Overall Mission and Congruence with State Plan Principles
1) The Local Business Plan demonstrates congruence with the Mission and Principles of the State Plan

Mission statements for the LMEs found in the local business plans varied significantly, across LMEs. Some plans lacked any discernable mission statement in their LBP. Others contained specific statements focused on MH/DD/SA services, while others included much broader statements about improving lives in the community. Two things were of interest in the mission statements. First was the fact that several mission statements seemed to reflect intent of the Area Program to continue to function as service provider as well as manager. Three of the LMEs specifically mentioned provision of services as part of their mission. Second, a number of LMEs clearly articulated collaboration with consumers and families as part of their mission statement. Five of the mission statements reflected this theme of collaboration and partnership with consumers and families.

As part of this review, the guiding principles articulated by the LME were compared with the State Plan principles. On the whole, there was congruence between State and LME principles. Of significance was the fact that several State principles were not mentioned by a number of the LMEs in their guiding principles:

• 12 of the plans did not mention the importance of research as a guiding principle
• 12 of the plans did not mention the fair and equitable distribution of resources
• 8 of the plans did not mention the importance of education and prevention
• 4 of the plans did not mention best practices

Each LME was asked to assess its strengths and weaknesses, to describe their assessment process, and to develop ways of addressing identified weaknesses. Scope and strategies of methodology varied significantly from program to program, and are discussed below.

No specific assessment methodology was provided by three of the LMEs. Two of the LMEs used external consultants to facilitate their assessment process. Of those describing their methodology, all reported a variety of strategies for collecting information and feedback from their various constituencies. Most frequently used were forums, surveys, focus groups, and meetings. Constituent groups most frequently consulted were consumers, providers, general interested citizens, and Area Program staff. In addition to gathering information from these sources, three LMEs used document data sources such as internal reports, census data, etc.

Examples of Methods Used

Piedmont used the following strategies to collect input on program strengths and weaknesses:

• meetings with Consumer Family Advisory Committee
• regular informational updates to public agencies, advocacy organizations, and other community partners
• 9 community forums, advertised through flyers, local news, press
• consumer and family surveys
• 4 provider forums
• provider survey
• staff focus groups and survey

Crossroads used a similar approach, with some additional groups contacted, and with the addition of document and data resources:

• consumer and family focus groups
• staff focus groups
• area board retreat and forum
• collaborative meetings with other agencies and public system leaders
• joint forum with county commissioners and their managers
• forum for school principles
• forum with local DSS and Public Health professionals
• forum with local advocacy groups
• forum with LME leadership team
• meetings with local providers
• stakeholder surveys
• demographic data including race/ethnicity, prevalence of MH, DD, SA in community, hospital utilization, insurance data, data on poverty rates, most common diagnoses

LMEs identified a wide range of strengths in their assessment—from a strong value base to strong elements of infrastructure. The most commonly mentioned strengths were

• existing collaboration with providers and agencies in the community (mentioned by 7 programs)
• skilled/dedicated staff (4 programs)
• existing collaboration with families (4 programs)
• a consumer focus (3 programs)
• existing utilization management system (3 programs)
• existing contract management (3 programs)
• case management (3 programs)

A wide range of weaknesses also were identified by the LMEs—including gaps in services through need for improved relationships with key players in the community. The most commonly mentioned weaknesses were:

• gaps in periodic and/or day treatment (7 programs)
• long waiting lists and lack of access to services (5 programs)
• lack of housing/residential services (5 programs)
• lack of transportation (5 programs)
• lack of adequate crisis services (5 programs)
• lack of adequate CAP MR/DD service (4 programs)
• lack of cultural competence and language capacity (4 programs)

In addition, under the discussion of weaknesses 7 programs mentioned concerns about the State reform plan, particularly the issue of divestiture, and expressed concerns about the number and ability of local private providers to serve target populations.

Not all LMEs articulated a clear plan for ameliorating weaknesses in this section of the LBP; the responses ranged from none to specific action steps linked to specific identified weaknesses. Three programs did not provide any plan at all, while 3 others did not have a plan to addresses weaknesses, but identified potential "opportunities" provided by the current confluence of service gaps and community resources. Three LMEs provided broad, general statements in response to identified weaknesses (e.g. "articulating a vision that will work in the county"). Another 4 LMEs addressed weaknesses through a number of broadly identified goals linked with identified gaps or problems (e.g. weaknesses included waiting lists and not enough communication with families and consumers, while strategies included improve waiting times and consumer empowerment and involvement.) Three of the LME plans included specific strategies linked to identified weaknesses.

Examples of Specific Strategies to Ameliorate Weaknesses

• Weakness: Lack of community integration; employment and housing for people with disabilities may only be supported if kept separate/segregated from the community at large.
  Response: LME will initiate an "Anti-Stigma Project" by July 2004. (VGFW)
  
• Weakness: Protocols and consistency needed between portals.
  Response: Meetings with portal sites, developing new procedures to address portal eligibility issues, LME drafts a procedure manual for portal sites for IT systems. (Mecklenburg)
  
• Weakness: Need for Regional ER disposition facility/24 hour crisis facility.
   Response: Partner with the Division to develop a facility-based crisis center in the region with funds presently supporting beds at Broughton Hospital. (Smoky Mtn.)

