HomeMy WebLinkAboutAgenda - 12-15-2009 - 3bORANGE COUNTY
BOARD OF COMMISSIONERS
ACTION AGENDA ITEM ABSTRACT
Meeting Date: December 15, 2009
Action Agenda!
Item No. 3 - b
SUBJECT: Town of Chapel Hill Mayor Kevin Foy's Mental Health Task Force Report
DEPARTMENT: County Manager PUBLIC HEARING: (Y/N) No
ATTACHMENT(S): INFORMATION CONTACT:
Report Natalie Ammarell, Convener/Consultant,
Mayor Kevin Foy's Mental Health
Task Force, 967-3062
Gwen Harvey, Assistant County
Manager, 245-2307
PURPOSE: To present to the Board with the final report of Chapel Hill Mayor Kevin Foy's
Mental Health Task Force.
BACKGROUND: On October 15, 2008 Chapel Hill Mayor Kevin Foy announced the
establishment of a Mental Health Task Force to discuss, examine, and assess the provision of
mental health care in Chapel Hill. The Mayor asked the Task Force to:
• Assess the state of the mental health care system in the greater Chapel Hill community,
focusing on services provided, funding, and impact on the community as a whole;
• Create a broader awareness of mental health care issues in Chapel Hill and generate
public discussion; and
• Provide recommendations regarding the future of mental health care services for
residents of Chapel Hill and Orange County.
Mayor Foy appointed a broad spectrum of concerned residents, including government officials,
service providers, and advocacy groups to participate on the Task Force. The Task Force held
two public listening sessions and engaged in a series of educational conversations over the
course of its proceedings which concluded in the fall of 2009. The final report of the Task Force
is being presented to Orange County elected bodies and other interested parties.
FINANCIAL IMPACT: There is no financial impact associated with the Board receiving the
Mayor's Mental Health Task Force Report as information.
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RECOMMENDATION(S): The Manager recommends the Board receive the Report.
MAYOR'S MENTAL HEALTH TASK FORCE
REPORT
October, 2009
MENTAL HEALTH TASK FORCE REPORT
MAYOR'S MENTAL HEALTH TASK FORCE
MEMBER LISTING
Natalie Ammarell, Chair Judy Truitt
Human Service Systems Director
Orange-Person-Chatham Area Prograrn
Rick Allen
President Michelle Turner, MSW, LCSW
Inter-Faith Council for Social Service Chapel Hill Police Department Crisis Unit
Kate Barrett, MSW, LCSW
Aging Transitions Administrator
Orange County Department on Aging
David Chapman
President/CEO
Caramore Community, Inc.
Linda Foxworth
Director
Kidscope
John Gilmore
Vice-Chair
UNC Department of Psychiatry
Gwen Harvey
Assistant Manager
Orange County
Trish Hussey
Executive Director
Freedom House
Thava Mahadevan
Executive Director
XDS, Inc.
Tom Reid
Carolina Outreach
Anna Scheyett
Associate Dean for Academic Affairs
UNC School of Social Work
Clay Whitehead
Advanced Psychotherapeutics
ACTIVE TASK FORCE PARTICIPANTS
Cim Brailer
Orange-Person-Chatham Area Prograrn
Lisa Lackmann
Orange-Person-Chatham Area Program
Barbara Smith
Department of Psychiatry
University of North Carolina at Chapel Hill
STAFF ASSISTANCE
Carlo Robustelli
Mayoral Aide
Andrew Pham
Mayoral Intern
Naveed Hassan
Mayoral Intern
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Mark Sullivan
Director
Mental Health Association Orange County
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MENTAL HEALTH TASK FORCE REPORT
i. Task Force Creation and Activities
On October 15, 2008 Mayor Kevin C. Foy announced the establishment of a Mental Health Task Force to
discuss, examine and assess the provision of mental health care in Chapel Hill (see Attachment: A). The Mayor
noted:
The future of mental health care is uncertain. Over the past seven years mental health programs
in counties across North Carolina (including Orange County) have either discontinued servi~;es or
become independent nonprofit organizations operating with limited resources.
The location of UNC Hospitals, a state hospital, uniquely affects Chapel Hill and Orange County.
Patients from around North Carolina who need mental health services may choose UNC Hospitals
as their treatment provider. UNC Hospitals can therefore serve as the initial access point to
Chapel Hill for some patients. Patients who seek care at UNC may remain in the area upon
discharge. Because of the current situation regarding treatment options, discharged individuals
can have trouble getting access to ongoing treatment. Local nonprofits attempt to provide
services, but often face the obstacles of limited budgets and limited staff.
The Mayor asked the Task Force to:
^ assess the state of the mental health care system in the greater Chapel Hill community, focusing
on the services provided, funding, and impact on the community as a whole;
^ create broader awareness of mental health care issues in Chapel Hill and generate discussion; and
^ provide recommendations regarding the future of mental health care services for residents of
Chapel Hill and Orange County.
From the outset, it was the intent of the Mayor that the Task Force understand "the community as a
whole" to mean both the Town of Chapel Hill and its environs -extending to Orange County as a whole. The
composition of the Task Force reflects this intent and to the extent possible this thought guided the Task
Force's work.
A BRIEF NOTE; From the outset, we wish to note that throughout its deliberations, and in this
report, the Mayor's Menta/Health Task Force defined "mental hea/th services/system ~ to
encompasses the menta/hea/th (community and institutiona/), deve%pmental disabilities and
substance abuse domains.
The initial "organizing" meeting of the Task Force was held on December 3, 2008 and subsE~quent
meetings were held monthly through June 10, 2009. Agendas, brief summaries and full minutes, of these
meetings are available at the Mayor's Mental Health Task Force section of the Town of Chapel Mill website
(http: //www.ci. chapel-hil I. nc. us/).
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MENTAL HEALTH TASK FORCE REPORT
In the course of its deliberations, the Task Force established two work groups which met five times. The
first group developed the proposal, "Supervision of Social Work Students and SA Professionals: Creating
Capacity", included as Attachment B to this report. The second group created graphic illustrations of the
mental health system that, at this writing, are being refined and will be posted on the Town of Chapel Hill
Mayor's Mental Health Task Force website. This work group wrote observations/notes about thE~ mental
health services for particular age groups; these are included in Attachment C.
The Task Force collected a variety of resources and materials related to mental health reform, local
mental services and climate and other pertinent topics. These were posted on an Internet blog site that was
active during the period of Task Force deliberations. Many of these materials will continue to bey available on
the Town of Chapel Hill Mayor's Mental Health Task Force webpage.
One of the objectives of the Task Force was to gather the perspectives of citizens and providers. Thus,
we asked Town of Chapel Hill department heads to inform us of their work with and/or exposure to mental
health issues; the staff of the Orange County Community Resource Court talked with us; and wee conducted
two public "listening sessions", where we heard from both family and community members directly affected
by mental illness and the providers who seek to serve them. We also received several comments on our blog
site.
II. State mental health system reform: background and context for Task Force work:
Reform. of the North Carolina mental health system of services was mandated by the Legislature in 2001,
after a series of federal reviews and actions, fiscal crises, and media exposes suggested that they mental
health system was coming apart at the seams (see Attachment D). The intent of the "system transformation°
envisioned by the legislature was to move services and programs into communities by 1) transferring
individuals from state-operated institutions to community residential settings; 2) spinning off direct service
provision from Local Management Entities (LME - in Orange County, OPC -the Orange-Chatham-Person Area
Program) to private, service contractors; and 3) redefining the mandate of LME's to be primarily policy,
oversight and management of the provider network, as well as certain screening, triage and other access-
focused functions. The reform legislation also required input into service planning through consumer and
family advisory councils (CFAC).
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MENTAL HEALTH TASK FORCE REPORT
The consensus view throughout the mental health community is that from the outset, system
transformation was under-resourced, poorly planned and monitored and bereft of skilled, coherent
leadership. By 2005, with adult admissions to state hospitals actually UP and per capita mental health
spending on the decline, criticism (e.g., "runaway train", "lack of accountability", "failure's was extensive in
all quarters.
By 2008, when several concerned members of the community began to talk with the Mayor, it was dear
that the vision of aconsumer-responsive, community-based network of care had not been fully realized in
Orange County. As was true elsewhere in North Carolina, the void of transition had been partially filled by
providers whose practices increased the instability of the local system of care. Most notable had been the
failure of the Caring Family Network as the primary operator of outpatient mental health clinics.
The following perceptions and observations regarding the state of reform in North Carolina capture what
the Task Force considers to be the state of mental health system reform in 2009:
• The envisioned transformation of the system has not occurred; the system is fragmented and
complex; it is characterized by "silos of care", .as well as service and access gaps;
• State leadership has been weak and "reactive";
• Providers are losing money;
• The indigent care system is inadequate;
• Funds get siphoned off in many ways, leaving a landscape with many inequities;
• There are many under-served individuals, including those...
a. ...lost from the system during reform and never found again;
b. ...whose care is funded through Medicare;
c. ...at risk of homelessness or already homeless;
d. ...whose care is not already funded through Medicaid or private insurance;
e. ...in the 18-22 age group.
III. Mental health service delivery in Chapel Hill and environs
As part of its work, the Task Force reviewed and discussed the state of mental health services in the
greater Chapel Hill area. Individual Task Force members and guests representing a variety of agencies and
interests within the system made presentations and at two public "Listening Sessions", citizens and providers
talked with us. Notes from all these presentations are available at the Task Force webpage at
http://www.ci.chapel-hill.nc.us/. In addition, as noted above, the work group that focused on visually
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MENTAL HEALTH TASK FORCE REPORT
describing the mental health/developmental disabilities/substance abuse system wrote notes which offer a
broader perspective on issues affecting individuals in particular age groups who require mental health
services (Attachment C).
The following represent key strengths of the mental health service delivery system in Chapel Hill and
environs:
1. Chapel Hill and environs are served by a committed provider community representing more
resources than are available in many other areas of state (Attachment E);
2. The University of North Carolina at Chapel Hill network of inpatient and outpatient clinics and
resources has served as a de facto~~safety net" for many in Orange County (and, of course, the
state) who have been unable to gain access to services;
3. Local governments offer a variety of services and supports for families/individuals coping with
mental health issues, as well as financial resources for some of the service agencies that work
with them (Attachments F and G);
4. Within the difficult constraints of chaotic state reform efforts, the LME serving Orange County
(OPC - http://www.opcareaprogram.com/) strives to maximize services;
5. The Orange County Mental Health Association (www.mhaorangeco.ora/) and NAMI Orange
County (http://www.nami.orq/MSTemplate.cfm?MicrositeID=284) provide active, engaged
leadership in the effort to better educate the public and overcome the stigma associated with
mental illness and to advocate for consumer rights and quality services.
While we understand that these assets are by no means suffiaent to address the many needs and concerns
faced by families and individuals struggling with mental health/developmental disabilities/substance abuse
issues, we do want to rewgnize that positive outcomes can be achieved through the existing system of
care. (see Attachment H).
Unfortunately, such results are often overshadowed by the challenges facing those served by the mental
health/developmental disabilities/substance abuse system in Chapel Hill and environs (see Attachment I). In
the course of its deliberations, the Task Force identified a number of important challenges, including:
A wide range of gaps in service, most notable of which appear to be:
a. Transportation for those needing/wishing to access services;
b. Adult day programming to provide caregivers with respite and participants with social
activities and services;
c. After hours and weekend services;
d. Post-hospitalization continuing care;
e. Services of all types for those aged 18 to 25 and their families;
f. Social work services for shelter residents;
g. Services for elderly individuals suffering from depression -with or without the co-
existence of dementia.
