
{"id":3517,"date":"2008-09-25T08:28:52","date_gmt":"2008-09-25T16:28:52","guid":{"rendered":"http:\/\/www.carrborocitizen.com\/main\/?p=3517"},"modified":"2011-12-15T12:22:46","modified_gmt":"2011-12-15T17:22:46","slug":"breakdown-reform-creates-a-bewildering-system","status":"publish","type":"post","link":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/2008\/09\/25\/breakdown-reform-creates-a-bewildering-system\/","title":{"rendered":"Breakdown: Reform creates a bewildering system"},"content":{"rendered":"<p><a href='http:\/\/www.carrborocitizen.com\/main\/wp-content\/uploads\/2008\/09\/clinica.jpg'><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/www.carrborocitizen.com\/main\/wp-content\/uploads\/2008\/09\/clinica-300x196.jpg\" alt=\"Photo by Ava Barlow. In 2006, as the result of an overhaul of the state\u00e2\u20ac\u2122s mental health care system, the OPC Area Program began outsourcing the majority of its services. Though still open, there\u00e2\u20ac\u2122s been a vast reduction of services at the Northside clinic as a result.\" title=\"clinica\" width=\"270\" height=\"175\" class=\"alignnone size-medium wp-image-3518\" srcset=\"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-content\/uploads\/2008\/09\/clinica-300x196.jpg 300w, https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-content\/uploads\/2008\/09\/clinica.jpg 900w\" sizes=\"auto, (max-width: 270px) 100vw, 270px\" \/><\/a><\/p>\n<p><strong>By Taylor Sisk<\/strong><br \/>\n<em>Staff Writer<\/em><\/p>\n<p><em>This story is the third in a series about mental health care<br \/>\nin North Carolina. <\/em><br \/>\n<strong>[<a href=\"http:\/\/www.carrborocitizen.com\/main\/2008\/10\/04\/breakdown-series\/\">Breakdown series main page<\/a>]<\/strong><\/p>\n<p>\u00e2\u20ac\u0153There\u00e2\u20ac\u2122s a lot of story,\u00e2\u20ac\u009d says Valerie Kramer, assessing the narrative of her only child, Jeff.<\/p>\n<p>\u00e2\u20ac\u0153I get really angry,\u00e2\u20ac\u009d Kramer says. \u00e2\u20ac\u0153I see him so sick, and my son is a very bright person. He made \u00e2\u20ac\u02dcA\u00e2\u20ac\u2122s in school; he won awards. All his cousins went to college and are very smart and successful in life, and I thought, \u00e2\u20ac\u02dcJeff will do that.\u00e2\u20ac\u2122\u00e2\u20ac\u009d <\/p>\n<p>At 19, Jeff Kramer, now 24, was diagnosed with paranoid schizophrenia.<br \/>\n<!--more--><br \/>\n\u00e2\u20ac\u0153I don\u00e2\u20ac\u2122t want to define my son with schizophrenia,\u00e2\u20ac\u009d Kramer wrote in her journal earlier this year. \u00e2\u20ac\u0153I want to know more of who he is. I want to be with him as he is, take every moment I have with him and cherish it. <\/p>\n<p>\u00e2\u20ac\u0153But then when his symptoms get really bad he becomes emotionally and mentally altogether unavailable.\u00e2\u20ac\u009d <\/p>\n<p>For the past five years, Kramer has been on an uninterrupted search for a place, both physical and emotional, where her son might find a measure of peace.<\/p>\n<p>It\u00e2\u20ac\u2122s been a hell of a journey, one made worse, advocates say, by the privatizing of mental health care services in North Carolina.<\/p>\n<p><strong>A new regime<\/strong><br \/>\nThe numbers are staggering.<\/p>\n<p>According to the National Institute of Mental Health, 26.2 percent of Americans aged 18 and older suffer each year from a diagnosable mental disorder. Based on the 2004 census, that\u00e2\u20ac\u2122s 57.7 million Americans.<\/p>\n<p>The institute further reports that \u00e2\u20ac\u0153the main burden of illness is concentrated in a much smaller proportion \u00e2\u20ac\u201c about 6 percent, or 1 in 17 \u00e2\u20ac\u201c who suffer from a serious mental illness.\u00e2\u20ac\u009d <\/p>\n<p>Jeff Kramer is among those latter. He\u00e2\u20ac\u2122s spent the past three weeks in Central Regional Hospital, his eighth or ninth visit (it\u00e2\u20ac\u2122s hard for his mother to recall for certain) to a state mental health facility. No treatment has proved effective for long. Jeff refuses to take his antipsychotic medication, which complicates his situation. Most, but not all, psychiatrists believe medication to be a critical component in the treatment of the majority of schizophrenics. He doesn\u00e2\u20ac\u2122t believe he\u00e2\u20ac\u2122s at all sick, and therefor has generally resisted any form of treatment.