After months of work, the Division of MH/DD/SA submitted "The State Plan 2001: Blueprint for Change" to DHHS Secretary Carmen Hooker Buell on November 1, 2001.

The state plan document was developed in response to reform legislation recently passed by the North Carolina General Assembly. The reform legislation intended the state plan to be a document that would implement the legislation and enact reform across the state. As such, the legislation was rather detailed about what should be included in the state plan. It also required that the Department present the state plan to the Legislative Oversight Committee on MH/DD/SA Reform on December 1, 2001.

NAMI North Carolina has attempted to summarize the draft state plan and its attachments. The summary does not review the sections of the state plan specific to Developmental Disabilities or Substance Abuse. It does summarize those sections on Adult and Child Mental Health and those sections common to all disabilities. The summary attempts to be as factual and unbiased as possible. Obviously, in condensing a document that is several hundred pages long to less than 30, a lot of detail has been left out. For those who want to review the plan itself, it can be found at

http://www.dhhs.state.nc.us/mhplan/draftplan.htm

Following the summary is a second document, "Where We Stand on the Plan," which details NAMI North Carolina’s response to the proposed state plan.

When you review the state plan and the NAMI North Carolina summary you should be aware of a new term, LME or Local Management Entity. Sometimes referred to as local program. An LME is comparable to the current area mental health program. The name has been changed because the reform legislation allows counties the option of taking over the management of mental health services from the area programs if they choose. The name also reflects the expectation that the primary role of the LMEs will be the management of service providers versus providers of service.

NAMI North Carolina hopes these documents will help inform you and stimulate dialogue within your community on the future of mental health services. The Legislative Oversight Committee on MH/DD/SA Reform will review the plan in December.

Uniform portal means that when a person thinks they need services, there will be a standardized way, across the state, for people to make contact and a standardized procedure for getting information from people, giving information to people, making referrals for services, and responding to crisis calls. To do this, the state will contract with a private company to set up a statewide 800-line. The contracted entity will have professional, clinically trained staff available 24 hours a day, 7 days a week.

When a person calls, either on their own or because they have contacted a provider or agency, initial information will be taken and a standardized screening form will be used to determine if it appears that services might be needed and if the person appears to be eligible for services as a member of a target population group. Basically, three things can happen:

• The screening determines the client may meet the criteria for a target population. The individual will then be referred to the local program or service provider in the area. If treatment services are not available or no funding, then interim treatment will be provided.
• The screening determines that the client may need some services but does not meet the criteria for the target population. A referral will be made to services and supports such as a provider network, community-based agency, self-help group or faith-based initiative.
• If a person calls and does not appear to need mental health services they will be referred to the proper agency (for example, credit counseling, or Department of Social Services).

People can also enter the system directly through a local program and the same process of information gathering, screening, and referral will take place. The state plan visualizes uniform portal as a set of functions (e.g. screening, assessment, referral, crisis) rather than a specific location. Once a referral to a provider or local program has occurred additional assessment may occur to help determine eligibility for services. Crisis calls will be referred to the emergency/crisis system put into place by each LME.

Having a uniform portal system will create a statewide data system to track who has requested service, whether those services are received, and what services are needed that are not available. It should reduce the number of people "falling through the cracks" as well as provide information for planning and management. The contract agency will communicate daily with the LME regarding calls, referrals, etc. This statewide data system also will reduce the need for individuals to provide the same information to multiple providers and agencies. To respond to concerns about confidentiality, a Confidentiality Consent will be obtained from the caller before submitting information into the database and confidentiality will be addressed in system design.

The mental health reform legislation requires that certain core service functions be available in all North Carolina communities. These include screening, assessment and referral, emergency services, service coordination, consultation, and prevention and education. The expectation is that these services will be organized, managed, and delivered uniformly across North Carolina. Some of these functions are those that were discussed in the Uniform Portal section above. Definitions of these functions are:

• Referral is providing information about available providers, generic resources, and community capacity that may best meet the needs of the individual.

• Screening is a brief standardized appraisal of an individual who is not a client of the "system" in order to determine the nature of the individual’s problem and his need for service. The "triage" must include both financial and clinical information to determine the next steps.

• Assessment is a follow up step to screening. It is a clinical procedure for determining the level of clinical eligibility. It may include an assessment of the nature and extent of the individual’s problem through a systematic appraisal of any combination of mental, psychological, physical, behavioral, functions, social, economic, and intellectual resources, for the purpose of diagnosis and determination of the disability of the individual, level of eligibility.

