BY TAYLOR SISK, Staff Writer
“It’s just very scary right now,†said Sen. Ellie Kinnaird, Orange County’s representative in the state Senate, of the latest developments in the state’s mental health care morass. “We’re all disturbed over what we think is happening. We don’t think this is the answer to much of anything.â€
Specifically, Kinnaird is referring to a proposed new mental health care provider designation called critical access behavioral health agencies, or CABHA, scheduled to take effect Jan. 1. Providers who fail to comply with the standards of the new designation by July 10 of next year will lose Medicaid dollars for a number of essential services, including case management.
Kinnaird is not alone in her concern.
Mental health care advocates from across the state are expressing their displeasure with both the speed and the manner in which this new framework for mental health care services has been introduced. Consumer advocates contend that they have once again been left out of the discussion of how to move forward with the provisioning of mental health care services in North Carolina.
Tough year
What most all mental health care advocates in the state agree on is that change must come.
At the Mental Health Association in Orange County’s annual meeting, held last Saturday at Orange United Methodist Church in Chapel Hill, Judy Truitt, director of the OPC Area Program, said, “There’s absolutely no question that this is has been an extraordinarily difficult year and that there are many more to come.â€
The OPC Area Program is responsible for the oversight and management of publicly funded mental health services in Orange, Person and Chatham counties, and Truitt pointed out that as a result of state budget cuts non-crisis services have been reduced 21.5 percent.
In response to the critical state of mental health care services in North Carolina, the N.C. Department of Health and Human Services (DHHS) has introduced the CABHA model, which DHHS officials say is designed to improve services by consolidating them. In order to be accredited as a CABHA, an agency must be able to provide four core services – case management for those with mental illness or a substance-abuse problem, comprehensive clinical assessment, medication management and outpatient therapy – and two more from a list of enhanced services.
A Nov. 2 DHHS memo introducing the CABHA designation stated, “The Department of Health and Human Services (DHHS) and system stakeholders have been discussing for some time the concept of identifying and recognizing provider agencies who deliver a comprehensive array of services.â€
Last Wednesday, Leza Wainwright, director of the DHHS’s Division of Mental Health, Developmental Disabilities and Substance Abuse (MHDDSA) told Kinnaird and her colleagues on a legislative oversight committee that the process had involved a wide range of stakeholders, including consumers and their family members.
David Cornwell, executive director of North Carolina Mental Hope, a mental health consumer advocacy group, disagrees.
“Our focus has been and continues to be on the exclusionary process by which CABHA and other designations and policies have been developed,†Cornwell said.
Cornwell argues that consumer representation has been token, citing the names of only a very few consumer advocates listed as attendees at planning meetings – which, he believes, were inadequately announced and advanced too rapidly.
“CABHA as a definition wasn’t unveiled until November,†said Martha Brock, a mental health care consumer advocate. “And they’re talking about instituting it Jan. 1? That’s crazy. Just plain crazy.â€
Kinnaird said she is concerned that “we’re going to put something in place that’s not going to work any better than what we have right now.â€
Rep. Verla Insko said at Saturday’s mental health care forum in Chapel Hill that she hopes to see the CABHA process slowed. Insko represents southern Orange County in the state House and is co-chair of the legislative MHDDSA committee.
Out of business
DHHS Assistant Secretary Michael Watson has said that the CABHA concept is founded in the concern that the state not repeat mistakes made in the provisioning of community support services, for which some providers were found to be dramatically overbilling. He said it was the department’s conclusion that services should be “housed within a clinical organization that promoted accountability and best practice.â€
DHHS officials have indicated they believe the CABHA designation will facilitate easier management because there will be fewer providers.
But smaller service providers have expressed concern that they will be driven out of business under the CABHA model. One worry is the requirement that each CABHA have at least a half-time medical director onsite, depending on clients served – a requirement many small providers say isn’t always necessary and that they can’t afford.
But, says Brock, even those providers that may be financially able to meet the CABHA criteria will be hard pressed to meet the deadline.
