THE SYSTEM: How The Commission of DD/MH/SA, the LME CFAC's, and OAH are paper tigers w/ no authority to address LMEor consumer complaints

Well, this pretty much sums up Madame Defarge's work up to this point. I've documented how the system does not work and the next step appears to be a class action lawsuit.

This is how The Commission 'works'; this important commission, inhabited by people appointed by the governor and the state legislature, as stated by the Chairman, attorney Pender McElroy, is only advisory.

(November, 2007)

Dr. Hammond,

I am responding to the specific numbered inquiries at the end of your email of November 21, 2007.

(1) The Commission for MH/DD/SA Services has no jurisdiction over complaints processed through the Office of Administrative Hearings. Our statutory mandate is make and amend rules with regard to MH/DD/SA services in North Carolina and to serve in an advisory capacity to the Secretary of HHS. The Secretary is given statutory authority to make rules in certain areas. Our Commission has no ability to impact what goes on at OAH. Incidentally, please do not confuse our Commission with the Rules Review Commission (RRC). The RRC reviews rules proposed by all state governmental commissions and agencies for compliance with their respective statutory authority and for clarity.

(2) The legislature is the source of empowering CFACs. Again, the Commission for MH/DD/SA Services has not been given rulemaking authority with regard to how CFACs are formed and operated.

(3) Members of our Commission are appointed by the Governor, the state Senate and the state House. We have no authority over appointments.

(4) Please see No. 1 above.

(5) Please see No. 3 above.

In further response, you may know that in some states, there is a commission which is granted significant authority with regard to policy and oversight of mental health programs. North Carolina is not one of those states. In our state, the authority to set policy and to oversee the mental health programs and services is vested in the Secretary of Health and Human Services and is delegated to the Division of MH/DD/SA Services. Our Commission makes rules within the authority granted it by the legislature, and we give the Secretary our advice from time to time.

All of our Commission members have a keen interest in the programs and services in our state and how they are delivered. Our number one priority is consumer care. Within our authority, we believe we have a positive impact on delivery of those programs and services. We have consumers and family members of consumers on our Commission and on our two committees. We are open to and do hear all points of view on rules that are before us - including consumers, family members and public and private providers.

North Carolina has suffered from an underfunding of these programs and services for many years. If we can find the political will in this state to come closer to properly funding programs and services, many of the problems you recount would not exist.

Thank you for your interest in our work.

Pender McElroy
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This is how the (Consumer and Family Advisory Committee) CFAC's are supposed to work: the CFAC's were written into law by the state legislature in order to provide a sounding board for consumers, providers, and citizens who wanted to bring issues of general importance before the LME:

http://www.ncga.state.nc.us/Sessions/2005/Bills/House/HTML/H2077v5.html

"§ 122C‑170. Local Consumer and Family Advisory Committees.
(a) Area authorities and county programs shall establish committees made up of consumers and family members to be known as Consumer and Family Advisory Committees (CFACS). A local CFAC shall be a self‑governing and a self‑directed organization that advises the area authority or county program in its catchment area on the planning and management of the local public mental health, developmental disabilities, and substance abuse services system.
Each CFAC shall adopt bylaws to govern the selection and appointment of its members, their terms of service, the number of members, and other procedural matters. At the request of either the CFAC or the governing board of the area authority or county program, the CFAC and the governing board shall execute an agreement that identifies the roles and responsibilities of each party, channels of communication between the parties, and a process for resolving disputes between the parties.
(b) Each of the disability groups shall be equally represented on the CFAC, and the CFAC shall reflect as closely as possible the racial and ethnic composition of the catchment area. The terms of members shall be three years, and no member may serve more than two consecutive terms. The CFAC shall be composed exclusively of:
(1) Adult consumers of mental health, developmental disabilities, and substance abuse services.
(2) Family members of consumers of mental health, developmental disabilities, and substance abuse services.
(c) The CFAC shall undertake all of the following:
(1) Review, comment on, and monitor the implementation of the local business plan.
(2) Identify service gaps and underserved populations.
(3) Make recommendations regarding the service array and monitor the development of additional services.
(4) Review and comment on the area authority or county program budget.
(5) Participate in all quality improvement measures and performance indicators.
(6) Submit to the State Consumer and Family Advisory Committee findings and recommendations regarding ways to improve the delivery of mental health, developmental disabilities, and substance abuse services.
(d) The director of the area authority or county program shall provide sufficient staff to assist the CFAC in implementing its duties under subsection (c) of this section. The assistance shall include data for the identification of service gaps and underserved populations, training to review and comment on business plans and budgets, procedures to allow participation in quality monitoring, and technical advice on rules of procedure and applicable laws.

In actuality, this is how the CFAC functions, bearing in mind that as associated with thet original intent of the NC Mental Health Reform law, there were not in existence anything like a CFAC. The following is from a member of a local CFAC:

<r-------c@yancey.main.nc.us> wrote:

What I sent was the most recent statute. It was passed as session law 142 in 2006 and is contained in present General Statute 122C as section 170 (NC GS 122C-170). It actually was not a change in the law as CFAC's were not included in the General Statutes previously. The best I can remember is that they were set up under the MH/DD/SAS Division's state plan. So previously, they were not required by law. Now they are, and as the law states "A local CFAC shall be a self‑governing and a self‑directed organization that advises the area authority or county program in its catchment area on the planning and management of the local public mental health, developmental disabilities, and substance abuse services system." To me, "self -governing and self-directed organization" means just that--- the LME Board, LME Director, or other outside entity do not tell the CFAC who to have as members unless the CFAC agrees to that. I think that most, if not all, CFAC members originally were appointed and/or approved by the LME boards, hence if the LME Board or Director wanted to remove a member or the whole group they could and, in at least one case, did so.

