
{"id":3353,"date":"2008-08-28T08:43:18","date_gmt":"2008-08-28T16:43:18","guid":{"rendered":"http:\/\/www.carrborocitizen.com\/main\/?p=3353"},"modified":"2011-12-15T12:20:23","modified_gmt":"2011-12-15T17:20:23","slug":"lost-in-a-lost-system-a-new-report-confirms-fears","status":"publish","type":"post","link":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/2008\/08\/28\/lost-in-a-lost-system-a-new-report-confirms-fears\/","title":{"rendered":"Lost in a lost system: a new report confirms fears"},"content":{"rendered":"<p><strong>[<a href=\"http:\/\/www.carrborocitizen.com\/main\/2008\/10\/04\/breakdown-series\/\">Breakdown series main page<\/a>]<\/strong><\/p>\n<p><strong>By Taylor Sisk<\/strong><br \/>\n<em>Staff Writer<\/em><\/p>\n<p>Valerie Kramer calls Carrboro her \u00e2\u20ac\u0153fairy-tale town.\u00e2\u20ac\u009d She and her son, Jeff, moved here when Jeff was entering the second grade and left, in 1997, when he was 14. Kramer was ending a bad relationship, was diagnosed with clinical depression and decided she and her son needed a new start in a new environment. She and Jeff moved to Asheville.<br \/>\n<!--more--><br \/>\nWhile in high school there, Jeff fell in with the Rainbow Family, to whom Kramer attributes his introduction to drugs. Jeff was busted for distribution of marijuana and was facing both felony and misdemeanor charges.<\/p>\n<p>Around this same time, Jeff had begun to often act strangely.<\/p>\n<p>Nothing he said made sense, Kramer says. \u00e2\u20ac\u0153He said God sent him to this Earth to grow marijuana for sick people, and that was his mission.\u00e2\u20ac\u009d <\/p>\n<p>Jeff\u00e2\u20ac\u2122s defense attorney advised her to pay a forensic psychologist to have Jeff evaluated. He was diagnosed with paranoid schizophrenia and deemed incompetent to stand trial. He was 19.<\/p>\n<p>\u00e2\u20ac\u0153I didn\u00e2\u20ac\u2122t know what schizophrenia was,\u00e2\u20ac\u009d Kramer says. \u00e2\u20ac\u0153But at 17 and 18, he really did things that I knew were not normal for him. And everyone said, \u00e2\u20ac\u02dcWell, he\u00e2\u20ac\u2122s just a teenager \u00e2\u20ac\u00a6\u00e2\u20ac\u2122 But I always knew. I mean, I had nightmares about it. I knew something was wrong.\u00e2\u20ac\u009d<\/p>\n<p>It must be drug-induced, Kramer believed. \u00e2\u20ac\u0153I said, \u00e2\u20ac\u02dcWhen he gets off the drugs, he\u00e2\u20ac\u2122ll be fine, right?\u00e2\u20ac\u2122\u00e2\u20ac\u009d She was assured by the doctors otherwise.<\/p>\n<p>So she packed up all of her and her son\u00e2\u20ac\u2122s belongings and moved back to the Triangle.<\/p>\n<p>\u00e2\u20ac\u0153I thought, \u00e2\u20ac\u02dcWe\u00e2\u20ac\u2122ll go back to Chapel Hill where, in general, there are more people with a higher education.\u00e2\u20ac\u2122<\/p>\n<p>\u00e2\u20ac\u0153I asked around \u00e2\u20ac\u201c everyone I knew \u00e2\u20ac\u201c and they said that as far as state hospitals go, John Umstead is the best because you\u00e2\u20ac\u2122ll have the brightest people there, the most resources \u00e2\u20ac\u201c and so by moving here, I\u00e2\u20ac\u2122m doing my son a favor. UNC Hospitals will take care of him and John Umstead is the best place. And now, five years later \u00e2\u20ac\u00a6\u00e2\u20ac\u009d<\/p>\n<p>Her nightmares persist.<\/p>\n<p><strong>The report <\/strong><\/p>\n<p>Last week, the newly formed legislative Program Evaluation Division released a long-awaited report titled \u00e2\u20ac\u0153Compromised Controls and Pace of Change Hampered Implementation of Enhanced Mental Health Services.\u00e2\u20ac\u009d The report is largely focused on the now well-documented excesses in the provisioning of community support services and chronicles the general mismanagement, overspending and lack of oversight in our mental health system since the passing of reform legislation in 2001, which called for privatizing services.