CHAPTER 3: DESIGNING A NEW PUBLIC SYSTEM
http://www.dhhs.state.nc.us/mhplan/stateplanpart3aa2.pdf

This chapter offers more detail around core functions, access to the system, and target populations than the previous state plan.

Core Functions

The reform statue requires that, within available resources, core functions be widely available. Core functions are ways to enter into the system and there are two types: 1) direct, individual-specific (screening, assessment, and emergency triage), and 2) indirect (prevention, education, consultation) to benefit the greater community.

Screening: a brief standardized appraisal of individuals not currently being served within the system to determine the nature of the problem and need for services. It is not an evaluation or assessment. It is a brief interview conducted either face-to-face or by telephone.

Assessment: is a follow-up next step if screening indicates further assessment is needed. Its purposes are diagnosis, determination of the person’s disability level, eligibility to be included in a targeted population, and evaluation of urgency and intensity of need.

Referral: offering information about available providers and resources to best meet the needs of the individual.

Emergency triage and services: a range of functions including 24-hour crisis hotline and urgent or emergent clinic/practitioner visits for people who initially enter the system in crisis and to those in target populations who are already receiving services. Services include crisis stabilization, respite, crisis shelters, detoxification services or hospitalization.

Care Coordination: as a core function means referring people who do not meet the criteria to be eligible to receive services to alternative resources.

Service Coordination: is an administrative function that ensures that services in a region are integrated, have consistent policies and practices, and are consumer and family friendly.

Consultation: provided to agencies, groups, organizations, or individual practioners to promote planning and development of mh/dd/sa services.

Education: inform and teach various groups, including consumers, families, schools, businesses, other community groups, about the mh/dd/sa services and supports in the state and community.

Universal Prevention: inform and teach the population at large about skills related to healthy living.

Uniform portal means a standardized way for people throughout the state to enter or leave public mh/dd/sa services. The core functions of screening, referral, assessment, and emergency management combined with procedures for discharge are what comprise uniform portal. A person can access or enter the mh/dd/sa system from many points such as a public agency (social services, vocational rehabilitation, schools, public health), a statewide referral service, providers, or the LME. Regardless of where a person enters the system, uniform portal requires that the standards for entry are consistent. A state-level workgroup is currently developing such things as screening and eligibility determination instruments, documentation and reporting methods, referral process, and assessment procedures that eventually will be implemented statewide.

The state will contract with an entity to provide information, referral, a statewide crisis hotline, and utilization management for certain high cost services. The contractor will support each LME by taking calls 24-hours-per-day, seven-days-a-week, through a single, statewide toll-free telephone system. This will include patching crisis calls directly through to the LME or emergency system. The contractor will screen and refer people seeking help and will provide utilization management for high cost services such as acute hospitalization, long-term placement, and out-of-state-placements. The contractor will be reimbursed in a way that does not provide a financial incentive to deny care. The LME will provide all other utilization management, using criteria currently being developed by the state.

The primary focus of mh/dd/sa services will be providing services to individuals with the most severe disabilities. This will be determined by a combination of diagnostic criteria, functioning level (as assessed by the Global Assessment of Functioning-GAF), and individual unique circumstances.

Resources will be targeted to adults with severe and serious mental illness. Within available resources, the system will provide at least a base minimum of services to all persons in the target population. Individuals with severe and persistent mental illness are those who are 18 years or older and exhibit functioning that is so impaired, as a result of a mental illness, that it interferes substantially with their capacity to remain in their communities (a GAF score of 40 or lower). Persons with serious mental illness are those 18 or older who have a mental, behavioral, or emotional disorder that can be diagnosed and substantially interferes with one or more major life activities. Functional status as assessed using the GAF is below 50. The state plan recognizes that some individuals may not have received a GAF score previously and allows a history of two or more hospitalizations, arrests, or homelessness as meeting the criteria for substantial functional impairment.

Within the adult target populations are priority populations including individuals with multiple diagnoses (e.g. MI/MR; MI/SA; MI/HIV), persons who are homeless and mentally ill, mentally ill adults in the criminal justice system, elderly persons, deaf mentally ill persons, and minorities.

Over the next five years the state hospitals will focus on providing inpatient care to the following populations:

• Adults with psychiatric illness requiring brief acute inpatient treatment of a few days to stabilize and return to their communities.
• Adults with psychiatric illness requiring long-term inpatient rehabilitative treatment of approximately three to six months
• Children with severe emotional disorders requiring acute inpatient treatment to stabilize an return to a less restrictive environment
• Older adults with psychiatric illness requiring acute inpatient treatment to stabilize and return to their communities
• Adults with psychiatric illness and substance abuse disorders or serious illness such as HIV requiring acute and/or longer-term inpatient treatment to stabilize and prevent relapse and readmission.

Specialty populations to be served within the state hospitals will be:

• Forensic patients
• Patients taking part in a research protocol
• Deaf consumers requiring acute or long-term inpatient services

The NC Special Care Center will provide intermediate and skilled nursing care for individuals referred from state hospitals and for people who can’t be served in their communities because of insufficient bed space and psychiatric services of sufficient intensity. Primary populations served will be:

• Consumers with severe mental illness requiring Intermediate Care Facility (ICF) level of nursing care
• Consumers with severe mental illness requiring Skilled Nursing Facility (SNF) level of nursing care

The specialty population to be served at the NC Special Care Center will be consumers with mid-state Alzheimer’s disease requiring nursing care.

Children under the age of 18 with atypical development or SED and functional impairment that seriously interferes with or limits the child’s functioning in the family, school, or community activities as evidenced by a Child and Adolescent Functional Assessment Scale (CAFAS) score of at least 90 (or greater that 60 if withdrawal of treatment would result in significant deterioration),

the child is in need of services from more than one child-serving agency (e.g. mh/dd/sa, DSS, special education services)

is placed out of the home or at risk of out-of-home placement.

Children under the age of 18 with atypical development or SED and functional impairment that seriously interferes with or limits the child’s functioning in the family, school, or community activities as evidenced by a Child and Adolescent Functional Assessment Scale (CAFAS) score of at least 60 (or greater that 30 if withdrawal of treatment would result in significant deterioration)

Children who are deaf, have SED and a diagnosis of mental illness and need specialized services provided by staff having American Sign Language skills and knowledge of deaf culture.

Children who are homeless, have SED and a diagnosis of mental illness.

The state plan also defines target populations for developmentally disabled individuals and for substance abuse but these are not reviewed here. For persons with diagnoses of substance abuse and mental illness, LMEs will be required to ensure that services are provided in a coordinated, integrated manner. Adult mental health services shall have primary responsibility for persons with severe mental illness who also abuse substances. There is a section on co-occurring disorders, recognizing that individuals who meet criteria for a target population often have more than one disability. This section also acknowledges that systems have done a poor job of recognized and responding to these situations but outside of calling for a cross-disability approach, the plan provides not details on how to better respond to the needs of individuals with multiple disorders.