There are no commission rules that cover CFAC, only GS 122C-170. Hope this helps. 2 of the CFAC's, the only CFAC's in western NC associated with Western Highlands LME and Smoky Mountain Center LME-----covering one-fifth of the counties in NC.
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And this is how Office of Administrative Hearings (OAH) is supposed to work & does work w/ the testimony of Diane Bauknight who has interfaced w/ OAH re: a family member:

The Office of Administrative Hearings is an independent state agency which provides impartial Administrative Law Judges to conduct fair and prompt hearings for persons affected by state agency actions. The Office of Administrative Hearings serves as a quasi-judicial tribunal for the expedient, independent and impartial adjudication of contested cases. Its mission is to provide a neutral forum for handling administrative hearings for certain state agencies, with respect for the dignity of individuals and their due process rights.

How it actually works:

After you go through the hearing and a decision is made by the judge, you may be pleased to learn that the judge agrees with YOU. Don't get too excited. The decision then goes back to the very agency you filed the complaint on. With mental health, this is Mike Moseley from DMH He can DISAGREE WITH THE DECISION and elect to do nothing to rectify the problem. The very agency you have filed the complaint regarding makes the final decision. Remember, this is a quasi-court. From the OAH website:

When the Administrative Law Judge issues a decision in your case, the case then goes to the agency or a commission for review. The parties will have an opportunity to file exceptions to the Administrative Law Judge decision with the agency or commission. This procedure will be set out at the end of the decision. The agency or commission must follow certain procedures when reviewing the judge's decision, and may reverse it only if it can demonstrate that the decision is clearly contrary to the preponderance of admissible evidence in the record. Once the agency has issued its final decision, you may ask for judicial review in Superior Court. Your right to judicial review is set out in North Carolina General Statute 150B, Article 4.

Will The Commission overseeing NC Mental Health Reform act on these Barriers to MH Care in NC?

Marsha V. Hammond, PhD: Clinical Licensed Psychologist : Asheville, NC E mail: hammondmv@netzero.com cell: 404 964 5338 fax: 8282532066

November 21, 2007

RE: rules query; complaint against Smoky Mountain Center LME

Dear Floyd McCullouch, Chair of the Rules Committee of The
Commission for Mental Health, Developmental Disabilities, and ubstance
Abuse Services (MH/DD/SA); Pender McElroy, Chairman of the
Commission (MH/DD/SA); and, other members of The Commission:

I am writing you as associated with several matters. All of these concerns are associated with the barriers to providing mental health services in NC by myself, a doctoral level psychologist licensed in NC.

I understand that the Rules Committee, of which Mr. McCulouch is chair, meets at the Clarion Capitol Hotel in Raleigh on January 16, 2008, 9:30 a.m. Subsequent to that, as per my telephone conversation w/ Rose Ann Forbes of Asheville, a member of both the Rules Committee as well as the Commission itself, there is a meeting of the full Commission on February 14th, beginning at 9:30 a.m., at the same location. I would like to have these issues entertained at those meetings. Thank you so much for your kind assistance.

I will highlight some general comments as well as some specific ones in the following. Then, I summarize the points at the end of this letter.

First of all, there are 1300 outstanding complaints which are being not addressed by OAH. This matter can be verified by listening to the latest meeting (online at the state website) of the Joint Legislative Committee of Mental Health Reform, chaired by Verla Insko and Martin Nesbitt.

I note on your website that you declare The Commission to be the place where the buck stops prior to going to the General Assembly (“The RRC is the last place a rule goes before going to the General Assembly.” http://www.ncdhhs.gov/mhddsas/commission/ruleprocess.pdf

I know that there are rules associated with such a process and I am appreciative of your guidance about how to efficiently take care of business. Please advise me as to how these complaints will be more efficiently addressed. It is not enough to say that DHHS has hired some temporary employees to do what should be a core process of NC Mental Health Reform. In general, citizens and providers see very little of their input being admitted into the mental health reform process. Can you comment as to the permanence of NC DHHS in terms of addressing the complaints issue? Can more resources be assigned to this complaints process so that NC Mental Health Reform can work?

Secondly, that matter is related to this matter: consumers, citizens, and providers are noting that the CFAC’s (Consumer and Family Advisory Committee) of the LME’s are commonly not functional. In part (and I am still educating myself as re: this), it may due to the lack of teeth (the CFAC is advisory only) as per the NC Mental Health Reform law which seems to be allowing DHHS to simply ignore the feedback that comes up through the LME CFAC’s at the LME level on through to the state CFAC.