<\/p>\n<p>Community support services include, for example, assistance with grocery shopping or homework or chaperoning to movies or ballgames. <em>The News &#038; Observer<\/em> reported that between March 2006 and January 2008, the cost of these services rose to nearly $1.4 billion, or 90 percent of all spending for community-based mental health care services. The cost of community support services was then nearly 20 times the state\u00e2\u20ac\u2122s original estimate.<\/p>\n<p>State officials now acknowledge that too much money has been wasted in the provisioning of community support services and \u00e2\u20ac\u201c granting that these services are vital for many who are poised to reintegrate back into their communities \u00e2\u20ac\u201c that too much money is being allocated to them at the expense of services that are more time- and cost-intensive to provide \u00e2\u20ac\u201c local inpatient care, for example, or everyday counseling.<\/p>\n<p>The legislative report cites delays in securing federal approval of new services, which led to a delay in the implementation of oversight procedures, which in turn led to some new providers taking advantage of the system by \u00e2\u20ac\u0153delivering an unchecked amount of services\u00e2\u20ac\u009d; a failure to establish a baseline \u00e2\u20ac\u0153against which to measure system performance and assess utilization and expenditures\u00e2\u20ac\u009d; and reports to decision-makers that included \u00e2\u20ac\u0153excessively dense data that are neither synthesized nor interpreted.\u00e2\u20ac\u009d<\/p>\n<p>In sum, the report is about mismanagement and abuses in the overhaul of our state\u00e2\u20ac\u2122s pre-existing mental health care system \u00e2\u20ac\u201c an initiative that most everyone now acknowledges is in serious need of some overhauling of its own.<\/p>\n<p>What the report is not about is how mental health care reform is failing people \u00e2\u20ac\u201c most particularly, those people most critically in need.<\/p>\n<p>What remains unaddressed is whether the system we\u00e2\u20ac\u2122ve put in place is structured to provide these more-intensive services.<\/p>\n<p>More to the point: Is it possible to provide comprehensive, effective mental health care services and make money at it?<\/p>\n<p>Dr. Nicholas Stratas doesn\u00e2\u20ac\u2122t think so. Stratas, a psychiatrist now in private practice in Raleigh, is one of the architects of a mental health care system in North Carolina that was, many years ago, considered a model of success. He served through the 1960s as deputy commissioner of what was then the state Department of Mental Health, which eventually was moved into the Department of Health and Human Services.<\/p>\n<p>\u00e2\u20ac\u0153How can you make money without cutting services?\u00e2\u20ac\u009d Stratas asks. \u00e2\u20ac\u0153I think it\u00e2\u20ac\u2122s possible to make money at this, but it\u00e2\u20ac\u2122s going to be at the cost of cherry-picking services\u00e2\u20ac\u009d \u00e2\u20ac\u201c providing only those services that are most cost effective \u00e2\u20ac\u201c \u00e2\u20ac\u0153and you\u00e2\u20ac\u2122re going to have to provide truncated services. And you lose the integration of a unified system.\u00e2\u20ac\u009d<\/p>\n<p>A unified system, Stratas says, is essential to providing continuity of care, and continuity of care is \u00e2\u20ac\u0153absolutely critical.\u00e2\u20ac\u009d<\/p>\n<p>\u00e2\u20ac\u0153But now,\u00e2\u20ac\u009d says Stratas, \u00e2\u20ac\u0153we\u00e2\u20ac\u2122ve got this person doing this piece and this person doing this other.\u00e2\u20ac\u009d<\/p>\n<p>Under the previous state-run system, community mental health clinics provided a broad suite of services under one roof.<\/p>\n<p>Dr. Thomas Smith, an Asheville-based psychiatrist, is another longtime mental health care advocate who\u00e2\u20ac\u2122s been vocal in his opposition to reform measures. He underscores the critical nature of those comprehensive, under-one-roof services.