Mental Health Reform in North Carolina

1. Mental Health Reform in North Carolina March 9, 2006 Beth Melcher, Ph.D.

2. Where We’ve Been • Overuse of Institutional Care - Durham had twice as many admissions per capita • Lack of Community Inpatient Care & Inpatient Alternatives • Lack of Accountability - Direct Service Provider and manager of funds; no emphasis on the use of “best-practices” • Inadequate Access • Tremendous variation in quality across the state

3. State Context • 2000 State Auditor’s Study of the State Psychiatric Hospitals and the Area Mental Health Programs. • Define specific target populations requiring specialized services that matched the needs of the targeted group • Require the development of new community-based capacities • Make changes in the structure of how services provided and managed • Change funding mechanisms (i.e. coordination with Medicaid; establishment of “bridge” funding)

4. Guiding Principles of Reform • Easy Access • Consumer and family involvement • Implementation of best practice • Accountability for consumer outcomes • Services and supports in the least restrictive environment • Collaboration with the greater community--System of Care • Expectation of system improvement

5. House Bill 381 • Enhanced accountability and cooperation between counties, area authorities and DHHS • Require development of State and local business plans • Secretary to certify local programs • Governance options • Changes in area board authority • Establish “target populations” and expectation that “best practice” services be offered • Must contract for services

6. What are the biggest changes? • Public mental health programs have a different role - a manager, not a provider of services (new role: assess, evaluate, refer, prevention, outreach, education, monitor quality, determine community service needs). • There are fewer public area programs • Tighter eligibility criteria and clearer target population (some people will no longer be eligible for service) • Increased accountability through community planning, performance agreements between state and local programs, and contracts between local programs and providers

7. Changing Role • Area Program to Local Management Entity (LME) • From Service Provider to Service Manager • Becoming Local Management Entity (LME) • LME as the manager of public policy

8. Manager of Public Policy • Within Available Resources Provided by the Public and Private Sector • Individuals with Needs in the Target Population Will be Assisted • Services will be provided by qualified community providers • Least Restrictive, Therapeutically Most Appropriate Setting • To Maximize the Quality of Life • Continually assess needs of the community

9. LME Core Functions • Screening • Assessment • Referral • Emergency services • Service coordination • Consultation • Prevention • Education

10. What “Reform” means to the people we serve • Person-centered Plan • Natural supports • Crisis Plan • Services are authorized • Greater continuum of “best practice” services • Customer Services • Quality Improvement • Comprehensive Emergency Services

11. Target Populations • Adults with mental illness • Children with mental illness • People with developmental disabilities • People with substance abuse problems

12. Adult Mental Health • People with severe & persistent mental illness (SPMI) • Substantially interferes with capacity to remain in the community • People with serious mental illness • Substantially interferes with life activities

13. Child Mental Health • Children with severe emotional and behavioral problems • Children with moderate mental health problems and their families • Children with mild mental health problems and their families

14. People with Developmental Disabilities People who meet the state definition of developmental disability AND meet criteria for priority services using the Intensity and Urgency of Need Assessment

15. Substance Abuse • Injecting drug users, those with communicable disease risk and/or those on opioid maintenance therapy • Substance abusing women with children • DSS involved parents who are substance abusers • High management adult substance abusers • Persons being served who are in the criminal justice system • DWI offenders

16. Services and Supports • Case Management and Coordination • Emergency and Crisis Services • Home-based services for families • Housing and residential services • Team-based wrap around services • Employment and education services • Substance abuse detox and treatment • Medication management

17. Reform Implementation in Durham County

18. Durham Reform Implementation • Durham was certified as a Local Management Entity (LME) - July 1, 2004 • Direct Services divested during FY 2003-04 • Request for Proposal (RFP) Process Used

19. How are we doing? • Centralized our access/screening (24/7). Walk-in or phone call • Fully developed Utilization Management Unit – all services to be authorized • Divested all services & programs since Jan 03 • Significant Increases in numbers of people served for all target population groups • Significant increase in continuum of services offered– over 165 provider organizations • Significant reduction in hospitalization for adults and out of home placements for children • Development of housing resources

20. How are we doing? • Durham Center Access - 24/7 Crisis/Emergency Facility –impact reducing hospital admissions • Rapid Response Homes (for children) • All providers will be first point of crisis contact • Court, hospital, jail, DSS, community liaisons • Promotion of services based on Best Practice • Care Review • Customer Service • Quality Management • Fiscal management and accountability • More responsive and accountable care of people receiving our services.

21. Challenges • Developing a qualified provider community • Capacity of provider community to meet demand • Limited resources, especially state funded services • Promoting and monitoring quality services

22. System of Care (SOC)Overview • History of SOC • Fragmentation/Poor Results create need for reform • Federal reform/Congressional Funding/National Evaluation • Implementation since 1992, nationwide and in NC • Strong evidence of improved outcomes cited in National Congressional Reports, President’s New Freedom Commission, Surgeon General’s Reports, etc. • SOC framework called for in States to improve MH service delivery for children with SED, for Child Welfare reform, consistent with Juvenile Justice Reform and Education Reform.