For instance, some LME’s have determined that they need to appoint members of the CFAC and that appears to predjudice such appointees to favoring the LME. Also, I assume that the rules that are associated with the state CFAC are applicable to the LME CFAC. Can you make clear in the rules which you oversee if this is true or not? The law is clear, I believe, as to what the purpose of the state CFAC is: http://www.ncga.state.nc.us/Sessions/2005/Bills/House/HTML/H2077v5.html

The State CFAC shall undertake all of the following:
(1) Review, comment on, and monitor the implementation of the State Plan for Mental Health, Developmental Disabilities, and Substance Abuse Services.
(2) Identify service gaps and underserved populations.
(3) Make recommendations regarding the service array and monitor the development of additional services.
(4) Review and comment on the State budget for mental health, developmental disabilities, and substance abuse services.
(5) Participate in all quality improvement measures and performance indicators.
(6) Receive the findings and recommendations by local CFACs regarding ways to improve the delivery of mental health, developmental disabilities, and substance abuse services.
(7) Provide technical assistance to local CFACs in implementing their duties.
(d) The Secretary shall provide sufficient staff to assist the State CFAC in implementing its duties under subsection (c) of this section. The assistance shall include data for the identification of service gaps and underserved populations, training to review and comment on the State Plan and departmental budget, procedures to allow participation in quality monitoring, and technical advice on rules of procedure and applicable laws.

I might speculate that SMC LME does not have enough personnel to put the minutes onto the SMC LME web page. If so, is not the law that states:

"....(d) The Secretary shall provide sufficient staff to assist the State CFAC in implementing its duties under subsection (c) of this section. The assistance shall include data for the identification of service gaps and underserved populations, training to review and comment on the State Plan and departmental budget, procedures to allow participation in quality monitoring, and technical advice on rules of procedure and applicable laws...."

also applicable to the LME CFAC site? Without information, citizen participation languishes.

As specific evidence, in the case of SMC LME, there is no information about what takes place at the CFAC, a very critical citizen watchdog group that sees to it, according to the law, that the LME admits into its procedures feedback that comes to the CFAC. Please note this site as being devoid of information in terms of minutes: http://smokymountaincenter.org/partners/meeting.asp:
Content goes here.

Please advise me as to how the LME CFAC’s can be nudged to perform their mandated duties. I have written Shelly Lackey of SMC LME (shelly@smokymountaincenter.com) as well as Bill Hambrick, the key administrative person (bill@smokymountaincenter.com) and I have no replies to my queries. I am regretful that I am such a pest on this matter but I am afraid it is very important.

Thirdly, again as associated with SMC LME, I have asked for months, since the beginning of the summer, via a dozen or more e mails, a question about the matter described immediately below. Specifically, I have asked Bill Hambrick; Steve Puckett, PhD (Clinical Director) and Charles Barry (over Quality Management) a question associated with providing services to a state funded MH client that I see. Moreover, this is not unassociated with the lack of ability of providers to bring forward a formal complaint to the LME. Specifically, I have sent a letter to Bill Hambrick asking he and SMC LME to address the matter of why providers have no evident process associated with bringing forward their complaints against the LME. There appears to be no formal mechanism for doing such.

There is written into law consumers’ formal complaint process (as evidenced by the existence of Quality Management Offices such as Charles Barry at SMC LME heads up), but there is no formal procedure for providers to utilize in order to make their own complaints about the LME.

This is also why I believe it is critically important to have representatives on The Commission which reflects the various LME’s. SMC LME and WH LME are associated with 19/100 of NC counties; yet, less than 5% of the members of The Commission are associated with western NC as associated w/ SMC LME and WH LME. Please advise me as to whether this can be remedied.

Ms. Rose Ann Forbes was of the mind that issues are common across the state; however, I am advocating that circumstances are unique and therefore require adequate representation. I am volunteering myself as a potential member of The Commission should that be something to be entertained as people serve their 3 year stint. I enclose my vitae.

In other words, unless the consumer complains about not receiving services, which I, as a provider am ethically beholden to deliver, the provider can simply carry on seeing the consumer and never be paid as associated with no formal process which advantages providers to interfacing with the LME about these barriers to providing treatment to consumers, in particular, state funded consumers which is the primary bailiwick of the LME.

I am not willing to stop seeing my state funded client and endanger her mental health just because there is no process for me to utilize and I have been completely ignored by the administration at SMC. I enclose my letter to Bill Hambrick. This was after many e mails on the same matter.

I have also asked Tara Larson of DHHS specifically about this matter. I have received no answers for my persistent questioning---nothing at all. Not a suggestion about whom to ask or where to go.

Please help me. The matter is this: I, as a doctoral psychologist, provide psychotherapy. I do not provide Community Support Services (CSS). Yet I am demanded by Charles Barry of SMC LME to attend 20 hours of CSS training in order to be paid for the work I do w/ my state funded client. As per SMC LME’s choice of funding streams, the funding for psychotherapy comes from a CSS funding source. That is not my affair. I have had specific, documentable conversations with the ACCESS care manager, Marsha Coe, about the services I provide to state funded consumers; the services we discussed were psychotherapy services, not CSS. Yet, SMC LME demands that I use my professional doctoral time in order to sit in 20 hours of training rather than treat clients. This appears to be a mis-use of my time. Please tell me where I should take this complaint so that I might efficiently serve my state funded client and be paid.

