In this issue:

Implementation of Budget Cuts: LME budgets, non-core services, etc

Impact of State Budget Cuts on MHA-NC

Community Support

Case Management

Critical Access Behavioral Health Agency (CABHA)/Comprehensive Provider

Commission for MHDDSA Update

Appointment of Mike Watson as Assistant Secretary

Additional Legislation of Interest from 2009 session:
H243 - MH Enforcement Custody (Involuntary Commitment
S799 - Increase Transparency of MHDDSA Facilities (Death Reporting)
S884 - Electronic Surveillance Pilot MI Youth
H1189 - Tracking Outpatient Commitments

Important Note: Policies around service definitions, provider requirements, and funding are changing on a weekly basis. MHANC is working to keep up with policy change and provide reliable information, but given the pace of change this can be difficult. Current policy can be found on The NC Division of MHDDSAS website http://www.dhhs.state.nc.us/MHDDSAS/ under "implementation updates" or "communication bulletins"  as well as on the NC Division of Medical Assistance http://www.ncdhhs.gov/dma/index.htm (check under "Providers - Claims and Billing or Medicaid Bulletin or Proposed Medicaid Clinical Policies (for proposed service definitions changes)."

Implementation of Budget Cuts: LMEs were asked to provide plans for how they would utilize funding allocations, fund balances and reduce services based on about 60 million in cuts to state funded services. Plans were submitted and approved in November. Many LMEs have announced their plans and put information on their websites, but at this time that information is not available in one central location. A presentation and spreadsheet of funding reductions that was presented to the Legislative Oversight Committee http://www.ncleg.net/documentsites/committees/JLOCMH-DD-SAS/LOC%20Minutes%20and%20Handouts/Minutes%20for%202009/Minutes%20November%2010,%202009/LME%20Funding%20Reduction%20-%20Attach.%20No.%202.pdf in November. Summaries of many of the policy changes being implemented as a result of budget cuts can be found in the update below.

Impact of State Budget Cuts on MHA-NC: The Mental Health Association in North Carolina has for many years provided services to individuals including housing, residential services, psychosocial rehabilitation (PSR) and since the divestiture of services from Area Programs we have also provided Assertive Community Treatment, Community Support Teams, jail diversion and post-hospitalization follow-up, among others. Our organization achieved national accreditation from the Council for Quality Leadership; an organization that we feel accredits organizations based not only on "paper" qualifications, but more importantly on having a focus of serving people in the community in a way that promotes recovery and community integration and puts the person first. This fits clearly with our mission and our history.

Based on recent budget cuts and cuts to service rates, MHANC can no longer financially support many of the services we have provided. This is the direct result of budget cuts made in the most recent state budget. The funding we have been offered will not allow us to pay for the people and infrastructure necessary to deliver quality services. It is with much sadness that we will be ending contracts for PSRs and residential services in several parts of the state including the Sandhills, Crossroads Behavioral Health and Eastpointe, among others and letting go around 160 employees. MHANC had to make this decision based solely on money - it is not a reflection of the quality of services or performance of employees.

Community Support: The budget passed in August effectively ended Community Support (CS) as a Medicaid billable service as of June 30^th 2010, with the exception of services to some children as required by Medicaid EPSDT regulations. Reduction in CS funding for the first year of the budget (the current budget year) means that a rapid transition must occur: individuals receiving Community Support must be transitioned either out of service or into other services. At this time, new service definitions have been submitted to The Centers for Medicaid and Medicare services (CMS) and are awaiting approval - however, no service will "replace" CS. Some people will move to higher levels of care, in Community Support Teams or ACTT, some will utilize Psychosocial Rehabilitation/Clubhouse programs, Outpatient Therapy. Information collected by Medicaid indicates that about 1/3 of individuals did not need services - however another 1/3 needed a higher level of care and 1/3 need a CS level of support. Two new stand alone service definitions, Case Management and Peer Support, are expected to fill in some gaps for individuals needing person centered plan development and other case management functions or recovery and supportive services. 

Two important points about CS: 1) Individuals are continuing to get Community Support between now and January 1, 2010. The service is delivered by qualified and licensed professionals; the paraprofessional billing ended October 12^th. 2) Community Support, for purposes of case management only, will continue after January 1, until a new case management service definition is approved by CMS.

Community support authorizations and re-authorizations have been limited to 90 days and must include a discharge plan; it's not clear at this time what restrictions will be placed on authorizations and if the discharge plan will still need to be in place. State funded Community Support will end as well, but those admissions and authorizations are subject to LME budget constraints - many LMEs are ending or limiting CS as a result of cuts to state funds (IPRS dollars).  

