The Little Understood 'WHY' the Family Care Homes are Problematic for Those With Mental Health Challenges

Though I have not infrequently written about my experience, as a professional, with the family care homes in Western NC, I had not realized just what the issue was as to why NC DHHS (Medicaid) was being called on the carpet by the Department of Justice as pertaining to citizens w/ mental health challenges living in these homes. Apparently it has to do with the PERCENTAGE of people in the home who have PRIMARY mental health diagnoses.

The matter of 'primary' is very important as the profile of clients I have seen in family care homes have what you might expect from a life-time of living by their wits, best they could, and frequently have histories of childhood abuse and/ or neglect. These clients have BOTH physical and mental health issues. They commonly have chronic pain, diabetes, hypertension and then they have co-morbid depression, or other mood disorders or personality disorders that go along with living such a life.

So, HOW will these 'assessors' mentioned below in the NAMI article from the Fall, 2011 newsletter (see below), assess the clients as having a PRIMARY mental health issue, which is to say, this is the main and number one reason why they are in the family care home.

I am betting that this is the outcome of the matter: the 'assessor', depending on whether it is a mental health person or a allopathic medicine professional e.g., MD, Nurse Practitioner, Physician's Assistant, etc., will note----according to their expertise-----the primary illness. If I were NC DHHS, I would be hiring non-mental health professionals to assess these family care home residents.

I am betting that little will change in terms of where these people live because the method of assessment will have a hidden issue in it which is what are the professional qualifications of the person who does the assessment. Also bear in mind, as per the NAMI article, that the assessment is completely voluntary.

And I might imagine that most people having 'primary' mental health diagnoses will not want to be assessed because they are understandably suspicious of that and they do not want to be forced to leave unless they want to. And so, will those people who decline to be assessed simply be chalked up as having a 'primary' mental health or physical health diagnosis?

When I was a more brazen practitioner, I assisted clients in looking at their family care home charts to see 'what's happened to my money' (a frequent complaint) in that the residents are left with only $66 (yes, exactly that)/ month out of their disability check. There used to be more frequent complaints that they didn't get their money or they didn't know when they were going to get their money for that month, etc. That was my impetus for assisting the clients regarding the matter of 'where's money' and I have to say the quality of the family care homes has improved significantly over the past couple of years . They are generally more responsible people that run them and they act more professionally.

Complaints like mine surely made a difference as I carried them all the way to the regulatory agency of the family care homes.

See, for instance, one of these posts here: http://madame-defarge.blogspot.com/2009/04/wnc-family-care-homes-dss-buncombe.html

So, this is how the family care homes are paid:

1. the resident's disability check is taken by the family care home or rarely the client manages their own money and pays the family care home out of their check. Commonly, disability checks are anywhere from $650-850/ month----depending on whether the resident has 'vested' in the Social Security System or not. Bear in mind, that if the resident was mentally ill prior to turning 21 or perhaps 18, they could be utilizing the Social Security Number (and associated benefits) of a deceased parent's Social Security.

2. In that it costs approximately $1300/ month for living at the family care home----which is not a particularly bad deal given that they have a comfortable room, usually shared with someone else, a bigger family room where there is a TV, and food put on the table, as well as transportation to appointments----the remainder of the tab is picked up by the local county DSS. I assume that this is the problematic Medicaid money of which the article speaks.

3. out of the $66/ month that is by law given to the resident, they have to pay for medical co-pays and medication co-pays which for Medicaid are generally $3/ prescription. That leaves very little spending money as you can see.

The devil's in the details.

Here is the NAMI article:

"Adult care homes, originally designed as homes for the elderly and that now offer housing to people with mental illness, are being scrutinized byNorth Carolina because of a conflict with the federal regulations governing how the state pays for their care. Medicaid will not pay for care for the mentally ill in facilities that have more than half of the residents with a primary diagnosis of mental illness. Those residents woud have to be moved to other housing. There are now 52 facilities in North Caroina at that level. There is one in Western Carolina.

These homes and their residents will be assessed startig in the next few months. Cient assessment is done only w/ the client's permission.

Lanier Cansler, sec retary of DHS said. "We're working on this constantly. The problem is there's no easy solution."

Mental health organizations and advocates are concerned that some of the affected residents will end up in emergency rooms, jails, homeless shelters or on the street. this problem is yet another result of the state's mental health reform ten years ago. .....

Please contact the office of DHHS to voice your concern: contactmh@dhhs.nc.gov Subject Lines: Adult Care Homes/ Mental Health........"

*******************************************

And so, accordingly, I wrote this e mail to that e mail address today:

Dear NC DHHS:

I note that there is an assessment taking place over the next several months----on a voluntary basis----of residents of family care homes that are deemed to have more than half the residents with a primary mental health diagnosis.