<\/p>\n<p>In sum, Jeff is very difficult to treat.<\/p>\n<p>For Valerie Kramer, that\u00e2\u20ac\u2122s the bad news. The kicker is the dizzying mental health care system through which she must navigate in hopes of finding the care Jeff requires, the outcome of the General Assembly\u00e2\u20ac\u2122s decision to overhaul the previous system and introduce reform.<\/p>\n<p>In 2001, Gov. Mike Easley appointed Carmen Hooker Odom as Secretary of Health and Human services with a mandate to shake up the mental health care system.<\/p>\n<p>Nicholas Stratas, a psychiatrist in private practice in Raleigh and former state deputy commissioner of mental health, recalls Hooker Odom coming to speak at a North Carolina Psychiatric Association meeting soon after she was appointed.<\/p>\n<p>\u00e2\u20ac\u0153She starts off by saying, \u00e2\u20ac\u02dcFolks, the train has left the station, and if you\u00e2\u20ac\u2122re not on it you\u00e2\u20ac\u2122re going to get left behind.\u00e2\u20ac\u2122 That was her opening remark, and I thought, man, who is this?\u00e2\u20ac\u009d<\/p>\n<p>Hooker Odom had been a Massachusetts legislator and a health care lobbyist. She put forth a plan, later passed into law, by which county mental health care area programs would no longer directly provide treatment to patients. Local Management Entities (LMEs) would oversee private providers and, theoretically, more treatment would be provided within the communities, thereby freeing up beds in the four state-run mental hospitals for those most critically in need. The two key concepts behind reform were privatization and the growth of community-based services.<\/p>\n<p>Things didn\u00e2\u20ac\u2122t go well. Private providers gradually began to go out of business. In many communities, particularly rural ones, needs were going unmet, most frequently those of the poorest and those most in need of help. Many providers were \u00e2\u20ac\u0153cherry-picking\u00e2\u20ac\u009d services, providing only those that could be profitably provided \u00e2\u20ac\u201c assistance with grocery shopping or help with homework, for example. Many providers were grossly overcharging for these services. <\/p>\n<p>Hooker Odom, herself \u00e2\u20ac\u201c who resigned in May 2007 to become president of Milbank Memorial Fund, a health-policy foundation based in New York \u00e2\u20ac\u201c acknowledged the problems. In April 2006, she told the <em>News &#038; Observer<\/em>: \u00e2\u20ac\u0153To create that change, you have to go through the process of destroying the existing system. You don\u00e2\u20ac\u2122t have to be a psychiatrist to know that people do not like change.\u00e2\u20ac\u009d<\/p>\n<p>What recipients of mental health care services and their families most particularly didn\u00e2\u20ac\u2122t like was that there didn\u00e2\u20ac\u2122t seem to be a new system to replace the previous one. There were some fundamental flaws that no amount of patience with change would remedy. There were elements of that old system that the new system needed to succeed.  <\/p>\n<p>For example:<\/p>\n<p>\u00e2\u20ac\u0153[Hooker Odom] decided these LMEs would do the work of the state,\u00e2\u20ac\u009d says Stratas. \u00e2\u20ac\u0153They would provide data processing, accountability, all of the things that I think the state is responsible for. The LMEs can\u00e2\u20ac\u2122t do that \u00e2\u20ac\u201c they\u00e2\u20ac\u2122re not going to recruit high-caliber data processors, sociologists, evaluators. They can\u00e2\u20ac\u2122t afford it.\u00e2\u20ac\u009d <\/p>\n<p>While acknowledging that perhaps larger counties such as Wake or Mecklenburg could handle such a responsibility, most, says Stratas, could not.<\/p>\n<p>Another, more critical issue was one of mandate.