Assessments will only occur as authorized and are not automatic. Existing assessment information will be utilized to the extent possible and "starting over" is not recommended. The outcome of the assessment protocol(s) will be standardized in order to assure consistency in the state. Protocols should be specific to the age/disabilities and for those with co-occurring diagnosis.

The combination of screening, assessment and referral is limited to 6 visits.

• Emergency Services benefit includes all crisis services outlined in the Division’s existing Crisis Services Policy, including both crisis response and crisis stabilization services. The full continuum of 24/7 services is available, e.g. phone response, face-to-face intervention, crisis respite, facility-based crisis services, mobile crisis services. Crisis stabilization services include follow-up visits, if needed by the client, until crisis resolution or full transfer to another clinical service. These services may be shared, and unless noted, will not be in every county.

• Consultation is a macro [system level] service provided to other agencies, groups or organizations to promote planning and development of MH/DD/SA services or to individual practitioners. The service is designed to assist in the development of insights, skills of organizations or individual practitioners thus increasing the quality of care available in the community.

• Education means a macro service which is designed to inform and teach various groups: including clients, families, schools, businesses, churches, industries, civic, and other community groups about the nature of MH/DD/SA disabilities and services in the state and community.

• Prevention means a universal service that is designed to inform and teach individuals, various groups, or the population at large about the insights and skills related to healthy living and possible avoidance of MH/DD/SA issues. This service includes activities designed to promote self-esteem and positive decision making of the recipients. Examples include speeches on stress management, fun/activity fairs for children.

This service is different from targeted prevention. Targeted prevention may provide universal prevention strategies but the strategies are "targeted" for high risk groups and as identified for targeted populations.

• Service Coordination benefit is a separate and distinct care coordination administrative function. It ensures that clients know about and are linked with the services that are available in the community, manages relationships with providers in the community, and includes capacity-building within the community when additional service capacity is needed (including peer support community resources).

The reform legislation makes a philosophical shift from the belief that everyone should be served by the public system to the recognition that there are not enough resources to serve everyone and the state must target resources to populations of people. The state plan identifies those populations of people that should be targeted. Within the targeted groups are special populations or "priority" populations. Below are the definitions of the targeted and priority populations and targeted populations for the state hospitals.

• Persons with Severe and Persistent Mental Illness: Persons 18 years or older who as a result of a mental illness exhibit functioning which is so impaired as to interfere substantially with their capacity to remain in the community. In these persons with mental disability limits their functional capacities for activities of daily living such as interpersonal relations, homemaking, self-care, employment, and recreation. The following diagnoses are included under the rubric of severe and persistent mental illness: schizophrenia, bipolar disorder, major depression, schizoaffective disorder, schizophreniform disorders, psychotic disorder Not Otherwise Specified (NOS). Initial Global Assessment of Functioning scores for these persons will usually be 40 or lower.

• Persons with Serious Mental Illness: Persons 18 years or older who have a diagnosable mental, behavioral, or emotional disorder which substantially interferes with one or more major life activities. Initial Global Assessment of Functioning scores for these persons will usually be 50 or lower.

Within these target populations, the priority populations are:

1. Persons with Multiple Diagnoses: Persons 18 or older with a severe and persistent mental illness and a diagnosis of substance abuse and /or mental retardation or serious health complication.
2. Homeless Mentally Ill: Persons 18 or older with a serious long term mental illness or a serious long term mental illness and substance abuse diagnosis who lack fixed, regular, adequate nighttime residence.
3. Mentally Ill Adults in the Criminal Justice System: Persons 18 or older with serious mental illness who are released from the Division of Prisons, or are in local jails, or on probation.
4. Elderly Persons: Persons age 65 and over with a serious mental illness, including dementia.
5. Deaf Mentally Ill Persons: Persons 18 or older with a diagnosable mental, behavioral, or emotional disorder who need specialized services provided by staff who have ASL skills and knowledge of deaf culture.

