North Carolina is in the midst of a comprehensive effort to reform its public MH/DD/SA system. While there are many reasons for this reform, central to it are a number of principles that form the vision for a better service system. Among these principles are a personal recovery focus; consumer/family involvement and choice; community collaboration, integration and involvement; clinical, administrative, and fiscal accountability; and identification and provision of best practice services to those populations most in need (i.e. "target populations").

The initial mechanism through which reform is operationalized is in the development and implementation of Local Business Plans. Local Business Plans were to be developed through a community-based inclusive and interactive strategic planning process collaborative led by the Area Programs/Local Management Entities. The plans detail how communities will meet state expectations around the goals and vision of reform. All programs were to submit Local Business Plans by January 1, 2003. NAMI North Carolina, in collaboration with the UNC School of Social Work and a panel of local experts in community-based services (see Appendix 1), reviewed elements of the plans from the 16 programs applying to be "phase one" programs and begin implementation of their plans on July 1, 2003. This review focuses on the underlying question of whether the submitted Local Business Plans reflect a move toward meaningful reform and underlying principles articulated in the State Reform Plan. In short, the question behind the review is "By implementing these plans to what extent will communities achieve the goals of reform?"

The current Local Business Plans reflect good first steps toward a comprehensive reform effort. For reform to be successful, however, these plans will need to be refined and improved over time through a partnership between the state, LMEs, and community stakeholders. Policy and operations will need to change at both the state and local level. Key elements that need additional attention:

• In the absence of financial data, clear financial objectives and lack of programmatic direction from the State, the Local Business Plans are difficult to evaluate and are in themselves not appropriately termed "business plans". Fully articulated business plans should be requested soon after LMEs are given the financial data and other direction with which to complete them.

• The structure of the Local Business Plan itself should be reviewed and refined. There is a need to reduce redundancy, particularly in the areas of Quality Management/Quality Improvement, and non-target populations and the development of community supports. Clarity of the information requested also needs to be refined. Throughout this review we identify a number of areas in the Local Business Plans that need improvement. Often what is needed is more clarity in expectations.

• To provide clarity, the Division of MH/DD/SAS will need to provide leadership to better define its expectations, particularly in areas that have cross program and statewide implications. Specifically, the Division needs to clearly articulate expectations for quality indicators, provider profile dimensions and provider technical assistance, outcome measures (system and individual), best practices, development of community supports, and client rights. We strongly believe that the development of these expectations needs to come from the state, not 20-30 different programs.

• The establishment of a statewide appeals and grievance process for all clients and the support and integration of client rights activities into quality management processes is essential. The state should immediately address this issue.

• At the present time there is no consensus around the critical areas of Qualified Provider Network Development and Quality Management and far too much variability around how these are defined and how they should be operationalized. The Division needs to facilitate the development of this consensus and should consider involving not only LME staff, but national consultants to develop state of the art protocols in these areas.

• At the state and local levels there must be an investment in meaningful technical assistance in all areas. We are concerned that the massive changes created by reform efforts are being undertaken without the resources and expertise to make the change positive and successful.

• The Local Business Plans themselves should be become a vehicle for system quality improvement. The written Local Business Plans should be updated and refined based on Division feedback and further clarification and development as noted above.

Our review focuses on 16 of the elements required in the Local Business Plan, a small subset of the total of elements. It is a selective, but representative review of key plan elements. These 16 elements represent major sections of the Local Business Plan but also to reflect the underlying principles of reform. The elements reviewed were in the areas of planning, qualified provider network development, service monitoring and oversight: quality management, and evaluation.

The General Information section for Local Business Plans in the State Plan (p.3) states: "The LBP should be approached as a strategic plan and process. A strategic plan acknowledges a fundamental understanding of the vision and known elements of pursuing the vision. Although the vision stays constant, the strategic process is dynamic and recognizes the need to adapt to the acquisition of new and better information". We strongly support this notion of constant improvement in the plans as more is understood and recognized. Thus, this review does not focus on critiquing individual plans but attempts to identify patterns and trends across plans where additional clarification or technical assistance may be necessary, and to identify exemplary elements of plan components that could be emulated. At points throughout the review specific plans are identified as examples of what we considered a very good response or approach to a particular business plan element. If a program is not identified it does not mean its plan or approach was not good. Our intent in highlighting programs was to identify those that had gone beyond the usual and perhaps encourage other programs to learn more about what their colleagues had done. Finally, we offer recommendations on how Local Business Plans can be strengthened and improved to support the implementation of the vision and principles of reform.

