
{"id":8079,"date":"2009-11-19T16:57:18","date_gmt":"2009-11-20T00:57:18","guid":{"rendered":"http:\/\/www.carrborocitizen.com\/main\/?p=8079"},"modified":"2009-11-28T14:37:41","modified_gmt":"2009-11-28T22:37:41","slug":"caution-optimism-on-mental-health-care-change","status":"publish","type":"post","link":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/2009\/11\/19\/caution-optimism-on-mental-health-care-change\/","title":{"rendered":"Caution, optimism on mental health care change"},"content":{"rendered":"<p><strong>By Taylor Sisk, Staff Writer<\/strong><\/p>\n<p>As the number of people with mental illness going without care in North Carolina continues to rise, there\u00e2\u20ac\u2122s been a recent shift in how the state will be provisioning those services.<!--more--><\/p>\n<p>The concept behind the new mental health care model announced earlier this month by the North Carolina Department of Health and Human Services is a good one, said Thava Mahadevan, director of XDS Inc., a mental health care provider in Chapel Hill.<\/p>\n<p>The idea was to create a new definition and description of mental health care providers called critical access behavioral health agencies, to go into effect Jan. 1. These agencies will be tasked with providing a comprehensive set of services to people living with mental illness. The agencies must provide four core services: case management for those with mental illness or a substance-abuse problem, comprehensive clinical assessment, medication management and outpatient therapy. They also must provide two additional services from a list that includes intensive in-home care, therapeutic family services, day treatment, psychosocial rehabilitation, a mobile crisis team and six others.<\/p>\n<p>While Mahadevan sees the potential upside of this move, he\u00e2\u20ac\u2122s concerned that many service providers, perhaps his own, don\u00e2\u20ac\u2122t have the infrastructure in place to meet this criteria. <\/p>\n<p>\u00e2\u20ac\u0153The concept is not a bad one,\u00e2\u20ac\u009d Mahadevan said. \u00e2\u20ac\u0153Having a comprehensive service agency, being able to provide all-inclusive services without brokering and sending the person out to different places \u00e2\u20ac\u201c that\u00e2\u20ac\u2122s how we\u00e2\u20ac\u2122ve always designed ourselves. But I think our biggest worry is the way it\u00e2\u20ac\u2122s being put out. It\u00e2\u20ac\u2122s too quick.\u00e2\u20ac\u009d<\/p>\n<p>As of July 1, 2010, those service providers that are unable to comply will no longer be eligible to receive Medicaid money for these services. Most will be forced to go out of business. Many people will go without care until transitioning to a new agency. Some will never find their way.<\/p>\n<p><strong>The \u00e2\u20ac\u02dcnew\u00e2\u20ac\u2122 model<\/strong><br \/>\nThis new model of mental health care provider, the critical access behavioral health agency, or CABHA, is in fact similar to the old model, the one that was disassembled under mental health care reform in North Carolina, which was implemented in 2001. The idea behind reform was to move people out of our state mental institutions and to provide them with more services within their own communities. While prior to reform, an array of services was provided by community mental health clinics, often under one roof, reform measures prescribed that services be offered by private providers \u00e2\u20ac\u201c some for profit, some not \u00e2\u20ac\u201c with funding from federal, state and local dollars.<\/p>\n<p>In most communities, particularly rural ones, a comprehensive set of services never materialized under the new model. Many providers cherry-picked services, extending only those that could most easily and profitably be provided. State mental institutions became even more overcrowded than before. The media and legislators began referring to people living with mental illness as \u00e2\u20ac\u0153falling through the cracks.\u00e2\u20ac\u009d Those cracks became chasms, and today the state faces a deeply seeded crisis.<\/p>\n<p>Newly-appointed state Senate majority leader Martin Nesbitt and Verla Insko, who represents southern Orange County in the state House, are co-chairs of the joint legislative committee on mental health, developmental disabilities and substance abuse. Last week, Nesbitt told his colleagues that the General Assembly had erred in cutting so severely into mental health care services. Insko this week agreed.<\/p>\n<p>\u00e2\u20ac\u0153We were not prepared to deal with the cuts that came as a result of that last $40 million coming out,\u00e2\u20ac\u009d she said of the cuts made to local management entities, which were direct service cuts to people without insurance. \u00e2\u20ac\u0153It\u00e2\u20ac\u2122s had a huge impact.