<\/p>\n<p>What that means, says Drew Bridges, a psychiatrist and former medical director for an area program that covered four counties north of Raleigh, \u00e2\u20ac\u0153is that someone is specifically identified as being responsible for caring for the sickest among us,\u00e2\u20ac\u009d as well as those with no insurance or money. <\/p>\n<p>Within the new framework, he says, that mandate was thrown out the window. The new mandate was to earn a profit. <\/p>\n<p>Meanwhile, with fewer services being provided in the communities, more people were entering the state institutions.<\/p>\n<p><strong>The carousel<\/strong><\/p>\n<p>After being released from Umstead the first time, in 2004, Jeff began outpatient treatment with the Orange Person Chatham (OPC) Area Plan, which at that time was resisting divestiture of its services. <\/p>\n<p>In 2006, OPC finally divested and Caring Family Network (CFN) became the primary provider of mental health treatment in the three counties. Then in February of last year, CFN announced that it would be discontinuing all outpatient and community-based services.<\/p>\n<p>Upon Jeff\u00e2\u20ac\u2122s release that first time, a team of professionals, including clinicians who would be supervising his outpatient services, had met to map out his treatment. More recently, that wasn\u00e2\u20ac\u2122t the case.<\/p>\n<p>After subsequent short stays in UNC Hospitals, Jeff was enrolled in UNC\u00e2\u20ac\u2122s Schizophrenia Treatment and Evaluation Program (STEP) and its Alcohol and Substance Abuse Program (ASAP). His mother said things went well for a while. <\/p>\n<p>But by 2006, Jeff Kramer\u00e2\u20ac\u2122s behavior had once again become erratic. He was using marijuana again and, his mother says, most probably harder drugs, and was encouraged to enter the UNC department of psychiatry\u00e2\u20ac\u2122s Outreach and Support Intervention Services (OASIS). <\/p>\n<p>He got worse though, and in the summer of 2006 Jeff ended up back in UNC Hospitals. His mother says that she was told by hospital staff that the only way Jeff could be released would be to agree to seek the help of XDS Inc. in Chapel Hill, who, she was told, could provide more comprehensive services. XDS assigns what\u00e2\u20ac\u2122s called an assertive community treatment (ACT) team to each of its clients. Jeff agreed to enter the program.<\/p>\n<p>In the past, Jeff had taken his antipsychotic medication sporadically if at all \u00e2\u20ac\u201c didn\u00e2\u20ac\u2122t believe in it; didn\u00e2\u20ac\u2122t believe he was sick. He was again refusing it. He was what many in the profession refer to as a \u00e2\u20ac\u0153hard case.\u00e2\u20ac\u009d<\/p>\n<p><strong>\u00e2\u20ac\u02dcPulling alligator teeth\u00e2\u20ac\u2122<\/strong><\/p>\n<p>If there is one \u00e2\u20ac\u0153super-colossal problem\u00e2\u20ac\u009d with the state\u00e2\u20ac\u2122s mental health care system as presently reformed, says Thomas Smith, an Asheville-based psychiatrist and longtime health care advocate, it\u00e2\u20ac\u2122s a lack of talented, comprehensively trained health care professionals. <\/p>\n<p>\u00e2\u20ac\u0153They\u00e2\u20ac\u2122ve been alienated,\u00e2\u20ac\u009d Smith says. \u00e2\u20ac\u0153A lot of them were just tossed out into the wind\u00e2\u20ac\u009d when mental health care services were privatized. <\/p>\n<p>Smith says he\u00e2\u20ac\u2122s been called upon to help recruit psychiatrists from outside the state. \u00e2\u20ac\u0153It\u00e2\u20ac\u2122s like pulling alligator\u00e2\u20ac\u2122s teeth,\u00e2\u20ac\u009d he alleges. \u00e2\u20ac\u0153To come into an atmosphere like this, where everything is in a state of disruption \u00e2\u20ac\u201c who would want to come and join this force?\u00e2\u20ac\u009d<\/p>\n<p>Perhaps even more critical though, says Bridges, is that a system of training new mental health care professionals is gone.