Dear Friends of NAMI North Carolina:

Just before she left to begin her new position, Beth Melcher submitted the
attached comments on the latest version of the state mental health reform
plan. We are grateful to her for doing so. Readers wishing to make
additional individual comments may do so up to the close of the business day
on June 20 and also review the plan again at:

http://www.dhhs.state.nc.us/mhddsas/

Thank you very much for your continuing interest in and support of NAMI
North Carolina's public policy program.

Beth Hardy
Chair, Public Policy Committee

Kay Flaminio
Executive Director

This version of the state plan has made great strides in its "readability." One member stated that it "exceeded" her expectations for a bureaucratic document. The Division has done a good job clarifying content and using direct and forthright language. The charts and graphs in the document were effective in showing the state’s intentions. Reviewers were appreciative that challenges were identified and, more than in previous plans, specific strategies and timelines were articulated for addressing them. In this third version, the document is truly looking like a "state plan."

As the state begins to move into a phase of rapid implementation of reform we are very aware of the immense needs at both the state and local level for training and technical assistance across a wide range of areas. We strongly urge the Division to provide leadership in bringing in the expertise necessary to assist with this transition. In particular:

• Joint technical assistance efforts between the Division and LMEs to fully develop the capacity of LMEs to create and manage a provider network are absolutely essential to successful reform efforts. Network development 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. We would urge an effort that links technical assistance to provider outcomes and the quality management process. Again, technical assistance to LMEs on the development of such a plan will be helpful.
  
• 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.
  

NAMI North Carolina is very supportive of the best practice services and supports for children and adults with mental illness outlined in Chapter 3. We applaud the Division’s work on clearly articulating a comprehensive array of these services and the essential elements that comprise the best practice. We are very appreciative of the support and expectation of best practice services.

Now that these services have been articulated it is essential that the Division support their implementation through service definitions, rate structure, supportive policy, and training and technical assistance initiatives. The greatest concern raised in this section was whether funds would be made available to pay for best practice services.

We are very appreciative of the clarification in this version of the state plan on the role and responsibility of the CFAC and the model relational agreement between the CFAC and LME. In order for the CFAC to be able to fulfill its responsibilities the Division will need to provide ongoing technical assistance and, where needed, mediation. Some early experiences between the CFAC, LME, and counties indicate that creating this new relationship will take more than signing an agreement. The Division must take a leadership role in ensuring that what is on paper becomes practice.

One reviewer noted that appeals to cultural diversity appeared throughout the state plan, beginning as early as page 16. It was felt that the Appalachian culture has been omitted from the State and Local plans and cited Ohio’s Appalachian study as evidence that we need to be sensitive to the culture of this group for reform to be accepted in some areas of the state.

In the discussion of case management functions, there was support for maintaining the "firewall" between the functions to minimize the conflict of interest.

The last bullet on page 86 seems to contradict the section on best practices services and supports. Chapter Three clearly articulates evidence based practices the Division expects to be developed across the state but the final bullet on p. 86 appears to suggest LME latitude in determining what a best practice service is. Best practice means there is a national consensus based on research and the state has made a commitment to incorporating these services into the service mix. While LMEs should seek to learn about and implement the national best practices that the state has adopted, it is not the function of, nor does the LME have the capacity to "make a decision to pursue a particular clinical advance and operationalize it in the provider network."

We support the role of the LME as the authorizer of services. The plan is not clear, however, on how this will interface with direct billing. Will providers be able to bill directly if treatment is approved? Will consumers have to receive an assessment from the LME or will the assessment by the provider be sufficient? Will billing have to be done through the LME (this would appear to be redundant)? It would be helpful to have greater clarity on this relationship.

The plan does a good job articulating what functions the LME will be responsible for but further work is needed to articulate the expectations and/or models of how those functions are to be done.

• 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.

• 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 also 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.

We are very pleased that Chapter 5 reflects the recommendations of the workgroup on the State CFAC and urge that the Division move forward on these recommendations. While Chapter 5 also recognizes a workgroup focusing on human rights, its recommendations are not presented. The continued failure to address the establishment of a statewide appeals and grievance process for all clients is perhaps our single greatest disappointment in this version of the state plan. Establishment of such a system and integration of client rights activities into quality management processes is essential. The state should immediately address this issue and add it to this version of the state plan.

We support allowing a longer transition time for non-target populations as articulated in Chapter 6. We are very pleased with the development of the child mental health services plan. While previous plans have been developed they typically have not focused on operationalizing the vision they articulate. Therefore, we are pleased that this plan will also focus on structural, financing, and organizational issues.

The discussion in Chapter 6 on the downsizing of the state hospitals continues to focus first on the elimination of state psychiatric beds instead of the development first of demonstrated community capacity. This continues to strike us as completely backwards. There continue to be far too many people who are discharged from the hospital (or denied admission) on the hope that a service will be available in the community.

Questions were raised about the bed day allocation. More than a few of the reviewers are active at the local level and expressed confusion and lack of information on bed days and the allocation funds. Clearly more clarity is needed.

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