\u00e2\u20ac\u009d <\/p>\n<p>\u00e2\u20ac\u0153We had discussed that as a committee,\u00e2\u20ac\u009d Insko said, \u00e2\u20ac\u0153and took a look at the impact it would have on the system, and decided the system could not absorb that.\u00e2\u20ac\u009d  <\/p>\n<p>Throughout the budget debate, health care advocates warned of the dire consequences of cutting too deeply into services. The cuts were nonetheless made.<\/p>\n<p><strong>\u00e2\u20ac\u02dcA pendulum swing\u00e2\u20ac\u2122 <\/strong><br \/>\nCompletely eliminated from the state budget were community support services, including assistance with everyday activities such as paying bills and picking up medications, that help those with mental illness be more productive members of their communities. These services came under scrutiny for rampant overbilling by some service providers, and new Department of Health and Human Services (DHHS) Secretary Lanier Cansler said he wants to build a system that focuses on more \u00e2\u20ac\u0153clinically founded\u00e2\u20ac\u009d care.<\/p>\n<p>\u00e2\u20ac\u0153I\u00e2\u20ac\u2122m all for that,\u00e2\u20ac\u009d said Bebe Smith, co-director of UNC\u00e2\u20ac\u2122s Center for Excellence in Community Mental Health and director of Schizophrenia Treatment and Evaluation Program Outpatient Services, which has offices in Carr Mill Mall. But she warns against overcompensating.<\/p>\n<p>\u00e2\u20ac\u0153I do see that there\u00e2\u20ac\u2122s this pendulum swing,\u00e2\u20ac\u009d Smith said. \u00e2\u20ac\u0153I thought that the idea of community support as a service fit very well with what I thought people with severe and persistent mental illness really needed.\u00e2\u20ac\u009d <\/p>\n<p>The way it was defined, she said, allowed for \u00e2\u20ac\u0153relationship building \u00e2\u20ac\u201c doing some clinical work, but also doing case management and focusing on helping people find housing and getting connected\u00e2\u20ac\u009d with medical and other services<br \/>\nEarly on, when community support services were being advanced, Smith said, the general view was that \u00e2\u20ac\u0153psychotherapy is the old way; community support is the new way.\u00e2\u20ac\u009d<\/p>\n<p>\u00e2\u20ac\u0153Now what I\u00e2\u20ac\u2122m seeing,\u00e2\u20ac\u009d she said, \u00e2\u20ac\u0153is the pendulum swinging in completely the opposite direction, to saying, \u00e2\u20ac\u02dcWe\u00e2\u20ac\u2122ve got to get back to the clinically sound services. Psychotherapy is in again, and everybody\u00e2\u20ac\u2122s got to have a psychiatrist.\u00e2\u20ac\u2122 But I think we\u00e2\u20ac\u2122re going a little bit too far.\u00e2\u20ac\u009d<\/p>\n<p>A complement of clinical and community services are required, Smith said, and she hopes the new CABHA model is intended to acknowledge that.<br \/>\nMeanwhile, community support services are due to expire at the end of the year. There has been some talk within DHHS of extending at least some of those services until a new service definition can be established and approved by the federal government. But as things now stand, though some providers, including XDS, will continue to offer whatever services they can \u00e2\u20ac\u201c without compensation \u00e2\u20ac\u201c for many in need, there will be, in Mahadevan\u00e2\u20ac\u2122s words, \u00e2\u20ac\u0153literally nothing.\u00e2\u20ac\u009d <\/p>\n<p><strong>Reason for hope?<\/strong><br \/>\nInsko says that reform in practice has been much different from reform in theory.<br \/>\n\u00e2\u20ac\u0153I had always supported and found the need for a comprehensive agency that could be the clinical home for a person with mental illness and substance abuse [issues],\u00e2\u20ac\u009d she said. \u00e2\u20ac\u0153And so that in itself is consistent with the intention of reform.\u00e2\u20ac\u009d <\/p>\n<p>She emphasizes, though, that consolidating services shouldn\u00e2\u20ac\u2122t \u00e2\u20ac\u0153mean that we do away with all the small providers.\u00e2\u20ac\u009d<\/p>\n<p>Which is a concern Mahadevan and Smith share. While they\u00e2\u20ac\u2122re hoping that with the implementation of the CABHA model early next year, single-provider comprehensive care will become more widely available \u00e2\u20ac\u201c in other words, that the new model will hold many of the strengths of the one the state disassembled with reform \u00e2\u20ac\u201c both are hearing that there may be as few as 50 current service providers in the state that meet the DHHS criteria for CABHA designation.