NAMI North Carolina Response to State Plan 2002

Executive Summary

NAMI North Carolina applauds the state’s commitment to move forward with comprehensive reform of the public MH/DD/SA system. We support the vision and the direction articulated in the State Plan. We welcome the unprecedented opportunity for family and consumer involvement, and we look forward to participating and working in partnership with the state to achieve the goals of reform.

NAMI North Carolina’s full response to the Plan details a number of issues we urge the state to address, the most critical include:

• Throughout the State Plan there is a commitment to provide best practice services. We urge that the Plan specify best practice services for target populations and how the state will support and promote such practices. There is a clear consensus within the treating community on what best practice services are for people with severe mental illness (including PACT, supported employment, supported housing, family psycho-education, social skills training; illness self-management; System of Care for children). If the state is serious about best practice it should support that consensus and require that it be implemented at the local level. Until this is done, the state’s commitment is empty.

NAMI North Carolina applauds the state’s commitment to move forward with comprehensive reform of the public MH/DD/SA system. We support the vision and the direction articulated in the State Plan. We welcome the unprecedented opportunity for family and consumer involvement, and we look forward to participating and working in partnership with the state to achieve the goals of reform.

NAMI North Carolina urges the state to address the following issues and concerns with regard to implementation of the State Plan:

• Throughout the State Plan there is a commitment to provide best practice services. We urge that the Plan specify best practice services for target populations and how the state will support and promote such practices. There is a clear consensus within the treating community on what best practice services are for people with severe mental illness (including PACT, supported employment, supported housing, family psycho-education, social skills training; illness self-management; System of Care for children). If the state is serious about best practice it should support that consensus and require that it be implemented at the local level. Until this is done, the state’s commitment is empty. (Chapter 3: Designing a New Public System)

• The section on individuals with multiple diagnoses is weak; they have a unique set of treatment/service needs and should not be considered simply a subgroup of a single disability. We urge the state to make a strong statement and require the development of special services that reflect best practice for individuals with multiple diagnoses. (Chapter 3: Designing a New Public System)

• NAMI North Carolina supports the concept of target populations. In implementing this concept, we urge careful, continuing attention to the validity of eligibility criteria. GAF or CAFAS scores can be subjective; eligibility could easily become a way to restrict and deny access into the target population. The state must establish a strong review and appeal process. (Chapter 3: Designing a New Public System)

• The Division should clarify the meaning of "priority population" when used to describe a subgroup within a target population, including how this relates to services and compares with those of individuals in the rest of the target group. (Chapter 3: Designing a New Public System)

• While the State Plan identifies individuals with mental illness in the criminal justice system as a priority population it says nothing about how to respond to this population. The State should immediately the recommendations from the Terry Sanford Policy Institute report on The Seriously Mentally Ill in North Carolina’s Criminal Justice System.

• The Plan should clearly state that individuals who are making a successful recovery (and who may not currently have the qualifying GAF score) will not be penalized. These individuals must be able to maintain the services that support their recovery; they should be able to quickly access additional services if needed. (Chapter 3: Designing a New Public System)

• We support the inclusion of children with severe emotional disturbance as a target population. We believe any definition that eliminates early intervention for at-risk children would be short sighted and we urge that children at risk of and/or evidencing symptoms of emerging emotional disorders be a target population. (Chapter 3: Designing a New Public System)

• NAMI North Carolina commends the state’s efforts to comply with the Olmstead ruling, but it appears that the primary focus has been on the development of community services to meet the needs of individuals identified in the Olmstead Planning instead of integrating the Olmstead process into the overall reform process. The state needs to make an absolute commitment to develop the continuum of community services for all individuals in communities who qualify for services, not only those who require services due to their involvement in the Olmstead process. (Chapter 2: Changes in the Current System)

• Families and consumers have not participated in regional groups that have created plans to develop services for individuals being discharged from hospitals due to Olmstead or hospital downsizing, nor have these plans been released for review. It is essential that families and consumers play an integral role in both planning and monitoring the implementation of these plans. Planning should encompass all individuals in communities who qualify for services, as well as individuals being discharged from the hospitals. The state should make a commitment that discharge to a homeless shelter should never occur. (Chapter 2: Changes in the Current System)

• Downsizing of state psychiatric hospitals is being planned and proceeding despite the absence of community services, and, we believe, based on incomplete data (e.g. admission denials, recidivism, individuals receiving treatment in prison). NAMI North Carolina strongly maintains its position that no individuals be released from the psychiatric hospitals without appropriate services being developed and ongoing funding identified for those services. The state should monitor those discharged and gather data on their functional status from program staff, consumers and their families. While such monitoring has occurred with the closure of the Wright building at Dix hospital, our concern is the Division’s lack of resources to continue it, once closures and number of people affected increase. (Chapter 2: Changes in the Current System)