The state hospitals will provide inpatient care to adults and children with severe mental illness and severe emotional disorders who cannot be appropriately treated in local communities

Primary populations to be served:

• Adults and older adults with psychiatric illness including schizophrenia spectrum, bipolar disorder, major depression, and personality disorder requiring acute inpatient treatment to stabilize and return to community
• Adults with psychiatric illness including schizophrenia spectrum, bipolar disorder, major depression, and personality disorder requiring long-term inpatient treatment to rehabilitate and prevent rapid relapse and readmission
• Children with severe emotional disorders requiring acute inpatient treatment to stabilize and return to lower level of care
• Adults and older adults with psychiatric illness and substance abuse requiring acute and/or longer-term inpatient treatment to stabilize and prevent rapid relapse and readmission
• Forensic patients, including HB95 (incapable of proceeding), NGRI (not guilty by reason of insanity), and other detained for legal reasons
• Research protocol patients
• Deaf and hard of hearing people requiring acute or long-term inpatient psychiatric services

Will provide intermediate and skilled nursing care for patients referred from the State hospitals. Sufficient bed-space and intensity of psychiatric services are unavailable in the community to address the needs of this population.

1. Primary populations to be served
1. Consumers with severe mental illness requiring Intensive Care Facility level care
2. Consumers with severe mental illness requiring Skilled Nursing Facility level care
2. Specialty population to be served
1. Consumers with mid-stage Alzheimer’s disease requiring nursing care

• Children with severe functional difficulties in home, childcare, school or community activities that lead to a CAFAS score of at least 90, or a CAFAS score 60 with at least one domain having a score of 30;
• Presence of an extreme level of psychosocial risk as measured by the presence of 4 or more psychosocial risk factors and 10 or fewer psychosocial protective factors on the AOI Part I (Resilience Assessment);

• Children and youth who fall into this Target Population are those from whom supports and interventions routinely provided through human service agencies are not working, those who need the highest level of support and treatment in order to regain the ability to function successfully;

AND

• Are identified as sexually aggressive; and/or
• Deaf; and/or
• Dually or multiply diagnosed.

AND

• Utilizing or having utilized acute mental health crisis intervention in the past year or intensive wraparound services in order to maintain community placement;
• Having had 3 or more state hospitalizations in the past year or at least 1 hospitalization of 60 continuous days;
• Having had DSS substantiated abuse, neglect or dependency in the past year;
• Having experienced school (or child care) failures, suspension or expulsion
• Having been convicted of a felony or 2 or more serious misdemeanors in juvenile/adult court or being currently placed in a youth advocacy program (training school), prison, juvenile detention center, or jail - any within the past year;

AND

AND

• Support network is not accessible to the child and family
• Support network is overwhelmed by current needs of the child and family
• Available supports are not sufficiently resourced to address current needs, e.g., safety

 

• Children with moderate functional difficulties in home, childcare, school or community activities that lead to a CAFAS score of at least 60, or a CAFAS score 40 with at least one domain having a score of 20;
• Presence of a moderate level of psychosocial risk as measured by the presence of 2 or more psychosocial risk factors and 6 or fewer psychosocial protective factors on the AOI Part I (Resilience Assessment);

AND

AND

• Crisis intervention (an individual or family crisis), behaviors may include those that impact the safety/well-being of self and/or of others, e.g., assaults, withdrawal/depression, suicide threats/attempt
• Wraparound services, behaviors may include those that impact the safety/well-being of self and/or of others, e.g., assaults, withdrawal/depression, suicide threats/attempt)
• Abuse, neglect, or dependency; foster care or adoption
• School failure, suspension, expulsion, Special Education services
• Adjudication in juvenile court; conviction of at least a significant misdemeanor; diversion from court involvement; charged (but not necessarily adjudicated) with a criminal activity; on probation

AND

AND

• Support network is not accessible to the child and family
• Support network is overwhelmed by current needs of the child and family
• Available supports are not sufficiently resourced to address current needs, e.g., safety

• Children with functional difficulties in home, childcare, school or community activities that lead to a score of at least 30 on the CAFAS

• Children who have not proven resilient enough to combat their level of psychosocial risk, as measured by the presence of 1 or more psychosocial risk factors and 4 or fewer psychosocial protective factors on the AOI Part I (Resilience Assessment);

AND

AND

AND

4.  Children in need of and/or receiving enhanced informal supports.

Utilization Management means that some entity uses clinical and other criteria to determine what services a person is eligible to receive, at what level of intensity, and for how long. The state plan proposes that an independent contractor be hired to provide this service statewide. The plan specifically states that there shall be NO financial incentive for denying care. The contractor will also provide each LME and the State a wide range of statistical and episode data. Presumably this contractor would be the same one providing the 800-line phone access line.