Please enlighten me as to where in the rules, regulations, or statutes as to how I can formally bring a complaint against SMC LME as associated with their lack of feedback pertaining to my persistent questioning. There appears to be no process associated with bringing a complaint about the functioning of the LME vis a vis the provider.

Additionally, I am alerting you to the barrier associated with the very long period of time it takes to have an authorization request attended to by this provider as pertaining to WH LME. The problem is this as associated with authorization requestions (for mental health treatment): if the LME denies the services which I have requested, if I am continuing to treat the client, as is appropriate and is associated with my psychologist ethical guidelines, I may not be reimbursed.

In summary, can you address the issues outlined above at the meetings on January 16th (Rules), January 17th (Advising) and February 14th (full meeting of The Commission):

1. How can consumer complaints be processed in an efficient manner by OAH? Can a time limit be created so as to improve the efficiency of this process?

2. Is the law associated with the functioning of the state CFAC pertinent to the individual LME CFAC’s or not? (Corollary): How can the CFAC’s of the LME’s be nudged to do their jobs more efficiently?

3. Is it not appropriate to have representative members of The Commission from the various LME’s and specifically, is not Western NC under-represented?

4. Where is the law which is associated with the (assumed to be in existence) procedure associated with the formal complaint process that a provider can utilize in bringing a complaint against the administrative process of an LME? (Corollary): (as per the attached letter to Bill Hambrick re: client 040974, state funded client): Where is the rule/ statute/ or regulation associated with DHHS NC creating a Bulletin which advises providers about this formal complaint process; (Corollary): Who can address my ignored concern about being required to obtain 20 hrs CSS when I do not provide that service?

5. Would you consider my application as a member of The Commimssion? (I am easily reached@: hammondmv@netzero.com & my vitae is enclosed to Mr. McElroy & Mr. McCullouch in a US Post letter to them)

Thank you so much for addressing these matters. I look forward to your comments.

Sincerely,

Marsha V. Hammond, PhD: Clinical Licensed Psychologist, NC

Please feel free to pass this e mail to any pertinent party.

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attachment to this e mail: hammond cl 040974 SMC LME
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Enclosed Hammond vitae to : Floyd McCullouch,CHAIR, Rules Committee of The Commission; Mr. McElroy, Chair of The Commssion
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cc:
(US Post letter sent to McElroy and McCullouch)
also, e mail to:
1. members of The Commission, inclusive of:
Rose Ann Forbes
PO Box 8511
Asheville, NC 28814
hm: 828-253-2501
email: wilannf@charter.net

Floyd McCullouch, CHAIR (Rules Committee) 120 Livingston Dr. Goldsboro, NC 27530 hm: 919-734-9046 fx: 919-735-6064 cell: 919-920-9046 email: fmccullouch@nc.rr.com
Pender McElroy, CHAIRMAN 600 S. College St. Charlotte, NC 28202 wk: 704-335-3880 fx: 704-350-9369 email: pmcelroy@jmdlaw.com
2. SMC LME: Bill Hambrick, SMC LME: bill@smokymountaincenter.com ; marsha coe: Steve Puckett, PhD; Charles Barry; Tom McDeviltt, Director: tom@smokymountaincenter.com

3. NCAdvocacy Listserv (w/ over 130 providers and consumers across NC)
Moderator: David Cornwall: NC Mental Hope: ,"David Cornwall" <david@ncmentalhope.org>: http://www.ncmentalhope.org/ & associated concerned citizens and providers in NC

4. Chris Fitzsimmons, NC Policy Watch

5. Adam Searing, NC Justice Watch

6. DHHS: Tara Larson; Mike Mosley; Leza Wainwright

7: joint legislative committee: Insko; Nesbitt

8. NCPA: Sally Cameron

9. Madame Defarge: NC Mental Health reform blogspot

10: Direct Care, LLC personnel: Barrance Roberts; Anthony Jones

It's Prety Bad when you have to COMPLAIN ABOUT THERE BEING NO COMPLAINT FORM

Marsha V. Hammond, PhD: Clinical Licensed Psychologist, NC
Mailing address: Asheville, NC 28806
Cell: 404 964 5338 fax: 828 253 2066
E mail: hammondmv@netzero.com

November 16, 2007

RE: formal complaint pertaining to administrative policies of Smoky Mountain Center LME

Dear Bill Hambrick:

This is a formal complaint related to an administrative procedure being followed by SMC LME. I wrote an e mail re: this matter this past week to you; Marsha Coe; Steve Puckett, PhD, Charles Barry. I am following it up w/ a formal letter of complaint posted to the SMC US Mail address. I wish that I could say that it is my understanding is that this must be attended to by the LME within a time-frame. However, in that there is no formal policy for providers to utilize for complaints about the LME, its hard to tell how far this will go or if it will go anywhere at all. Therefore, the co-chairs of the Joint Legislative Committee for NC Mental Health Reform (Insko; Nesbitt) are cc'd.

The (Bulletin 7#77) ‘LME Complaint Reporting’ http://www.ncdhhs.gov/mhddsas/announce/commbulletins/commbulletin77/lmecomplaintreporting8-07.pdf appears to be the most recently revised information (Revised August 13, 2007).