I have a couple of questions, when you get a moment:

1. What will be the status of the resident who does not want to engage in the assessment process, in that this is a voluntary process? More specifically, will their primary diagnosis be deemed to be what was already in their chart or will it be reassigned and on the basis of what criteria?

2. Who will be the assessors? Will they be mental health practitioners; will they be physicians, nurse practitioners? Will it be a team? Where are the rules/ regs regarding that assessment process.

Thanks for your hard work, NC DHHS.
Marsha V. Hammond, PhD

Did Smoky Mountain Center LME's Utilization Review Department Have a Role in the Downfall of New River Behavioral Health Care?

Hey, all I know is my own experience and I have outlined it here re: the comment I have made to Richard Craver's article pertaining to the $6.5 million black hole associated with New River Behavioral Health Care.

Here is Craver's article:
http://www2.journalnow.com/news/2011/oct/21/wsmet01-new-river-behavioral-healthcare-losses-put-ar-1522170/

Here is my comment (and there are others at the article's URL):

"WHOA already. So, this appears to be what we 'know' at this point in time: (1) New River started experiencing money losses in 2010 of a significant degree (2) Medicaid 'fraud' accusations have been received from a 'credible source' according to NC DHHS.

I don't see how the two are necessarily related. WHY and what were the particulars of New River losing money in 2010? Was it because of some behavior on the part of the LME, specifically, Smoky Mountain Center LME? Was the director of New River 'misdirecting' money? Without the details which are pretty darn slow in coming forward, no one, except those on the inside, have any idea what has happened and why.

Who or what entity has made the Medicaid 'fraud' accusations? What are the accusations?

This is the question that I wonder about having worked with the Utilization Review Department (call that: 'tried to work with") of SMC LME: New River could not get paid for some reason. For me, it was merely a single client.

As regarding that case, for the life of me, regardless of what information I submitted about a very mentally ill client of mine who had been in the mental health care system since a child, I could not get dependable authorizations to see and be paid to see that state funded client. I threw in the towel re: working w/ SMC LME's state funded clients five years ago. Moreover, I won't take any state funded clients due to the paperwork re these clients. My worry, as a solo practitioner, has been that w/ the LME's taking over the management of Medicaid, that they will re-create paperwork equally onerous for Medicaid clients.

So, with the refusal of the SMC LME Utilization Review Department which provides the authorizations to work with the client (and thus get paid) and the overkill overviewing of what I submitted as 'the reasons' why the client needed therapy to the Clinical Director of SMC LME at that time----still the same people in place best I understand it from a recent review of their staff----I took the medical records of the client TO THE HOME of the Social Security adjudicator so that the client could at least be advanced to Medicaid----and that very well could have saved the client's life.

Given my experience with the Utilization Review Department of SMC LME 5 years ago, I have to wonder did SMC LME play any part in the non-payment/ non-authorization downfall of New River.

Details, please.

Who Stood to Gain by Killing New River LME After a Game of Patty-Cake: Follow the Money

Counties will bear fiscal support of New River in transition

by Jesse Campbell

County managers and interim officials with New River Behavioral HealthCare continued to chart the transition for a new service provider at a meeting Monday morning as the final days of the organization begin to unfold.
Managers agreed Monday to pay for the services of contracted physicians and therapists, some of which have not been paid since August, along with past due utilities, property insurance, and other general operating costs.
Managers had already agreed to pay for last Friday’s payroll.

“We are in dire straits,” said interim Chief Executive Officer Sharon Wilcox in regards to the current provider’s past due expenses. “Some of these physicians refuse to come to work until they are paid.”

A week after her selection as interim finance officer by the five-county board for New River, Amy Oliver expressed her desire to step down. She has agreed to continue assisting the board until her replacement is found.
Although county officials still do not know what accounted for the provider’s current financial state, they do know that NRBHC had reported financial losses as early as 2007.

According to Ann Wilson, an auditor who has worked closely with NRBHC in the past, the provider incurred a $5.8 million loss for the two-year period leading up to fiscal year 2011.

Officials from the five affected counties formed a new board upon the dissolution of a 160A interlocal agreement to assist in the transition to a new service provider for Ashe, Alleghany, Wilkes, Watauga and Avery counties.
County officials revealed that Daymark Recovery Services will serve the area as the new mental health service provider. NRBHC will cease to exist on Nov. 15.

Daymark Services has expressed interest in using NRBHC’s current buildings once the transition is complete."

http://averyjournal.com/News/story/Counties-will-bear-fiscal-support-of-New-River-in-transition-id-008959

So, as per the above article outlining the demise of New River LME, insuring/ providing services 13,000 lives (more than the company that sank out of sight about 5 years ago in western NC which insured 10,000 lives), what are the details outlining that New River LME was sucking wind as far back as 2007? If their difficulties were so onerous, why didn't the multi-county commissioners ask some serious questions?