<\/p>\n<p>\u00e2\u20ac\u0153What I\u00e2\u20ac\u2122ve heard is that the intention of the state is to really narrow the field of providers across the state,\u00e2\u20ac\u009d Smith said. She acknowledges the need to try to eliminate the fraudulent or poorer-quality providers. \u00e2\u20ac\u0153But I think the way they\u00e2\u20ac\u2122ve got it defined now, they\u00e2\u20ac\u2122re really at risk of eliminating some quality small providers.\u00e2\u20ac\u009d<\/p>\n<p>Another concern for Mahadevan is that what\u00e2\u20ac\u2122s still missing is an outcome-based approach to providing good and comprehensive mental health care.<\/p>\n<p>\u00e2\u20ac\u0153It\u00e2\u20ac\u2122s good to have these concepts put out there,\u00e2\u20ac\u009d he said, \u00e2\u20ac\u0153but I think they need to come and look at agencies \u00e2\u20ac\u00a6 and ask, \u00e2\u20ac\u02dcHow many of your clients are ending up in the hospital on a regular basis?\u00e2\u20ac\u2122 \u00e2\u20ac\u02dcHow many of your clients are in jail?\u00e2\u20ac\u2122<br \/>\n\u00e2\u20ac\u0153Somehow the outcome of the client is still missing; somehow that\u00e2\u20ac\u2122s not tied in.\u00e2\u20ac\u009d<\/p>\n<p>Simply put, Mahadevan said, DHHS needs to be asking of service providers: \u00e2\u20ac\u0153How are you performing?\u00e2\u20ac\u009d<\/p>\n<p>Another issue, posed by Bebe Smith, is a very practical matter: \u00e2\u20ac\u0153How many licensed professionals are you going to find across the state that are going to be willing to work with the poor and very ill?\u00e2\u20ac\u009d she asked. \u00e2\u20ac\u0153Because I think we\u00e2\u20ac\u2122ve really destroyed the workforce. Licensed clinicians have gone into private practice or they\u00e2\u20ac\u2122ve gone into other careers.\u00e2\u20ac\u009d <\/p>\n<p>Who\u00e2\u20ac\u2122s now going to fill the jobs required to provide clinical services within these CABHAs? <\/p>\n<p>\u00e2\u20ac\u0153And then the other question,\u00e2\u20ac\u009d Smith said, \u00e2\u20ac\u0153is, \u00e2\u20ac\u02dcHow are you going to make it possible for the private providers to afford to have all of the clinical staff.\u00e2\u20ac\u2122\u00e2\u20ac\u009d<\/p>\n<p>Still, many mental health care advocates across the state are guardedly optimistic that things could be moving in the right direction. Some have spoken encouragingly of the appointment of Michael Watson as DHHS assistant secretary. Watson has extensive experience in the field, having served as director of the Sand Hills mental health center.<\/p>\n<p>Insko said that she believes \u00e2\u20ac\u0153everyone at the state level is concerned about extending existing services so that people don\u00e2\u20ac\u2122t fall through the cracks.\u00e2\u20ac\u009d<\/p>\n<p>Smith has spoken with both Cansler and Watson: \u00e2\u20ac\u0153I\u00e2\u20ac\u2122m trying to talk to people and say we know how to provide good care for people with severe mental illness, and there\u00e2\u20ac\u2122s no reason we shouldn\u00e2\u20ac\u2122t be able to do that. You don\u00e2\u20ac\u2122t have to do it in a way that\u00e2\u20ac\u2122s going to require a huge amount of funds. It\u00e2\u20ac\u2122s a level of basic care that people need, and it includes the psychiatric treatment and it includes the case management to get people to the psychiatric treatment and to get them to the medical treatment. That\u00e2\u20ac\u2122s really the basic stuff. <\/p>\n<p>\u00e2\u20ac\u0153We\u00e2\u20ac\u2122ve got to start with getting people\u00e2\u20ac\u2122s basic needs met and keeping them safe. I mean, we\u00e2\u20ac\u2122re really at risk of people not being safe.\u00e2\u20ac\u009d<\/p>\n","protected":false},"excerpt":{"rendered":"<p>By Taylor Sisk, Staff Writer As the number of people with mental illness going without care in North Carolina continues to rise, there\u00e2\u20ac\u2122s been a recent shift in how the state will be provisioning those services.<\/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-8079","post","type-post","status-publish","format-standard","hentry","category-news"],"_links":{"self":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/8079","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=8079"}],"version-history":[{"count":2,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/8079\/revisions"}],"predecessor-version":[{"id":8178,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/posts\/8079\/revisions\/8178"}],"wp:attachment":[{"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/media?parent=8079"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/categories?post=8079"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.ibiblio.org\/carrborocitizen\/main\/wp-json\/wp\/v2\/tags?post=8079"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}