Posts tagged ‘Mental Health’

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.

March 21, 2011

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?

February 24, 2011

Peer Support Services — the Service of the Future…

by Richard Edwards

…and at this rate, it always will be. Ba dum bum. Thank you, thank you…I’m here all week.

North Carolina–attempting to infuse its public system of supports to people with mental illness with a recovery-focused approach, has received Medicaid (CMS) approval to launch a Peer Support Services (PSS) definition.  You can read about it here, starting on page 95. The service, which has been approved in varying models in eleven states, utilizes individuals who have mental health issues themselves, and have successfully maintained their personal recovery, in engaging persons with mental health issues in active treatment.

In the substance abuse field, historically, many substance abuse counselors were, and are, persons in recovery themselves. In my graduate training as a counselor, I encountered many in the SA treatment field who believed you could not be an effective counselor to people dealing with alcoholism and addiction, unless you had a similar background. At the time, I was pretty quick to say that was poppycock–but that was partially because it threatened my role as a professional, without a personal history of addiction and recovery. Over the years, I have come to appreciate that peers in mental health recovery can establish rapport with those they support in a way I will never be able to.  And that rapport is vitally important, because recovery is, in many ways, about showing up–and a qualified Peer Specialist can be particularly effective in helping people see the importance of taking personal responsibility for their health and well-being.

So, from that perspective, I think it’s fantastic that Peer Supports is set to go live in NC in July, 2011.

Unfortunately, Peer Supports may only be “live” in the academic sense–available in theory, but not in practice. Here’s why…

First of all, the rate for PSS ($22/hour) is simply too low to be seriously considered. I’ve spoken with several providers, who all say they would lose significant amounts of money (well over $100k by one estimate) providing this service over a year.  Any provider agency who does their homework will come to the conclusion that the rate is insufficient for the service as it is defined.

Secondly, only CABHA-certified providers (Critical Access Behavioral Healthcare Agencies) can provide PSS, and CABHAs are already straining under the costs of their own infrastructures (see previous post–“Mental Health Reform is Dead!”), not to mention the requirement that CABHAs provide services that also lose money like psychiatric management and outpatient therapy. Given these pressures, it is very unlikely that an organization is going to expand into another service that is so obviously under-funded.

Thirdly, the current definition is very restrictive, and will require intensive management and oversight. For instance–

  • PSS requires a full-time licensed or provisionally-licensed supervisor who cannot bill for any services her/himself;
  • PSS is a short-term service–maximum six months per year, which doesn’t really seem to match up with outcomes typically associated with recovery;
  • PSS has to be provided with outpatient therapy–so only the people you serve on an outpatient basis are eligible, which further limits potential referrals;
  • PSS–because of a weekly, individual supervision requirement–discourages the employment of many skilled Peer Specialists who only want to work part-time; and full-time employment means…
  • Productivity requirements of 60% per week–meaning 24 hours of a 40 hour workweek must be billable activity. Sound easy? It’s actually very difficult when you add travel (this service is community-based); meetings; documentation; supervision; etc…

These requirements may not seem onerous to the casual observer, but add them to insufficient funding, and they present a very high barrier.

Lastly, there are currently few CABHA providers that  have any significant experience with Peer Support Services, unless they have been running an Assertive Community Treatment Team (ACTT), or recovery-focused services such as a Peer Drop-In Center or Recovery Center.  And even if they have been running an ACT Team, they may have as few as one Certified Peer Specialist in their organization.  The point is, few CABHAs really understand Peer Support Services, but they do understand that, poorly handled, the well-being of the people supported, and the people employed, is at risk.

Ironically, many of the peer-run organizations who have the most experience and skill at providing and administering peer support services aren’t qualified to deliver Peer Support Services under the new definition, because they don’t have a Medical Director, a Clinical Director, and a QM/Training Director (i.e., they are not CABHAs).

So, for now at least, the future of PSS in NC remains, well, in the future. And while this might sound like I blame the authors of the defintion at the state, that is absolutely not the case. Service definitions, like the one for PSS, are really not so much definitions as they are conversations, and they occur over years, even decades, between persons served, providers, advocacy organizations, state and federal governments, and the general public.

So rather than throw up my/our hands, my angle is that we need to take the long view on peer support services, because the potential upside for people with mental health issues–indeed all people with disabilities–is too great to be ignored. The current service definition and the accompanying rates–inadequate though they are–are part of the process of bringing these supports to NC’s citizens dealing with mental illness. And this means committing to staying at the table of making peer support services a reality today, with or without the defined service.

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

January 28, 2011

An Unbalanced Mind–Thoughts on Jared Loughner

by Richard Edwards

(Note: this post probably seems a little out of date, but it has taken me a while to collect my thoughts. Still not sure if I’m there…)

Jared Loughner is, in very plain terms, mentally ill. I’m not a diagnostician, but that seems to me to be the truth of it.

