By Taylor Sisk, Staff Writer
As the number of people with mental illness going without care in North Carolina continues to rise, there’s been a recent shift in how the state will be provisioning those services.
The concept behind the new mental health care model announced earlier this month by the North Carolina Department of Health and Human Services is a good one, said Thava Mahadevan, director of XDS Inc., a mental health care provider in Chapel Hill.
The idea was to create a new definition and description of mental health care providers called critical access behavioral health agencies, to go into effect Jan. 1. These agencies will be tasked with providing a comprehensive set of services to people living with mental illness. The agencies must provide four core services: case management for those with mental illness or a substance-abuse problem, comprehensive clinical assessment, medication management and outpatient therapy. They also must provide two additional services from a list that includes intensive in-home care, therapeutic family services, day treatment, psychosocial rehabilitation, a mobile crisis team and six others.
While Mahadevan sees the potential upside of this move, he’s concerned that many service providers, perhaps his own, don’t have the infrastructure in place to meet this criteria.
“The concept is not a bad one,†Mahadevan said. “Having a comprehensive service agency, being able to provide all-inclusive services without brokering and sending the person out to different places – that’s how we’ve always designed ourselves. But I think our biggest worry is the way it’s being put out. It’s too quick.â€
As of July 1, 2010, those service providers that are unable to comply will no longer be eligible to receive Medicaid money for these services. Most will be forced to go out of business. Many people will go without care until transitioning to a new agency. Some will never find their way.
The ‘new’ model
This new model of mental health care provider, the critical access behavioral health agency, or CABHA, is in fact similar to the old model, the one that was disassembled under mental health care reform in North Carolina, which was implemented in 2001. The idea behind reform was to move people out of our state mental institutions and to provide them with more services within their own communities. While prior to reform, an array of services was provided by community mental health clinics, often under one roof, reform measures prescribed that services be offered by private providers – some for profit, some not – with funding from federal, state and local dollars.
In most communities, particularly rural ones, a comprehensive set of services never materialized under the new model. Many providers cherry-picked services, extending only those that could most easily and profitably be provided. State mental institutions became even more overcrowded than before. The media and legislators began referring to people living with mental illness as “falling through the cracks.†Those cracks became chasms, and today the state faces a deeply seeded crisis.
Newly-appointed state Senate majority leader Martin Nesbitt and Verla Insko, who represents southern Orange County in the state House, are co-chairs of the joint legislative committee on mental health, developmental disabilities and substance abuse. Last week, Nesbitt told his colleagues that the General Assembly had erred in cutting so severely into mental health care services. Insko this week agreed.
“We were not prepared to deal with the cuts that came as a result of that last $40 million coming out,†she said of the cuts made to local management entities, which were direct service cuts to people without insurance. “It’s had a huge impact.â€
“We had discussed that as a committee,†Insko said, “and took a look at the impact it would have on the system, and decided the system could not absorb that.â€
Throughout the budget debate, health care advocates warned of the dire consequences of cutting too deeply into services. The cuts were nonetheless made.
‘A pendulum swing’
Completely eliminated from the state budget were community support services, including assistance with everyday activities such as paying bills and picking up medications, that help those with mental illness be more productive members of their communities. These services came under scrutiny for rampant overbilling by some service providers, and new Department of Health and Human Services (DHHS) Secretary Lanier Cansler said he wants to build a system that focuses on more “clinically founded†care.
“I’m all for that,†said Bebe Smith, co-director of UNC’s Center for Excellence in Community Mental Health and director of Schizophrenia Treatment and Evaluation Program Outpatient Services, which has offices in Carr Mill Mall. But she warns against overcompensating.
“I do see that there’s this pendulum swing,†Smith said. “I thought that the idea of community support as a service fit very well with what I thought people with severe and persistent mental illness really needed.â€
The way it was defined, she said, allowed for “relationship building – doing some clinical work, but also doing case management and focusing on helping people find housing and getting connected†with medical and other services
Early on, when community support services were being advanced, Smith said, the general view was that “psychotherapy is the old way; community support is the new way.â€
“Now what I’m seeing,†she said, “is the pendulum swinging in completely the opposite direction, to saying, ‘We’ve got to get back to the clinically sound services. Psychotherapy is in again, and everybody’s got to have a psychiatrist.’ But I think we’re going a little bit too far.â€
A complement of clinical and community services are required, Smith said, and she hopes the new CABHA model is intended to acknowledge that.
Meanwhile, community support services are due to expire at the end of the year. There has been some talk within DHHS of extending at least some of those services until a new service definition can be established and approved by the federal government. But as things now stand, though some providers, including XDS, will continue to offer whatever services they can – without compensation – for many in need, there will be, in Mahadevan’s words, “literally nothing.â€
Reason for hope?
Insko says that reform in practice has been much different from reform in theory.
“I had always supported and found the need for a comprehensive agency that could be the clinical home for a person with mental illness and substance abuse [issues],†she said. “And so that in itself is consistent with the intention of reform.â€
She emphasizes, though, that consolidating services shouldn’t “mean that we do away with all the small providers.â€
Which is a concern Mahadevan and Smith share. While they’re hoping that with the implementation of the CABHA model early next year, single-provider comprehensive care will become more widely available – in other words, that the new model will hold many of the strengths of the one the state disassembled with reform – both are hearing that there may be as few as 50 current service providers in the state that meet the DHHS criteria for CABHA designation.
“What I’ve heard is that the intention of the state is to really narrow the field of providers across the state,†Smith said. She acknowledges the need to try to eliminate the fraudulent or poorer-quality providers. “But I think the way they’ve got it defined now, they’re really at risk of eliminating some quality small providers.â€
Another concern for Mahadevan is that what’s still missing is an outcome-based approach to providing good and comprehensive mental health care.
“It’s good to have these concepts put out there,†he said, “but I think they need to come and look at agencies … and ask, ‘How many of your clients are ending up in the hospital on a regular basis?’ ‘How many of your clients are in jail?’
“Somehow the outcome of the client is still missing; somehow that’s not tied in.â€
Simply put, Mahadevan said, DHHS needs to be asking of service providers: “How are you performing?â€
Another issue, posed by Bebe Smith, is a very practical matter: “How many licensed professionals are you going to find across the state that are going to be willing to work with the poor and very ill?†she asked. “Because I think we’ve really destroyed the workforce. Licensed clinicians have gone into private practice or they’ve gone into other careers.â€
Who’s now going to fill the jobs required to provide clinical services within these CABHAs?
“And then the other question,†Smith said, “is, ‘How are you going to make it possible for the private providers to afford to have all of the clinical staff.’â€
Still, many mental health care advocates across the state are guardedly optimistic that things could be moving in the right direction. Some have spoken encouragingly of the appointment of Michael Watson as DHHS assistant secretary. Watson has extensive experience in the field, having served as director of the Sand Hills mental health center.
Insko said that she believes “everyone at the state level is concerned about extending existing services so that people don’t fall through the cracks.â€
Smith has spoken with both Cansler and Watson: “I’m trying to talk to people and say we know how to provide good care for people with severe mental illness, and there’s no reason we shouldn’t be able to do that. You don’t have to do it in a way that’s going to require a huge amount of funds. It’s a level of basic care that people need, and it includes the psychiatric treatment and it includes the case management to get people to the psychiatric treatment and to get them to the medical treatment. That’s really the basic stuff.
“We’ve got to start with getting people’s basic needs met and keeping them safe. I mean, we’re really at risk of people not being safe.â€