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Links and Resources for 2008 Policy Priorities |
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System Reform/Transformation/Hospitals
One can hardly pick up a paper or turn on the news without hearing about “mental health reform” in North Carolina . Following the passage of HB381 in 2001, North Carolina embarked on
a process to change the governance and service delivery structure of local mental health, developmental disability and substance abuse systems. Area MH/DD/SAS Programs were expected to divest
themselves of delivering services and supports to people, separate management functions from service functions, contract with private for profit and non-profit service providers, consolidate from
42 separate organizations to achieve economies in administrative functions (we currently have 25 Local Management Entities - LMEs), and develop local consumer and family advisory councils to help
inform their practices. The reform law also directed the state (via the Department of Health and Human Services) to develop and implement a (new) plan for MH/DD/SA services, which included
defining who should receive services from the state, the expansion of evidence-based practices, downsizing state institutions and focusing the system on community based
care.
What went wrong? Very little new funding was provided to accomplish
any of these extensive reforms. Divestiture of services took place quickly, and sometimes before new, stable provider entities were in place. Oversight and monitoring was not adequately funded or
emphasized, and what did exist was lost in the need to adapt to constant policy change by the Legislature, Administration and consolidation processes at the local level. Workforce retention and
training was either not considered, or expected to be taken care of by the private providers, even though rates and regulations did not support it. Despite mandated consumer and family input,
stakeholder groups were not consulted and policy consequences were not adequately considered. Public funding sources could not adapt to a privatized model of care: some rates were too low to
attract providers, lack of start-up funding deterred others, and increasing costs coupled with slow or no payment drove some providers out of business. Where rates were reasonable, broad service
definitions, lack of oversight, and conflicting policy guidance combined to promote fraud, confusion, financial paybacks and inappropriate care. Quality indicators, benchmarks, and outcomes did
not drive the process of change at any level. Hospital downsizing began, although stable community based care was not increasing at a pace to keep up with demand for care. All
this during a time period when the state population is growing and private inpatient treatment is diminishing.
What is next? North Carolina can have a MH/DD/SAS system we can all be proud of: a number of LMEs are making
“reform” work for those they serve, some have reduced use of inpatient and crisis care and expanded community based best practices, and recovery based programs are helping persons
with mental illness live healthy lives. We have world renowned university researchers, mental health experts, consumers and families able to advise on which changes we should make. In the end,
our system should be based on ensuring that everything we do results in quality outcomes for the people we serve, not just serving more and more by doling out a little bit of help to
each. MHA-NC recommends that the first steps are 1) include consumers and families in the process at every level; 2) stabilize the system by limiting policy changes and
piloting new policies/programs before statewide implementation; 3) improve crisis care across the state and ensure that persons with mental illness have access to clinical care; 4) create and
implement workforce recruitment, retention and training plans to address professional and direct care needs and; 5) fund the management and service delivery system created to ensure access to
services and supports.
Links and resources for more information on these
issues:
MHA-NC reform “primer” – the basics on reform 2000 to now from MHA-NC can be found
on our Advocacy page:
http://www.mha-nc.org/english/index.php/Advocacy.html
NC Psychiatric
Association reports cards on reform, funding, and access to psychiatry can be found at the bottom of the NCPA homepage at
http://www.ncpsychiatry.org/
State Plan for MH/DD/SAS: Information on The Division of MH/DD/SAS System Transformation, including the current state plan can be found
at:
http://www.ncdhhs.gov/mhddsas/stateplanimplementation/index.htm
The Legislative Oversight Committee on MH/DD/SAS is charged with examining “system wide issues affecting the development, financing, administration, and
delivery of mental health, developmental disabilities, and substance abuse services” [statute listing purpose of committee can be found at: http://www.ncleg.net/enactedlegislation/statutes/html/bysection/
chapter_120/gs_120-241.html]
Information from the LOC on MH/DD/SAS, including past reports, agendas, meeting dates can be found at http://www.ncleg.net/gascripts/DocumentSites/browseDocSite.asp?nID=20
News and Observer series “Mental Disorder: The Failure of Reform” and related articles can be found on the N&O
website:
http://www.newsobserver.com/news/health_science/mental_health/
Smoky Mountain News – “The State of Mental Health Care” by
Julia Merchant:
http://www.smokymountainnews.com/issues/01_08/01_16_08/fr_mental_
health.html
Winston Salem Journal series from 2005 “Breakdown, Crisis in Mental Health Care”
http://www.journalnow.com/servlet/Satellite?pagename=WSJ/Page/WSJ_ContentPage&c=Page&cid=1128768676103
Access to a Continuum of
Care
Persons with mental illness need consistent, quality community
based services that emphasize recovery principles. These should include a full continuum of care: assessment, crisis services, inpatient care, some form of case management (or “recovery
coordinators”) to oversee care and navigate complex needs, a plan for care developed based on their strengths and input, and community based services that work with them to meet their
specific needs and achieve their goals whether that is housing, support, therapy, medical care, employment, and/or relationships. Access
to a medical “home” ensuring physical and mental health needs are met is crucial,
as is access to appropriate medications. MHA-NC supports persons with mental illness having open access to therapeutic medications: at this point, medications for mental illness are not
interchangeable. The therapeutic value of medication is different for each person and must be focused on the needs of the individual in consultation with their
prescriber.