Limitations: There are several limitations to this study that must be acknowledged. First, we do not review all dimensions of every plan; such an undertaking is beyond the scope of our resources. In so doing, however, we may have missed important elements in and across plans. Second, this is a review of plans submitted to the Division. No attempt is made to review implementation or to check whether plans accurately reflect the community planning and implementation process. Finally, all plans reviewed were submitted before the April 1^st deadline to submit modifications to Local Business Plans. Some changes to individual plans may have been made, however, we feel that the overall patterns and themes in the Local Business Plans did not change in any significant manner.

Methodology

The state requirements for local business plans were reviewed by a group of local experts. (Appendix 1) Certain components of the plan were determined to be central to the success of reform efforts. These local business plan components chosen to be reviewed are:

    a) Performance indicators (long, long list. How do we reflect it?)
    b) A description of how data will be used for planning

EVALUATION

Five graduate students (Appendix 2) from the UNC School of Social Work reviewed key plan dimensions across the 16 Local Business Plans applying to be "phase one" programs (Appendix 3). These students provided a summary of each of the sixteen elements across the 16 programs. Following the review of individual plans, NAMI enlisted the review panel of local experts to compile this report (Appendix 2). The panel reviewed the data compiled by the students in order to identify patterns and themes. Recommendations were developed based on issues and themes identified.

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.

QUALIFIED PROVIDER NETWORK DEVELOPMENT     

Service Capacity
1) The local business plan identifies the current qualified provider services lists and service array
   b) A current lists of all qualified service providers matched to service category and target populations
   c ) A comprehensive assessment of service capacity need has been completed, and a summary of its conclusions and recommendations are attached

There were significant differences in how programs determined capacity. Methods included surveys of providers, community forums, and service data. OPC went beyond simply trying to identify the existence of providers and used multiple sources of information and data analysis to compare projected need with provider capacity. Pathways program looked at linking capacity to a model of service, access, cultural competency, etc. versus simply trying to determine whether providers were interested in taking clients. Few plans looked at whether the service array reflected best practice or whether it reflected too much of a particular model of service, e.g. residential.

All plans recognized the need to expand the provider network. In most plans there were few specifics on how the expansion of the provider network could be accomplished. Rather, statements such as "will provide incentives", and "identified gaps will become priorities" were made. There also was wide variability in strategies to recruit providers and to provide training and technical assistance. Unfortunately, a few programs used this section to present data, usually simple surveys, that private providers weren’t interested in providing services and to justify the continuation of service provision by the LME.

Best Practices and Technical Assistance
2) The local business plan complies with the State Plan requirements in establishing a qualified provider network
   d) A QPN development plan is attached addressing

While some plans mentioned specific best practice services for target populations, most indicated that they were waiting for the state to identify best practice services. Most plans dealt with technical assistance activities in broad brush strokes, noting that technical assistance would be offered if requested. It wasn’t clear if all providers would receive technical assistance, or targeted assistance, how often and in what circumstances. Centerpoint’s plan did a good job of trying to link provider outcomes with technical assistance and contract development.

Identification of Individuals in Transition
4) The local business plan complies with State Plan requirements and establishes a system of services and supports for existing populations

•  Provides a plan for identification of individuals in transition
• Identifies generic community resources, such as faith-based groups, to provide services and supports to members of the non-target populations

There was a great deal of variability in terms of how well programs knew the transition population and, in particular, the service transition needs. Several plans mixed the issue of service divestiture in with transition of non-target populations. Plans generally reflected an effort to survey existing community resources and provide referral services to non-target populations. Outreach efforts or identification of community gaps were usually not discussed.

Significant development of this area needs to be undertaken through joint technical assistance efforts between the Division and LME’s to fully develop the capacity of LME’s to create and manage a provider network. The development of a strong provider network is absolutely essential to successful reform efforts. This effort needs to go well beyond being able to identify the name of a provider for a particular service. Systems need to be put in place to determine the required provider/service mix based on the needs of the target populations of the LMEs, to identify and recruit potential providers, to provide training and technical assistance on best practice services that will be purchased, and to engage in ongoing assessment of multiple provider dimensions, including both client and process outcomes. There should be clear links between network development and quality management activities. The state and LME’s, along with provider organizations, need to collaborate in the development of training and technical assistance to support LME’s in the development and implementation of these plans.

The state is in the process of providing guidance on best practice services and should require resubmission of that section by LME’s once best practices have been clearly defined for all target populations. Clearly the financing plan and rate structure will have a major impact on plans to develop provider networks.

North Carolina does not have a well-developed provider network and a major task of the reform effort is changing (and incentivizing) the models of services offered. Thus a strong technical assistance effort is necessary. A more planful approach is needed than is articulated in most of the plans reviewed. We would urge an effort that links technical assistance to provider outcomes and the quality management process. Again, technical assistance to LME’s on the development of such a plan will be helpful. We would also urge more development of plans to not only survey what exists in generic services but engage in community discussion of where gaps are and how to support service development.