Reporters do us such an injustice by not digging into the details.

This is what I wonder about the entire matter:

"Medicaid fraud" could be leveled at most any provider/ company in NC. "Medicaid fraud' accusations are what reportedly sank New River LME. No one has given the public any information about the details of this' Medicaid fraud' that I know of. So, where's the proof? (I expect the answer to this question to magically turn up on the Piedmont Behavioral Health LME website within a week, as is often the case when 'queries' are posed and the public is 'given an explanation.' )

People do not seem to be questioning, as French philosopher, Michele Foucault, who outlined how power manipulates, suggested we ask: "Who is speaking?" Who or what entity stands to gain by shouting fire in the theatre or 'Medicaid fraud?" When one bills Medicaid----from the standpoint of this solitary practitioner billing directly to Medicaid for therapy only services----the information that is 'demanded' by Medicaid is multi-focal. It would be pretty damn easy to commit Medicaid fraud. And if your company or LME was sucking wind because the larger parent LME (that would be Smoky Mountain Center LME) had jerked your contracts and given them to another brown-nosing organization----well, its just a matter of time you have to tread water. There's waaaayyyy more news here that is not apparent.

A more salient question might be, "Who wanted New River LME dead?" I do not have an insider's knowledge; however as per articles recently by Richard Craver of the Winston Salem Journal (newspaper: see: http://www2.journalnow.com/news/2011/oct/16/wsmet01-group-has-ideas-for-health-service), there is an outline of a pretty concerted power struggle between providers in order to wrest the reins from (what was) New River LME administration. Apparently and reportedly, providers local to Piedmont Behavioral Health (PBH) LME, which launched, basically, a hostile take-over bid on Western Highlands Network LME in western NC in June, 2011, will not talk to local reporters for 'fears or retributions.' PBH LME's hand sits lurking in the background as per Craver's articles that they were 'willing' to 'offer suggestions' which, of course, were associated with they taking hold of the reins. Moreover, the people who ARE talking to reporters and feeding them information stand to gain by slanting a take on the news that causes their companies to appear like 'knights in shining armor.'

Follow the money, as, I believe, Bill Clinton suggested. And remember to ask yourself "Who is speaking" which is to say, "Who stands to gain from this matter?"

All I know is that the last line of that article states the following:"Daymark Services has expressed interest in using NRBHC's current buildings once the transition is complete."

A curious reporter would wonder: what is the relationship between Daymark Recovery and Smoky Mountain Center LME; how much 'business' does Daymark Recovery have re: SMC LME clients?; did contracts to care for clients 'get jerked' from New River LME---somehow---and rewarded to Daymark Recovery?

Yeah, and who framed Roger Rabbit and who was playing patty-cake with New River LME? (wikipedia: " When he shows Roger photographs of Jessica 'cheating' on him by playing patty-cake (literally) with Acme, Roger becomes distraught and runs away. This makes him the main suspect when Acme is found murdered the next day."http://en.wikipedia.org/wiki/Who_Framed_Roger_Rabbit

Marsha V. Hammond,PhD Licensed Psychologist, NC

NC mental health reform blogspot since 2007: http://madame-defarge.blogspot.com/

Piedmont Behavioral Health (smack! slurp!): How Can We Help You Out re: Collapsed New River LME (AND SHRED YOUR PUBLIC RECORDS LAWS)

There's a very good article by Richard Craver of the Winston-Salem Journal re: what amounts to a hostile take-over bid by Piedmont Behavioral Health (PBH) of New River LME, recently accused of 'Medicaid Fraud.' PBH wants to magnanimously offer that they have many good solutions to all these mettlesome LME's and would like for you to look at their latest rendering of the Trojan Horse. This is my reply to Mr. Craver's article and it is online with other like-minded comments:

"Group has ideas for health services"

http://www2.journalnow.com/news/2011/oct/16/wsmet01-group-has-ideas-for-health-services-ar-1504370/#fbcomments

Here are my comments re: what PBH is proposing:

Do NC lawmakers want to see the Public Records law shredded? That is the question we are presented with here, basically.

Mr. Craver's article outlined the following points: "Rebecca Troutman, the intergovernmental relations director for the N.C. Association of County Commissioners, said the association "sees a need for a study committee to review the statute in its entirety, given that the statutes are woefully out of date."