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MENTAL HEALTH TASK FORCE REPORT
2. Over-reliance on University of North Carolina -Chapel Hill resources as both first and last resort.
3. The attraction our area holds for people with mental health issues, both because of UNC and the
general climate (e.g., free transportation; lower unemployment; richness of resources).
4. The difficulty families and individuals experience with navigating the mental health system.
Often, they do not have knowledge/capabilities to make their way through the system and there
is no simple road map to help with this.
5. The advantage for access to services held by individuals with Medicaid coverage. HOWEVER,
qualifying for Medicaid coverage takes a very long time. Those with private insurance often find
themselves having used up allotted hours or unable to afford the co-pay.
6. An inadequate supply of safe, affordable housing -adding to the challenges faced by those
served by the mental health system.
N. The newest challenge: A shrinking resource base
During the period in 2008 when the Mayor was planning for and convening this Task Force, the full
extent of the recent, national economic crisis had not yet been revealed. Unfortunately, as we were reviewing
the local impacts of an already weak state mental health system, members of the Task Force both withessed
and directly experienced the tightening grip of recession. Within a month or two of her election in November
2008, the new Governor was anticipating a $2 billion budget revenue shortfall and the Department of Health
and Human Services was contemplating reduction of the Medicaid budget by some $224 million, as well as
sharp cuts in mental health services -including shut-down of the Wright and Whitaker schools for disturbed
children.
In August 2009, the Legislature approved the 2010 state budget, which includes major cuts
(approximately $75 million) to the mental health/developmental disabilities/substance abuse service system -
including elimination of community support services. (See Attachment J.) According to OPC,
This translates into $2,250,518 in cuts to the state funds available for services in
Orange, Person, and Chatham Counties. This represents approximately 21.5% of our
non-crisis state service funding. These cuts in service dollars limit the amount of state
dollars available to serve adults and children who do not have health insurance, but
are in need of mental health, developmental disabilities, and substance abuse
services. In addition, reductions in Medicaid services will affect people with these
challenges as well.
We have included in Attachment K a detailed Question and Answer document put together by OPC to
address the many questions that local citizens and governmental officals may have about the impact of state
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MENTAL HEALTH TASK FORCE REPORT
budget cuts. This information is posted on the OPC web page (htt~•//www opcareagrogram com/) and will be
updated as changes occur.
All of us who care about the availability and provision of quality mental health/developmental
disabilities/substance abuse services view this turn of events as a major and serious blow to efforts of local
citizens, policy-makers, advocates and providers to improve care in our community.
V. Task Force conclusions and recommendations
It is difficult to identify concrete, meaningfu/ways that we at the local level can have an impact on either
state system reform or the particular choices made by legislators to address the budget shortfall. Certainly,
we can add our voices to those of active advocates for change at the state level (e.g., our local legislators;
NAMI; Mental Health Assodation; other professional organizations). In addition, we believe that efforts to
more fully educate and sensitize state legislators and policy leaders would be enhanced if local providers were
to come together, develop an advocacy/education agenda and speak collectively. The providers in our
community have been working against the tide for many years. Aside from the families and clients
themselves, who better understands the devastating impact of over-regulation and under-payment, service
gaps and fragmentation, Medicaid cuts, barriers to information-sharing and the litany of other system flaws?
While we understand that time spent toward system improvement is not reimbursable and might be viewed
as "taking away" from client service, we believe that a strong, collective provider voice could, in fact,
significantly "add value".
Ultimately, it was the Task Force's conclusion that our own efforts were best directed to identification of
local actions that might be taken by citizens and leaders of our community to improve awareness,
coordination, capacity and delivery of mental health, developmental disability and addiction services within
the Orange County community. Within an environment of extreme constraint, we believe that the following
recommendations, if implemented, could lead to positive local change, in the form of 1) additional service
capacity and 2) increased community awareness of and sensitivity to the needs and challenges of the
mentally ill AND greater inclusiveness.
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MENTAL HEALTH TASK FORCE REPORT
Service Capacity Increases
1. Increase MSW student p/acements in provider agencies and add dinical supervision for students and
provisions//y licensed workers
One of the key partners in mental health service delivery in our community is the School of Social Work
at the University of North Carolina-Chapel Hill. This past year, the school had 68 students in 58 field
placements in Orange County. Of these placements, 55 were considered mental health placements.
Nationally and in North Carolina, there is a serious workforce shortage of trained mental health social
workers, due primarily to retirement, attrition and training-related issues. The school would like to place
more students in Orange county mental health agencies with supervision. However, placement locations with
good supervision are lacking because students cannot bill for their services; clinical supervision time is time
taken away from billable activities; and economic uncertainties make potential field instructors reluctant to
take students.
As noted earlier, a Task Force work group met several times to discuss these issues. They developed the
proposal included in Attachment B..This proposal is already being circulated as part of the search for funding.
Hopefully, a partnership of UNC School of Social Work, Task Force members, town and county leaders, social
workers and others concerned about mental health service capacity issues will emerge to carry this plan to
fruition.
2. Create a partnership with the Menta/Health Association in Orange County to expand the Pro Bono
Counseling Network.
The Mental Health Association in Orange County (MHAOC) is the local, nonprofit affiliate of the Mental
Health Association of North Carolina. In its work, MHAOC emphasizes coalition building/collaboration, peer
and social support, volunteerism and public education and advocacy. The Pro Bono Counseling Network is a
program operated by MHAOC in partnership with Healthy Carolinians of Orange County, OPC and private
practice therapists. The goal of the program is to fill the service gap for people in need of counseling who do
not qualify for publicly-funded services and who lack private insurance and cannot afford to pay out of
pocket. The Pro Bono Counseling Network recruits private pracctice therapists to see 1 or 2 clients per year
on a pro bono basis. The program coordinator screens and matches referrals and conducts ongoing follow-
up.
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MENTAL HEALTH TASK FORCE REPORT
Recognizing that Orange County is rich in professional resources (both active and retired), the Task Force
is recommending expansion of the Pro Bono Counseling Network. We believe that both recruitment of more
volunteers and increased volunteer time commitments are possible and we hope that OPC, the MHAOC,
provider agenaes and town/county leaders will actively promote this volunteer opportunity as a way of
increasing the capacity of the mental health service system. The possibility has also been suggested that key
professional associations (e.g., National Association of Social Workers) might be asked to consider providing
continuing education credits for volunteers or adding participation in such a network as a requirement for
licensure.
Enhanced local law enforcement/safety personnel awareness of and sensitivity to mental health
issues
1. Extend Crisis Intervention Training (CIT) throughout the ranks of local /aw enforcement and, ultimately,
to other safety personne%
The CIT program is a partnership of the mental health/developmental disability/substance abuse service
system and consumer, advocacy and law enforcement agencies. Twice yearly, the program provides 40 hours
of specialized training by OPC staff to sworn law enforcement officers. Program benefits include:
^ Decreased incidents of incarceration of persons with mental illness for misdemeanor charges.
^ Connections of persons in mental health crisis to appropriate mental health services rather than
the criminal justice system.
^ Decreased consumer and officer injury rates.
^ Decreased use of force occurrences.
^ Creation of an earlier opportunity to engage consumers in mental health services.
A CIT-certified law enforcement instructor must attend each of the 40-hour training sessions and teach
certain modules, and personnel from the law enforcement agency must participate on the CIT
Implementation Committee on an ongoing basis to assist with development of policies and procedures. The
Chapel Hill Police Department has been very involved with OPC in planning crisis intervention training.
The Mental Health Task Force recommends that, over time, C1T be extended throughout the ranks of all
law enforcement agencies in Orange County. We urge County and Town leaders (e.g., Mayors, Managers,
Commissioners, etc.) to 1) learn more about the benefits of CIT for the community and 2) exercise leadership
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MENTAL HEALTH TASK FORCE REPORT
in encouraging local law enforcement personnel to participate in training. While the recent shooting of a UNC
student by a law enforcement officer did not occur within the boundaries of our county, the incident provides
a strong reminder of the need for spedal care and attention as law enforcement personnel handle individuals
with mental health issues.
Strong local government leadership around mental health/developmental disabilities/substance
abuse concerns
1. Use local government offices (Mayors and Managers) and legislative bodies (Counci/, Commissioners,
Aldermen) as platforms ("bully pulpits and vehic%s of support for campaigns/efforts to proactive/y
increase community awareness of mental health/deve%pmental disabilities/substance abuse issues and to
reduce associated socia/stigma.
The need for stronger political and community leadership ran clear as a theme through the deliberations
of the Task Force. We heard this in the pleas of those who spoke to us at our listening sessions and offered a
"public face" for the issue. We ourselves had long discussions about the importance of promoting a
"message" that would draw members of the community-at-large to a fuller understanding and realization that
we have many among us who are facing difficult challenges and who, often, are not living the comfortable
and "safe" lives that we assume. As one Task Force member articulated: What does it mean when it is quiet
in our towns and county? Is all well? NO. Something is wrong across our dedicated pool of service providers
and across our county. A group of community members who were already struggling are now challenged
almost beyond imagination. Yet, no alarm is being sounded by our political and community leadership.
We believe that the persistent work of message dissemination and awareness-raising could make a
difference for the mentally ill in our county. A clear message from our political leaders that we care about a//
our vu/nerab/e citizens would set a new tone for our community. The Task Force recommends that town and
county legislative bodies consider establishment of ongoing capacity for providing issue leadership over the
longer term. Possibilities indude:
^ Standing committee(s) of Commissioners/Town Council/Aldermen
^ Subcommittee(s) of Human Services Advisory groups
• Joint local government committee/group formed through Assembly of Governments
^ Capacity within Mayor/Manager offices
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MENTAL HEALTH TASK FORCE REPORT
The presence of ongoing capacity and issue leadership within local government would greatly contribute
to the ability of OPC, individual Task Force members, MHAOC and others to partner with local government to
carry out these particular recommendations:
a. Collaboration of local governments with MHAOC, Healthy Carolinians and other advocacy groups
to reduce the social stigma assodated with mental illness through a public information campaign:
advertising on town buses, public service announcements and other materials for distribution.
(Many national resources are available.)
b. Dissemination of information about mental health issues/resources in town/county employee
orientations, through pay check notices, OWASA bills, etc.
c. Proactive efforts by town/county officials and school system leaders to 1) increase collaboration
between schools and mental health professionals and 2) educate families and children about
signs of depression, substance abuse, etc.
d. Increased local government collaboration with UNC Center for Excellence education efforts.
e. Use of the Town of Chapel Hill Mental Health Task Force web page and other local government
web pages as vehicles for public education and dissemination of information.
f. Local government support for volunteer groups that are working to increase public awareness of
the needs of the mentally ill.
g. Local governments and OPC collaborate to increase public awareness of the OPC Star Unit as the
primary entry point into the mental health system. Campaign to publicize telephone numbers -
919-913-4100 or 1-800-233-6834.
In addition, Task Force members themselves have made a commitment to:
a. Continue working with the Town of Chapel Hill to ensure that the Town website includes
important information and resources related to issues faced by those with mental
health/developmental disabilities/substance abuse issues.
b. Write letters to the editor and seek media opportunities (profiles of provider agencies, Op Eds,
etc.) tied in with a campaign to increase public awareness.
c. Increase community awareness of mental health-related issues through appearances before
various local government bodies, meetings with governmental staffs, dialogue with the County
Human Services Commission and Town Human Services advisory groups, presentations to local
service groups and other related activities.
d. Explore ways to partner with the county Third Sector Alliance -perhaps to create an ongoing
work group around mental health/developmental disabilities/substance abuse issues.
e. Partner with the Town of Chapel Hill and the UNC Center for Excellence to convene issue-focused
symposia.