Quality Assurance Plan
The Local Business Plan describes a quality management process to meet the State Plan requirements, including how the LME will address the following:

There was wide variability in how plans defined quality management and the components that comprised a Quality Assurance Plan (QAP). While many plans would articulate and define the components of their QAP, it was not always clear how the components related to each other and to the goal of assuring quality. Plans often consisted of a listing of many committees but it was unclear how these various committees related to each other and what exactly they were accountable for. A few plans identified the involvement of consumers and families but clearly this is an area that consumers and families can plan a vital role and this role should be reflected in all plans.

In many cases, quality seemed to be equated with the review of critical incidents and risk reduction although this may be as much of function of how they were asked to report this section. The Division should review its expectations and clarify and broaden it beyond a function that is primarily monitoring role.

Plans did not reflect standard provider profiling dimensions. Many plans seemed to equate provider profiling with provider credentialing. Again, this is an area where the Division’s leadership is needed. It will be important to have state identified provider profiling dimensions so that providers do not have to respond to multiple expectations, and to allow for comparisons across the state.

It is unclear how most plans would relate quality improvement to client rights. This is not necessarily a problem with the plans. The state has not given clear guidance on the role of the client rights committees and other rights activities within reform efforts.

Many plans used consumer satisfaction instruments as their quality improvement measure because it was cited by the Division as an outcome measure. While necessary, client satisfaction is not a sufficient measure of quality. This appears to be a case of using what is currently available instead of using state of the art measures of quality. This is an area that should not be defined by each area program. The Division needs to take leadership in developing quality improvement and outcome measures so that these can be compared across programs.

It was generally unclear how all the data generated was going to be used to improve quality. LMEs should be provided with technical assistance as needed in order to develop an interactive quality improvement process that integrates all data collected and uses it in ongoing improvement efforts across the LME and provider network.

New River had perhaps the most detailed QAP, citing not only functions, but responsibilities for each component along with goals for the next three years.

Policy Identification for Best Practice for Each Target
The Local Business Plan describes a policy that adopts state identified best practices for each target population and individual outcome-based goals.

Two programs had no specific comments on this section. Most made general statements about the need to provide best practice services for different populations. One recognized importance of fidelity to models of best practice. Smoky Mtn. identified a general process of how to move current services toward best practice models. Mecklenburg had a very detailed process for identifying best practices, measuring adherence to practice guidelines, reporting exceptions and requesting exemptions from requirements. It should again be noted that the Division’s identification of best practices for all target populations is not yet complete, and many LMEs may be waiting for this document before they begin their specific best practices policy development.

MIS Capabilities, Consumer Status and Outcomes
The local business plan describes management information systems capabilities sufficient to meet State Plan requirements including the ability to effectively track service events, track outcome data related to public funding and generate performance indicators.

One plan did not address this section. One reported they were already meeting requirements. Some programs listed the software package they intended to use for billing and medical records. Most listed the various tools and outcome measures to be used. Piedmont noted that outcomes would be part of provider contracts. Again, we would submit that this should not be an area that each area program defines or there will be no capacity to compare across programs and dimensions. It is clear that there is a greater need for planning and implementation of MIS capabilities. One major task will be linking a distributed provider network system with the LME and to the state.

Use of Performance Indicators in Planning
Performance indicators

One plan did not address this section. Across plans, performance indicators and outcomes were not uniform. Many plans made broad statements (e.g. "will help generate recommendations for corrective actions…") Pathways had the most well developed outline of system of indicators, measures used, and purpose of those measures. But overall, there was so much variability in this section it is impossible to determine any trends. For the most part, some entity was identified with responsibility for reviewing information. But what information was reviewed, by whom, for what purpose was significantly different from LME to LME. There was not a clear use of indicators in a strategic planning process.

It is evident from this review that of models and protocols for "best practice" quality management systems need to be developed. The state should immediately begin work with LMEs and seek national consultants to help develop these models and provide training and technical assistance to ensure quality and consistency of a QM process across the state. This will be one of the primary functions of the LME but one with which many have limited experience beyond the monitoring function. Fortunately, there is considerable national experience in this area and we should seek it. In addition, consumers and families should be involved in the full range of QA/QI activities.

EVALUATION      

Previous Use of Evaluation
2) The Local Business Plan is consistent with State Plan requirements for managing a continuous quality improvement process
   b) A description of how the LMEs earlier configuration of counties/area program participated in evaluation processes for the last two years and actions taken as a result of the evaluations

Most programs cited a previous accreditation process (one program reported how much the documentation had weighed), Division review, or current CQI process and client rights committee activity. In ten of the plans, however, it was not clear what improvements or actions were taken as a result of these evaluations. Some plans restated various outcome measures from previous sections or restated information from the Quality Management section. For the most part, those who reported specific actions as a result of previous evaluations made improvements in organizational processes around quality management and systems operation issues. Pathways was notable in that one of its actions resulted in the identification of actions to reduce suicide risk.