I believe it is an administrative issue complaint in accord w/ the information associated with Bulletin #77: “Administrative Issues Any concerns regarding administrative issues such as compliance with rules, paperwork, facility-related (not incident or safety concern), etc.”

As background associated with my complaint which I have reiterated many times : I do not provide CSS. I provide Individual Therapy. I am affiliated w/ Direct Care, LLC, an Endorsed Provider. In several telephone conversations, Individual Therapy, CPT code 90808, is what was approved by the ACCESS lead care manager, Marsha Coe for two state funded clients. CPT code 90808 is what was submitted via the BUI electronic authorization web page associated with www.smokymountaincenter.com. The authorization request for 90808 was apparently changed by SMC LME to a CSS coding and/ or stream of money. I do not know the reason and neither is it my business.

Charles Barry, Quality Control Manager at SMC LME, then required me to have 20 hours of CSS training in order to receive and keep my money paid to me by SMC LME for servicing the two clients in agreement w/ phone conversations w/ Marsha Coe.

Barrance Robert, who heads up Direct Care LLC has returned the money paid to me as Charles Barry’s office threatened Direct Care LLC w/ an audit if I did not go through CSS training. I am not going to go through 20 hrs/ CSS training when I do not provide CSS. I want to be paid the money I earned. This is the background of this complaint.

Bulletin 77, DHHS NC, concerns itself with ‘complaints.’ I cannot use the complaint form associated with that bulletin, specifically, The Customer Service Form (ACS01): http://www.ncdhhs.gov/mhddsas/announce/commbulletins/commbulletin77/lmecomplaintreporting8-07.pdf, as the form is to be used by LME staff. That form states at the top: “Purpose: This form is to be used by Local Management Entity (LME) staff to document customer service issues such as concerns, complaints, compliments, investigations, and requests for information involving any person requesting or receiving publicly funded MH/DD/SA services from a LME or a MH/DD/SA services provider.”

The form appears to assume that private providers will not have complaints about the LME and/ or the private provider will deny services to the consumer, the consumer will make a complaint, and the LME will then address the issue. If the private provider is ethical, the private provider cannot in some cases withdraw from the client. Not only would this create a therapeutic impasse, but it could create a serious ethical dilemma for the private provider.

Neither does this Bulletin appear to be associated with a complaint against an LME; it is the consumer who makes the appeal:
Bulletin #067 Update to Bulletin #063 Non-Medicaid Appeal Process
12-18-06
http://www.ncdhhs.gov/mhddsas/announce/commbulletins/communicationbulletin67-12-19-06.pdf

Neither does this Bulletin appear to be associated with a provider making a complaint about an LME:
Bulletin #063 Memo re: Non-Medicaid Appeal Process
10-9-06

Neither does this bulletin allow providers to complain about the LME:
Bulletin #056 Memo re: LME Complaint Reporting
6/12/06

That takes us back to August, 2005 and I did not continue to look for ways to formally complain about the LME as it would be out of date and certainly not considered as on the correct form.

So, my complaint is also about not having a complaint form to complain upon.

I am not willing to risk harm to the state funded clients I see because there is no appropriate complaint form as associated with the notion that there is no need to complain. If there is a complaint form buried in the NC DHHS bulletins, if someone will kindly point it out, I will be glad to fill it out.

In speaking to SMC employee Shelly Lackey today on the phone as associated with this process and bringing my complaint before the SMC LME board, SMC Human Rights Committee, and SMC CFAC, she agreed to pass my name to the two Haywood citizens who serve on that committee. I have also contacted Haywood County Commissioner Mary Ann Enloe.

Thank you for taking the time to read this letter of complaint and I am happy to provide you w/ any information which may not be clear.

Sincerely,

Marsha V. Hammond, PhD: Clinical Licensed Psychologist
Cc:

Chris Fitzsimmons, NC Policy Watch

DMH/DD/SAS Customer Service Office
DMH/DD/SAS Customer Service and Community Rights Team
Phone: (919) 715-3197 Fax: (919) 733-4962 dmh.advocacy@ncmail.net

DMH/DD/SAS Customer Service and Community Rights Team
Phone 919-715-3197 FAX: 919-733-4962

Glenda Stokes or Cindy Koempel
Customer Service and Community Rights Team
Advocacy and Customer Service Section
Division of MH/DD/SAS
North Carolina Department of Health and Human Services
3009 Mail Service Center
Raleigh, NC 27699-3009
FAX: 919-715-3197
Phone: 919-733-4962

CoChairs of the Joint Legislative Oversight Committee: Verla Insko; Martin Nesbitt

Tara Larson, DHHS NC

Shelly Lacky; Charles Barry; Steve Puckett; Bill Hambrick; Tom McDeviltt; Doug Trantham: Marsha Coe: SMC LME

NC Advocacy MH listserv

NC Psychological Association

Madame Defarge: NC Mental Health Reform blog

Community Support Services: REHABILITATION OR BUST

Marsha V. Hammond, PhD: Clinical Licensed Psychologist, Asheville, NC
E mail: hammondmv@netzero.com cell: 404 964 5338 fax: 828 253 2066

November 9, 2007

RE: rehabilitative model associated with Community Support (as per new guidelines receiving comment at this time); recommendation to remove psychotherapy from CSS

Dear NC Department of Health and Human Services Director, Mr. Benton (and associated ‘make a comment’ e mail address: dma.webmedpolicy@ncmail.net:

I read with interest the latest information about Community Support Services (CSS): (as per DHHS announcement): “An emphatic statement that Community Support is a rehabilitative treatment service and not a social support, recreational or mentoring program…. Last month, the department announced the first stage of the community service improvement plan – proposed new definitions for the services. Those changes, which are in a 45-day public comment period…” http://www.ncdhhs.gov/dma/mp/Community%20Support%20Adult%20Marked.pdf

I’m afraid I call this notion ‘rehabilitation or bust.’ I would like to propose that there are some problems w/ that thinking.