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ATTACHMENT A
AGENDA #5a
MEMORANDUM
TO: Town Council
FROM: Kevin C. Foy, Mayor
SUBJECT: Mayor's Mental Health Task Force
DATE: October 15, 2008
PURPOSE
The purpose of this Task Force is first to identify the impact on the Chapel Hill community of changes in the
mental health service system, second to create awareness and generate discussion about the mental health
service system, and third to make recommendations for the future.
BACKGROUND
In 2001, the North Carolina General Assembly implemented reforms to the State's mental health service
system. The intent of the reform was to transfer patients from hospitals and other state institutions to
community programs. However, a combination of the privatization of services and new regulations left many
people without services. In addition, hospital admissions continue to rise. Local Management Entities (LMEs)
have sometimes been unable to effectively navigate the new regulations and provide adequate care for
people in need.
The future of mental health care is uncertain. Over the past seven years mental health programs in counties
across North Carolina (including Orange County) have either discontinued services or become independent
nonprofit organizations operating with limited resources.
The location of UNC Hospitals, a state hospital, uniquely affects Chapel Hill and Orange County. Patients
from around North Carolina who need mental health services may choose UNC Hospitals as their treatment
provider. UNC Hospitals can therefore serve as the initial access point to Chapel Hill for some patients.
Patients who seek care at UNC may remain in the area upon discharge. Because of the current situation
regarding treatment options, discharged individuals can have trouble getting access to ongoing treatment.
Local nonprofits attempt to provide services, but often face the obstacles of limited budgets and limited staff.
DISCUSSION
I am creating a special Mayor's Mental Health Task Force to discuss, examine, and assess the situation of the
mental health care system in Chapel Hill. The charge of the Task Force is:
1. To assess the state of the mental health care system in the greater Chapel Hill community, focusing
on the services provided, funding, and impact on the community as a whole.
2. To create broader awareness of mental health care issues in Chapel Hill and generate discussion.
3. Based on the Task Force's findings, provide recommendations regarding the future of mental health
care services for residents of Chapel Hill and Orange County.
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ATTACHMENT B
Supervision of Social Work Students and SA Professionals:
Creatin4 Capacity
Background
^ There are decreased resources for medically indigent clients (i.e. those without Medicaid or other
insurance)
^ The current market is a "seller's market", where providers can pick and choose clients
^ This results in real difficulty in accessing services for two groups-medically indigent and difficult to serve
^ In addition, there is a workforce crisis, for both P-LCSWs/LCAS registrants (workers who are provisionally
licensed) and MSW (Master of Social Work) students.
o State changes in policy result in P-LCSWs being unable to bill for many services -they must have
full licensure, or work as Qualified Professional in Community Support Services or other
enhanced services, in order to bill and generate revenue
o P-LCSWs and LCAS registrants also require clinical supervision in order to get their full licenses,
but this clinical supervision can be a burden on the agency, since it takes time of a licensed
professional away from billable services. So "growing" the next generation of licensed
professionals is hard
o For MSW students, the challenge is finding good field placements that do 3 things: 1) provide
good training in evidence-based practices; 2) get students excited about and committed to public
sector work; and 3) provide good clinical supervision. The cost of clinical supervision, as
mentioned above, is prohibitive in some places.
^ Summary: for a number of reasons, we have reduced sen~ice capacityand are notgrowing the next
generation of trained workforce in the public sector.
Possible Solution
^ For MSW Students:
o Increase the number of MSW students with internships in Orange County public mental
health/developmental disabilities/substance abuse service agencies. Have them focus on
providing services to medically indigent to increase service capacity
o Provide them with strong clinical supervision and with cross-agency training in evidence-based
practices, with agencies sharing training resources. By providing a diverse supervision
experience in the field, we are literally "taking walls down on silos"
^ For P-LCSW and LCAS registrants
o Provide additional best practice clinical supervision hours to allow them to get their full licenses
and to become stronger members of the workforce. Cross-agency group supervision would also
provide cross-population training and "cross fertilization"
Strategies
^ Provide agenaes with a stipend to hire a LCSW or LCAS to provide group clinical supervision to P-LCSW
and LCAS registrants, so they can hire more of them and provide supervision without incurring additional
prohibitive financial burden.
^ Provide agencies with a stipend to offset the cost of providing clinical supervision to MSW students, so
that agencies can take on more students. This could be group and individual.
^ Share information across agencies about trainings that students could attend (Google calendar?)
^ Fnd resources via grants, leveraged through the Mayor's office
Estimated Costs
^ 30 hours per year per student @ $100/hr ($3000/student), 10 additional students==$30,000
^ $5000 for supervisor for P-LCSW group
^ TOTAL=$35,000
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MENTAL HEALTH TASK FORCE REPORT
Evaluation
^ For MSW Students: Use Feld Evaluation form (database) and track to see how many students go into
and stay in public system 5 years post-graduation
^ For P-LCSW and LCAS registrants, see how many are successful at getting full license, and see how
many go into and stay in public system 5 years post-graduation
Year is
^ Look for funding
^ Design evaluation
^ Shared education piece
^ Gathering resources for supervision model
^ Calendar & training
Phases
Year 2:
^ Provide stipends to agencies and begin to place and supervise 10 additional MSW concentration year
students in Orange county agencies
^ Provide funding for a clinical supervisor across agencies and begin to provide clinical supervision to
additional P-LCSW and LCAS registrants in Orange county agencies
Proposal developed by:
Trish Hussey
Tom Reid
Anna Scheyett
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ATTACHMENT C
Work Group Notes
Mental Health Service Delivery System
0-2 AGE GROUP
^ Referrals come from a variety of sources including DPH, DSS, school systems, families, child care, Early
Head Start and other community agencies.
^ TEACCH is an important resource for individuals who need to be assessed, or have been diagnosed with
Pervasive Developmental Disorder or Autism. Families move to Chapel Hill to access TEACCH.
^ Although pediatricians are not the PRIMARY point of entry, there is a widespread effort to increase
refen-als through the "medical home". There is a requirement that children who have Medicaid and are in the
Carolina Access system be given a developmental screening at each well-child visit. Adherence to this
requirement could help identify children for referral to the CDSA for assessment.
Funding Sources
^ Infant Toddler (In services are funded through Medicaid, Public Health (Purchase of Medical Care
System) and private insurance.
^ Children referred for Infant Toddler services primarily qualify under "developmentally delayed".
^ If children are referred for mental health concerns and don't qualify for Infant Toddler services they can
be funded through Medicaid, or on rare occasion, with state mental health funding. Providers are all private
under this system.
^ Enhanced services through DMH do not include this group. Basic outpatient services start at birth.
3-17AGE GROUP
Typical Referral Sources for Public Mental Health Services
^ Juvenile justice (typically up to age 16 yrs)
^ Department of Soaal Services
^ Chapel Hill Police Crisis Units
^ Schools
Funding Sources/Issues
Funding for MH/SA/DD services for indi-~dual children
^ Medicaid (0-21 yrs)
^ IPRS (3-18 yrs)
^ Private insurance (age is based on policy and student eligibility)
^ HealthChoice (6-19yrs)
^ Occasional specialized grant programs
Funding for supports for individua/ chi/dren
^ Multiple DSS funds for individual children in DSS custody (ex. room and board, LINKS for teenagers)
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MENTAL HEALTH TASK FORCE REPORT
^ Exceptional Children's services for who have qualified for an IEP (Schools pay for special education
services from age 3 to 21 yrs; prior to three years CDSA/public health fund services for d~ildren with
developmental delays)
Funding for Support of MH/SA/DD Programs
^ Smart Start 0-5 year olds
^ Some IPRS funds (with approval from the Division)
^ Towns of Chapel Hill and Carrboro
^ Orange County
^ Schools
^ Local Foundations
^ Grants
Major Challenge
If over 16, a young person is handled in the adult criminal system, but is still wnsidered a child in the service
(care) system.
i8-21 AGE GROUP
Observations
There are two groups of particular concern:
1) Young people who have been served in the child mental health system
2) Young people who start to experience psychiatric symptoms in their transition years (first break of
psychosis, emergence of substance abuse)
Both of these groups may have similar development life issues that lead to ambivalence for continuing or
seeking treatment. These young people may be living away from home for the first time and associating with
peers involved with drug/alcohol abuse/use which may mask their symptoms for some time before a crisis
propels their entry into the system. So when these young people enter or reenter the system, their level of
need is quite high. Homelessness is often hidden with this group. If they are homeless, they are often
'couch surfing" with friends and not using homeless shelters.
Oasis' (http://www.psychiatry.unc.edu/oasis) experience is that those seen with first psychotic breaks are
70% male and 30% female. They have not been served in the public child system and very few have gone
through OPC to access adult services. Many have private insurance. Young people and their families are
trying to simultaneously understand this new potentially devastating illness at the same time they are trying
to work through what insurance will wver. The insured in this age group are also vulnerable to losing private
insurance if they leave school.
Challenges -Young People
^ Young people who have been served in the child system may disappear from the service system for some
time before reemerging on their own or through mandate by involvement with court system.
^ If a young person loses Medicaid after turning 18 yrs, the criteria for eligibility for adult IPRS services is
much stricter and some young people will not qualify for services.
^ If a young person moves beyond DSS foster care age, (s)he can maintain their Medicaid until age 21.
Young people aging out of foster care also have supports for higher education and some limited LINKS funds
to support their transition to adulthood.
^ Youth previously covered under parents' private insurance may become uninsurable when no longer in
school.
^ A particular challenge in the system is that if a young person has Medicaid and a service is medically
necessary, the mental health provider should be able to request authorization from Value Options to provide
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MENTAL HEALTH TASK FORCE REPORT
an array of services that meet that young person's set of needs. When XDS has attempted to obtain
authorization for ACCT services for young people 18-21 years of age, the amount of time spent on seeking
appeals has prohibited XDS' ongoing ability to serve this age range.
^ There are few housing and programming options for young people with mental health challenges. The
existing mental health programs are often not a good developmental fit for this age group.
^ Unless the parents have obtained guardianship, the young person becomes their own guardian at age 18
years.
Challenges -Providers
^ For provider to serve this age group, must make a huge expenditure of non-billable time. This is a
challenging age group -very few providers.
^ Provider agenaes never know exactly what their budgets are/can be -cuts can come anytime and can be
retroactive.
ZZ-64 AGE GROUP
Challenges
^ The system is fragmented - no one knows where to go.
^ Lack of preventive care.
^ Developmental Disabilities agency can't provide both services and case management; must be separate
functions.
^ Current case management is ineffective. Agencies set up shop and then find there is no money and leave.
Agencies cherry-pick clients who have billable hours. Case management disappeared -there needs to be an
access team that knows about local providers and resources and processes
^ Sharing of information is a huge challenge -differing interpretations of confidentiality laws. Challenges to
continuity of care. Under old system, state hospitals, area programs, and UNC hospitals could share
information on shared clients to ensure continuity of care. With privatized, fragmented system, much more
difficult.
^ Difficult to find providers for particular groups,. such as people who set fires and sex offenders; .borderline
personality disorders; DBT Dialectical treatment areas. These individuals use up resources if not treated
properly.
Funding Sources/Issues
^ Providers can bill Medicaid but many clients are not eligible for Medicaid AND there are several different
types of Medicaid, for which there are various eligibility restrictions. Reapply based on other diagnosis after
initial entry. Takes time to follow the client.
^ Difficult for mentally ill who do not have Medicaid to access services. Many disabled adults have disability
income that is too high for them to qualify for Medicaid. They may have significant service needs that
Medicare does not pay for. Co-pays are high. Limited number of providers in the community are certified as
Medicare providers. Similar difficulties apply to dual-eligible's -those with Medicare and Medicaid. Medicare is
considered the primary insurance, so providers who are not certified Medicare providers cannot receive
Medicaid payments either.