The contractor will use eligibility criteria established by the state. These criteria have not yet been developed. All local programs and service providers would need to have services approved through this statewide utilization management entity. How would this work? An LME or service provider would call the UM contractor and request a particular service(s) for a particular client based on a clinical assessment of that individual. The contactor would compare the information given to the established state criteria to determine if the individual met the criteria to receive the service, how often, and for how long.

After an individual has gone through the uniform portal and is determined to meet the criteria of a target population, what services can they receive? Below are excerpts from the plan that detail who gets what:

• Inpatient services
• Outpatient services
  Medication evaluation and management
  Individual therapy
  Group therapy
  Case management (including transition case management from hospital to community, which may require more than 30 days prior to discharge)
  Education around mental illness, physical health, and substance abuse issues
  Peer support
  Family intervention
  Relapse/decompensation prevention services
  

The Local Management Entity (LME) is the administrative body that develops, implements, oversees, monitors and evaluates system services in a specific region or area. Currently LMEs are the area program structure. The reform legislation allows for county government to manage or operate as a LME instead of the area program if they choose.

The Local Management Entity (area/county program) is responsible for managing the core service functions of screening, assessment, referral, emergency/crisis response services, service coordination, consultation, universal prevention and education. In addition, the LME will direct the development, maintenance and oversight of a provider network sufficient to address the needs of its target populations. The plan recognizes that this new role will need to evolve over time and planning needs to be done so as not to disrupt or cancel existing services.

The primary duties and functions of the LME are:

• Develop, implement, and oversee MH/DD/SAS in a geographic area.
• Develop and implement local business plan.
• Continuously assess local needs for MH/DD/SA services throughout the geographic area.
• Incorporate unmet needs into the Local Business Plan as resources become available
• Develop and maintain a comprehensive service area provider network
• Assure that network providers provide services in accordance with approved local business plan state criteria, state standards.
• Develop a continuum of professional, associate professional and para-professional and peer, and voluntary services for the area.
• Develop creative approaches to engaging priority or target populations including taking services to rural areas.
• Provide technical assistance, coaching and/or mentoring to new or lay providers as needed.
• Evaluate statistical and other program data from UM contractor to make corrections or decisions regarding clinical management and provider development.
• Develop and monitor program budgets, make course corrections as needed
• Liaison with other public and private agencies throughout region
• Manage multiple points of access across an area.
• Provide face-to-face screening, assessment, and referral within timeframes.
• Provide service coordination.
• Assess client and provider satisfaction on ongoing basis.
• Troubleshoot group or specific individual issues of access, treatment, services and/or supports to assure that consumers get the services they need.
• Participate in State level committees, workgroups, and taskforces.
• Liaison among providers of different levels of care to assure that services are provided in an integrated, seamless manner.
• Develop effective methods of communication among providers and program elements to assure that the provider network is kept informed of system issues
• Assure opportunities for consumers to mainstream into the community
• Work to develop relationships with local business that encourages employment of consumers.
• Establish a permanent, standing Consumer Advisory group, drawn from direct service consumers in the target populations and the family members of service consumers under the age of 18, to provide input, suggestions, recommendations and active participation in policy and program issues.
• Provide referrals for non-targeted populations as well as for target populations.
• Provide or manage crisis services as outlined in state standards.
• Track data required by state.
• Assure that consumers and the family members of child consumers receive meaningful and respectful consideration of their suggestions and recommendations.
• Include service consumers and family members of child consumers in quality management and service monitoring activities.

The reform legislation and state plan seek to encourage the development of networks of private and non-profit providers in communities across North Carolina. If this occurs, many more people will be able to be served and consumers and families will be able to choose which providers they think will best address their needs. LMEs may not be the provider of services without the approval of the Secretary. The state plan requires that each LME develop an extensive provider network assuring that there are enough providers to meet the needs of consumers throughout the area and that each consumer has a choice of providers from which to select. All providers eligible for Medicaid or Medicare reimbursement will be encouraged to join the network. One of the main jobs of the LMEs is to identify qualified potential providers and encourage participation in the network of providers offering services in the public MH/DD/SA system. The LME is responsible for verifying the credentials of professionals.

