Monday, May 21, 2007

Emerg psych serv; clear perception diff between Legis/ DHHS vs consumers as to success;H973 will pass;11th Dist Dems note ment. hlth care issue

NC Policy Watch & NAMI luncheon: Raleigh: 5.21.07: 11:30 – 1:30 pm : long applause was for NAMI-Wake former director, Ann Akland: her statements that ‘the system is not working’ were well received.

"“Getting or changing services is a lengthy, confusing, complicated, bureaucratic process,” explained Ann Akland, a panelist at the forum who also has an adult-aged child suffering from mental illness. She added the intricate system leaves “patients and families to fend for themselves.” You can play the video of the meeting by accessing that web page.

About 300 people attended; Western NC continues to be under-represented, it appears. As noted by District 11 Dems pertaining to District meeting this past Saturday held at Pisgah High School:

"...We passed resolutions on our forests, universal health care and mental health care issues. This last one is becoming a serious issue in western North Carolina, since the state has turned it into all private providers and then really messed with the providers...."

MAIN POINTS TO CARRY AWAY: (see below for details)

Item 1: a great number of the concerns had to do w/ lack of crisis care: INSKO stated that the reform never intended to take away crisis care and stated she was working on making this clear again. (see below); she stated that this was also true re: case-management : (thus, there is some real backing up here and our complaints are being heard , in part, related to emergency psychiatric services)

I walked over to Verla Insko's office and she indicated that this is being augmented in order to make more clear the point that indeed, the LME's are responsible for emergency services. That which is in bold, immediately below, is what is new and Insko indicated that she expects this to be passed this legislative season:

"115.4. Functions of local management entities. (a) Local management entities are responsible for the management and oversight of the public system of mental health, developmental disabilities, and substance abuse services at the community level. An LME shall plan, develop, implement, and monitor services within a specified geographic area to ensure expected outcomes for consumers within available resources.
(b) The primary functions of an LME are designated in this subsection and shall not be conducted by any other entity unless an LME voluntarily enters into a contract with that entity under subsection (c) of this section (skipping down to section c) ....(c) Subject to subsection (b) of this section and all applicable State and federal laws and rules established by the Secretary (the following is being struck through) , an area authority, or county program or consolidated human services agency.

My understanding is that the LME's MUST provide emergency services or see that it is reliably provided. This will effect, for instance, the mobile crisis unit in Western Highlands re: inability to cover all the needs associated (in particular) with children/ adolescents. (good person to talk to about this is Diane Bauknight, who is the mother of a consumer: "Diane Bauknight"

State Legislator, who is the co-chair of Joint Mental Health Reform Committee Verla Insko is at: 919-733-7208; "Verla Insklo"

It is problematic that the LME’s have no formal links in order to do their work e.g., links with counties/ county commissioners; Insko stated legislatively they are attempted to improve the relationship s and linkages that LME's have in the community and counties (see below)

All in all, audience, and consumers, were making very vigorous points how the system is not working and is indeed broken.

H973 will pass thru both houses; substance abuse has been taken out and there is some other dumbing down re: the mental health issues (per Tote, Mental Health Alliance; last legislative year, a full mental health parity bill passed through NC House, but then stalled out in the Senate)

Per Wainwright,DHHS, the new Service Design will address the transportation issue associated with clients who cannot get to appointments re: mental health care : (this is in direct contrast to Steve Puckett’s statement at the Smoky Mountain Center provider’s meeting less than 10 days ago/ re: there is no payment for transporting clients.

Mental health care reform is a recovery model NOT a rehabilitation model (how did that term come into usage? I don't know. They are different in that rehabilitation is a medical model term; Insko was clear about mental health reform was not intended to be a medical model).