23. What is a System of Care? • A System of Care is an integrated network of community services and resources supported by collaboration among families, professionals, and the community. • A System of Care links education, juvenile justice, health, mental health, child welfare, family court and other helping agencies with families to assure that children with significant health, mental health, education, and safety issues have access to the services and supports they need to be successful at home, in school, and in the community

24. SOC Principles • System’s of Care provide for: • prevention and early identification and intervention; • service coordination or case management; • smooth transitions among agencies, providers, and to adult system; • human rights protection and advocacy; • nondiscrimination in access to services; • a comprehensive array of services and supports; • individualized service planning; • services in the least restrictive environment; • family participation in ALL aspects of planning, service delivery, and evaluation; and • integrated services with coordinated planning across the child-serving systems.

25. Traditional vs. SOC Services/Practice “1 size fits all” Individualized Service Pieces One Family/One Plan Separate Delivery Collaborative CFTeam Specialty Training Cross -Training Family Recipient Full & Active Partner Root of Problem Core of Solution Dependent Self-Reliant

26. Development of SOC in Durham • Initial Issues of Concern • Over utilization of out of home placements (~ 50%) • Lack of community services • Lack of best practices reflected in community services • Fragmentation and lack of agency cooperation in service Delivery (court ordered placements, etc.) • Lack of continuity of care in service delivery

27. How does SOC work ? • Services, supervision of services, program development and policy development are already occurring in all agencies & sectors. SOC does not add on this work, it simply integrates it by developing team-based decision-making. • Each agency maintains its mandates and ultimate decision-making authority, but by working together, fragmentation & duplication are reduced and consumer outcomes are significantly improved.

28. How does SOC work, con’t ? • All participating agencies, families and the community must work together in teams in order to achieve outcomes for consumers with complex needs: • Child and Family Teams – wraparound svc delivery/integration • Strong Families Durham – families advocating and supporting each other • Care Review Teams – supervisors working together/QI • Community Collaborative – program administrators working together • Durham Deputies – policy implementers working together • Durham Directors – policy makers working together

29. Child and Family Team Basics1 Family/1 Team/1 Plan • A CFT is built around each child and family who needs help from more than one source • A strong CFT has a mix of family members, friends, community members and service providers • Goal - Family, friends and community members make up at least half of the team. • CFT size – no set number, usually 6-10 people, depending on what the family wants/needs

30. Child and Family Team Basics1 Family/1 Team/1 Plan, con’t • Team membership can change over time – members leave when their help is no longer needed – new members taker their places to address different needs • Members typically include: • Family • Child, if age appropriate • Local service providers involved with family’s care, child’s custody, education and treatment • Court, DSS, School members • Others significant in the daily lives of the child/family

31. Child & Family Teams @ the Point of Service: 1 Family/1 Team/1 Plan Pastor MH /DD/SA Professional Housing Authority Friends Consumer Credit CFT Facilitator & Family Lead Role Advocate DSS Professional LEA Teacher Parks/Rec Job Coach Courts JJProfessional Neighbors Primary Care Phy. Health Dept. Nurse Wraparound Approach across Life Domains

32. SOC IS EFFECTIVE • Reduces duplication • pooling resources & unifying services • Helps keep children and families together - • reduces costly out of home placement for treatment or incarceration • Provides incentives for communities to engineer enduring positive change • Establishes a system that promotes • family strengths, greater self-reliance and less dependence on the system, and children who will grow up in success

33. Results of SOC Implementation in Durham to Date • Number of children/families served more than tripled • Out of home placements (CTSP) drop from 50% to 30% • Cross-agency training and education in best practices • Agency cooperation/direct participation in service delivery • Agency Directors, Deputy Directors and supervisors working together • Significant drop in county funded court ordered placements (from $700 K to $0) • County Commissioners invest $225,000 in SOC Community Support positions via cross-agency advocacy • Continuity of care via CFTs for over 500 children/families • New services identified, recruited via cross-agency RFI process • Funds braided to support new services & new positions: DSS/Court/MH Liaison, DJJ/Court/MH Liaison (e.g., DSS + DJJ + MH) • 2004 Ketner Award - NC County Commissioners Association • 2004 Programs of Excellence Award - NC Council of Community Programs

34. We Got There Through . . . A collective commitment of public & private agencies and community partners to make the System of Care work in Durham County. 1 Family/1 Plan/1 Team

35. More Information • www.dhhs.state.nc.us • www.dhhs.state.nc.us/mhddsas • www.ncleg.net • www.durhamcenter.org

36. Questions?