<\/p>\n<p>People with mental illness, he says, often face prohibitive transportation issues \u00e2\u20ac\u201c no driver\u00e2\u20ac\u2122s license, no car, little money for a taxi and, in rural areas, few if any public-transportation options.<\/p>\n<p>\u00e2\u20ac\u0153So to have everything in a central location within a community mental health clinic,\u00e2\u20ac\u009d Smith says, \u00e2\u20ac\u0153that was great. And to let that be destroyed was absolutely atrocious.<\/p>\n<p>\u00e2\u20ac\u0153Now there are private providers out there scattered here from hither to yon, all over the place, and it\u00e2\u20ac\u2122s hard for these folks to get to them.\u00e2\u20ac\u009d<\/p>\n<p>Of cherry-picking services, Smith says: \u00e2\u20ac\u0153Nobody wants to treat the difficult-to-manage folks,\u00e2\u20ac\u009d those with whom it\u00e2\u20ac\u2122s necessary to build a relationship over time, those who are most in need.<\/p>\n<p><strong>Things changed<\/strong> <\/p>\n<p>Jeff Kramer occupies a quiet space outside Weaver Street Market as a Friday afternoon gathers energy. He\u00e2\u20ac\u2122s undisturbed; focused, in his manner. He\u00e2\u20ac\u2122s a handsome young man; steady for the moment and sturdy. He\u00e2\u20ac\u2122s on an outpatient commitment order, required to report once a month to Orange County\u00e2\u20ac\u2122s community resource court. <\/p>\n<p>The court is a cooperative effort of the Orange County judicial and mental health systems that strives to help people who have mental health issues by linking sentences for selected offenses with services and support. <\/p>\n<p>After another brush with the law, and yet another brief stay in Umstead, Jeff is once again tasked to regain his footing.<\/p>\n<p>Jeff has been refusing to take his medication. He\u00e2\u20ac\u2122s taken it intermittently in the past, and his mother sees clear improvement in his ability to function when he does. He says now, though, that he\u00e2\u20ac\u2122s through with it.<\/p>\n<p>\u00e2\u20ac\u0153They want to see me on medicine that is not doing anything but damage to my brain,\u00e2\u20ac\u009d Jeff says. \u00e2\u20ac\u0153When you put chemicals in the brain, they don\u00e2\u20ac\u2122t do anything but harm. Antipsychotics will make someone sick.\u00e2\u20ac\u009d<\/p>\n<p>\u00e2\u20ac\u0153He says he doesn\u00e2\u20ac\u2122t have schizophrenia,\u00e2\u20ac\u009d Valerie Kramer says. \u00e2\u20ac\u0153He says it\u00e2\u20ac\u2122s too bad that they convinced me of that. He says he thinks that it\u00e2\u20ac\u2122s something that he did when he was younger, when he took the wrong path in life; maybe the drugs he did. He always blames himself for the way he feels and thinks he can eventually work it out. He told me the other day that he\u00e2\u20ac\u2122d rather die than take the medication.\u00e2\u20ac\u009d<\/p>\n<p>Kramer has been frustrated by the care her son has received at UNC Hospitals: \u00e2\u20ac\u0153They\u00e2\u20ac\u2122ve turned him down; they\u00e2\u20ac\u2122ve released him after several days. The last time he was in there \u00e2\u20ac\u201c it was January of this year \u00e2\u20ac\u201c he stayed only several days, was very sick, very delusional, paranoid, and this woman\u00e2\u20ac\u009d \u00e2\u20ac\u201c another patient \u00e2\u20ac\u201c \u00e2\u20ac\u0153kept kissing him.\u00e2\u20ac\u009d<\/p>\n<p>\u00e2\u20ac\u0153They would say, \u00e2\u20ac\u02dcWe can\u00e2\u20ac\u2122t help him because he\u00e2\u20ac\u2122s noncompliant. He doesn\u00e2\u20ac\u2122t want to take his medicine.\u00e2\u20ac\u2122 At the same time, that\u00e2\u20ac\u2122s a classic symptom of paranoid schizophrenia. They also say he has zero insight \u00e2\u20ac\u201c another classic symptom \u00e2\u20ac\u201c and so they send him home.\u00e2\u20ac\u009d<\/p>\n<p>\u00e2\u20ac\u0153The first time at Umstead,\u00e2\u20ac\u009d Kramer says, \u00e2\u20ac\u0153it was before all of these laws changed, and it was a good time. That was 2003. They kept him for, like, six weeks. They gave him the best treatment. I mean they really seemed to care.