Item 7. Wainwright of DHHS makes point that Feds were slow re: Service Definitions and that ACT team, as it is now in NC, has been a rejected model, by Feds, in NM (see below),

My notes taken during this meeting (yes, I am typing that fast but you'll notice it's in outline form)

VERLA INSKO (NC STATE LEGISLATURE, ORANGE, DEM) : I use a systems overview as associated with all the pieces / partners re: mental health reform; mental health reform not intended to be a copy of medical model; ‘recovery’ model, not rehabilitation model: ‘what went wrong’: a waste of time to begin blaming any of the partners in the system; inadequate planning: actually needed a full year of planning; should have outlined a planning process; state was supposed to write a business plan and LME to write theirs; LME plans were insufficient; oversight committee should have laid out guidelines; when governor had to tap 2001 mental health funds, that should have been a signal to slow down; we removed certain functions that we had expected the LME to perform: assessments; when they were removed, since we wanted the LME’s to manage the matter locally, there was nothing put back into place; relationship between DHHS & LME, tensions; these have to get down to a manageable level; 1 of biggest problems: no one is serving our most seriously mentally ill and they end up in jails; solutions: don’t go into any other changes until system is stabilized: no big changes now; another model: child developmental assessment agencies; move toward the agencies that are successful already.

LEZA WAINWRIGHT (cohort of Mike Mosley, Department of Mental Health: DHHS): what was necessary re: mental health reform was comprehensive approach; addressed governance; prior to reform we didn’t even have a term called target population. As re: old system, there were problems: 1. over-reliance on state system 2. conflict re: manager being service deliverer. We didn’t pilot this reform; we took it state-wide at the same time we were identifying target pop; all of this change has served to destabilize the system. These are some of our successes: more oriented towards the consumer: consumer and family advisory committees: we have tried very hard to give consumers a voice; its not where it needs to be yet but at least there are formalized mechanisms. There is another partner in this whole equation who is playing a more service role: the federal government: other states are currently unsuccessful using our identical ACT bill information (New Mexico is unsuccessful) We have to recognize the role of federal government; we have implemented crisis intervention teams; particularly successful in Wake County. Another challenge which has been taking place, happening at the same time is that changes were being made in the private sector; Also parity is a critical matter which we do not have in NC. 200 community hospitals closed over the past several years; they were picking up psychiatric consumers; clearly that has had the effect of putting more of a strain on the state hospitals. What we have seen is a large spike in short term stays, primarily due to substance abuse; again, all of this is taking much longer than we would like; all of us underestimated the skill set it would take in order to manage this massive change

JOHN TOTE: Mental Health Association in NC: oldest advocacy group in NC: we are also providing services; looking back at old system: clearly our system needed some tweaking. Mental health reform and what has taken placed is not just a paradigm shift but a completely new experience: clearly we have not hit the mark: some services have done well and so this is not just an abject failure: there are some things that are now in the system that were not. Clearly, however, this is not where we need to be; its not good that we have to keep changing the system every other week. We do need to let local communities to get a handle on where they are. The legislative oversight committee came up with some recommendations; thus far the general assembly has not hit the mark; there must be policies that drive funding; we do need new money. Local money level, per Fitzsimmons, is lacking at the local control level. Again it comes back to policies. We do need to take of the people who are in the most severe need. Parity addresses this issue. Where can we do a better job at early intervention. There are not a lot of officials here today, Gov Easley, most of all. Where are the state legislators?

ANN AKLAND: NAMI-Wake; retiree from EPA; has schizoaffective daughter; prisons house many more people with mental health issues than psychiatric hospitals. Used daughter as example; it was obvious that this mental health reform was doomed for failure; I sent e mails to Verla: we’re moving too fast, we need to slow down; the focus was on the closing of hospital beds: you know why?: because they wanted the money; we had to have that money to put the services in place; there was not much money to be had from the closing of hospital beds. We need to delay the closing of Dix until we have the services. Another reason that the system is not working is that the services have to be delivered by private providers. Now I just heard what Verla said, that this isn’t so. The LME’s should not have to ask for waivers as their staff does not know if they are going to stay or go. What is it about the LME’s not able to spend 93 million dollars. Verla says we need to keep things like they are. Yes, we cannot afford to keep things like they are. Maybe some things need to be stabilized but we sure need to change some things. I don’t see the progress; I don’t feel the progress. I’m here to say that the system is off track. I have been my daughter’s case worker. My daughter now has the services from the ACT team. The idea is to help them reduce stressors in order to keep from hospitalization. Even the ACT team is not working to keep Kristen safe. There is not any money to be made. There is not a big economic incentive to give her the support she needs. The idea of 24/7 from an ACT team is only a dream. I am my daughter’s crisis line; we are tired and we are getting older. We worry that Kristen will become another nameless person in this system. When we’re gone, will she find herself in prison. Will she just give up, take her own life. Deputies have been to Kristen’s house 3x / past month. Multiple hospitalizations. Her ACT team leader thinks she is receiving adequate services. It won’t be long until she will need a long term commitment. I don’t see the progress. Everyone is chasing a buck. Most local mental health officials are afraid to speak out; that’s where they get their funding. Just like an addict until we admit we have a really serious problem, we won’t get better until we admit to the problem. Keep Dorothea Dix hospital open. Please keep that safety net in place. LME’s should have flexibility to administer money. Until NC has a governor who pays attention to this, this will not happen.