• The State Plan provides no information with regard to the planning process for consolidating John Umstead and Dorothea Dix Hospitals. Since the release of the State Plan the Secretary has announced her decision to build a new hospital in Butner. While we support the building of a new hospital we are very concerned that family members, consumers, and advocates had no involvement in the decision-making process. Many legitimate concerns exist regarding this decision and how it will be implemented. The state should provide both technical and financial assistance to Wake, and other affected counties, to ensure the establishment of community services and community psychiatric inpatient capacity prior to the closing of Dorothea Dix Hospital. We call on the Secretary to immediately appoint a committee that includes families and concerns to guide and advise the transition. (Chapter 2: Changes in the Current System)

• LMEs and the client rights committees must be empowered to monitor quality and rights protections in contract services as the system moves toward establishing provider networks. Supporting "best practice" in the area or client rights is critical. We urge the Division to support the establishment of a strong, statewide client rights system and grievance and appeals processes that includes the ability to appeal beyond the LME to the state. (Chapter 3: Designing a New Public System)

• Utilization management is necessary at the state and local level. But there is a risk it can be manipulated to deny services. To minimize the risk, criteria should be carefully considered and developed to allow flexible services. Criteria should not include restrictive medication formularies that deny access to newer, more effective medications. Families and consumers should be involved in monitoring the utilization process at state and local levels. (Chapter 3: Designing a New Public System)

• The state plan, while requiring family/consumer involvement in monitoring activities, provides no guidance as to what this involvement should include. We are concerned that without guidance families and consumers will be relegated to a marginal role. Several states have supported the establishment of family/consumer monitoring teams that play an integral role in assessing quality of services. We urge the Division to support the establishment of such a system across the state. (Chapter 3: Designing a New Public System)

• We welcome the unprecedented opportunity for family and consumer involvement at state and local levels. If the state values family and consumer involvement, it must ensure that sufficient resources are provided for the functions specified in the Plan. In particular, training should be required for consumer/family members of the Consumer Family Advisory Committee. The Division should identify what should be covered in that training. We are pleased to see the state plan endorse staffing for the Consumer and Family Advisory Committee, and recommend that the family/consumer advisory members have input into hiring of the staff person. (Chapter 5: Structure and Management)

• We request a clarification on the status of the proposed Office of Consumer Affairs within the Division, which the Secretary previously reported to the legislature would be staffed 100% by consumers and family members. No such office appears on the organizational chart in the Division’s reorganization. (Chapter 5: Structure and Management)
  
• The State Plan calls for consumers to be employed within the system. Given the state’s current fiscal situation, we are concerned the State will fail to maintain that commitment. (Chapter 5: Structure and Management)

• The State Plan offers no real detail for financing the reform effort. It is essential that the State provide the fiscal resources to support reform at the local level or reform will fail. While we recognize that finance modeling is underway, we urge the Division to immediately complete this effort; delay compromises planning and implementation efforts at the state and local level. (Chapter 5: Structure and Management)

• We support changes to provide detail and clarity in the local business plans. However, we urge the Division leadership to establish a mechanism to develop and approve policy directives more quickly. For example, while detail on compliance with Division expectations is required in the local business Plan (best practice or client rights), the Division has yet to release those expectations. This results in confusion and frustration at the local level as communities try to "guess" where the Division is headed. (Chapter 5: Structure and Management)

CAFAS: Child and Adolescent Functional Assessment Scale. A measurement system to determine the level of functioning of a child or adolescent.

Division: The state Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

GAF: Global Assessment of Functioning. Measurement scale used to determine the level of functioning of an adult.

LME: Local Management Entity. The mental health reform legislation requires that the current area mental health programs become LME’s responsible for service management, planning, and monitoring and provider network development but with a very limited role in providing services.

Olmstead Ruling: Refers to the 1999 US Supreme Court ruling that individuals residing in state institutions have the right to live in the community if they desire and their treating professionals determine they were able to do so. Requires states to identify individuals and work toward developing community support services for them.

PACT: A best practice model of Assertive Community Treatment (ACT) that offers intensive community support through a multi-disciplinary team, low staff-consumer ratio, and 24 hour availability seven days a week on a long-term basis.

State Plan: A statewide plan for mental health, developmental disabilities, and substance abuse services. It is revised and updated annually.

System of Care: A best practice model of providing mental health services for children that offers an array of services individualized to the needs of the child and family and integrated into all systems (school, social services, mental health, juvenile justice) involved in the child’s life.

Target Population: Groups of people with disabilities with attributes considered most in need of services available within the service system. For example, the State Plan, identified adults with severe and persistent mental illness and children with serious emotional disturbance as members of target populations.

Utilization Management (UM): A process to regulate services by balancing the services that are available with the needs of consumers.

[NAMI NC home]               [State Plan 2002 Summary]