Medicaid language, means essentially that the managed care organization has much greater control over the services in its array and the providers in its array. Waiver operations, unlike the current NC state plan for Medicaid services, are closed networks–they do not have to admit any willing provider, and they manage the network more closely.

The state has been moving towards a waiver-based system for a while. PBH began its pilot operation in 2005, and two additional Local Management Entities–Mecklenburg County and Western Highlands Network–have also been approved. There are several others that are in the cue, but according to the release by the DHHS, all services will be overseen by Managed Care Organizations (nee LMEs; nee Area Programs) by July, 2013.

Why is this relevant? Remember all those CABHAs who hired their medical directors and clinical directors and QI/training directors and provide outpatient therapy and psychiatric services…remember how we thought they were the future? Under the waivers, there is no guarantee that any of them, anywhere, will be part of the contracted provider community. Of course, many of them will, because one of the primary responsibilities of the MCO is to provide access to services, but many of them won’t–perhaps as many as half–and if you’re a CABHA, there’s simply not a thing you can do about it.

A bill on the statewide rollout of the waivers has been introduced–you can read about it here.

My angle is that public systems should not be set up to protect anyone but the people receiving services and the public at large. CABHAs, any more than LMEs, or DHHS staff, or state operated services, or the Adult Care Home industry, do not have guarantees they’ll be here tomorrow.  But my great concern in all of this is that it seriously calls into question the long-term vision for the mental health and substance abuse system in North Carolina–what is the ultimate plan? Is there an ultimate plan? And does it really include undermining what was until recently the underpinning of the whole system?

Further underscoring this concern is the announcement–made in a flyer (warning: pdf) posted on the Division of MH/DD/SAS website for people with intellectual and/or developmental disabilities–that Targeted Case Management (remember that service?) would not exist as it does today under the waivers. (There have been subsequent communications, but this was the first official statement.) So, if you’re a CABHA…and if you survive the next two years…and if you make it into the provider network of the MCOs for the communities you serve…you will lose the ability to provide the one service that it supposed to help you cover the costs of being a CABHA in the first place.

What a difference a year makes.

Oh, wait, it hasn’t been a year, yet. It hasn’t even been six months.

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

May 4, 2011

North Carolina ranks 8th in…Institutional Bias??

by Richard Edwards

Recently, United Cerebral Palsy issued its national report card on inclusion, ranking the fifty states on their attempts to serve individuals with intellectual and/or developmental disabilities in community and family settings.

North Carolina ranked 43rd over all. You can read the press release here, and the complete report here. (Warning: pdf) Most notable to me is that NC continues to rank in the top 10 states nationally in terms of the number of people–over two thousand–housed in large institutional settings (16+ residents).

And while several states have closed their institutions entirely (Go, “Bama!), North Carolina is rebuilding ours.

Just this year, Governor Perdue participated in the ground breaking of a replacement for Cherry Hospital in Goldsboro, NC. And recently, the NC Department of Health & Human Services began seeking bids for the reconstruction of Broughton Hospital in Morganton, NC–a project with a total budget of $154,772,802.

Why, in the face of data that supports downsizing institutions as good policy, and the clear example of our neighbor states, do we continue to invest in these types of large congregate settings? Even with a federal DOJ investigation pending against NC regarding our failure to provide community-based living options for people with disabilities as required by the ADA and the Olmstead Decision?

I am not saying that hospitals are not an important part of the continuum–they are. But consider this–for what we are spending to build a hospital in Morganton, we could invest in community hospital beds in Charlotte and Asheville and serve the vast majority of people who are displaced to that state hospital.

My angle is that we do it, not because it’s truly needed, but because jobs are truly needed. Communities–like Goldsboro, and Morganton, and Butner–depend upon the institutions in their community for employment. Not to mention the construction work that goes into maintaining facilities that are falling apart.

And the problem with this seemingly symbiotic relationship is that people with disabilities are stuck in the middle. As long as we continue to divert funds to institutional care, there will never be enough money to support people living in the community. And as long as there isn’t enough support for people to live in the community, there will always be a need for institutional care.

NC’s people with disabilities deserve better than 43rd in the nation.