While the notion of ‘rehabilitation or bust’ may be issued at the federal level, which we trust less and less, the state of NC has a ‘choice’ (like consumers were supposed to have re: mental health treatment, but which has faded drastically with time) about treatment guidelines. Basically, I want to know what the state’s intention is in terms of mental health consumers who require interventions over a sustained period of time.

Research indicates that many DSM diagnoses require sustained intervention, though diminishing over time. There are two issues here, one which is current and one which is surely eminent. State funded consumers with target population diagnoses have had their psychotherapy included with CSS. It is my understanding that as of July, 2007, Basic Services was created which included psychiatric f/u, inclusive of medication f/u, and psychotherapy.

****I would like to support the notion of removing psychotherapy from CSS. It does not belong there. ****

Specifically, Smoky Mountain Center LME continues to include psychotherapy w/ CSS and my clients are not being availed of necessary services. The second point is this: if Medicare and Medicaid go the way of state funded services, the inclusion of psychotherapy within CSS will collapse the entire mental health apple cart.

I hope to make my points below about the following two matters:

(1) Psychotherapy is as necessary as medication in mental health recovery. It therefore needs to be included w/ psychiatric f/u for state funded consumers and NOT grouped w/ CSS which is being defunded, say what you will.

(2) For state consumers/ Medicaid or Medicare consumers (or privately insured consumers, for that matter) all targeted mental health illnesses are NOT the same in terms of the trajectory of their recovery. Therefore, applying a rigid template of ‘rehabilitation or bust’ is not appropriate for all mental health illnesses.

As a doctoral level psychologist, I find it very dismaying that all target population diagnoses (and those below are such) are treated in the same manner. Major depression is assumed to be as ‘curable’ and can be rehabilitated utilizing the same time-table as, say, PTSD; ditto Borderline Personality Disorder.

Prior to July 2007, CSS included therapy and emergency services for state funded consumers. My concerns are particularly acute as pertaining to state funded mental health consumers. They appear to be more ill in terms of physical and mental illnesses as they have no health insurance and they are availed of many fewer services until they at last become so ill that they qualify for social security disability and Medicare/ Medicaid-----when the remedying of the matter was BEFORE they became that ill.

As regards adult consumers, research by the American Psychiatric Association and the American Psychological Association and their associated peer-reviewed journals, indicate that mental health illnesses, like schizophrenia, schizoaffective disorder, major depression, dissociative identity disorder, substance dependency, head injury (Cognitive Disorder NOS) and personality disorders, to name most of what comes into the clinician’s office---ALL----require follow-up years into the future.

YES, unequivocably, people improve given appropriate and medically necessary treatment. Yes, as per research, target population disorders such as PTSD are more treatable and research as developed, for instance, by the VA System, has moved treatment along to the point we are now. However, many mental health challenges, either acquired or congenital, require sustained but diminishing follow-up. There appears to be no room for the research and therefore, I’m afraid, NC mental health reform will simply fail. The following is simply a quick overviewing of the matter as can be gathered by any interested party who knows how to use google and recover the research:

Item 1: Schizophrenia and Schizoaffective Disorder have a low recovery rate

The American Journal of Psychiatry notes the following as associated with recovery from schizophrenia and schizoaffective disorder in the following article ‘Symptomatic and Functional Recovery From a first Episode of Schizophrenia of Schizoaffective Disorder’ Am J Psychiatry 161:473-479, March 2004 © 2004 American Psychiatric Association:

“…after 5 years, 47.2% of the subjects achieved symptom remission, and 25.5% had adequate social functioning for 2 years or more. Only 13.7% of subjects met full recovery criteria for 2 years or longer….”
*******************

Item 2: Major Depression requires maintenance treatment

http://www.westernhealth.com/providers/downloads/MDDQRG.pdf Guideline Watch: Practice Guideline for the treatment of patients with Major Depressive Disorder, 2nd Edition Laura J. Fochtmann, M.D. Alan J. Gelenberg, M.D.