^ Private insurance does not pay for services needed by the more severely ill (ACTT, Community Support).
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MENTAL HEALTH TASK FORCE REPORT
65f AGE GROUP
UNC
UNC has three psychiatrists who specialize in geriatrics. Clients can get appointments at UNC, but
follow-up psychotherapy is limited because the teaching practice focuses on medication
management. There are no licensed psychologists or social workers to provide evidence-based
interventions as an adjunct to medication.
• No mental health staff in geriatric psychiatry or the geriatric medicine clinic focuses on caregivers to
provide behavioral recommendations to mitigate patient's symptoms. Caregiver education and
behavior training is not reimbursed by Medicare or private insurance.
Community Providers
^ There are very few mental health practitioners outside of the university system who specalize in geriatric
mental health. Few therapists have specialized skills or interest in the geriatric population.
^ Few mental health practitioners accept Medicare. Those who do often limit the number of Medicare clients
they accept in their client mix. At any given time, which therapist will accept a new Medicare client is
unknown. This makes referrals difficult and time consuming.
^ Home and Community Block Grant funding in local aging agencies can pay for mental health counseling,
but this is only theoretics/since no aging agency in the state uses the funding for this service. Instead
HCCBG funds are traditionally used for in-home aides to assist with personal care and other functional tasks
with the goal of postponing nursing home placement.
Public Mental Health System
^ OPC pays $20,000 to 3 private MH providers to incentivize acceptance of Medicare,
^ NC MH/DD/SA has one program for geriatric mental health. They provide "Geriatric Care Specialist Teams"
that usually consist of a nurse and a social worker who provide mental health education and consultations to
long-term care staff in assisted living facilities and nursing homes in a few counties. The use of designated
personnel in facilities has met with mixed reviews at best.
^ Individuals who experience late-life mood disorders and/or dementia do not receive public mental health
services because they have insurance (Medicare) -even though it is infrequently accepted by mental health
providers.
Barriers to Successful Geriatric Mental Health Care
^ For people 65+ there is a heightened sense of stigma about mental health issues. Therefore, diagnosis
and acceptance of a mental health treatment is rare.
^ Geriatric depression estimates in the 65+ community dwelling population range from 16%-32%.
^ Mood disorders are often under-diagnosed -partially due to the priority of other acute and chronic illness
and partially due to stigma and the lack of skilled geriatric providers.
^ Most geriatric patients seek treatment in a primary care setting. Most primary care physicians do not have
time to address psychiatric issues, and when they do so, they rely solely on medication, but few 65+ patients
take psychotropic medications consistently. In fact, 68% of the 65+ population in primary care practices stop
taking anti-depressant medication within 4 weeks of starting it.
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MENTAL HEALTH TASK FORCE REPORT
Results of Inadequate Mental Health Care in the 65+ Population
^ Suicide risk is high. 65+ population accounts for 25% of the suicides but only 13% of the population. The
majority of completed suicides in the 65+ population were seen by a primary care doctor in the last month,
highlighting a missed opportunity to intervene.
^ Geriatric mood disorders lead to increased medical costs, increased hospitalizations, longer hospital stays,
physical disability, decreased functional ability, and placement in long-term care faalities.
^ Geriatric depression and geriatric behavioral symptoms, especially those caused by dementia, cause
significant family stress leading to adjustment and mood disorders among caregivers and early
institutionalization of 65+ patients.
Future of Geriatric Mental Health
^ There are not enough geriatric psychiatrists in training to manage the next generation of seniors. Current
payment structures are a disincentive to practice geriatrics.
^ UNC School of Soaal Work does not have any faculty who specialize in clinical geriatric mental health
practice; therefore, students are not being prepared to meet the mental health care needs of the current 65
population or aging boomers.
^ Mental health practices will be challenged by the epidemic of dementia-related disorders and the resulting
behavioral issues and care needs.
-- The best practice models of geriatric mental health treatment involve the use of mental health
providers in primary care practices to follow through on medication use and to provide therapy based
on problem solving and behavioral models. At present, Carolina Access is in conversation with UNC
Geriatric Psychiatry to initiate pilot use of a geriatric depression care specialist in primary care
practices in Orange and Chatham Counties.
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MENTAL HEALTH TASK FORCE REPORT
ATTACHMENT D
COMMENTARY ON STATE MENTAL HEALTH REFORM
News & Observer
Published Sun, Apr 30,.,2006
Jean P. Fisher -Staff Writer
For mentally ill, reform falls short
Dorothea Dix Hospital was home to Kathi Dunphy's 39-year-old daughter, Jacki, for six yeazs. But a few months ago,
Jacki started on a new medication for bipolar disorder that helped her reach her best emotional health in years, so her
doctors decided she was well enough to leave.
But instead of going home, Jacki went to a Cary rest home, where most residents are frail and elderly. The place is clean
and the staff seems friendly, but Dunphy wonders how long her daughter will stay healthy there. Jacki is prone to
depression and thoughts of suicide, and her health deteriorates without structure and daily activities. "Last week, she said
she'd give me $20 if I'd take her back" to Dix, Dunphy said.
Trading one institution for another was not what state leaders promised five years ago when they revamped how and
where people are treated for mental illness. People like Jacki -- The News & Observer agreed not to reveal her surname
-- were supposed to be able to live in small groups or independently in their hometowns. They were supposed to have
medical appointments, get job training, learn life skills, socialize -- all within their communities, outside of institutions.
Most everyone involved in the mental health system says those ideals are unmet. This year, however, there are signs that
mental health care might finally get the significant funding that was promised. When state legislators return next week,
mental health funding will be among the top issues.
Carmen Hooker Odom, state Health and Human Services secretary, acknowledges that transforming the state's mental
health system has been difficult. "To create that change, you have to go through the process of destroying the existing
system," she said. "You don't have to be a psychiatrist to know that people do not like change."
Many people who aze dismayed at how mental health reform has progressed agree in principle with its goal. The idea is
to give people with brain disorders every chance to live full, productive lives amid family and friends. "It's a good idea -
- Itotally embrace it," said Debra King, executive director of CASA, a Raleigh agency that manages affordable housing
for people with mental illness. "But it's how you pull it off. I just can't figure out how we could have planned so long for
things to have turned out so poorly."
Not a lucrative field
Five years into the reform process, the state still faces a desperate shortage of subsidized housing for the mentally ill.
Patients released from state mental hospitals aze frequently dischazged to homeless shelters or, like Jacki, to adult care
homes. And despite predictions that free market forces would ensure an ample supply of mental health programs, many
communities have not seen private businesses clamoring to set up new services.
It's not a lucrative field. Many patients live on disability income and aze covered by Medicare and Medicaid, which
typically pay less than market rates for care. Others are uninsured or covered by private insurance that strictly limits
access to treatment and services.
Compounding matters, private businesses aiming to offer new programs didn't know what services the government
would pay for, and at what rate. The state Medicaid program was expected to publish that information years ago; it came
last month.
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MENTAL HEALTH TASK FORCE REPORT
"Many providers didn't want to sign contracts, didn't want to step into this until they knew," said Janet Schanzsnbach,
interim executive director of the N.C. Council of Community Programs. The council represents local mental health
agencies, which must line up community-based services and manage patient care. As a result, when some families have
sought community care, they have found few options.
Few choices
A lack of enriching day programs in the Triangle was the main reason Chary and Robert Sandstrom of Cary sent their
28-year-old daughter, Juli, who has schizophrenia, to a private residential program in Western North Carolina When
Juli was younger, the Sundstroms enrolled her in college to keep her active and engaged. Chary Sandstrom went with
Juli to classes at Meredith College, and if Juli grew disruptive, her mother was there to intercede. With that support, Juli
earned a bachelor's degree in mathematics -- with honors. "But I'm not going to live forever, so I can't follow her around
forever," Chary Sandstrom said.
At CooperRiis, a working farm community in Mill Spring that residents help run, Juli has a job in housekeeping. She can
take exercise classes, explore the 80-acre grounds and join other therapeutic activities. "She's gotten better there," said
Chary Sandstrom. "She loves it."
But CooperRiis is not a permanent residence. Its mission is to teach people how to maintain lives in the outside world,
and Juli graduates in October. Her parents hope she can be placed in a program affiliated with CooperlZiis, though that
would keep her hours away. If that isn't possible, the Sundstroms will reconsider the Triangle.
Some new resources have opened in Wake County since the Sundstroms last looked. A clubhouse that helps members
practice vocational and social skills, Club Horizon, opened in Knightdale in 2004. But if Club Horizon isn't right for
Juli, Robert Sandstrom wonders where the rest of the choices are. "I just don't see a lot of these programs out there," he
said.
Cash on the horizon
Bob Hedrick, executive director of the N.C. Providers Council, which represents private service providers, said families
and advocates for the mentally ill need to give reform a little more time.
State leaders, anticipating a budget surplus for the first time in years, appear ready to make a significant investment in
the mental health system. A legislative oversight committee is seeking $155 million in state money for mental health
care. Hooker Odom said Gov. Mike Easley's office thinks a $100 million allocation might be doable. "This will indeed
be the year we will have our infusion of money," she said.
Hedrick said he is confident such an infusion will draw more mental health providers into communities that need
services. "Some people are judging mental health reform as having failed when in fact it's just getting started," he said.
Meanwhile, parents such as Kathi Dunphy are waiting and wondering whether their family members can hold out until
the help they need is available. When Jacki lived at Dix, she got art and music therapy and took workshops on cooking,
personal care and social skills five days a week.
Now, living in the rest home, her only planned activities are twice-weekly shopping trips organized by the home's staff.
Occasionally, her social worker takes her out for coffee. Her mother brings her home to stay with her at least one night
every weekend. "If they don't find her something to do, I don't think it will work," Kathi Dunphy said. "This is just not
going to do."
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MENTAL HEALTH TASK FORCE REPORT
Published Sun, Mar 04,,.2007
Lynn Bonner-Staff Writer
Scarcity of mental-health care traps patients in vicious cycle
In the days when mental patients were put away, the symbol of the state mental hospital was a locked door. Now in
North Carolina, it's a revolving one. Mental patients are rapidly cycling in and out of the state's four mental institutions.
Those checking in for stays of one to seven days increased more than 82 percent from 2001 to 2005. Many are admitted
multiple times.
Federal investigators are reviewing the turnover. They found a woman in her 40s being treated at Dorothea Dix last year
who was in the Raleigh hospital for the 60th time and overall has been admitted to state mental hospitals more than 100
times. A woman at Broughton Hospital in Morganton last year was being treated there for the 78th time.
Changes at the. local level are driving the high admissions rate. Counties are offering fewer mental-health services, and
community hospitals are increasingly reluctant to set aside beds for psychiatric patients. When people suffer amental-
health crisis, the state hospitals are often the only choice. The hospitals cannot force stable patients to stay and often lack
room to accommodate those who want to remain.
For some, the turnover is too fast. Some kill themselves shortly after being released. Others turn up in jails, homeless
shelters, drug treatment programs or emergency rooms.
Mental-health care in North Carolina wasn't supposed to work this way. Under changes made in 2001, more people were
supposed to be treated in community hospitals, special crisis centers or at home. In many places, those community
services have been slow to appear.
"If you overwhelm a system beyond its point of capacity, it can't do everything it needs to do," said Dr. Jeffrey Geller, a
psychiatrist from the University of Massachusetts medical school who is monitoring the hospitals for the federal
government.
Geller is working for the state and the U.S. Department of Justice, reviewing hospital practices and procedures. His work
is part of a federal investigation of the four state psychiatric hospitals: Dorothea Dix, John Umstead in Butner, Cherry
Hospital in Goldsboro and Broughton.