\u00e2\u20ac\u009d<\/p>\n<p>When Jeff was given his outpatient treatment plan, Kramer says, \u00e2\u20ac\u0153they took so much time with me and Jeff\u00e2\u20ac\u009d \u00e2\u20ac\u201c doctors, social workers, a team of clinicians that he was to work with on the outside all participated.<\/p>\n<p>\u00e2\u20ac\u0153We all sat down and we covered this outpatient treatment plan in depth and my son actually followed it. It\u00e2\u20ac\u2122s the only time in the five years that he has done that.\u00e2\u20ac\u009d<\/p>\n<p>Eventually, though, Jeff stumbled.<\/p>\n<p>\u00e2\u20ac\u0153And then they changed everything,\u00e2\u20ac\u009d Kramer says, \u00e2\u20ac\u0153and they started keeping him two days, three days, a week if you\u00e2\u20ac\u2122re lucky.\u00e2\u20ac\u009d Most recently, he stayed two weeks.<\/p>\n<p><strong>A pill, a platitude, a pat on the back  <\/strong><\/p>\n<p>The liaison community mental health clinics used to have with hospitals was an important element in continuity of care, helping ease the transition back into the community. Once out, an ongoing relationship with a trusted professional is the next critical step.<\/p>\n<p>\u00e2\u20ac\u0153It takes time to build those things,\u00e2\u20ac\u009d says Thomas Smith. \u00e2\u20ac\u0153But they just threw that all to the four winds. Now it\u00e2\u20ac\u2122s just a piecemeal thing.\u00e2\u20ac\u009d<\/p>\n<p>Smith refers to \u00e2\u20ac\u0153P-P-P\u00e2\u20ac\u2122\u00e2\u20ac\u009d clinics: \u00e2\u20ac\u0153You come in and you get a pill, a platitude and a pat on the back.\u00e2\u20ac\u009d<\/p>\n<p>He hastens to add that there are certainly still good providers out there \u00e2\u20ac\u201c but believes most are just in it for the money. And the continuity of service, that comprehensive suite of services delivered by a team, as a team, is what appears to be lost.<\/p>\n<p>In order to be effective, says Nicholas Strata, that team should include a representative from a state institution, another from a local inpatient program, another from an outpatient program; a team to provide whatever the patient needs.<\/p>\n<p>\u00e2\u20ac\u0153The survivor in me, my inner peace,\u00e2\u20ac\u009d says Jeff Kramer, \u00e2\u20ac\u0153will find a way to survive and figure out some kind of method of dealing with reality.\u00e2\u20ac\u009d<\/p>\n<p>His mother isn\u00e2\u20ac\u2122t nearly so sure.<\/p>\n<p><em>This story is the first in a series about mental health care in North Carolina. The names of the mental health care recipient and his mother have been changed.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>[Breakdown series main page] By Taylor Sisk Staff Writer Valerie Kramer calls Carrboro her \u00e2\u20ac\u0153fairy-tale town.\u00e2\u20ac\u009d She and her son, Jeff, moved here when Jeff was entering the second grade and left, in 1997, when he was 14. Kramer was ending a bad relationship, was diagnosed with clinical depression and decided she and her son&#8230;<\/p>\n","protected":false},"author":12,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4],"tags":[],"class_list":["post-3353","post","type-post","status-publish","format-standard","hentry","category-news"],"_links":{"self":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/3353","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/users\/12"}],"replies":[{"embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/comments?post=3353"}],"version-history":[{"count":6,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/3353\/revisions"}],"predecessor-version":[{"id":22362,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/3353\/revisions\/22362"}],"wp:attachment":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/media?parent=3353"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/categories?post=3353"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/tags?post=3353"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}