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Mental health collapse leaves network in shambles

By Taylor Sisk
Staff Writer

“I’ve come to the conclusion,” says Karen Dunn, director of Club Nova, a Carrboro clubhouse that helps people with mental illnesses lead productive lives in the community, “that there must be a new diagnosis that hasn’t yet ended up in the DSM” – by which she refers to the Diagnostic and Statistical Manual of Mental Disorders.

“It’s some kind of delusional disorder on a bureaucratic level.”

“I know people are well intentioned,” she continues, “but you just get into that institutional thinking, and it’s just …” She pauses; shakes her head. “Talk about the definition of insanity….”

As Dunn sees it, the breakdown in the provisioning of mental health care services in North Carolina was easily enough forecast. Mental health care reforms that were intended to provide more community-based care and thereby reduce the need for more intensive services were, Dunn says, flawed from the beginning, and yet we continued to drive these reforms headlong into what she and many of her colleagues attest is a pretty much full-blown mental health care crisis in North Carolina.

Across the state, private companies tasked to provide services are going out of business. Last month, Caring Family Network (CFN) – the primary provider of mental health treatment in Orange, Person and Chatham counties – announced that it would be discontinuing almost all of its services in the three counties. CFN will no longer provide outpatient and community-based services but will continue to provide therapeutic foster care.

As a result, Marilyn Ghezzi, who until last week was a therapist with CFN, has had to tell clients with whom she’s built relationships, some as many as 20 years in duration, that she’ll no longer be their therapist. Other therapists have had to do likewise.

“They were devastated,” Ghezzi says of her clients’ reaction to the news. “One person said to me, ‘How can they just change your therapist?’” – which would seem to reflect a tacit belief in mental health care as a fundamental right.

Perhaps it’s not. But it’s certainly a critical service – and one that’s in critical condition. What those professionals along the front lines of mental health care will tell you is that in addition to weaving a safety net for those with mental disorders they’re protecting us as citizens and taxpayers, or at least attempting to do so, from further headlines of shootouts along I-40 and from the exorbitant costs of hospitalization and incarceration.

Mental health care reform has failed. Keeping people with manageable mental disorders in their  communities, cared for by those communities, was the spirit behind that reform. It was well intentioned, as Dunn suggests, but very poorly executed.

Who are ‘they’?

“How can they just change your therapist?” Ghezzi’s clients asked. But she found that she couldn’t even tell them who “they” were.

“I’m not really sure who they are,” Ghezzi says, wondering aloud who to blame for the crisis we’re now facing here in Orange County.

There’s plenty of blame to go around, she says: the Department of Health and Human Services, the governor, legislators, CFN as well. But, Ghezzi says, “I think it mostly falls on the state reform plan. I think that’s definitely the main cause of all this.”

The idea behind reform was that there were certain mental health care services the private sector could better provide. In 2001, the General Assembly voted to overhaul the system. Counties would no longer directly provide treatment. They would instead form local management entities (LMEs) that would oversee private providers. More treatment would be provided within the communities toward the objective of keeping people out of the four state-run mental hospitals.

As has been documented in a recent series of articles in the News & Observer, many private companies have been using employees with only high school educations, called para-professionals, to provide community support services – such as assisting with grocery shopping or homework – for which the companies bill the state $60.96.

The allegations are that, at that rate, state reform created an incentive for companies to provide community support services, and to provide them with para-professionals, and not to provide more intensive services.

The News & Observer reported that between March 2006 and January 2008, the cost of community support services rose to nearly $1.4 billion, or 90 percent of all community spending. According to the N&O, “During that same period, the government spent $78 million – 4.9 percent – on the seven services more likely to reduce the need for hospitalization.”

The cost of those community support services had risen to nearly 20 times the state’s original estimate.

A ‘different animal’

In some ways, the post-reform delivery of mental health services has played out differently in Orange County, where using para-professionals for community support services has not been as widely practiced.

When CFN took over the Orange Person Chatham (OPC) Area Plan in 2006 – OPC having resisted divestiture of its services as long as it could – Ghezzi says there was a team of four community support workers: two of them had master’s degrees in social work; two had bachelor’s degrees. CFN did then hire more para-professionals, but not a great many.

That aside, CFN wasn’t entirely prepared for the task at hand.