The state plan recommends that the state continue the current mechanisms for ensuring consumer and family involvement. Specifically, currently, many boards, committees and councils have consumer and family representation that is mandated by state or federal laws. These include, but are not limited to, seats on the Commission on MH/DD/SAS; Area Boards; the Mental Health Planning Council; and the Council on Developmental Disabilities. Inclusion of consumers and families in other groups is mandated by state policy; for example, the statewide Client Rights Policy Advisory Committee and state, regional and local System of Care Collaboratives. The state plan recommends these mechanisms continue, with one important change: information, education and supports should be provided as needed to ensure that consumers and family members are able to participate effectively.

A second recommendation in the state plan is to establish a State Consumer and Family Advisory Committee; and in each region of the state, as part of the Local Business Plan, establish a Local Consumer and Family Advisory Committee. These Committees would be independent of state and local agencies. The Division and LMEs should provide meaningful support to members of Consumer and Family Advisory Committees, including:

• Compensation for time
• Transportation or compensation for travel
• Childcare and eldercare if needed
• Flexible scheduling of meeting times
• Information and education regarding the service system, for example:
  User-friendly primer regarding existing system and funding sources
  A list of the services that are available and how to access them and
  Materials regarding model systems and best practice services/supports

The state plan recommends that the Division establish an Office of Consumer Affairs. The Office should be led by a consumer who reports directly to the Division Director and is a member of the Division's management team. Staff of the Office of Consumer Affairs should include a designated position for each of the disabilities and should be provided administrative support.

Finally, the state plan recommends that LMEs have a clearly defined planning process asking consumers and families for their views about the service system and, especially, about service gaps.

To ensure quality of services you need:

• To identify and define what quality means and how you will measure and evaluate quality
• A system to provide oversight and monitoring (Quality Assurance)
• A system to identify problems and be able to take actions to improve quality (Quality Management and Quality Improvement)

Periodic report cards will be issued for the MH/DD/SA System. These reports of system quality will consist of an easy to understand evaluation format (such as letter grades) for a range of performance and consumer outcome measures. System quality domains and sample indicators for a report card are below.

The state plan identifies Quality Assurance activities to address the following functions:

• Consumers are free from physical and chemical restraints, except in instances when the use of such interventions are therapeutically indicated, and explicitly authorized and implemented in accordance with state law, rules, and policies;
• Consumers are protected from abuse, neglect and exploitation, and procedures are in place to detect, report, and investigate related cases thoroughly and take prompt and effective remedial actions where indicated;
• Serious incidents are promptly and effectively reported, tracked and appropriate follow-up actions are taken to rectify individual misconduct and/or systemic shortcomings that are identified as a result of such investigations;
• All deaths within publicly operated, licensed, or certified programs and facilities are thoroughly investigated and fully reported according to law, and prompt steps are taken to rectify any underlying factors contributing to the death; and
• Prompt actions are taken to protect the safety and health of program participants in the case of natural disaster or when other unforeseen crises occur.

• Complete comprehensive assessments of the service/support needs of participants, including the capability to perform or acquire any medical, psychological and/or social evaluations that might shed light on an individual’s service/support needs; and
• Assist individuals, with the help of family members and significant others, to prepare person-centered plans that take into account their capabilities, interests, aspirations, and treatment and person support needs. Local/area-wide service systems also must have in place systematic methods of reviewing the quality, appropriateness and comprehensiveness of individual service plans and a process for initiating plan revisions based on the results of such reviews.

• Afford individuals and their families clear channels for filing complaints and having their grievances considered by responsible officials at succeeding levels of the service system, with the aim of achieving resolutions satisfactory to all;
• Assure that due process rights of individuals and families (including legal guardians) under federal, state, and local laws and regulations are fully protected;
• Assure that individuals are afforded the opportunity to choose among available community service and support providers who meet established qualifications; and
• Establish human rights functions within designated types of provider agencies to oversee related activities and reconcile potential ethical/moral conflicts that sometimes arise in applying individual rights to particular situations. The rights protection mechanisms employed within the service system (e.g., confidential telephone hot lines, ombudsperson, certified mediators; etc.) should be consumer-friendly.

• Verifying the qualifications of service/support providers;
• Assuring that all pre-service and in-service training and continuing education requirements are met;
• Conducting periodic licensure and certification reviews as well as analyzing and reporting the results;
• Overseeing the implementation of correction plans, the imposition of sanctions such as fines or penalties, and termination as well as other follow-up actions resulting from provider oversight reviews; and
• Arranging technical assistance to help providers rectify deficiencies and formulate and carry out service improvement plans. In addition, the State must have the capacity to review and enforce performance provisions contained in contractual agreements (e.g., achieving specified levels of consumer satisfaction, or holding administrative costs below a certain percentage of total expenses.)