Case Management: Based on the budget and Legislative direction, changes will be made to Medicaid case management across physical and mental health services over the next year with the goal of limiting case management to very specific defined elements (assessment, development of the person centered plan, referral and monitoring) and ensuring there is no duplication of case management across providers. Physical health case management will be centered in the individual's "medical home" and coordinated by Community Cares North Carolina. At this point, the plan is for case management in mental health, developmental disabilities and addictive disease to be provided by Critical Access Behavioral Health Agencies or through enhanced services which have case management embedded within them (for MH and SA) and by Targeted Case Management providers (for DD). [There is more information on CABHAs below.] The new case management definition and the CABHA model are awaiting approval from CMS (Federal Medicaid agency).  Because Medicaid intends to limit billing for case management to only one case management entity per month, mh/dd/sa providers and case managers are expected to coordinate with physical health providers.  Plans for case management are ongoing; rates, rate structure, timeline for implementation, staff qualifications, etc. have yet to be released.

Critical Access Behavioral Health Agency (CABHA)/Comprehensive Provider: Over the last year or two the idea of a more comprehensive, service integrated, provider model has been discussed by policymakers. This originally came about in response to problems with community support and questions about how to ensure individuals with mental illness and addiction are able to move along a continuum of care and how to ensure providers have a clinical focus while providing quality services.  Although Community Support is being eliminated, the idea of a "comprehensive" provider has lingered as a way to limit the migration of poor-quality Community Support providers from CS to other service platforms such as "Day Treatment" or "Intensive In-Home" (just used as examples). Some policy makers have stated that this will allow for easier management of the system since there will be fewer providers to oversee, especially now with the serious financial and physical constraints on resources.

The CABHA as currently outlined (but not yet approved) would require providers of Intensive In-Home, Day Treatment, and Community Support Team to provide a continuum of services including medication management, outpatient therapy, and comprehensive clinical assessment. In addition, they would need to provide two enhanced services such as case management, peer support, ACTT, PSR, etc. that "fit" together. Stand alone peer support and case management would only be able to be provided through the CABHA. CABHA providers serving fewer than 750 people could utilize a part-time medical director, while those serving more than 750 would need to retain a full-time director. CABHAs must employ a full-time clinical director and a full-time quality management staff/ training director. If the Medical director is a psychiatrist or physician the Med Director and Clinical Director functions can be performed by the same person, as a contract or employee. More details are provided in Implementation Updates #63 and #64 at http://www.ncdhhs.gov/mhddsas/servicedefinitions/servdefupdates/index.htm .

It's not yet clear if the policies being issued by the Division of MH/DD/SAS will go into effect as written or undergo additional changes. Officials at NC Division of Medical Assistance have included the CABHA model as the entity who will deliver the new stand alone service definition for Case Management, but have not yet submitted an explanation of CABHA to CMS. The Federal government usually requires states to allow "any willing provider" who meets very basic requirements to provide services under Medicaid, unless that state has an approved waiver to limit providers and consumer choice such as the one currently operating in the Piedmont LME region.  

There are several problems with going in the direction outlined in the CABHA model: it emphasizes large providers who can absorb the up-front additional costs of a medical director and other staffing requirements, its puts more emphasis on a medical model rather than a rehabilitative one, and it makes assumptions about the quality of service provision based on qualification of staff and size of the agency instead of the outcomes of individuals being served. In some communities, services like intensive in-home may be provided "part-time" by another health agency or by part time clinical staff. The new definition and CABHA requirements would not allow for part-time providers. Overall, the pace at which these changes are taking place is of great concern to advocates including MHANC. At the most recent LOC on MHDDSAS, Executive Director John Tote addressed the legislative members with three major concerns: 1) there is no information about how the referral process from LME to CABHA will work and if it will impede consumer choice,  2) coverting to this model is a costly process that providers must respond to in days and weeks, and 3) there has been no outlined vision for where we, as a state, intend to take our MHDDSA system thus there is no context for how the CABHA fits into the big picture. 

NC Mental Hope posted video of the CABHA debate at the LOC meeting. It can be viewed at http://ncmentalhope.org/ . [Video files are in Flash formats and information about downloading and viewing can be found at NC Mental Hope below the picture frames.]. Materials from the LOC meeting, including the CABHA presentation can be found at http://www.ncleg.net/gascripts/DocumentSites/browseDocSite.asp?nID=20&sFolderName=\LOC%20Minutes%20and%20Handouts\Minutes%20for%202009  

Commission for MHDDSA Update: The Commission for MHDDSA is one of the rule making entities for the MHDDSA system in North Carolina and has a mission to promote excellence.  There have been some recent changes to the Commission membership, beginning with former Gov. Easley's appointment of John Corne as Chair of the Commission. To view other recent appointments to the Commission, click here: http://www.ncdhhs.gov/mhddsas/commission/organization/commissionmembership.pdf.

