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Beyond the crisis: Revisiting the community-based model

By Taylor Sisk
Staff Writer

Debbie Carraway is 37, works in information technology and has bipolar disorder. For 14 years, until just a couple of weeks ago, she was a client of Marilyn Ghezzi, a therapist at Caring Family Network. Caring Family Network no longer provides therapy services in Orange County, and Carraway is feeling the blow. The loss of continuity is at the top of her list of concerns.

“What I had before that I don’t have anymore is history,” Carraway says, “having someone who actually knows my story, who knows me, who has been with me through this walk. It’s been a long time, and having to leave that very suddenly is very hard.”

Carraway says that she and Ghezzi had only three or four sessions in which to close things out.

“We did some good work to try and wrap things up, but there’s a lot of unfinished business and it’s a major transition, and having to do that, having to leave without having somebody else in place …” Her voice trails into a sigh.

In 2001, when the General Assembly voted to overhaul the state’s mental health care system, it was decided that counties would no longer directly provide treatment. They would instead form local management entities (LMEs) that would oversee private providers. The OPC Area Plan is the LME for Orange, Person and Chatham counties, and the Caring Family Network (CFN) was selected as the primary provider for those three counties. Until last spring, when CFN announced the initial cutback in its services, it had approximately 1,000 clients in Orange County.

“I had my little delusions that somehow it would all be okay,” Carraway says. “But it wasn’t.”

Despite the fact that the reform legislation called for LMEs to oversee but not directly provide services, OPC director Judy Truitt said in an email to The Citizen that while OPC would have been allowed to step in when CFN closed, “one of the fundamental issues that you have to demonstrate is that no other options were available. That is not the case in our area.

“OPC has a strong provider network that has joined with us in the challenge of making this as smooth a transition as possible. While there remain many details that will have to be resolved over the next couple of months, the option of OPC resuming service provision would not have reduced or eliminated those transition issues.”

Among those stepping in is Freedom House in Chapel Hill.

Ghezzi says that Freedom House is hiring from among the therapists and support staff who were laid off by CFN (some had already found work elsewhere; she, herself, has elected to pursue other opportunities), and, overall, she says, “I think that is good because Freedom House is actually from this community and cares about their reputation.”

But Freedom House will not be accepting clients with Medicare.

“This is not a minor point,” Ghezzi says.

It means that only those who make below the Medicaid threshold of approximately $750 a month and those who can pay with private insurance will be able to receive services.

“People who are not eligible for Medicaid are the folks that fall through the cracks,” says Karen Dunn, director of Club Nova, a Carrboro clubhouse for people with mental illnesses. “[These] are the people who worked long enough in their lives that they were able to draw disability, but then they’re not eligible for Medicaid because they are above that threshold.”

‘More fragmented, uncertain services.’

Debbie Carraway has private health insurance, which she acknowledges makes her somewhat luckier than many. But starting again with a new therapist isn’t the full extent of her concerns.

Can anyone promise that other private providers that may be brought in – who, theoretically, will be facing many of the same budgetary issues as was CFN – will stay in business?

And because Carraway’s relationship with Ghezzi was about a whole lot more than their weekly sessions, she’s also worried about losing a holistic approach to her care.

“Marilyn has worked as a sort of liaison with my psychiatrist,” she says, “which has been incredibly helpful, having them work together as a team.”

Psychiatric services were also provided through CFN. Those psychiatrists will now be employed by OPC. Carraway’s team will no longer be under one roof.

“The times when I wasn’t really able to function very well,” Carraway continues, “or the times when I needed to be hospitalized, Marilyn was there, and helped make sure I got through to my doctor and was able to get medication adjustments. And when I did have to go into the hospital, she made sure that services were waiting for me when I got out.

“That was a very important part, and it’s one of the things that I’m really concerned about.”

John Mader, a local therapist, has stressed the importance of having comprehensive services under one roof, and of providing a sense of continuity.

“These people are supposed to get more and better care, but what they’re getting is more fragmented, uncertain services,” Mader says.
“And we don’t even know if the next agency coming in will establish any more continuity than the one that’s leaving.”

Mark Sullivan, executive director of the Orange County Mental Health Association, isn’t very optimistic. “Lots of us in the advocacy community have lost faith,” he says.

He says the provisioning of mental health care services is working within a “faulty framework,” in which we’re overly dependent on private providers. He’d like to see the county set up a safety-net clinic – a comprehensive-services agency – a place that people know is going to be there and isn’t going to close its doors the next time changes occur – one that would not be run by a private provider.

A community-based model.

John Gilmore is a professor in the UNC Department of Psychiatry. He and his colleagues have put together a proposal for just such a facility: a community-based, comprehensive-services mental health care facility.

The first step, says Gilmore, would be the Schizophrenia Treatment and Evaluation Program (STEP) Clinic, administered by UNC Hospitals and the Department of Psychiatry.

“We would like to expand the clinic out into the community,” Gilmore says. The facility would initially focus on those with schizophrenia and schizoeffective disorder.

“We see it as a phased thing,” Gilmore says, “so we would start with that and then we would think about expanding to the SPMI group in general – which is serious and persistent mentally ill.

“It’s possible that this could end up being what people are starting to talk about as a safety-net clinic.”

Gilmore and his colleagues have made applications for funding to the county and to the state’s Mental Health Trust Fund and are also looking to apply to several foundations.

According to Commissioner Mike Nelson, the application to the county has gone to the Human Services Advisory Commission but has not yet reached the county commissioners.

“There’s talk in Raleigh now about establishing centers of excellence in mental health,” Gilmore says, “and we would definitely be thinking along the lines that this would be one of those.”

In addition to providing vital community-based services, Gilmore says the clinic could provide practical experience for psychiatry residents, nursing students, social work interns and others from among the university population.

Carraway recognizes the appeal of programs that are designed and administered from within the community – that was, after all, the spirit behind our reforms. Regardless, she says, privatization should be revisited.

The free market is great for many things, she says. The economy “goes up and it crashes down – and maybe, on average, over time, things are good.

“But you can’t have that when you’re dealing with human beings. You can’t wait for things to get better. You have to have a continuity of care; and if it’s not profitable, then it’s not profitable. It’s not supposed to be profitable.”

  1. The article stated, as re: the mental health provider, Freedom House: “Freedom House will not be accepting clients with Medicare.”
    Why? If a mental health provider is working w/ a physician re: meds or chronic illness matters, you can bill using CPT 96152 series. This is how it can work: use the Health & Behavior CPT codes which pay better than Medicaid. Few mental health providers know how to use them. These are the restrictions: ‘place of service’ must be ‘office’ or code ’11.’ Bill must include NPI of physician associated w/ the client: here is the NPI roster: https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.
    Session notes must pay attention to the following: client adherence to medical treatment; health promoting behaviors; health related risk taking behaviors; and overall adjustment to physical illness.
    Marsha V. Hammond, PhD: NC Mental Health Reform blogspot:
    http://madame-defarge.blogspot.com/