RUTH SHEEHAN: reporter: Raleigh News & Observer : (200,000 reader circulation) has written repeatedly about one person w/ serious mental health issues: Phil Wiggins . she stated, there’s lots to be commended about a well maintained community care. The promise of that care was not always in place; cuts came; he went to psychosocial rehab; now, there is a question as to whether this can continue as the community support is being cut to 15 hours/ week. The individual stories are what we all care about. I am sorry that the members of the legislature are not here; the governor is not here. I wish each of them had a family member with mental illness so they could understand what is going on.

NANCY RYAN, NC NAMI: state board: the services are a very mixed bag across the state, county to county: poor counties, rich counties; rural and not so much so; If things were really good before, then they quite probably look bad now, she suggested, in terms of how people view mental health reform; if they were bad previously, then things have improved.

HEALTH CARE ADVOCATE: Paperwork overload: psychiatrists crying to me everyday dying because they can’t get care.
INSKO: there are some things that we have to put back in place which we never intended thru the statute to take away from LME’s: crisis services/ crisis functions. If they can’t contract it out, we should require the LME’s to provide this themselves. Also, case management might be necessary. We did not intend to give these services away. MIKE NELSON: county commissioner Orange County: in my county, we’re a fairly affluent county; even here it feels like the system is near total collapse. Clinic in operation for 38 hears, closing to 2 days/ week; 110 clients have to find new care; many of the clients do not have cars. What can we do at the county level INSKO: when we initially proposed reform, we were going to move the matter to the counties; this was roundly refused by the county commissioners. LME’s have no real linkage thru a formal established relationships; they are an odd beast. Counties had a lot on their plate, so the next step was to look at the LME’s . If counties would pay some of the administrative dollars, they would get involved. This is a real disconnect in this system. County managers have a way of strengthening this linkage. We are talking about this at the state level, how to make these administrative linkages better. WAINWRIGHT: part of the new service design is to address the transportation issue (this was exactly contrary to what Steve Puckett, PhD, said at the SMC provider meeting less than 1 week ago). SHEEHAN: Very sick people need stability. Area programs need to be our safety net again. TOTE: County commissioners stated upon reform that they would stand behind this reform. This has not played out. For valid reasons and not valid reasons, the counties have not stepped up. The counties do have responsibility now. What we said in this reform effort, these people in this target population; people outside target pop would be taken care of by the counties in order to keep them out of the target population. INSKO: (she stated that she did not remember anything about the counties volunteering to become active as associated with mental health reform; quite the contrary).
SCHIZOPHRENIC CLIENT: Give us back our day hospital. We need it: INSKO: about 22 LME’s have something like this. I hope that there will be a renewed effort to put facilities in Wake county. If we can authorize to the LME’s and give them more flexibility that may be one way to address this problem. PHYSICIAN: In 1960’s, we had a model system. There seems to have been a concerted effort to destroy this. ADVOCATE COMMENT: If you had been working for a corporation, you would have been fired. People should be able to keep their mentally sick children on health insurance. Tax relief for families taking care of mentally ill children: housing, health care; food, so that we families can take back the power of the state and not have to wait for decades for state government to get right. INSKO/ TOTE: Alexander has agreed to remove Substance Abuse provision; mental health parity will pass thru both chambers.


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