Our MH/DD/SAS system continues to be
under-funded. Programs regularly run out of funds for persons who have no health insurance and little to no income. The system cannot support a large influx of service dollars without first
considering were they would be best utilized and ensuring a balance between funding for start-up and funding for service delivery. Despite this, we do need more service dollars and a fair way to
distribute them across 25 LME catchement areas.
Surgeon General’s
Report: Released in 1999, the information and recommendations are still valid today
http://www.surgeongeneral.gov/library/mentalhealth/home.html
President’s New Freedom Report: Outlines the kinds of support and services that people need and many do not get.
http://www.mentalhealthcommission.gov/reports/FinalReport/toc.html
Funding needs? Here are two perspectives, although both agree that in order to ensure access to care, especially for those who are
“indigent,” services need more funding:
http://ncpsychiatry.org/NCPA_Report_Card_II_-_Final1.pdf
http://www.ncleg.net/fiscalresearch/frd_reports/frd_reports_pdfs/2007_
fiscal_briefings/mental_health_briefing_feb_7_2007.pdf
Mental Health
America – Position on “Access to Care”
http://www.nmha.org/go/position-statements/71
Mental Health America – “Issue Briefs – Access to
Medications”
http://www1.nmha.org/affil_extra/advocacy/briefsAccessMedications.cfm
CATIE Study info:
http://www.mentalhealthamerica.net/go/research/catie/advocate
Mental Health America Position Statement – Access to
Medications
http://www.nmha.org/go/position-statements/32
National Alliance on Mental Illness (NAMI) – “Access to Effective Medications: A Critical Link to
Mental Illness Recovery”
http://www.nami.org/Content/ContentGroups/E-News/20003/July_20002/Access_to_Effective_Medications__A_Critical_
Link_to_Mental_Illness_Recovery1.htm
Law Enforcement and Jails
Sadly, our prisons have become the largest providers of mental health services. According to a recent report, jails across NC have inadequate resources, training, and policies to
deal with people with mental illness. In North Carolina , Sheriffs departments are responsible for the transport of individuals needing to be
involuntarily committed. With increased admissions and commitments, Sheriffs spend more and more time and resources devoted to this task. One unintended
consequence of reform is that LMEs no longer had the funds to assign staff to work with jails; consumers may go without any contact with their treatment team or access to medications. Those in
jail not known to the MH/DD/SAS system wait weeks or months for assessments and help. There are numerous programs and policies that can help ensure that persons with mental illness who come in
contact with law enforcement and the courts have better outcomes: Community Intervention Training (CIT), other law enforcement training, jail diversion projects, Mental Health Resource Courts,
retaining Medicaid eligibility in jail, and funding treatment. Below are some sources that discuss these issues in depth.
Mental Health Criminal Justice Consensus Project
http://consensusproject.org/
Governor’s Advocacy Council for Persons with Disabilities – “North Carolina Jails and
Inmates with Mental Illnesses and Developmental Disabilities:”
http://www.gacpd.com/publications/JAILStudies--report.pdf
North Carolina
Jail Diversion Program
http://www.ncdhhs.gov/mhddsas/justice/jaildiversion/index.htm
NAMI - Prison
rules affecting people with mental illness:
http://www.naminc.org/dihoff_documents/%20August%2030MLamb.pdf
Returning Veterans and Reserve
North Carolina is home to the fourth largest group of active and retired
military in the country, estimated to represent 10% of our population. About 30% of the US military serving in Iraq or Afghanistan are National Guard and Reservists with limited access
to Veterans Administration resources. Over 20% of active duty, and more than 40%
of reserve soldiers, are identified as requiring mental health treatment. Soldiers frequently reported alcohol concerns, yet very few were referred to treatment. A common misconception is
that our military members and families have full access to health care benefits, including mental health care. The reality for them is a complex system of benefits, insurance
plans, providers, and veterans’ centers which may or may not cover these services. The issue is further complicated by the intense stigma
of mental illness, addiction, and related conditions within the military. Many of those returning from battlefields are diagnosed with post–traumatic stress, traumatic brain injuries, and
other brain disorders and may have used/or use alcohol and drugs in an attempt to cope with the aftermath. MHA-NC is committed to working with the local, state, and federal agencies to create
policy change and new programs to support veterans.