Geller's review of Broughton's records last year found several cases in which patients killed themselves after hospital
stays of a few days or weeks. He said hospital records on those patients were not up to standard.
Among the cases was that of a 33-year-old woman from Union County who was admitted in November 2005.On her
chart, a psychiatrist wrote that the patient "planned to take too many pills to kill herself. She is clearly a danger to
herself." She was released after two days and killed herself three days later with a drug overdose.
A 33-yeaz-old Watauga woman shot herself about six weeks after leaving Broughton.
And Jerry Rodrique Love, a 36-yeaz-old Charlotte man, hanged himself five days after spending two days in the hospital.
"I don't think he did get the help he needed," said his mother, Gail Love. Jerry Love, whom friends and family called
"Dreky," was diagnosed at the hospital with severe depression. His mother said he drank too much and abused drugs but
had tried many times to break the habits. Jerry Love asked hospital staff to keep him, his mother said, and he asked her to
send him a coat, thinking he would be at Broughton for a while. But Love was back home before his coat got to him.
"His dying like he did -- to send him back [out] -- I'm still struggling," Gail Love said.
In and out -and back in
Of about 17,000 people admitted to the state hospitals in 2005, more than 1,400 were admitted for a second time within a
month. About 2,600 returned within six months.
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MENTAL HEALTH TASK FORCE REPORT
The quick release from hospitals and the lack of community treatment forces those with mental illnesses to seek help
elsewhere. It is becoming more common for the Healing Place of Wake County, an addiction recovery program, to have
residents who have been in and out of mental hospitals, said executive director Dennis Parnell. He said he is worried that
when Dorothea Dix closes next year, the Healing Place shelter and detox program will be overwhelmed by people whose
main problem is mental illness. "It could really endanger our whole mission," he said.
The U.S. Justice Department wants the state to have a better grasp of what happens to patients once they leave the
hospitals. It has asked Geller for more information about how the hospitals plan for treatment once patients leave. In
2002, a team ofinental-health experts working for the Justice Department found that hospitals were discharging patients
to unhealthy or dangerous living arrangements. For example, a consultant working for the Justice Department found a
28-year-old man at Broughton who had a sexual relationship with his mother. The hospital's plan was to send him to
Florida under his mother's supervision. The consultant described the arrangement as "clinically inappropriate to say the
least."
Patients from Cherry left the hospital to live with other former patients. In some cases, those living arrangements offered
easy access to illegal drugs.
Michael Moseley, director of the state Division of Mental Health, Developmental Disabilities and Substance Abuse
Services, said post-release problems aze not the hospitals' fault. Such problems occur, he said, because the state does not
have enough housing for patients or emergency mental-health treatment at the county level.
Once hospitals stabilize patients, they often have little choice but to send the patients back to the same circumstances that
brought them to the hospital. That fosters a cycle of admission, release and readmission. "If they're returning to what
they came out of, the writing's on the wall," Moseley said.
Geller acknowledged the hospitals' dilemma. Hospital staff members cannot force patients to get follow-up caze, he said,
and they cannot fill gaps in local mental-health services. Still, he recommended Cherry Hospital set up a committee to
figure out why it was repeatedly admitting patients for short stays.
All four hospitals are trying to find out why some patients keep coming back, said Laura White, a state administrator.
The rate of mental hospital use in North Cazolina is more than twice the national rate. "One of the things the hospitals
are really working on is how to work better with the communities azound those people who have high numbers of
admissions because that's just terrible," said White, who oversees the four hospitals. "We really want to reduce that."
In the past five years, connections have weakened between hospitals and community counselors who help make doctor
appointments and living arrangements. Fewer community mental-health workers are available for meetings with hospital
staff and patients to prepaze patients for life outside.
Some patients say the hospitals are too quick to discharge them. Durham resident Hazel Gulley needed new medications
in late 2005 for an illness that combines symptoms of schizophrenia and a mood disorder. She said she spent about a
week in John Umstead Hospital to have her medication adjusted, then returned home. A case manager who works with
Gulley, 49, noticed she was having delusions, and she was back at Umstead a few days later. "My mind wasn't cleaz
enough to come home," Gulley said. "The medications were all messed up."
Erin Delaney, 30, said she spent a little more than a day at Dorothea Dix in January at the end of a trek through hospitals
and clinics in Raleigh. Delaney, who has bipolar disorder and had substance abuse problems, said she was discharged
from a private hospital after three days when her insurance coverage ran out. She tried to make an appointment to see a
psychiatrist with Wake County but was told the wait would be up to three weeks. She ended up in a WakeMed
emergency department bed in Raleigh and was sent to Dix from there. At Dix, Delaney said, a doctor told her during a
brief interview that she was not bipolar, though she had been repeatedly diagnosed with the disorder.
"I talked to him for 15 minutes, and he undiagnosed me," she said. Delaney said the doctor took her off one of her two
medications and prescribed another. She had a place to sleep for a few hours, then left Dix. She is now in TROSA, a
two-year residential program in Durham for substance abusers.
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Delaney thought she was sick enough to stay at Dix but was discharged with an appointment to see an outside
psychiatrist. Dix hospital director James Osberg said he could not discuss a patient's case, but he said space in Dix's
crowded short-term unit is at a premium. Delaney described it another way: "If you're not suicidal and you're not
homicidal, they give you meds and send you on your way."
(News researchers Paulette Stiles and Becky Ogburn contributed to this report.)
News & Observer
Published Thu, Aug`21; 2008
Report: Reforms lacked controls
The state Department of Health and Human Services wasn't prepared for changes that came with handing most public
mental health treatment over to private businesses, a legislative analyst said Wednesday. When businesses are offered
money through government programs and learn that there's little oversight, they will seek to capitalize, John Turcotte,
head of a legislative office that evaluates state programs, told a legislative oversight committee. "When you turn off
front-end controls, word gets out," he said.
Legislators on an oversight committee reviewed a report by Turcotte's office that was critical of the way the department
introduced a variety of new mental health service in March 2006. The report focused on the out-of-control spending on a
basic mental health service called community support. Much of the information in the legislative report echoed findings
published in The News & Observer in February and in a recent state auditor's report. The N&O reported the state wasted
at least $400 million on community support. The state paid companies about $61 an hour for services often provided by
workers without college degrees, and companies offered community support to people who did not need it.
The legislative report said the high spending on community support "caught the department by surprise." But the report
did not draw any conclusions about the amount of overspending. Rep. Paul Luebke, a Durham Democrat, said the
Department of Health and Human Services was slow to tell legislators about the problem and to make corrections. He
pointed to a chart that showed community support cost more than $90 million in February 2007 and far outpaced
spending on more intensive services. "There were no controls," Luebke said during the meeting. "Nobody knew what it
was for. Who is responsible for that?"
Leza Wainwright, a co-director of the state Division of Mental Health, did not answer Luebke. But she said later that
there were so many changes happening so quickly, and with so many people working on them, that no single person was
responsible for the mistakes.
Rep. Drew Saunders, a Mecklenburg Democrat, called the report "gory." "It appears to me that some of these decisions
almost rise to the level of being criminal," he said. "And looking at this report is almost like looking at crime scene
photos."
News & Observer
Published Thu, Dec 11,,2008
Wake, Orange risk losing funds
Only half the patients discharged from state mental hospitals received follow-up community care, a new report says.
Five mental health offices around the state could lose millions in state money for failing to make sure former hospital
patients receive ongoing treatment. At stake is nearly $1 million that goes to the Wake County mental health office and
about $400,000 to the office that covers Orange, Person and Chatham counties. Those offices are in danger of losing
their responsibility for ensuring follow-up care, along with the money.
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MENTAL HEALTH TASK FORCE REPORT
State reports show that those offices are below the state average for getting patients from mental hospitals into
community treatment. "They have until the end of the month, or we will be taking action," said Leza Wainwright, a co-
director ofthe state mental health division. Administrators in the Wake and Orange offices say more people receive
follow-up care in their areas than the records show.
The state uses Medicaid spending to track patient care, and that misses people whose treatment is paid for with county
money, said Crystal Farrow, head of the Wake mental health office. Wake has been talking with the state for months
about getting more accurate counts.
"I'm pretty confident that reasonable people will be able to take a look at it and say Wake consumers are seen at least the
same rate as consumers across the state," she said. The local administrators said they did not expect their money to be
cut at the end of the year because it takes months to collect and evaluate information collected.
Connecting patients to community care after they leave hospitals is a key to getting the struggling mental health system
to work as envisioned. The effort is stymied by a lack of psychiatrists, a shortage of beds for psychiatric patients at
community hospitals and a lack of intensive mental health programs meant to serve the sickest people.
A report by a legislative office responsible for evaluating state programs exploded a commonly held assumption that
community care helps keep people out of hospitals. The report looked at care given to patients in 2007 who were
hospitalized at least once in 2006. People who received community services were more likely to be rehospitalized than
those who did not receive ongoing care.
Carol Ripple, a program evaluator, said it's likely that the most unstable patients who needed at least one return trip to
the hospital were also receiving community treatment. Most of the patients receiving community treatment are in "low-
intensity" programs, such as the skill-building program called community support. Only about 54 percent of patients
receiving community treatment saw a psychiatrist.
The information used to track patient treatment has limitations, Ripple said. One of her recommendations was to have the
state mental health division use electronic health records, which could improve care when patients move between
hospitals and private providers.
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MENTAL HEALTH TASK FORCE REPORT
2009
STRTE REPORT CH.ROS u' $
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~~` /~ ^ YttPgrated physical and media! care pllc% pro~arn
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n 2QQ6, Nord[ Carolina's mental health system re-
ceived a grade of L?,17tree years later, the grade re-
mains the same, but does not eaen begin to conrly the
chaos that now pervadr.re rite stttte's nrntal health rnre
system.
NAMI warned three years ago drat the state`s reform
initiatives were changing too much, too fast, resulting in
an increasingly disorganized enrlronment This predic-
tion was accurate. Fortunately, a change in governors in
2@09 provides broader hope for the future.
Some bright spats exist. North Carolina enacted a
mental health insurance parity law in 20Q7, a major step
towards impm.lnrg access to care. The state has taken jail
diversion nainUt$ seriously acrd has worked to build ec-
idence-based practices. Assertive Comtnunity Treatment
ACT; is an acknou-ledKed interest, although the state re-
cemly atmounced a sec en percent cut ut the prngram-
North Carolina has pitoted lrrandng resources to
Local Aianagetnent Entities CLRiEs} to build kcal capacity,
drereby reducing reliance on mercroivded state hospitals.
it also has a promising pilot program that integtari's men-
ntl and physical health care at four LhiEs, including shared
data s} teems and comtrmn measures to track results.
The state else gives feedback to donors about their
prescribing patterns. which is a pasitinr des-elnpment,
North Carolina certifies peer specialise and antlc-
pates growing this area of its mental health workforce, if
fundutg can be sustained.
AntMhcrS<terrgtlt is itrtprwement in aaess to tyL'tiicaid
Ear cattsuttxrs who are. incarcerated lry suspertdurg, rather
than terminating, L~erxEits,
North Catalina faces muhiple challenges, care of the
[Host complex changes drat the state atlrmpted uas ptn~a-
ti:ation of community mental health sereccs, creating
LkiEs for geographic regions..~fter two years of btllntg, an
auditor found that cart $9t~omillion had been ~~asted; an-
other fevel n[ revieww suhsequendy [otmd that number
was aveascated. Bill¢tg issaes cotun`buted to both fittar-
cial and clinical disarray and coincided u~th the resigna-
tion i?f the HHS secrctarv.