“…..Psychotherapy combined with pharmacotherapy
As noted in the guideline, studies examining combination treatment with psychotherapy and
pharmacotherapy have shown mixed results. Although this has continued to be true in subsequently published studies (66, 67, 72, 73), a recent meta-analysis suggested that a combination of psychotherapy and pharmacotherapy is more effective than pharmacotherapy alone (74). Combination therapy may be particularly useful in improving treatment adherence (73, 74) and might be of some use in targeting particular symptoms or patient subgroups (75–77). _ CONTINUATION AND MAINTENANCE TREATMENT
At the time the guideline was published, much data suggested the importance of continuation and maintenance treatment in individuals at high risk of recurrent depression, although the
majority of studies on this practice examined the use of tricyclic antidepressants. Several more
recent studies have confirmed the benefits of continuation and maintenance treatment with
antidepressants in other classes (e.g., sertraline, venlafaxine, and mirtazapine) in decreasing the
likelihood of recurrence (78–82). Supplementing the earlier data on continuation and maintenance psychotherapy, most (83–87) but not all (88) additional studies of CBT support its use either alone or in addition to pharmacotherapy in decreasing depressive recurrence...."
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Item 3 The most common personality disorder, Borderline Personality Disorder, requires ‘extended psychotherapy’

http://www.psych.org/psych_pract/treatg/pg/BPD_05-15-06.pdf
American Psychiatric Association (2001): Practice Guideline For The Treatment of Patients with Borderline Personality Disorder : WORK GROUP ON BORDERLINE PERSONALITY DISORDER John M. Oldham, M.D., Chair
Glen O. Gabbard, M.D. Marcia K. Goin, M.D., Ph.D. John Gunderson, M.D. Paul Soloff, M.D.
David Spiegel, M.D. Michael Stone, M.D. Katharine A. Phillips, M.D.

“Borderline personality disorder is the most common personality disorder in clinical settings,
and it is present in cultures around the world…. most patients with borderline personality disorder will need extended psychotherapy to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning
***************************

Item 4: With appropriate treatment, current PTSD treatments render good results; however, PTSD commonly has co-occuring DSM diagnoses e.g., depression

"....The majority of patients treated with psychotherapy for PTSD in randomized trials recover or improve, rendering these approaches some of the most effective psychosocial treatments devised to date…. Studying PTSD in an urban population, Breslau and colleagues (15) reported that 83% of individuals with PTSD met criteria for one or more other disorders…. psychotherapy for PTSD produces substantial effects… Across all treatments, 56% of all those who entered treatment, including those who did not complete the study (i.e., the intent-to-treat group), and 67% of the patients who completed treatment no longer met criteria for PTSD posttreatment (Table 5). ..."

In summary, my first point is this: I hope that my request that psychotherapy be removed from CSS and included consistently w/ Basic Services will provide it some protection from the defunding process occurring w/ CSS. It is as critical as psychiatric f/u.

Secondly, I also am advocating that as per quality peer-reviewed research, various target population mental health diagnoses merit more than just a 'one size fits all' treatment policy. 'Rehabilitation' is only a useful term if it adequately addresses the matter of the diverse natures of mental health diagnoses that fall into the target population.

Sincerely,

Marsha V. Hammond, PhD


Cc: North Carolina Department of Health and Human Services Mark Van Sciver; NC Advocacy; Smoky Mountain Center LME, Bill Hambrick, Steven Puckett, PhD, Smoky Mountain Center; NAMI director

TEMPLATE FOR DENIAL OF TAX FUNDED SERVICES: Fed Treatment of New Orleans = DHHS Treatment of Mental Health Providers & Consumers

It seems there is a template utilized by government services in order to circumvent the usage of tax funded services (like mental health services):

Critics Cite Red Tape in Rebuilding of Louisiana

http://www.nytimes.com/2007/11/06/us/nationalspecial/06fema.html


“….the federal government has agreed to pay $2.3 billion so far for rebuilding Louisiana public works like schools, sewers, and politce stations. But so far, only $650 million---28%----of that money has been spent. In Mississippi, only 27% has been spent….

Intricate, inflexible and open-ended, the process seems to value perfect paperwork over speedy resolutions, local officials here say, and requires endless haggling over every acoustic ceiling tile and paper towel dispenser…..

In particular, state and local officials contend that FEMA has routinely underestimated the amount of damage caused by Hurricanes Katrina and Rita…..

They also say the agency has repeatedly reversed itself, been reluctant to put anything in writing, and has interpreted the rules too narrowly….

City officials still worry that FEMA officials could change their minds and take back money they have obligated….FEMA officials say they have seldom done that, and say they do not understand why state officials keep raising the prospect….”


***********************************
Last night I tried to upload a Person Centered Plan (PCP) on a state funded client of mine (necessary for authorization to see the client) whom I have been seeing though I am not paid. Client is intermittently suicidal and more so over past several weeks. As associated with authorization, the 15-20 page PCP is uploaded onto the internet-bound BUI system of Smoky Mountain Center LME. Upon entering the two sets of passwords, the BUI system 'locked up' and would not accept the document which means I cannot yet get the authorization for the now thrice submitted PCP. If I have time today I will try and upload it again. This is the 3rd rendering of the PCP much like, 'endless haggling over every acoustic ceiling tile and paper towel dispenser…..'

Yesterday, I utilized 3 phones in my household in order to try and get through the stated Medicare Provider number (866 520 4007), calling repeatedly over the course of 45 minutes. Then at 3:40, the message at Medicare/ NC CMS simply stated that the assistance was 'temporarily unavailable.' The office was not closed; it was simply 'unavailable.'

THIS SYSTEM IS BROKEN.

11th Congressional District: will NC failing mental health reform become an agenda item?