Excuse me, county commissioners-----overseers of the LME's-----you already have your information from the UNC Chapel Hill School of Government, rendered several months ago by Mark Botts in association with colleagues there, due to the persistent efforts of the Western Highlands Network LME Board who tried to back away from this (new! expanded!) version of hostile health take-over bid by Piedmont Behavioral Health, all the while having their heads held to the stink by the board's attorney telling them the board would be 'eaten alive' by PBH because NC DHHS was driving that PBH car, or at least sitting in the passenger seat. The WHN LME Board finally concluded it had to cave. And so here we have the PBH monster, fat and gluttonous after having rammed through its 'Non Disclosure Agreement' as per the WHN LME Board----now intending to do this at a state level. Is there no one here who can rid us of this troublesome LME and its head, Betty Taylor?

Here is what that School of Government attorney states re: PBH's hostile take-over 'mutual agreement' contract they floated to the WHN LME Board like a Trojan Horse in June, 2011:
(Published in its entirety, as passed to the public at the WHN LME June, 2011, Board meeting, and at my NC Mental Health Reform blogspot, June, 2011):

Saturday, June 25, 2011UNC Chapel Hill's Institute of Government Outlines Problems w/ Non Disclosure Agreement Driving Medicaid Waiver

".....To put it another way, the PBH non-disclosure agreement does not appear to strike the harmonious balance between public records law and copyright law that is described in the Seago case. The PBH non-disclosure agreement, at paragraph 3,b., not only restricts the subsquent commercial use or distribution of records received by LME's but has the recipient LMEs promise that they will not, without the prior written consent of PBH, "copy, use or disclose" any information that "has value in PBH's business," remove the information from the premises of the LME, or "deliver" any information "to any person or entity outside the LME." (LME contractors are excepted from this promise). The terms of the agreement appear to prohibit the LME that receives PBH records from providing public access to the records under the state public records law. Thus, the LME that signs the agreement appears to agree that it will not only protect the records from commercial use and distribution, but also that is will not comply with the North Carolina Public Records Act. ,,,,"

So, working w/ PBH = shredding of public records law = inability of consumers/ clients to obtain medical records efficiently and to hold accountable the LME.

Oh, boy, PBH certainly does have some terrific suggestions and the only reason they have gotten this far is that they are being tacitly supported by Lanier Cansler at NC DHHS. Remember: Mr. Cansler has not always been a public servant and will not remain one either.

Oh, did I say: WE NEED A ONE PAYER SYSTEM and that means a Federal system, such as Medicare/ Medicaid---not these bits and pieces of managers run amuck, amassing CEO salaries, not being held legally accountable. I say, 'Let's Occupy PBH.'

Marsha V. Hammond, PhD, Licensed Psychologist
http://madame-defarge.blogspot.com/

New River Mental Health Agency Being Investigated for Medicaid Fraud : How Clients Are Demanded to Manipulate the Medicaid System

There is an article in the recent Mountain XPress out of Asheville regarding the investigation and withholding of payments to a large mental health provider in western NC. See:
www.mountainx.com/article/35870/N.C.s-Medicaid-agency-launches-investigation-of-major-WNC-mental-health-provider

These old 'Community Support' companies continue to offer similiar supports but only for six months at a time for Medicaid clients. Thus, there is an intense flurry of activity which may or may not overlap very well w/ ongoing therapy (I am thinking of a client of mine w/ a severe mental health challenge that this was happening with recently) and then poof!....it disappears. It would be nice to know just how much help this is. I could tell that the additional resource of a person 'to call' was advantageous to the client when he was in crisis but basically the crisis was determined by whether he had his meds or not.

Relatedly, I received a call from a county DSS re: the client's ability to parent children yesterday and very clearly stated to the DSS social worker that the problem was not that the client could not parent children-----but that Medicaid drops off every six months (even though the client receives SSDI---but paid Social Security such a lot of money that client 'earns' just a bit too much to keep Medicaid in place)...thus Medicaid drops off every six months. That means that the client is then without all medication which may be necessary to support mental health functioning which include parenting children.

So, then the client manipulated the system----which is built to be manipulated in that you can take only two years of CURRENT medical bills and have them applied to a Medicaid deductible in order to reinstate Medicaid OR you can make a small payment on medical bills up to 7 years old and then DSS can then 'pull forward' those medical bills to create the deductible. There is no other way to get Medicaid reinstated. One has to meet the deductible if one's Social Security Disability check is more than about $1200/ month. Nevermind that there are 4 mouths to feed and take care of on that.

So, very tiresomely and using a lot of time and organization, the client has to make a minimal payment on an old unpaid medical bill, usually a long stint at a psychiatric hospital, which allows the local DSS to 'pull forward' the bill and apply it to the commonly $5,000-7,000 deductible----which then----months later----allows the Medicaid to be put back into place for-----YOU GUESSED IT-----six more months. Then we do the whole thing all over again and if necessary the client goes into the hospital w/ the specific agenda of cranking a bill so that Medicaid can be recreated again.

This is a great way to save Medicaid $$$, don't you think?