Cutrerttty, ~aluet?gdons manages Medicaid fund-
ing, while. other stair dollars 3c' to the LMEs, resulting to
lJ~gen~.Ne~ds v. ~y. >. , ,,, >
^ R~aTOf~~A7flfldeFFti~ aal~i 4Fih3f iD OYE21{ 5ys1L~7i
improve stateho-splfal5toenableiraaslbontflnewerfacllity
^ RestnteAGTfvndtnQcus
Cotlsumer and Family +:omments .
^ 'The state reorganized services several years ago:... the psychia-
tdsts at! tefE--`the area"
^ "the krrptemer~abon of the peer support program has been the best
Yhtrrg since sRCed broad."
^ "Jt takes 2d-d8 hours to get a hospital Ded X 1 reed to De adnt7tted'
^ °Wake Gorrnty has a crisis lnEenrention program rrhtch l am
giatefttl for."
more. complexity and &agmemadon. Essentially, there is
a dual system fi7r outpauene care.
additionally, in Zt105, the U.S. Lkpartment ofjustice
(L~J} documented numzrnus safety concerns in Nirrtlt
Carolina's state hospitafs. EHarts to remedy these. issues
hatix not been rea~vring. L1tJJ monitors nngningprobletns
at l~ix and Brout Hospitals. Cherry and Bruughtcm
Hospital in Mar~trtton have- lest federal ftttidatg due tea
numerous cnttcerns.
The newly-.?lxnod Central Regional Hospital CQtHI
in Butner was putt on notice: in 20t`aB that t`t too was at risk
of losing federal. futrds. The lass of federal funds fix Cherry
Hospital a e~imated N cyst the state $t3QQ,t)[1Q per month.
The state's plan w close L?ix 1-laspital and txarrsfcr
staff and patients to CRH has aroustd numerous con-
ccrnsabout safety and staff training. The move has been
dela}ed fine rimes to date.
The new governor, &~v Purdue, fnherit_a a complex,
dis~,~,~anted, and difficult ~gacy, but at least her dtarge is
dear-ua restore cnnf3dence and order to the system.
Ckaningup the mess mid improving care Enr rite state's cit-
i~rts will require leadership, politleal detertmination and
invoh~ernent of the. legislature, and sound in~~tments.
Additional links to coverage of state mental health reform can be found at the Task Force web page at
http://www.ci.chapel-hil I. nc. us/.
See also tide Carrboro Citizen "Breakdown" series at httn://www.carrborocitizen.com/main/breakdown/
26
29
MENTAL HEALTH TASK FORCE REPORT
ATTACHMENT E
ORANGE-PERSON-CHATHAM AREA PROGRAM
PROVIDER SERVICES
OPC cun'entiy has either a Memorandum of Agreement or IPi25 service contract with 183 providers. The
service array includes the services identified on the following table.
Service # of
Providers Service # of Providers
A~ 2 Level 2 residential (family type) 22
Assertive Outreach (PATH) 1 Level 2 residential (program
type) 5
ADVP 3 Level 3 residential 20
Community Rehabilitation 1 Level 4 residential 1
Community Support Child 39 Long Term Vocational Supports 5
Community Support Adult 39 Mobile Crisis 1
Community Support Team 22 MR/MI Day Supports 5
CAP Services 58 Multi-Systemic Therapy 4
Child Day Treatment 4 Non-hospital detox 1
Developmental therapy 14 Psychiatric residential treatment
program 2
Developmental day activity 2 Psychosoaal rehabilitation 2
Diagnostic assessment 31 Substance abuse
comprehensive outpatient 1
Facility based crisis 2 Substance abuse IOP 3
Family living low 5 Supported employment 6
Intensive in-home 19 Target case management 19
(Updated September, 2009)
27
30
MENTAL HEALTH TASK FORCE REPORT
ATTACHMENT F
To: Mayor's Mental Health Task Force
From: Andrew Pham, Mayoral Intern
Date: January 14, 2009
Subject: Town of Chapel Hill
At the last meeting of the Mayor's Mental Health Taskforce, the membership requested data from the town and its
departments. In response several departments submitted data regarding their role in providing services for the mentally
ill in Chapel Hill.
The data requested was threefold: the funds allocated for mental health service deliver (or services to other populations
who also have mental health issues) to various local agencies/ providers/public departments, provider or agency budget
information, and data on their clients.
The following is a brief summary of the responses.
Chapel Hill Police Department has three units that deal with mental health: Crisis, Human Services, and Project
Turn Around. Expenditures: Primary $56,100; Secondary $50,500. In-kind contributions: $210,000 Staffing Costs:
CU: $315,000 PTA $160,000
^ Human Services distributes $250,000 to 39 different organizations, nine of which primarily provide for those
with mental illnesses and four more organizations serve mentally ill populations.
^ The Crisis unit serves as a liaison with the community mental health resources and those impacted by
victimization. The Crisis unit serves around 3,000 people with an estimate that 30% have mental health issues.
^ Project Turn Around provides case management for substance abuse criminal charges, some participants
have mental health issues. PTA serves 175 total partcipants.
2. Chapel Hill Parks and Recreation Department serves populations with mental health issues with the Special
Olympic program and Therapeutic Recreation Program. The Special Olympics provides athletic activities for those
with intellectual disabilities. The program served 271 people in the last year, taught 120 children sports and had 250
volunteers. The budget from the Town is $60,308 for 08-09 with $15-20,000 in additional fundraising. The
Therapeutic Program's main mission is to provide inclusion for those with disabilities into typical recreation programs.
The program supports 1,000 people with mental health concerns many of which are school age children. The budget
for 08-09 is $102,153
3. Chapel Hill Public Works does not provide direct service to those who have mental health issues. It provides
services which may benefit those who have mental health concerns. These services include: curbside collection
exemptions, ADA ramp curb cuts, commercial inspections and in kind financial support to the IFC Community House.
The Town's contribution to the IFC Community house is $192,000 per year in rent and $59,000 a year in utilities.
4. Chapel Hill Planning Department contributes to mental health issues on the issue of homelessness; a percentage
of the homeless have a mental illness. This department spent $24,600 to employ a Coordinator for the Orange
County Ten Year Plan to End Chronic Homelessness. Additionally the Planning Department granted $15,000 to the
Real Change from Spare change program to fund a street outreach worker.
5. Chapel Hill Transit does not have funding to provide direct mental health services. However, Transit provides daily
trips from Northside Mental Health, Caring Family Network Center and Club Nova on the EZ Rider Program. The
estimated yearly cost is $13,000 for transportation. Transit notes that transportation issues may prevent many
menta//y ill residents from receiving menta/ hea/th services
6. Chapel Hill Public Libraries provide mental health services such as maintaining collections with information
regarding mental health, free access to the Internet, safe location for reading, and information and referral sources -
all in an environment that promotes respect for all patrons. Additionally, the town library often hires workers from
Club NOVA to help shelve library materials.
28
31
MENTAL HEALTH TASK FORCE REPORT
ATTACHMENT G
LOCAL GOVERNMENT FUNDING FOR AGENCIES
PROVIDING MENTAL HEALTH AND ASSOCIATED SERVICES
A HELPING HAND
Goals: to enable senior citizens to live independently, maintain high levels of wellness and avoid institutionalized care.
Services include accessibility to health care, mobility assistance, medication reminders, adequate nutrition, a safe home
environment, respite for caregivers and advocacy.
Chape/ Hi// 2008-09 A//ovation; $4,000 2009-ZOZO A//ovation; $3,500
Carrboro $2,500
Orange County $5,000
BIG BROTHERS BIG SISTERS OF THE TRIANGLE
Mission: Help children reach their potential through professionally supported, one-to-one relationships with measurable
impact. The program provides adult mentors to children who live in single parent homes or other children in need of a
secondary role model.
Chape/ Hi// 2008-09 A//ovation; $5,000 2009-2010 A//ovation; $6,000
Carrboro $ 500
Orange County $5,000
CHAPEL HILL-CARRBORO MEALS ON WHEELS
Mission: Provide nutritious food and personal visit to individuals who are unable to prepare meals for themselves due to
illness, disability or convalescence.
Chape/ Hi// 2008-09 A//ovation; N/A 2009-2010 A//ovation: $3,000
Carrboro $2,000
CHARLES HOUSE
Mission: Care for older adults with disabilities, providing enriching social and recreational activities during daytime hours;
providing respite, service referrals and educational services for family caregivers; advocating for and supporting
development of a system of community eldercare alternatives.
Chape/ Hi// 2008-09 A//ovation; $7,500 2009-2010 A//ovation; $7,500
Carrboro $2,500
Orange County $11,000
CLUB NOVA
Promotes and provides opportunities for individuals with mental illness to lead meaningful and productive lives of their
choice in the community.
Chape/ Hi// 2008-09 A//ocarion; .$5,000 2009-2010 A//ovation; $5,000
Carrboro $4,000
Orange County $75,000
DISABILITY AWARENESS COUNCIL
Orange County 2008-09A//ovation: $ 3,500
DISPUTE SETTLEMENT CENTER
Conflict resolution and mediation services.
Carrboro 2008-09A//ovation; $ 7,000
Orange County $34,000
29
32
MENTAL HEALTH TASK FORCE REPORT
DUKE HOMECARE AND HOSPICE
Mission: Provide palliative care for terminally ill patients regardless of ability to pay. Provides medical, psychosocial,
spiritual and bereavement care for terminally ill patients and their families.
Chape/ Hi// 2008-09 A//ovation: $3,500 2009 2010 A//ovation; $3,500
Carr6oro $3,500
Orange Caunty $4,000
EL FUTURO
Mission: Provide and advance model behavioral health resources for underserved Latinos in North Carolina. Offers
outreach/education, capacity-building and clinical services.
Chape/ Hi// 2008-09 A//ovation: $4,000 2009-2010 A//ocatron: $4,000
Carrboro $2,000
FAMILY VIOLENCE PREVENTION CENTER
Mission: Prevent and end family violence through client services and community education.
Chape/ Hi// 2008-09 A//ovation: $15,000 2009 2010 A//ovation: $15,000
Carrboro $ 4,000
Orange County $19,400
FREEDOM HOUSE
Provides extended care, transitional living and outpatient services to promote recovery from the disease of substance
abuse addiction and mental illness. Provides halfway house/treatment services, non-hospital detox, acute SA stabilization
and transitional living services.
Chape/ Hi// 2008-09 A//ovation; $17,000 2009-2010 Af/ovation: $17,000
Carrboro $7,000
Orange County $24,000
FRIENDS OF THE ROBERT AND PEARL SEYMOUR CENTER
Association of persons interested in providing and improving facilities to promote the well-being of all older adults in
Orange County.
Chape/ Hi// 2008-09 A//ovation; $30,000 2009 2010 A//ovation; $5,000
HOUSING FOR NEW HOPE
Encourage and assist homeless people and other persons in crisis to move toward lives marked by increased levels of
stability, dignity, hope and independence.
Chape/ Hit/ ZOOS-09 A//ovation: N/A 2009-2010 A//ocairon: $6,500
Carrboro $2,500
INTER-FAITH COUNCIL
To meet basic needs and help individuals and families achieve their goals. Provide emergency shelter, food, direct
services, advocacy and information to people in need.
Chape/ Hi// 2008-09 A//ovation; $9,600 2009-2010 A//ovation; $10,000
Carr6oro $8,550
Orange County $36,480
JUDICIAL DISTRICT 15B DRUG TREATMENT COURT
Offer the substance abuse participant a comprehensive individualized treatment program that includes court sanctions
and incentives to address his or her substance abuse issues and minimizes costs to community without compromising
community safety.
Chape/ Hi// 2008-09 A//oration: N/A 2009-2010 A//op[ron; $2,500
30
33
MENTAL HEALTH TASK FORCE REPORT
fIQDSCOPE (CHAPEL HILL TRAINING AND OUTREACH)
Early intervention program seeking to provide comprehensive services to young children, their families and providers who
are experiencing social, behavioral and/or developmental issues.