“I think one thing that was striking,” Ghezzi recalls, “was that they didn’t seem very knowledgeable about outpatient clinics.” CFN arrived with a solid reputation as a foster care agency. “But a busy mental health clinic is a pretty different animal.” CFN had operated smaller clinics, but Orange County alone had nearly 1,000 clients. “They didn’t really know what a busy mental health clinic was like.”

In 2007, according to Ghezzi, “things started to fall apart.” Three rounds of layoffs ensued. In May, CFN announced that due in large measure to rate cuts by the state for community support services (in response to charges of overspending, the hourly rate of $60.96 was reduced to $51.28), it would be cutting back services and closing facilities.

“Once layoffs started,” Ghezzi says, “people lost their therapists; staff who weren’t laid off started job hunting.”

John Mader, a therapist who prior to divestiture worked for OPC, points out that those who were receiving these services are not only having to now cope with the transition to new caregivers, adjust to relationships with new providers, but are having to do so in the “face of complete ambiguity.”

“This is not effective therapeutic closure,” Mader says, “and that’s hard.”

Mader says that people are being told to be patient, that new providers will be found. “But in the meantime, we don’t know when or who they will see.”

‘Nobody knew’

State government officials have now acknowledged that we have a very serious mental health care problem. They’ve had no choice. There it is, on the front page of the state’s paper of record – stories of waste and, worse, abuse of the mentally ill – of the disintegration of our health care infrastructure.

And here it is in our communities – where health care professionals such as Karen Dunn, Marilyn Ghezzi and John Mader have collectively spent over 65 years caring for those with mental health disorders, many of whom are today facing, optimistically, uncertainty – the fraying of a safety net that in the best of times was tenuous, and no clear understanding of their path to further care – and, at worst, a frightening world in which that care is not to be had.

“I was just trying to do the best thing by each client on a case-by-case basis,” says Ghezzi, “and we didn’t have a lot of guidance on what to do – partly because nobody knew.”

Nobody knew. But how, Karen Dunn asks, could that be?

Providing just the basics, says Dunn, was the way the state wrote the plan:

“The whole plan was to get people this basic community support in order to reduce hospitalizations and to prevent utilizing these higher levels of service unnecessarily.

“And now it’s kind of like this huge surprise that this is how the system is playing out, when it was planned out that way from the beginning?”

She agrees with administering more services within our communities. But not at the risk of neglecting other, more intensive services.

Dunn is particularly perplexed by Gov. Easley’s attempts at distancing himself from the reform legislation. In the News & Observer series, Easley is quoted as saying at a December news conference, “It just happened overnight in late October [2001], and we never thought they would do it.”

And yet at the time, both Easley and then-Secretary of Health and Human Services Carmen Hooker Odom seemed to be champions of that legislation.

“If the governor had no clue,” Dunn says, “he was asleep at the wheel and should be charged with reckless driving. And that’s putting it mildly. Because it’s not just reckless driving – it’s been an endangerment of all our citizens who are living with serious mental illness.

“It really has put lives at risk, and continues to do so.”

This week, Easley held a press conference at which he proposed turning direct control of the state’s mental health system back to the Department of Health and Human Services and establishing differential pay for community support services depending on the level of those services.
In some respects, Orange County is in a worse predicament than most counties.

“Sort of a Chapel Hill phenomenon is that we have so many uninsured,” says Ghezzi, “and that’s really a problem. We’ve always had a really high number of uninsured, and we were the safety net, which is now gone.”

We know of the ones we’ve failed. But what of the others out there?

“I think there are a lot more people who have not touched base with the system at this point,” Dunn says. “That’s a whole other level of community outreach that doesn’t happen … people the system hasn’t even seen.” How do we begin to address those?

Despite all, says Dunn: “I always hold out hope.”

We’ll all soon learn if that hope is founded.

Next: Where do we go from here? 

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  1. John Mader

    Taylor, you may already have this, but on p.9 of the State Plan 2001 is identified as Sec. Hooker Buell’s “plan transform the system.” Perhaps the Governor missed this in the midst of his concentrated efforts to resist the “reform.”

    http://www.ncdhhs.gov/mhddsas/stateplans/sp2001/sp01-main11-30.pdf

    also her letter may be of interest

    http://www.ncdhhs.gov/mhddsas/stateplans/sp2001/sp01-coverletterforweb.pdf