“They can’t gear up and hire staff and everything by the deadline to get certified,†Brock said.
At the table
“It needs to be modified,†Kinnaird said of the CABHA designation. “If they’re going to do this, they need to make sure that the small provider that’s doing a good job is able to stay in business.
“I want to see everybody at the table and have a chance to really discuss the vision,†Brock said. “I’m tired of going through change after change with no real philosophy or thought behind it.â€
Kinnaird agrees that all concerned parties must be in on the decision-making process.â€
She said she’s hoping the DHHS is “not going to steam ahead without a lot more input and a lot more tinkering†with the specifics of the CABHA model.
“I don’t really understand what’s behind this,†said Brock, “but I know there’s no vision behind it.â€
A Vision and Model Law for People Living with Mental Illness
Regarding the latest changes in our North Carolina Mental Health System, the pending CABHA requires the following:
Half time or full time physician
Full time clinical director
Full time quality improvement/quality assurance/training staff
The clinical and administrative oversight is costly. The physician is allowed to bill 60% of their time. Other than allowing the physician to bill 60% of their time, there is no information regarding how these required positions will be funded.
Rather than constant, chaotic, poor patchwork, reactionary, costly changes that do not move us forward, North Carolina must create a vision for mental health. Olmstead, the US Supreme Court Decision, ruled that individuals with psychiatric disabilities have the right to live in the least restrictive setting with the necessary supports and services in the community. This is not only a matter of civil rights, it is a matter of basic human rights.
History demonstrates that states have been slow to implement Olmstead, and litigation has been the primary impetus for states to uphold the Olmstead Ruling. It is now upon us as citizens and the North Carolina General Assembly to establish a vision and model law that provides quality health care and community integration for our citizens living with mental illness. The model law must include a legally enforceable entitlement to supports and services needed for community integration. An enforceable entitlement means that we have an obligation to fund these necessary services. It is much more cost effective to fund these services than not to fund them.
The model law for mental health must include the following:
Medical/Clinical Care
Access to the array of quality health care, including, but not limited to, psychiatry, primary health care, and medication.
Community Integration (Non Clinical)
Supports and opportunities for community inclusion and engagement. Community integration includes the following:
Education
Employment
Housing
Recreation & Leisure
Social Roles
Spirituality & Religion
Citizenship and Civic Engagement
Community Inclusion and Acceptance
Transportation
Benefits and entitlements
Club Nova stands ready to engage with all citizens, including stakeholders and elected officials, to create a vision and establish a model law that upholds the civil and basic human rights of our citizens living with mental illness.
I have been receiving counseling for the past two years from a the Clinical Director in NC. I was recently informed that I could no longer receive services from this Director because he can no longer take on a patient load. Even though I was appropriately referred to an equally competent clinician for services, I am very upset about the situation. I made a few phone calls and found out that the agency is applying to be a CABHA. In order for the agency to be a CABHA (which is in their best interest), the Clinical Directer can no longer take on a caseload of patients themselves. There duties will entail overseeing caseloads of others along with administrative duties.
Due to this ruling, I can no longer see my therapist for services. I have put in a lot of time, energy, and money to establish a therapeutic relationship and work on issues only to find out that I can no longer see my therapist anymore. Do to your new rule, this therapeutic relationship has been destroyed, and I am without a therapist. So why don’t I find a new therapist? That is easier said than done. So I guess I have to start all over again with a stranger discussing issues about my family and my life. I have so many transference issues and abondonment issues, It probably wouldn’t be a good idea to inflict that on a new-bee.
I just want to add that I think it will be a huge mistake to have the Clinical Director of CABHA’s just oversee others caseloads and not have clients of their own. Basically you will eventually cripple them into a) inflating their ego to believe unrealistic caseload demands, or b) damaging them by restricting the services even more. Furthermore, It will most likely incure more costs having someone do adminstrative work full- time. I think it should be left up to the individual Clinical Director whether or not he or she wants to take on patients in practice.