Chape/ Hi// 2008-09 A//ovation; $4,500 2009-2010 A//ovation; $4,500
Carrboro $1,000
Orange County $89,000
MENTAL HEALTH ASSOCIATION
Dedicated to improving the life of Orange County residents impacted by mental illness, through direct service, advocacy,
education and information dissemination.
Chape/ Hi// 2008-09 A//ovation; N/A 2009-2010 A//ovation: $5,000
Carrboro $1,500
OE ENTERPRISES
Vocational services for developmentally disabled people.
Carrboro 2008-09 A//ovation: $ 3,000
Orange County $63,175
ORANGE COUNTY DEPARTMENT ON AGING
Provides comprehensive and integrated approach to the delivery of services to Orange County's senior citizens in the
fields of health, mental health, social services, recreation, employment and other programs under federal, state and local
authority.
Chape/ Hi// 2008-09 A//ovation: N/A 2009-2010 A//ovation: $18,900
Carrboro $5,552
ORANGE COUNTY DISABILITY AWARENESS COUNCIL
ADA-related workshops, etc.
Carrboro 2008-09A//ovation; $1,000
ORANGE COUNTY RAPE CRISIS CENTER
Stop sexual violence and its impact through support, education and advocacy. Provides direct services through a 24-hour
crisis line, support groups and community education.
Chape/ Hi// 2008-09 A//ovation: $14,000 2009-2010 A//ovation: $14,000
Carrboro $ 3,000
Orange County $28,000
PIEDMONT HEALTH SERVICES
Increase access to high-quality affordable primary health care services for underserved communities in north-central
North Carolina. Delivery of bilingual medical and dental care to underserved Chapel Hill residents.
Chape/ Hi// 2008-09 A//ovation; $ 3,000 2009-2010 A//ovation; $3,000
Orange County $10,750
PR07ECT TURN AROUND
Court diversionary program for first-time, non-violent drug offenders with a goal of enabling drug offenders to overcome
drug-dependent lifestyles and contribute to the community in a positive manner.
Chape/ Hi// 2008-09 A//ovation: $70,824 (CHPD) 2009 2010 A//ovation; $25,000
Carrboro $ 2,000
Orange County $64,424
SENIOR CARE OF ORANGE COUNTY
Adult day care.
Orange County 2008-09 A//ovation: $ 50,000.
STREET SCENE TEEN CENTER
Provide a safe, drug and alcohol free environment for Chapel Hill teens in the downtown area where community youth
traditionally go to meet their friends and spend their leisure time.
Chape/ Hi// 2008-09 A//ovation: $3,500 2009-2010 A//ovation: $3,500
31
34
MENTAL HEALTH TASK FORCE REPORT
THE ARC OF ORANGE COUNTY
Provide advocacy and services to Chapel Hill residents with developmental disabilities that promote community
involvement, active lifestyles and social value.
Chape/ Hi// 2008-09 A//ovation; $8,500 2009-2020 A//ovation; $8,500
Carrboro $3,000
Orange County $4,000
TRIANGLE RESIDENTIAL OPTIONS FOR SUBSTANCE ABUSERS
Enable substance abusers to be productive, recovering individuals by providing comprehensive treatment, work-based
vocational training, education and continuing care.
Chape/ Hi// 2008-09 A//ovation; $4,000 2009-2010 A//ovation; $4,000
32
35
MENTAL HEALTH TASK FORCE REPORT
ATTACHMENT H
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I'd feel ntrc4~aL E~3.e every~tmctp Vie. Wth
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let rr~e."thinlc dearly with- Self. t5, fi to E:30 p.m. t!?~t Ca~'t~s Y, 2spA t ur~r-
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la's" rn~n± r~tLc~nal. Now I ~~uestlvrz rts}~ . LlhtarY t40 t;tasaty' €1ri~e CttapPl fzitl.
_ For; mc~e imfflr~tvan contact James Rntfe, Try a d~wa.i nmcher, dc~!Lrrrined to
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33
36
MENTAL HEALTH TASK FORCE REPORT
ATTACHMENT I
Frustration and Grief
Not long after reform was implemented, one of my long-term therapy clients who had a very severe
psychotic disorder developed multiple sclerosis (MS). She blamed the MS on her antipsychotic medication and
was angry at her psychiatrist so she decided to change providers (She had been with [our program] for more
than 10 years). She had also moved from Chapel Hill to Durham. When she got to her new provider, she
refused to sign a release for them to get her prior history. After establishing care with the new provider, she
called me upset about the psychiatry services she was receiving. I talked with her about ACT services, as she
clearly met the criteria and had Medicaid. She thought it sounded great, so I told her to ask her new
community support worker to refer her for these services. She called me again to say that her new worker
didn't know what ACT was. I called her provider and told them she was interested in a referral to ACT. They
said they couldn't refer her because they didn't have the history to support the need. I called the Durham
Center to see if I could refer her for ACT. They said I couldn't because I was no longer her provider. Well, the
final outcome of this was that the woman died of an accidental overdose of pain medication. She was floridly
psychotic at the time of her death, and refusing all mental health services. So my frustration with what has
happened to the system is also tinged by grief. I know there are other stories like this.
News & Observer -Editorial
Published Wed, Aug 26; 2009
A verdict on violence
Prosecutors and defense attorneys agreed on one thing regarding Alvaro Castillo, the 22-year-old
man who will serve a life term for the murder of his father and other crimes: he is mentally ill, and
seriously so. Castillo's story played out in dramatic fashion in a Hillsborough courtroom last week,
but in the end, the jury seemed to reach the inevitable verdict in finding him guilty.
Judge Allen Baddour said he would recommend that Castillo get mental health treatment in prison.
That's good, for this was a tragic tale indeed, in which earlier treatment might have helped.
As related in the course of Castillo's trial (his attorneys were seeking a verdict of not guilty by
reason of insanity) his father, Rafael Huez Castillo, ruled the household with an iron hand. His son
was clearly disturbed. At one point he talked his mother into taking him to see the site of the
infamous Columbine school shooting of 1999 in a suburb of Denver.
In addition to his father's murder, Castillo was convicted of firing on students at his former high
school, Orange High. Clearly he was obsessed with committing school violence. In light of horrific
school massacres around the county in recent years, his action against the school, which he planned
in advance, was inexcusable. Apparently, only alert action by a teacher and school security guard
prevented bloodshed there.
While Castillo clearly and by his own admission is disturbed, the jury faced a serious challenge. Not
to imprison someone who did what he did would be to engage in a risky optimism. Even though
34
37
MENTAL HEALTH TASK FORCE REPORT
there are treatments for people who are suffering from illnesses that can make them violent and
dangerous, young Castillo had turned that potential into reality, and it's profoundly fortunate that he
did not do harm to others before and after killing his father.
And as prosecutor Jim Woodall said, no matter what may have been said about the father, Rafael
Huez Castillo, during the proceedings, ..."the bottom line is, he was brutally murdered."
It's impossible to know for sure what might have been done to prevent this tragedy. There were tears
all around in the Hillsborough courtroom. But in holding Alvaro Castillo responsible for what he
did, jurors took a necessary step toward discouraging similar violence in the future.
35
38
MENTAL HEALTH TASK FORCE REPORT
ATTACHMENT ]
STATE FUNDING CUTS
News & Observer
Published Thu, Aug 05, 2009
Lynn Bonner -Staff Writer
Mental health spending slashed
The mentally ill in North Carolina will have less access to care as the state makes dramatic changes
to save money in the recession. The budget approved by the legislature Wednesday cuts about $40
million, or 12 percent, in mental health treatment for people without other insurance. The cuts come
despite the state's goal of providing more treatment to people where they live.
The cuts and changes rip holes in an already-weak mental health system, advocates say. They predict
it will be harder for poor people without insurance to get community mental health care, and more
could end up in emergency departments and jails.
Other changes are under way:
• The legislature is phasing out a mental health service called community support, low level services
to help people with mental illnesses or addictions to gain skills, such as how to manage bus
schedules or a household budget, or to help a child stay out of trouble in school. Lawmakers are
cutting money for the service and eventually will replace it with one that has not yet been developed.
•The state will reduce spaces in group homes for children and adolescents, with plans to start a new
program of high-intensity therapeutic foster care. Local mental health offices would work harder to
return children to their homes, enrolling them in high-level services. Some children would be
eligible for admission to community psychiatric treatment centers.
These new services have not been tested or approved by the federal government, which must OK all
services paid by Medicaid.
The $40 million reduction to aid for uninsured patients surprised patient advocates.
Michael Murray, director of the Disability Action Network, an advocacy group, said such a cut could
lead to more admissions to state mental hospitals, patient pileups in emergency rooms and more
mentally ill inmates in jail. "I think there's the potential for overcrowding in places they don't need
to be," Murray said. "They can't stay in the least-restrictive environment because of the lack of
support."
Doomed to reheat it?
The state does not seem to have learned from its failed efforts to improve mental health care, said
Frank Edwards, a co-president of the National Alliance on Mental Illness' Wake County chapter.
Programs and policies should be tested before they are launched, he said.
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In 2001, a state mental health reform resulted in increased short-term stays in hospitals and
expensive, poorly monitored care in local communities. "They didn't plan it well then, they're not
planning it well now," Edwards said. "That really does honestly scare me."
Legislature 'being forced'
The legislature has no choice but to make changes, said Rep. Verla Insko, a Chapel Hill Democrat
who helps run an oversight committee on mental health.
"The problem is right now, we're being forced into this," she said. "We don't have the option of
taking a lot of time doing in-depth planning. What we can do as an alternative is watch very closely
and be ready to make adjustments."
The cut in community support, the basic mental health service, will be particularly hard on rural
patients, said Barry Graham, chief operating officer at Advantage Behavioral Healthcare, which
provides the service.
Rural counties don't have the therapists with advanced degrees that the more intensive community
care programs require, Graham said. That leaves community support, Graham said, which legislators
have targeted for cuts because of past financial abuses by providers.
A News & Observer investigation last year found that the state had wasted more than $400 million
on community support in less than two years. A recent legislative report said the state wasted even
more.
Cuts will hurt patients, Graham said, while companies committing fraud will find a way to survive.
"They are the ones who will suffer from reform," he said of patients. "A crook will find a way to
beat the system."
Hospital nav increased
One of the few significant increases in the mental health budget is $12 million to allow the state to
pay local hospitals that agree to short-term treatment for mentally ill patients.
Last year now-Gov. Beverly Perdue campaigned on how she would handle the mental health system,
promising accountability and a focus on rural and underserved areas. She promised to develop
mental health courts, programs that seek to keep mentally ill people out of trouble. She also said she
would improve care by creating "centers of excellence" at colleges and universities. There's no
additional money for courts in the budget and no mention of "centers of excellence."
Perdue's spokeswoman, Chrissy Pearson, pointed to the money that will open more local hospital
beds as evidence of Perdue's attention to improving care.
With money from past budgets, the state was able to reserve 75 local hospital beds, according to
DHHS, though 19 fell into disuse at the end of June because the budget had not passed.
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The new $12 million will increase the number of beds to 175, said Lanier Cansler, secretary of the
state Department of Health and Human Services.
"The concept of trying to have enough beds to keep people in the community is a solid concept," he
said. "The goal is "having the beds at the community hospital where people don't have to travel
across three or four counties to get care."
Club Nova faces immediate challenge
Sep 1D; 2009 News lump to Comments
By Taylor Sisk
Staff Writer-Carrboro Citizen
North Carolina Speaker of the House Joe Hackney's Wednesday morning visit to Club Nova in Carrboro was
a social call, astop-in by invitation of club members to hear how things are going. Not that he wasn't already
aware, but what Hackney heard was that Club Nova faces some tenuous times in the immediate future, and
that it soon may have to turn out some clients with no alternative services in sight.