The state plan proposes that the Division of Facility Services serve as the regulatory agent for the state oversight of licensed MH/DD/SA services. As the regulatory agent, DFS will be responsible for conducting annual or biennial inspections of facilities or services. Results of these inspections shall be published and used as quality indicators for performance.

The local managing entity shall be responsible for conducting local monitoring of providers within the network. This local monitoring shall focus on the quality of clinical and programmatic delivery and should not be a "licensure" inspection. Providers who have received national recognized accreditation shall participate with the local monitoring activities but will not be subject to annual DFS inspections unless local monitoring prompts complaints or need of onsite investigations.

Professional licensure for professional practitioners shall be utilized as indicators of qualifications of service. Providers of non-facility based services shall be subject to licensure in the future.

Direct enrollment requirements shall be directly linked with licensure and also performance of quality indicators. Ability to meet outcomes will be standards to measure effectiveness and eventually payment of services. This shift has many implications and should be the one of final steps of implementation. As an interim step, reports of provider performance will be published and will be an integral part of education clients and families in their selection of providers as well as a factor used in examination of provider rates.

Memorandum of Agreements will be required for direct enrolled providers who provide services to target populations. These MOAs will be standardized and established by a participatory process including state staff, LME staff, providers and consumer/family representatives. Direct enrolled providers who are not providers of services to target populations but do deliver services within a specific area will be encouraged to also have formal linkages to the LME.

• Consumer and Family Advisory Committees will obtain input from consumers and families

• Assessments of the effectiveness of local/area-wide services coordination/case management systems in terms of the availability and quality of such services, as well as the effectiveness with which case managers or service coordinators perform their various individual guidance/systemic advocacy and administrative support roles;
• The completion of consumer-centered quality reviews (i.e., on-site monitoring of program participant – usually applying a sampling methodology – in order to reach generalizations about agency/system-wide performance); and
• Independent, third party monitoring by peer review and stakeholder teams (i.e., parents, self-advocates, and neighbors) to assess the quality of life of program participants.

6.  Financial integrity. The Department and LMEs must have the capacity to ensure that public funds are disbursed and managed in an accountable manner. The State has an obligation to ensure that tax dollars are used effectively, efficiently and in accordance with the requirements of law. This means that the State’s quality management system must include methods of assuring that:

• Payment claims are submitted timely and verified for accuracy and completeness;
• Annual audits are conducted of the financial accounts of all service agencies/organizations in accordance with accepted auditing standards and practices, and any questionable transactions are identified and resolved; and
• The personal accounts of individuals participating in publicly financed programs are secured and audited on a regular basis to prevent any fraudulent transactions. In addition, the State must maintain an active program of fraud prevention and detection that includes the capacity to investigate alleged incidents of misappropriation of funds and the imposition of penalties to punish transgressors and prevent re-occurrences.

• Ensure coordination with primary care and other healthcare providers;
• Assess and address co-occurring mental health or substance abuse problems; and
• Monitor the therapeutic effectiveness of prescription medications (including, in particular, psycho-active and anti-convulsive medications). Prescription medications should not be used in the absence of specific psychiatric diagnosis and a properly designed treatment plan.

• Individual and family satisfaction measures;
• Indicators of comparative performance in key outcomes areas (e.g., employment, integrated community living, etc.); and
• Quality of life measures. Typically, data are gathered from a random sample of service recipients using statistically valid and reliable data collection instruments. Consumers and family members should be involved in the design and implementation of the assessment system and should have full access to the resulting information and data, consistent with privacy safeguards.

The quality management means using information and data to identify problems and concerns and have a system in place to use the information to continuously improve the quality of treatments, services, and supports provided to consumers. Components of this system include:

• Utilization review activities at institutions as well as LMEs;
• Utilization management on all services provided with public system funding using standardized review criteria;
• Quality assurance, including licensure, credentialing, program monitoring, and financial audits;
• Quality improvement activities conducted across system entities.

This system will have a Division level Quality Improvement Committee (DQIC), which serves as the overarching QI entity for the system, oversees and approves quality improvement activities and results generated by the Division, Local Quality Improvement Committees (LQIC), and other components within the system. In addition, there is also a local quality improvement committee for each of the LMEs in the State.