Citizen Soldier Support
Project – Ribbons to Reality
http://www.ribbonstoreality.org/
Recent Government Accountability Office (GAO) Reports on Veterans Health Care and Disability
Benefits:
http://www.gao.gov/docsearch/featured/healthcaredisabilitybenefits.html
State Center for Health Statistics -
“Health conditions and behaviors among North Carolina and United States military veterans compared to non-veterans” by Ziya
Gizlice
http://www.schs.state.nc.us/SCHS/pdf/SCHS-133.pdf
USA Today – “Veteran Stress Cases Up
Sharply” by Greg Zoroya
http://www.usatoday.com/news/washington/2007-10-18-veterans-stress_N.htm
News and Observer – “Fighting War’s Demons, Soldier Seeks
Help” by Barbara Barrett
http://www.newsobserver.com/2710/story/770680.html
The Californian – NC Times - “Stretched Thin: Concern Mounts Over
Soldiers’ Mental Health Care” by Jon Sarche
http://www.nctimes.com/articles/2004/12/29/military/17_59_5212_28_
04.txt
Involuntary Commitment and Gun Permits
Mental Health
Association in North Carolina Executive Director John Tote’s statement regarding the gun debate and treating persons with mental illness.
http://www.mha-nc.org/english/index.php/Advocate-s-Perspective-2/21/08.html
Mental Health America – 2008 policy statement on
violence
http://www.nmha.org/go/position-statements/72
Mental Health America Position
Statement – Standards for management of and access to consumer information
http://www.mentalhealthamerica.net/go/position-statements/27
NAMI – “National Gun
Reporting Law”
http://www.nami.org/Content/ContentGroups/E-News/20073/June7/House_Passes_National_Gun_Reporting_Law.htm
Mental Health America – Position statement on involuntary commitment
http://www.nmha.org/go/position-statements/22
Collaborative/Coalition Initiatives
MHA-NC participates
in numerous state level coalitions and collaborative partnerships that are crucial for moving our advocacy efforts forward. Below are the websites of a few of our coalitions and collaborative
partners:
Coalition for Persons Disabled by Mental
Illness
www.cpdmi.org
The Coalition (formerly
Coalition 2001)
http://www.coalition2001.org/
CPDMI and
Coalition Cyber-Advocacy site (Look up elected officials, respond to alerts, send letters!)
http://capwiz.com/cdpmi/home/
NC Collaborative For Children, Youth and Families
www.nccollaborative.org
Covenant with North Carolina ’s Children (link to cyber advocacy
site)
www.nccovenant.org
Housing
Safe permanent housing is one of the missing
elements in a system of care for adults with mental illness. For many disabled persons, Social Security Disability payments do not provide enough income to afford market value housing. MHA-NC
continues to work to develop housing and advance support for housing for persons with mental illness. In past years, the majority of the funding has come from Federal agencies like Housing and
Urban Development (HUD) and was directed to disability specific housing projects. Over the years, HUD bureaucracy has become more and more difficult to navigate as funding has decreased. New
models of developing housing for low income people with mental illness or other disabilities now focuses on tax credit programs for developers, mixed-income developments, and housing for
“disabled” populations that are not specific to any one illness or condition.
North Carolina Housing Finance Agency – Housing 400 Initiative
http://www.nchfa.com/About/housing400.aspx
North Carolina Housing Coalition – Housing for People with Disabilities
http://www.nchousing.org/advocacy/housing_issues_nc/housing_for_
people_with_disabilities
Insurance
The mental health parity bill passed in the
2007 session goes into effect for group insurance plans July 1, 2008. Many plans are effective for a calendar year Jan – Dec,
so expanded coverage may not take effect for most health care consumers until January of 2009. HB 973 covers all group plans and requires plans to include mental health coverage. Nine diagnoses
are covered at full parity – bipolar disorder, major depressive disorder, obsessive compulsive disorder, paranoid and other psychotic disorder, schizoaffective disorder, schizophrenia,
PTSD, anorexia nervosa and bulimia. All other mental illness diagnoses have financial parity – meaning deductibles, coinsurance factors, co-payments, maximum out-of-pocket as well as
annual and lifetime limits must be the same as for physical illnesses. Mental illness diagnoses not included in the 9 listed above may have different durational limits, but the minimum
benefit required must provide for thirty (30) combined inpatient and outpatient days per year and thirty (30) office visits per year. We are excited about working with the Substance Abuse
Federation as they begin to strategize about expanding the law to cover addictive disease.