Jerry Ratley with the Department of Justice was named Chair of the Rules Committee. The Rules Committee is a sub-group of the Commission established to provide guidance in Secretary Rules and to review in detail Commission Rules.  In most instances Secretary and Commission rules are first evaluated by the Rules Committee with final approval given by the full Commission for Commission Rules. Following is a link to the Rules Committee Roster: http://www.ncdhhs.gov/mhddsas/commission/organization/rulescommitteemembers.pdf

Larry Pittman with Southeastern Regional Medical Center was named Chair of the Advisory Committee.  The purpose of the Advisory Committee is to serve in an advisory capacity to the Secretary of DHHS by studying topic areas that impact people within the MHDDSA system, ultimately reporting back their findings and recommendations to the Secretary.  Following is a link to the Advisory Committee Roster: http://www.ncdhhs.gov/mhddsas/commission/organization/advisorycommitteemembers.pdf

The next Rules and Advisory Committee meetings will be held on January 20, 2009 at the Clarion Hotel.  The next full Commission meeting is scheduled for February 25, 2009 at the Clarion Hotel.  For more details about the work of the Commission or to view meeting updates and agendas, see the Commission website: http://www.ncdhhs.gov/mhddsas/commission/index.htm

Appointment of Mike Watson as Assistant Secretary: In September, DHHS Secretary Cansler appointed Sandhills LME Director Michael Watson to the new position of Assistant Secretary of Mental Health Services Development for the Department of Health and Human Services. Mr. Watson is charged with increasing community capacity of mental health, developmental disabilities and addiction services and supports as part of the overall effort by NC DHHS to oversee and improve the MH/DD/SAS system. New Assistant Secretary Watson is quoted in the NC DHHS press release as saying, "Our consumers and their families deserve and should expect access to effective community services. Despite the stark fiscal realities that confront our state, we must work to create a stable, competent and efficient provider network that meets the needs of our citizens." To read the entire release, go to http://www.ncdhhs.gov/pressrel/2009/2009-9-4-watson.htm . Legislative Oversight Committee on MH/DD/SAS members heard a bit about those stark realities when Mr. Watson addressed the committee in November, in part saying that recent budget cuts meant that some effective and innovative programs would be ended.

Additional Legislation of Interest from 2009 Session of the General Assembly: We covered a number of bills in our last update, but here are a few additional new laws that impact individuals with mental illness in North Carolina.

H243 - MH Enforcement Custody (Involuntary Commitment). This allows the facility conducting a first exam for involuntary commitment (for example an ER or community hospital) to end the commitment order, when appropriate, when a 24 hour facility is not available. The first examiner may also recommend outpatient commitment, if there is no facility available after 7 days, the 1st examiner can report this to the court and have the IVC proceedings terminated. New commitment procedures can be instituted, but not with the information from the previous order; the petitioner needs to show new evidence of need for involuntary commitment.

S799 - Increase Transparency of MHDDSA Facilities (Death Reporting): Requires state facilities to report, without redactions (except for personnel confidentiality) the death of a current or former client served who dies within 14 days of release. During the bill deliberation process advocates were asking for that to be extended to 30 days; 14 was the compromise. The bill also requires reports be released to state Protection and Advocacy agency (Disability Rights NC). It also allows the NC Secretary of Health and Human Services to release any information about incidents in state facilities (death or not) excluding identifying info about the person served. Note that much information about individuals who die in state facilities is already publicly available; this reporting extends to those who die elsewhere once they leave the facility, and clarifies to whom these reports should be sent. 

S884 - Electronic Surveillance Pilot MI Youth: This pilot program would allow for alternative staffing patterns and use of electronic surveillance of children and youth in residential facilities for a specific pilot program. The pilot use cameras to monitor children in their beds thus reducing the number of awake staff needed at night.  Advocates and DHSR have been cautious about this pilot; the widespread use of electronic  monitoring and reduced staffing is a concern given that just a few years ago following a group home death NC required increased staffing in youth group homes. It seems likely that this sort of surveillance will work well for specific populations, especially those traumatized individuals likely to be disturbed by someone stepping into a room to do a bed check and in specific settings where other indicators of quality care are being met.

H1189 - Tracking Outpatient Commitments: For involuntary outpatient commitment, the doctor or eligible psychologist is now required to inform LMEs of the outpatient commitment appointment. This bill also allows for telemedicine to be used by a doctor or eligible psychologist in conducting an IVC first exam and allows for a joint security force to be utilized for Long Leaf Neuro Medical Center and The Eastern School for the Deaf in Wilson County.

Final Note: MHANC encourages everyone to express their opinion about changes to the MHDDSA system to their elected officials, whether that is County Commissioners, General Assembly Representatives, or the Governor. If you need information on how to do so or if you have questions about mental health policy, please contact Erin McLaughlin at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it or Jennifer Mahan at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it or by calling 919-981-0740.

Happy Holidays and good tidings for the New Year!