Plan for Quality Improvement Process
   c) A plan for the development of quality improvement process is provided

Most plans provided a broad overview of quality improvement effort, committees involved, and broad functions that the process would focus on. Some plans went beyond and specifically identified how their current plan would be changed and improved. Mecklenburg, for example, had a very detailed 12-month QIP workplan and noted specifically that it would increase population-based quality improvement projects as well as focus on continuity of care issue.

Nearly all plans recognized the need for consumer/family involvement in this process. Plans most often cited various committees or the CFAC as entities that would receive information, but it was not always clear what they would do with the information or how their input would be incorporated to improvement efforts.

Use of Performance Indicators in Evaluation Reports
3) The local business plan meets State Plan requirements for evaluation system performance
a) The plan for develop of the quality improvement process adopts system performance indicators in internal evaluation reports that include:

The Division has done a good job in identifying four system indicators. How the plans decided to assess these indicators and what data they chose to gather varied dramatically. This is not necessarily negative, depending on what the purpose is. If the intent is that this be strictly an internal LME process then this variability can be tolerated. If, however, the Division intends to compare these system performance indicators across programs the variability will make comparison impossible.

Evaluation Conclusions/Recommendations: In general, there seemed to be a strong commitment on the part of the LME’s to quality improvement processes. But many plans made rather broad statements and the degree to which programs have the specific plans and expertise to implement these processes remains to be seen. A successful Quality Improvement Program will require more than multiple committees meeting and reviewing data. How these committees use the data, interact with each other, and more importantly, create a system that can actually change and improve how things are done will be a tremendous challenge. Most programs have not engaged in Quality Improvement Programs to the extent required for successful reform. The Division also has not had this experience. It will be very important for the Division, LMEs, and CFACs to work with external consultants to jointly develop best practice quality improvement models and to provide a mechanism for technical assistance to programs as they develop such processes. Significant portions of this section seemed to be redundant with the Quality Management section. The Division may want to consider combining the Quality Management and Quality Improvement sections of the LBP into an overarching Quality Section.

COLLABORATION   

Specific Mechanisms for Involving Consumers/Families/Communities
    2) The local business plan delineates a process that supports and encourages collaboration among community agencies and organizations.

Most plans cite present collaboration efforts and provide a list of established committees or point to the CFAC as a mechanism for collaboration. It is not always clear what the purpose of the collaboration is and how information will be used. Some plans identified ways to enhance collaboration, for example, scheduling meetings at convenient times.

Piedmont will establish an Office of Prevention, Education, and Outreach to coordinate across agencies and community groups. Crossroads will establish an interagency consortium with specific roles and responsibilities. Mecklenburg provided a good list of indicators of successful collaboration.

Plan for Identifying, Developing, and Managing Information Services & Resources
3) The local business plan describes how the LME will identify, build on, develop and manage a network of informal services and resources necessary to provide the foundation for individualized support and community integration at the consumer, family and community level.

Most plans cited efforts to establish some sort of directory of community resources and referral system. Few seemed to recognize the considerable resources needed to maintain and implement such a system. Some plans indicated a role for the CFAC in this effort. Overall, however, there was little discussion of building a full network of informal services across a wide range of interests and topic areas. Rather, there was a more traditional focus on non-human service community agencies and groups. Ways of using natural community supports to maximize community inclusion were not really explored.

Collaboration Conclusions/Recommendations:
Collaboration, including collaboration with natural community supports, should be seen as an important component of system quality improvement. We applaud the efforts of those programs that have made a commitment to dedicate staff and resources to make this an integral part of their system operations.

Review Panel of Local Experts
Beth Melcher, Ph.D NAMI North Carolina
Joe Morrissey, Ph.D. UNC Sheps Center
Anna Scheyett, MSW, LCSW, CASWCM, UNC School of Social Work
Marvin Swartz, M.D. Duke University

Appendix 2
NAMI North Carolina is extremely grateful to the following UNC School of Social Work

Graduate Student Reviewers:
Erin Drinnin
Billie Guthrie
Christina Rausch
Nora Schuette
Susan Stroud

Appendix 3
Phase One Plans Reviewed
Albemarle
Centerpoint
Crossroads
Duplin-Sampson-Lenoir and Wayne
Edgecombe-Green-Halifax-Nash-Wilson
Guilford
Mecklenburg
New River
Neuse
Orange-Person-Chatham
Pathways
Piedmont-Davidson
Smoky Mountain
Tideland
Vance-Granville-Franklin-Warren
Wake