Immediately following the shooting of Rep. Giffords and many others at a speaking event in Arizona, there were emails and blog postings and press releases from NAMI and MHA and the National Council for Behavioral Healthcare around the lack of evidence to show that people with mental health issues are any more violent than the general population.

And research shows that that’s true–you can read about it here, here and here–and it’s important that we don’t paint all people with mental health issues as criminally violent. Studies show that mental illness does not lead to violence, although the likelihood goes way up when you add substance abuse to the mix. So let’s not stigmatize the millions of Americans with mental health issues–many of whom are successfully managing serious and persistent mental illness–by assuming they will–or even could–become the next Jared Loughner.

But in recent weeks, following President Obama’s Tucson speech, I notice the conversation turning to mental health support services….Did we do enough? Should the Community College where Jared Loughner attended classes done more? Should the community have noticed? Should his parents have noticed and taken action? Not so much discussion about whether the national discourse was to blame, but much more about the nitty gritty–at the ground level, what went wrong? This too, seems appopriate to me. In order to prevent the next Jared Loughner, we need to understand the current one.

Several national advocacy agencies are pointing to declining services in Arizona and elsewhere for people with mental health issues as cause for concern. There is also such a thing as mental health first aid, and it’s not hard to imagine how a well-informed community could have recognized the signs of Jared Loughner’s paranoia, before it reached crisis levels, and, given the tools to act, intervened. However, services to people with disabilities and mental illness cost money, and in states across the country, including NC, which faces a 3.7 billion dollar shortfall in FY11-12, money is in short supply.

But doesn’t that sound like we want it both ways? We need to improve access to mental health services for people like Jared to prevent this kind of tragedy from happening–a tragedy which, in the end, also happened to Jared. But how do we advocate for more services on that basis without playing up the potential for violence, and thereby stigmatizing the millions of Americans who deal with emotional or mental health issues everyday and have no propensity for violence whatsoever?

My angle is that Jared’s mental illness had a direct relationship to his crime, but criminal insanity is a legal term, not a diagnosis, and one charged with understandably negative feelings about loopholes and savvy criminals who walk, scot-free. But if Jared Loughner could have been helped with services because he was mentally ill, and if that intervention could have prevented the criminal and insensate act that resulted from his mental illness, and if we think we simply can’t afford those services…

What kind of wall will Arizona build now?

Jared Loughner is, in very plain terms, mentally ill. And his kind of illness took his mind and the lives of 9 people with it, not to mention the nightmare-free existence so many people in Tucson thought they would live until a few weeks ago. In making a way forward from this tragedy, there is, I believe, a middle path–service without segregation; awareness without paranoia; and yes, fiscal restraint without neglect–this is the kind of balance Jared Loughner’s mind couldn’t maintain.

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

January 27, 2011

And the choir said, “Amen!”

by Richard Edwards

This past weekend, NAMI of Orange County and MHA of the Triangle hosted their annual legislative breakfast. Over 300 people attended, including legislators, advocates, providers, persons receiving services, as well as a variety of local elected officials. It was a fantastic event, and I was proud to be a part of it.

Sitting at the Benchmarks NC table, I got a chance to speak with Rep. Floyd McKissick of Durham, and District Attorney James Woodall of Orange County, about concerns over treating juvenile offenders as adults and what could be done to address this issue.  Having participated in a recent task force themselves, they were fully on board.  In fact, I realized later, everyone present was on board. Of course, there are always disagreements within the mental health community about where dollars should or should not be allocated…Dorothea Dix Hospital, for instance. But generally, we were of one mind, and our thoughts were on protecting human services in the coming budget process.

Leaving the meeting, I had a conversation with Orange County Commissioner, Bernadette Pelissier, with whom I am on the Board of the Orange-Person-Chatham Local Management Entity. She is rotating off the OPC Board, due to other commitments, and while that’s disappointing, she pointed out that she is not the Orange County Commissioner that OPC needs to convince–she is already on board. Just like the people at the Legislative Breakfast–even the legislators, all Democrats, all re-elected, all in the minority–they have our vote. And they’re not in power.

It got me thinking about Chatham County’s recently elected County Commissioner, Brian Bock, a conservative Republican who was elected in November. He has been appointed to our mental health board as Chatham’s Commissioner representative, but he didn’t attend the most recent meeting, or the legislative breakfast, and he hasn’t returned phone calls from the LME Director.

So, even though the NC Association of County Commissioners has mental health as one of its top 5 legislative priorities for this year, I’m guessing Commissioner Bock is probably not on board.

And my angle is that this is a golden opportunity to have a conversation with someone who is not sitting in the choir pit, as it were.  Because as sad as I am that Commissioner Pelissier won’t be on the OPC Board anymore, she isn’t–and never has been–the person we needed to win over, and what’s more, she couldn’t give us access to the community of citizens who don’t see mental health services or substance abuse services or services to persons with developmental disabilities (much of which is paid for through tax dollars) as a priority.