<\/p>\n<p>The area programs were essentially training programs for mental health care professionals, Bridges says. \u00e2\u20ac\u0153There was a workable relationship between the training programs and the area programs where people could learn how to do this work, and that was just all wiped away. <\/p>\n<p>\u00e2\u20ac\u0153No one graduates from a university-based training program really knowing how to work with the chronically mentally ill population. You have to learn that working alongside more experienced people.\u00e2\u20ac\u009d <\/p>\n<p>That\u00e2\u20ac\u2122s true, he says, for psychiatrists, nurses, social workers \u00e2\u20ac\u201c anyone in the profession. <\/p>\n<p>How, in a profit-motivated system, Bridges asks, can inexperienced people be accommodated?<\/p>\n<p><strong>The \u00e2\u20ac\u02dccomplicated people\u00e2\u20ac\u2122<\/strong><\/p>\n<p>When mental health care services in North Carolina were privatized, says Bridges, \u00e2\u20ac\u0153It was pretty clear that the more complicated people \u00e2\u20ac\u00a6 were not going to be served.\u00e2\u20ac\u009d<\/p>\n<p>That would include Jeff Kramer.<\/p>\n<p>Which means Valerie Kramer, who herself deals with a number of health issues, has continued to doggedly soldier through in pursuit of the care her son requires, to better learn how to maneuver through a system that baffles and beleaguers even the professionals within it.<\/p>\n<p>Bridges says that it takes a lot of money and time to create a system that those most in need can navigate, and \u00e2\u20ac\u0153if the value is a profit motive, nobody is going to create this kind of system because you can\u00e2\u20ac\u2122t make any money on it.\u00e2\u20ac\u009d<\/p>\n<p>Jeff will be released this week from Central Regional Hospital. He chose not to take antipsychotics while there and wasn\u00e2\u20ac\u2122t forcibly medicated. <\/p>\n<p>On the eve of his discharge, his mother reports that his \u00e2\u20ac\u0153mind seemed so clear today. The structured environment really helps. We all agree on that.\u00e2\u20ac\u009d <\/p>\n<p>A team that included a hospital social worker and psychiatrist and a member of Jeff\u00e2\u20ac\u2122s ACT team met to discuss his next steps. Jeff has agreed to return to the ACT program.<\/p>\n<p>About the immediate future, Valerie is today more optimistic than she was a week ago. \u00e2\u20ac\u0153But the long term,\u00e2\u20ac\u009d she adds, \u00e2\u20ac\u0153is still up in the air.\u00e2\u20ac\u009d<\/p>\n<p>That\u00e2\u20ac\u2122s because there\u00e2\u20ac\u2122s \u00e2\u20ac\u0153a lot of story\u00e2\u20ac\u009d \u00e2\u20ac\u201c this story of Valerie Kramer\u00e2\u20ac\u2122s son\u00e2\u20ac\u2122s struggle with schizophrenia \u00e2\u20ac\u201c a narrative made considerably more complex and uncertain by the failures of mental health care reform in this state.<\/p>\n<p><em>The names of the mental health care recipient and his mother have been changed.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>By Taylor Sisk Staff Writer This story is the third in a series about mental health care in North Carolina. [Breakdown series main page] \u00e2\u20ac\u0153There\u00e2\u20ac\u2122s a lot of story,\u00e2\u20ac\u009d says Valerie Kramer, assessing the narrative of her only child, Jeff. \u00e2\u20ac\u0153I get really angry,\u00e2\u20ac\u009d Kramer says. \u00e2\u20ac\u0153I see him so sick, and my son is&#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-3517","post","type-post","status-publish","format-standard","hentry","category-news"],"_links":{"self":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/3517","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=3517"}],"version-history":[{"count":4,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/3517\/revisions"}],"predecessor-version":[{"id":22437,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/3517\/revisions\/22437"}],"wp:attachment":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/media?parent=3517"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/categories?post=3517"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/tags?post=3517"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}