Consumer and Family Advisory Committee (CFAC)
    f) There is a separate report submitted by the local CFAC

The requirements for the LBP include that there be a statement attesting to consumer/stakeholder involvement in the LBP process, and that a separate report be submitted by the local CFAC. All of the plans submitted by LMEs noted an inclusion of consumer/stakeholder input. However, not all LBPs included a separate report from the CFAC, and not all CFACs approved of the LBPs as submitted. Four of the LBPs did not specifically state that the CFAC had examined and approved their plans. Only one CFAC was documented as approving the LBP without comment or amendment.

Six of the LMEs noted that the CFAC had approved the LBP with comment, or had suggested amendments that had been incorporated into the final plan. Of these, two CFACs made detailed requests around CFAC involvement, evaluation, and consumer and family education, services, and the future role of the CFAC. One CFAC stated its support for continued provision of direct services by the Area Program/LME, rather than divestiture as per the state plan. Three CFACs provided generally supportive comments but with little detail so it was difficult to determine the role and involvement of these committees.

Four of the plans had very little information on the involvement of the CFAC. Some identified the structure of the committee or made broad statements about the importance of input but it was not clear what the committees actually did.

Of the remaining 6 plans, three were accepted with reservation, and in three it was stated that upon amendment and review of the final version of the LBP the CFAC would approve the document. All 3 CFACs expressing reservations included a discussion of concerns about the viability of the state reform plan in general, including concerns about the limitations of target populations and client transitions, concerns about lack of private provider capacity in the area, concerns about funding and Medicaid issues, support for Area Program/LME continued service provision, and questions about monitoring and authority. The final 3 plans did not clearly receive approval from their CFACs and included concerns such as: did not have time to review the entire plan; concerns about provider network adequacy; concerns about funding adequacy; concerns about access, collaboration, and service management.

It should be noted that several themes emerged across most of the CFAC comments, irrespective of their final decision to approve them LBP. These included a lack of time for full understanding and careful review of the plan by the CFAC, and concerns about the viability of the state reform plan requirements in general.

• contains goals, objectives and activities
• addresses steps necessary to transition individuals now in services who do not meet target population criteria to other community resources as necessary

There was wide variability in how goals were stated in the plan. Seven plans presented goals as a narrative with broad policy or program statements instead of providing specific tasks and objectives with target dates. As a result it will be difficult to measure whether or not goals and objectives are being met. This lack of specificity is concerning given that these business plans are from phase one programs. The remaining plans provided various objectives and completion dates but the specificity of both the goals and how they would be achieved varied greatly.

Three plans did not address the issue of transition of individuals to other community services. The remaining plans described a process that was primarily a referral to existing community resources. Few plans dealt with the issue of follow-up or monitoring of the transition for these individuals. Guilford, however, included the need to develop a crisis plan component for those being transitioned. Centerpoint had the most well developed plan for ongoing monitoring of individuals being transitioned.

Planning Conclusions/Recommendations:

Mission: All LMEs who have not revisited their mission statements since the LBP planning process began should work with their constituencies to develop a mission congruent with state reform.

Strength/weakness: All plans seemed to understand the importance of a baseline assessment of the strengths and weaknesses of their system. However, the range of approaches taken to gather baseline data varied dramatically, both around the sources of data (i.e. who was asked to give input, what other data sources were used) and around the method of data collection (i.e. focus group vs. survey vs. meeting, etc.). Given the great differences among LMEs, it seems unrealistic to demand that the exact same methodology be used in all cases. However, methodology used should ensure that information is gathered from the maximum number of participants representing the widest possible range of constituents.

The results of the strengths/weakness analysis demonstrate a significant concern around lack of service capacity in the system. It will be essential that capacity be expanded in targeted service areas if the LBPs are to succeed. We encourage intensive State/LME collaboration around service system development strategies.

CFAC: All plans seemed to recognize the importance of family/consumer involvement yet many programs seemed to struggle with how to meaningfully engage, respond to, and incorporate the role and future activities of families and consumers and the CFAC. The Division is developing a clarifying policy memo on the role and responsibilities of the CFAC and the LME. While this will certainly help, more assistance will likely be necessary. State technical assistance to CFAC’s and to LME staff will be important to support the development of CFAC’s into the effective community resource they can become. Where necessary, the state should offer mediation to assist in the establishment of effective processes and relationships between the CFAC and LME.

Goals and Transition of Non-target populations: We strongly recommend that specific goals be articulated and that associated objectives and activities to meet those goals be detailed along with dates of completion. Going through such a process pushes LMEs to think concretely about implementation of change. It also infuses a degree of accountability to ensure that proposed changes can be reviewed and monitored.

We also would urge that transition of non-target populations be viewed as more than a referral process. LME’s should work to develop transition plans, including provision of crisis services, and mechanisms to monitor the outcome of those transition plans. Results of this review should be used to help identify and develop needed community transition resources.