And, so, as we prepare for what is bound to be a very difficult budget cycle–and not to take anything away from the aforementioned legislative event–my angle is that two people who genuinely disagree with each other having a one-on-one breakfast may be more critical than a 300-person rally where everyone is of the same mind.

January 7, 2011

Mental Health Reform is dead. Long live Mental Health Reform!

by Richard Edwards

Today, at a press conference, NC DHHS Secretary Lanier Cansler stated that the era of mental health reform was over. You can read about it here, here and here.  That’s a bold statement, to say the least, bordering on hyperbole, but I suppose it depends upon how you define reform and set the boundaries for the era itself.

Strictly speaking, mental health reform ended when Local Management Entities, previously community mental health centers, divested their mental health, intellectual and developmental disability and substance abuse services in an effort to increase efficiencies by privatizing the system. The vast majority of this transition occurred years ago, from 2004 to 2006 or so. So, yes, that era of mental health reform is over.

Another focus of mental health reform was to bring people living in institutions back into the community–a move that would be supported by the development of community services. This part of reform never happened–there are still many people living in institutions, and there doesn’t seem to be any inclination to support the community-based service capacity necessary to assure a safe transition. So, also, that era of mental health reform is over–in fact, it ended before it ever began.

So, I suppose, the processes that were supposed to bring about system transformation are over, if they ever really began. But the era of mental health reform is emphatically not over.

The establishment of Critical Access Behavioral Health Agencies (Kah-bas), described in the articles and press releases, is a response to the failures of mh reform, but it’s not the end of it. Far from it.

CABHAs are, in many respects, private mental health service providers who provide an array of services to a given population (adults and/or children) in at least one area of the state. Certain services can only be provided by a CABHA-certified agency, including case management and peer support, but also intensive mental health and substance abuse services. Ostensibly, the goal is to create a more professional, more competent provider network. See, when the state ordered the LMEs to divest their services, they didn’t order them (or pay for them) to divest their clinical and medical oversight. Consequently, some providers had it, and some didn’t. There was no requirement to have it, and there was no funding to support it. The CABHA certification requires that level of clinical and medical oversight to be held within the provider agency, and there is a lot of hope–as evidenced by today’s press conference–that oversight will address many of the problems in the system.

And I would agree, it might, but here’s the rub–there is no guarantee as to how many of the some 175 certified CABHA entities will survive the next 6 months. Consider the following:

Each CABHA must have a Medical Director, for which there is no additional funding.

Each CABHA must have a Clinical Director, for which there is no additional funding.

Each CABHA must have a Quality Improvement/Training Director, for which there is no additional funding.

Each CABHA must provide Outpatient Therapy and Psychiatric services, both of which are loss-leaders in the field and are inadequately supported by state rates.

The cost of the three unfunded positions could easily top $300k annually, and even if you take into account that many agencies may have had a Clinical Director or a QI Director, most small agencies were doomed from the start. Out of some 600+ provider agencies, only 175 or so made it through the certification process. Of that 175, it is almost certain that a third to a half will not survive the next year.

You could argue that the 11-12 budget will actually be to blame for that, and that’s not unfounded, but my angle is this…

In trying to assure mental health reform went over smoothly, the state made it too easy for a business to get into the mental health industry, and for the last four years, has been trying to clamp down on this proliferation.  So, call it what you will, but we are still dealing with the effects of mental health reform.

The era of mental health reform may be over, but the vision is still a long way off.

December 1, 2010

A Lack of Southern (Psychiatric) Hospitality?

by Richard Edwards

Last week, it was announced that the US Department of Justice has filed a lawsuit against NC, alleging that thousands of people with mental illness are being improperly housed in Adult Care Homes, in violation of the Americans with Disabilities Act and the Olmstead Decision.

Rose Hoban has a great write up of the lawsuit here, but the link to the Georgia settlement isn’t working, so you can read more about that here.

Chris Fitzsimon has a post on the general state of things here, but, in my opinion, his posts are often a bit over-simplified. When talking about the public mhddsas system, it is never good to start a sentence with “It sounds like…”  What it sounds like is just a surface representation of what it actually is, Mr. Fitzsimon. (I would have commented on his post at his site, but his posts don’t allow for commentary, so I’m doing it here.)

The timing of this lawsuit coincides with the closure this month of Dorothea Dix Hospital, raising concerns that the state does not have enough hospital beds. That people with serious mental health issues are languishing in emergency rooms is shameful, and dangerous, but my angle is that more hospital beds is not, in fact, the answer. 

What is missing when we try to fix a struggling community-based system with more inpatient facilities? You can bet Georgia did not resolve their lawsuit by opening more inpatient facilities, and North Carolina shouldn’t–and won’t–either.