Club Nova operates under a clubhouse model designed to promote rehabilitation and reintegration into the
community for individuals living with mental illness. In the best of times, it struggles financially to get by. But
with the cuts made to mental health services in the new state budget, times are growing harder still.
In 2006, clubhouse services were reclassified as enhanced services, which means that for Club Nova to
continue to receive state and federal funding its members are required to receive community support
services. But the new state budget called for the phasing out of community support services by June of next
year. These services include assistance with such everyday activities as paying bills, shopping for groceries
and picking up medications.
This leaves Club Nova in a predicament. Club director Karen Dunn said that two steering commitees
comprised of state officials and other stakeholders are trying to develop a plan that may help keep people in
clubhouses such as Club Nova. But nothing is known for certain. And if a solution isn't found, Dunn will have
to begin discharging clients in December.
Hackney expressed his support for Club Nova. "It's a great program," he said. "The staff is very committed
and is dedicated to getting through this difficult period....
"I'm hopeful they can survive this and come out the other side so we can get them properly funded, because
they certainly aren't now."
Club Nova has been allocated $99,000 in the state budget, but Dunn isn't counting that money until it's in
hand. She received $75,000 for the coming year from Orange County's human services grant and $100,000
through the county's mental health local management entity, the latter having been cut 50 percent from last
year. The club has been bringing in between $90,000 and $140,000 in private funds, but, as Dunn points out,
those dollars are more difficult to come by these days.
"We're still here," Dunn said, "and that's pretty amazing. It's just been an ongoing onslaught of bad news."
The decision to eliminate community support services baffles her.
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"I understand that North Carolina is short on revenues, but what I don't understand is why they would
dismantle something when there's nothing in its place for people with mental illness," she said.
She points out that when mental health care reform legislation was passed in 2001, community-based
services were seen as the linchpin by which those with mental illness could be moved out of state institutions
and reintegrated into their communities.
"Now they're the worst thing in the world?...
"How could we be that wrong?
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ATTACHMENT K
OPC Area Program Q & A
Regarding Impact of State Budget Cuts
(September, 2009)
How will the state budget cuts affect mental health, developmental disability, and substance
abuse services in Orange, Person, and Chatham Counties?
Approximately $75 million dollars were cut from the statewide mental health/ developmental
disabilities/substance abuse services, in addition to reductions in Medicaid rates and services. This translates
into $2,250,518 in cuts to the state funds available for services in Orange, Person, and Chatham Counties.
This represents approximately 21.5% of our non-crisis state service funding. These cuts in service dollars
limit the amount of state dollars available to serve adults and children who do not have health .insurance, but
are in need of mental health, developmental disabilities, and substance abuse services. In addition,
reductions in Medicaid services will affect people with these challenges as well.
How will these cuts affect adult recipients of mental health (MH) and substance abuse
(SA) services? Will there be services that are no longer available? What services will be
available?
Reduction in state funds for mental health and substance abuse services will have a huge impact on
OPC's array of services. We have received a cut of approximately 21.5% to our state funds, causing
major strains on already under-funded services. It will definitely affect how we provide care to
consumers in the OPC catchment area. We have to reduce the number of slots available for the
enhanced services and also reduce the number of units for individual therapy. After the limited units
of services have been utilized, consumers may be moved to group therapy or referred to self-help
groups and /or natural support systems in the community.
• How will these cuts affect people with developmental disabilities? Will there be services
that are no longer available? What services will be available?
OPC's developmental disability (DD) state funds will be cut in two ways. First, a portion of the overall
reduction in state funding ($55M statewide) will be taken from OPC's DD service dollars. Sewndly,
the legislature reduced DD funds by $16M, with the idea being that limited state dollars should not
be spent on individuals who are CAP-MR/DD waiver recipients. OPC's share of this cut is $928,923.
Combined the cuts will mean a reduction of just over 23% in DD state service dollars. In terms of
Medicaid services, cuts to service rates for CAP-MR/DD services and the freeze on CAP-MR/DD slots
will have the biggest impact on individuals with DD.
Cuts of this magnitude will require significant reductions in funding to many of our DD programs and
services including residential services (group homes), Adult Day Vocational Programs (ADVP/
employment services), Developmental Day services for children 3-5 years of age, as well as other
services such as Developmental Therapy. As a result of these reductions it is expected that providers
will have to downsize programs. Fewer people will be able to receive services and those that do get
service will likely be getting less.
Will there be services that are no longer available? What services will be available to individuals with
developmental disabilities?
There has been no determination to fully eliminate any DD service entirely at this time. Rather,
significant reductions will be required to the types of services listed above. Services that will remain
available to individuals with developmental disabilities (in limited quantities based on available
funding) indude: Targeted Case Management, Developmental Therapy, Personal Assistance, ADVP,
Supported Employment, Long Term Vocational Support, Respite, Developmental Day, residential
services, services for individuals who are dually diagnosed, and Mobile Crisis services.
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• How will these cuts affect children and adolescents who are receiving services and their
families? Will there be services that are no longer available? What services will be
available?
The cuts in funds and changes in legislation will impact child/adolescent mental health and substance
abuse services in primarily three areas. These include the reduction in the use of certain types of
group care, elimination of community support which provides the bulk of case management and skill
building services, and a reduction in service funds for youth who are uninsured.
Reduction in Use of Level III and IV GrOUDS Homes:
The use of Level III group homes (typically small homes of 4-6 youth in a neighborhood) and Level
IV group home (locked facilities) will be reduced as it will become harder to enter these facilities and
the lengths of stay will be shorter (maximum of 120 days). OPC Area Program has been working for
years to reduce its use of level III and IV group homes as we have felt it was not best practice to
congregate youth with behavioral challenges together. There are certainly young people who use this
level and have benefited, but many youth can be served in therapeutic foster care. North Carolina
has requested a strengthened definition of therapeutic foster care from the federal Medicaid
authorities.
Group homes that have over 16 beds will either need to close or reduce their beds to below 16.
Therapeutic wilderness camps like Three Springs and Timberidge will be closed. Three Springs,
which is located outside of Pittsboro, will close its level III facility, but is planning to open a
Psychiatric Residential Treatment Facility (PRTF), day treatment, and offer intensive in-home
services.
In July, OPC had 46 children in Level III or IV group homes. Presently there are 21 youth in level III
and IV group homes. Transition plans for all youth in levels III and IV are being reviewed through
county based care review teams.
Challenges:
• Sufficient capacity of therapeutic foster parents especially within our three counties.
• Small number of youth for who therapeutic foster care is not a good option and who do not
qualify for PRTF.
Elimination of CommunitYSupport: This service which encompasses case management services and
skill building services will be phased out in the next few months. No new youth will be able to have
this service after 10/12/09. Presently there is not a substitute service for this the case management
function. In the beginning of September there were approximately 400 youth receiving community
support in Orange, Person, or Chatham counties.
Reduction in Service Funds for Uninsured Youth: OPC will receive fewer funds to serve the
uninsured. This will translate into less available services for young people who do not have
insurance. This means that there will be tighter criteria for receiving state funded services.
What services will be available for children, adolescents, and families in Oranoe, Person, and
Chatham Counties? .Outpatient therapy, medication management, intensive in-home, Multisystemic
Therapy, Day Treatment, Therapeutic Foster Care, Psychiatric Residential Treatment Facilities, and
Hospitals. Residential services are only available to clients with Medicaid.
• How will these cuts affect providers of services in our community?
Providers will be significantly impacted by the budget reductions and service changes in many ways.
Not only will the amount of overall funds available to provide services be decreased, but in some
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cases the reimbursement rates for services will be reduced as well. In addition, providers of
Community Support services will have to decide which, if any, services they will provide instead, as
this service will be reduced significantly over the coming months and will no longer be available as of
June 30, 2010. These changes will require providers to make changes in both staff and the amount
of service they are able to provide. It is anticipated that providers will have to implement a variety of
cost saving measures over the coming months.
• How will the OPC benefit plan be amended?
In anticipation of budget cuts, changes were made to the OPC IPRS benefit plans reducing outpatient
services effective 7/1/2009:
• Adult MH basic benefits were reduced from 26 to 8 individual sessions (69% cut) and from
52 to 12 group sessions (77% cut) for each consumer for the fiscal year.
• Adult SA benefits were reduced from 26 individual sessions to six (76% cut) and from 52 to
24 group sessions (54% cut) per fiscal year.
• All adults must meet much more restrictive criteria to qualify for CSS and the units have been
reduced. Many individuals who might have qualified for this service in the past no longer do
so. This has resulted in a drop from 344 consumers having been authorized for this service
last fiscal year to 105 at present, a 69% decrease.
• An exception to cuts in the Adult SA benefit plan is for consumers referred by TASC
(Treatment Accountability for Safer Communities). Services for this population have not been
reduced.
• Child MH benefit benefits were reduced from weekly individual and group therapy to no more
than 26 sessions per year of each of those services, a 50% cut.
• CS Support for children is somewhat more restrictive; now only those children who are at risk
of imminent out of home placement qualify for the larger amount of units.
• No significant changes were made to the Child SA Benefit Plan.
• All other services such as Psychosocial Rehabilitation (PSR), residential, etc, have suffered de
facto reductions as a result of fewer funds being allocated to the providers of these services.
• All providers are encouraged to link consumers with natural and community resources early
in treatment, to develop solid crisis plans with each consumer and to inform consumers of
the process for accessing crisis services.
• What is OPC Area Program doing to manage these changes and cuts?
OPC staff is meeting on a regular basis to plan and prepare for the budget reductions. Workgroups
are developing strategies to address both short-term and long-term issues. Benefit plans have been
revised (see above.) OPC staff is meeting with key providers on a regular basis to address issues of
concern, service system changes, etc. OPC wilt also be updating our community partners,
stakeholders, CFAC, OPC Area Board and providers at meetings attended, via email communication,
and on our website as developments occur over the coming weeks.
• What crisis services will be available?
Crisis services will remain available in all three counties in a variety of means. Daytime weekday
crisis services are available to residents of each county at the following sites:
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Orange County: Person County:
Chapel Hill Outpatient Clinic Person Counseling Center
104 New Stateside Drive 355 S. Madison Blvd.
Chapel Hill, NC 27514 Suite C1
919-942-2803 Roxboro, NC 27573
or 336-599-8366
UNC Hospitals/
Dept of Psychiatry
Walk-In Clinic
Neurosciences Hospital
1~* Floor
101 Manning Drive
Chapel Hill, NC 27514
919-966-2166
Chatham County:
Chatham Counseling Center
287 East St, Suite 421
Pittsboro, NC 27312
919-542-4422 or
1105 E. Cardinal St.
Siler City, NC 27344
919-742-5612
Crisis Services are available 24/7 by calling the OPC STAR line at
919-913-4100 or 1-800-233-6834
Mobile Crisis Services are available 24/7 by calling 919-967-8844 or 1-800-233-6834
• Who do I call if i have concerns and questions?
Providers: Call your provider relations representative at OPC Area Program
Consumers: Talk to your provider about the changes and call OPC Customer Services if you
continue to have questions and concerns at 919-913-4120 or
1-888-277-2303.
Community partners:
For questions about services to adults and children with developmental disabilities contact, Cim
Brailer at cbrailerCa ooc-mhc.org or 919-913-4150.
For questions about services for children and adolescents with mental health and substance abuse
challenges, contact Lisa Lackmann at Ilackmann(~opc-mhc.org or 919-913-4011.
For questions about adults with mental health or substance abuse challenges, contact Tom Velivil at
tvelivilCaopc-mhc.org or 919-913-4014.
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