House Bill 973 – Ratified Bill:
http://www.ncleg.net/Sessions/2007/Bills/House/HTML/H973v6.html
Child, Youth
and School Mental Health Issues
North Carolina has been a proponent for system of care principles to be utilized for children with mental health needs, and those involved with other child serving agencies. System of care
(at its most basic) refers to the idea of supporting children and their families by wrapping services around them, focusing on family and child strengths, and coordinating care amongst the many
child and family serving agencies that are involved in the life of the child. System of care may also refer to a specific program that utilizes these ideas along with others to serve children and
families. Please see the links below for more information. MHA-NC was a founding member of the Collaborative for Children Youth and Families and continues to work with them to
strengthen the inter-agency, advocacy, and family collaboration that began 10 years ago.
It is critical that North Carolina addresses children’s mental health needs from early intervention to services for youth in transition to adulthood. Although we have
a
model for collaboration that is the envy of other states, there is much more to do to ensure that collaboration happens in each family for each child. Much attention has been paid recently to
NC’s dropout problem and low high school graduation rate. The rate for students with disabilities is the LOWEST among any group currently tracked. Last year 4 LEAs did not graduate any of
their disabled students. Many policy
changes and programs can help to change this: anti-bullying legislation and
programs, mental health services in schools, family advocacy to help with Individual Education Plans (IEPs), alternatives to school suspension, positive behavioral
support (PBS) programs, specialized services and alternative school programs, to name a few. Many more may be discovered if we focus funds for dropout prevention
on developing model programs and interventions for students with disabilities.
North Carolina Collaborative for Children, Youth and Families Homepage:
http://www.nccollaborative.org/page.php?mode=privateview&pageID=1
School Based Behavioral and Mental Health Workgroup:
http://www.nccollaborative.org/page.php?mode=privateview&pageID=10
Shared Work highlights the efforts of school mental health and other child
related practice groups, including those from North Carolina . We are doing great work here
– register on the site to check it out!
www.sharedwork.org
Office of Special
Education Programs (OSEP) - National Dropout Data (pg. 69-73)
http://www.ed.gov/about/reports/annual/osep/2003/25th-vol-1-sec-1.pdf
OSEP – North Carolina Dropout Data (pg.
148-149)
http://www.ed.gov/about/reports/annual/osep/2003/25th-vol-1-sec-2.pdf
National High School Center
– “Dropout Prevention for Students with Disabilities”
http://www.betterhighschools.org/docs/NHSC_DropoutPrevention_
052507.pdf
NAMI – “Virginia Tech Tragedy: Responses and Resources”
http://www.nami.org/Content/NavigationMenu/Top_Story/Virginia_
Tech_Tragedy_Responses_and_Resources.htm
Employment
In our
society, employment is central to feelings of self worth, to connecting with others, and to achieving financial independence. Persons with mental illness should
be able to choose, obtain, and maintain employment, but current policies prevent this from taking place. People with mental illness often qualify for their health care service by virtue of being
on social security disability. They need a way to continue health benefits while employed, or while transitioning to employer based health care. A Medicaid buy-in program (part of Ticket to Work)
has been authorized for the state, but put on hold due to our lack of information technology infrastructure. Other consumers need support to develop work skills and
interpersonal skills that make permanent employment possible, while others may need to work in structured environments. The goal is to enable employment choice by individuals. Many states
are looking to Peer Support Specialists programs to provide both peer-to-peer supportive services for people with mental illness, as well as job opportunities for those who once experienced the
same problems. Several service definitions in North Carolina allow for peer support specialists working within a treatment team, but NC is not yet funding stand alone peer support services on a
statewide basis.
SAMHSA – Supported
Employment http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/
employment/
NAMI – Supported Employment
http://www.nami.org/Template.cfm?Section=TRIAD&Template=/ContentManagement/ContentDisplay
.cfm&ContentID=19919
Social Security Administration – Ticket-to-Work Program
http://www.socialsecurity.gov/work/ResourcesToolkit/legisregfact.html#top
Peer Support Specialist Program at UNC School of Social
Work
http://bhrp.sowo.unc.edu/index.php?q=node/122
Article on a training program in Winston-Salem
http://mentalhopenews.blogspot.com/2008/02/peer-support-program-emphasizes-whats.html
Georgia Peer Specialist Project (The links on the left, CPS job description, code of ethics, and Medicaid guidelines have good
info.)
http://www.gacps.org/Home.html
Georgia Peer Support Project (has a definition of peer support on the right side of the
page)
http://www.disabilitylink.org/docs/psp/peersupport.html
Research base of peer-run support through
the National Empowerment Center website (www.power2u.org
)
http://www.power2u.org/emerging_research_base.html
Much thanks to Bekah Kingston, Public
Policy Intern at MHA-NC for helping to put together the resources and links in this document. If you have any questions about these policy priorities or you would like to know how you can get
involved as an advocate, please contact Jennifer Mahan, Director of Policy and Advocacy Initiatives, Mental Health Association in North Carolina , 919-981-0740 x270 or
This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
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