The following is associated with a discussion that Carl Mumpower, psychologist (R) has been having w/ a blogger. I am passing it on as associated with the ongoing problems that mental health reform has had in western NC, in particular. Dr. Mumpower will be running against Health Shuler (D) in 2008 as associated with the western NC Congressional seat for the 11th District.

The associated blogspot is here: http://themountainblog.blogspot.com/

These are my points of disagreement or query, as per Dr. Mumpower's post, below; my comments are discriminated by a series of ****:

Item 1: "...Brief therapy interventions with ongoing education, medication, periodic maintenance visits and group therapy follow-up options can help contain costs and maintain continuity of care - a crucial component for success..." ****In my experience, 'maintenance visits' seldom work in terms of working on deeper issues. What is required is persistent therapy, depending on the GAF or severity of the problems that the client is having. We have now moved into the place wherein the LME's (the old community health centers) are now acting like the insurance companies frequently have: the non-clinicians assume they know more about mental health than the clinicians. This begins at the top, re: NC DHHS, and continues all the way thru to the LME employees.

Yes, medication can give a critical leg-up but not unless you can obtain it. Yesterday I called the Buncombe County Health Department in order to access a state funded client in Asheville to someone who could simply prescribe an antidepressant and quite possibly an anxiolytic so the client can work and sleep. The Buncombe County Health Department person told me that the client could call on this Thursday, starting at 8 a.m., continuing to call until he could get through the phone line, in order to set up an appointment next month-----maybe. The client had tried and tried to obtain information about an appointment. I tried. I referred him to Good Samaritan Clinic, out of Buncombe county. This mental health care system is BROKEN. *****

Item 2: ".... Bureaucratic overlay and paperwork must be persistently trimmed to assure that caring for patients is a priority over caring for the system...." ******DHHS NC, who is implementing NC mental health reform, with an overviewing, a critical overviewing to be sure, by the State Legislative Committee for mental health reform (Chairs: Verla Insko; Martin Nesbitt) is perfecting a mountainous production of demanded paperwork. Person Centered Plans are now 15-20 pages (whileas the old community mental health center Service Plan which outlined symptoms and treatment was 2-3 electronic pages). No, NC DHHS: it does not matter that you have created a 'person centered plan' if the template must meet criteria set by the LME. It frankly does not matter what the 'person' wants. You simply want us to think that it matters.

A request sent into Western Highlands several weeks ago associated with authorization for a state funded client has still not been attended to. Yes, I have called them about it.
Veering over to Smoky MOuntain Center LME (Western Highlands and Smoky Mountain Center LME are the only 2 LME's in western NC which coordinate mental health care mostly re: state funded consumers), my 17 page Person Centered Plan, a requirement every 3 months for a state funded consumer, has been rejected twice now by (most recently) a non-clinician office person with the admonition that I had not paid enough attention to the client's use of marijuana and street Klonepin. That is not the client's major mental health problem. *****

Item 3: ".... In today's world, leaving addiction treatment out of the mental health equation makes little sense, in that addiction is probably our number one source of mental health issues...." *****Dr. Mumpower seems to have jumped on the bandwagon of 'you've got to treat (what we think is) an addiction first. Outside the abstinence crowd of the 'moral majority right' of the US, drug abuse rather than drug dependence is treated by minimizing harm until the client can avail themselves of mental health treatment such that the abuse recedes into the background as a problem. Where are the statistics that addiction is 'the number one source of mental health issues', Dr. Mumpower? And where is the timely mental health treatment for these clients??

marsha hammond, phd
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Dr. Mumpower's outline of the problems w/ mental health reform in NC, particuilarly western NC:

"An accessible, effective, and affordable mental health service system...

We are in the midst of a deteriorating culture. Values, supports, cultures, etc. are shifting in a way that are leaving folks more and more vulnerable and stressed. Addiction, of both legal and illegal drugs, is growing at a frightening rate. By failing to sustain the promise of state supported mental health services, we insure that homelessness, addiction, and other social issues grow exponentially. Mental health and addiction services are a necessary lifeline to insure out ability to pull off the other two legs of this stool.

Solutions - It is too our collective shame that we have allowed our mental health delivery system to wallow in "no man's land" for 6+ years. There should be accountabilities for elected and appointed officials who have at best been passive or complacent with this reality and at worst, complicit in the harms. All new initiatives must be field tested for realism and efficiency before implementation. Costs factors require that treatment modalities be targeted, reality based, and focused on functional improvements over more exotic or costly interventions. Brief therapy interventions with ongoing education, medication, periodic maintenance visits and group therapy follow-up options can help contain costs and maintain continuity of care - a crucial component for success. Bureaucratic overlay and paperwork must be persistently trimmed to assure that caring for patients is a priority over caring for the system. In today's world, leaving addiction treatment out of the mental health equation makes little sense, in that addiction is probably our number one source of mental health issues. We have people in Raleigh and around the state who can fix the mess - if we can develop the will and sense of urgency that our failing mental health delivery system deserves.

Excuse my rush, but this is a quick take on your question. I hope others will jump into the mix and create some productive dialog about these issues. Without a stronger emphasis on this "Community Health Equation" our future slides toward a darker place.

Thank you,

Carl Mumpower
Asheville City Council
Candidate for the 11th District Congressional Seat"