Network providers will be required to develop and implement quality improvement activities. These activities are subject to periodic review by the LME responsible for that network. Problems in service/support delivery and other opportunities for improvement are acted upon by local entities, and quality issues that effect other system provider entities are brought to the attention of the Local Quality Improvement Committee for review and action.

A competency-based system for qualified providers of services has been developed to achieve measurable outcomes and raise the level of quality and consistency statewide. Recognition is given to already existing licensing and certification boards. The following are the seven core competencies that are required to meet minimal standards;

1. Technical knowledge
2. Cultural awareness
3. Analytical skills
4. Decision-making
5. Interpersonal skill
6. Communication skills
7. Clinical skills

The plan requires shared planning among state and local agencies. It states a clear intent that funding be focused on, or follow, the consumer and/or family. It identifies the newly established MH/DD/SA Trust Fund as a source for bridge dollars to expand community capacity and assist in the implementation of the Olmstead plan and encourage joint agency ventures for housing, transportation, and employment. The plan also suggests paying LMEs to provide administrative and management functions and basing all funding for services on realistic costs. But the plan also recommends that payments for services or to providers that do not meet standards should be stopped. It suggests that Medicaid and state funding be revised and Medicaid waivers be considered. The implementation plan sets a date of March 2002 to present a five-year financing plan.

The implementation plan is a long, long, long list of 174 tasks that need to be accomplished between now and January of 2007. While some are required by the reform legislation, most are organizational, policy, training, etc. tasks necessary for implementing the state plan. This plan will likely change over time as new issues emerge but is a good place to look to get a sense of the time frames involved in the reform.

The local business plan, as defined in the reform legislation and in the state plan, is a document that details how local communities intend to implement the expectations outlined in the state plan. Communities will have to go through a public process involving all stakeholders to develop a plan for service management, financial management, service monitoring, evaluation, access, provider networks, and collaboration. Local business plans must identify service gaps and methods for filling the gaps, ensure the availability of an array of services based on consumer needs, core, and targeted service requirements, provide adequate access to MH/DD/SA services across the continuum for all persons served, and be based on efficient and effective use of all funds for targeted services. The state plan includes a very detailed set of elements that must be addressed in the plan and how the state will evaluate the adequacy of the response. It also details what an LME must demonstrate if they wish to provide services in a community.

Several issues remain controversial and under discussion, especially around the role of the LME. The reform legislation sought to strike a balance between state and local control by requiring the state to establish clear and consistent expectations and standards. Local communities were to determine how they would meet those standards and expectations through the development of a local plan that would be implemented and managed through the LME.

Through the plan, the state has put forward its expectations and standards. Although some refinement and clarification will probably be needed, it is the most comprehensive and detailed effort ever put forward by the state. The result is a system that is more state driven. The state has established a state access and referral line, is requiring state utilization management of all services, is proceeding with billing by providers directly to the state, and has tapped the state Division of Facility Services to provide statewide monitoring and licensing activities. When combined with the criteria limiting the provision of services by LMEs, some question what the role of the LME will be. More work and discussion needs to occur to clarify this.

There also is some controversy around the question of service provision. The intent of the reform legislation was to encourage the development of networks of private and non-profit providers. The idea was to put LMEs in charge of developing and managing these networks. The legislation does not prohibit LMEs from offering services but requires the Secretary to approve LMEs that want to offer services. This was done to limit the conflict of interest that exists when an LME offers services while also having the responsibility of developing a network of competitors for that same service. The idea was that the Secretary would look to see that the LME had really tried to develop a network of quality providers. There are some concerns, however, that criteria put forward in the local plan document may be too restrictive and some modifications my need to be made. Unfortunately, some individuals are raising alarms with consumers and families by claiming that area programs will have to "shut down all services". Neither the legislation nor the state plan requires programs to shut down all services. It does require that communities look at what services are needed, develop provider networks wherever possible, identify services where sufficient qualified providers are not available or where the LME is uniquely qualified to provide a service. The LME can then apply to the Secretary to provide those services the local plan has identified the LME ought to provide.

The Secretary of DHHS is well aware of the balance that is trying to be struck. She is open to considering giving LMEs UM authority some time in the future, but not now. She is committed to developing a standard for services and management that is applicable across the state and that minimizes paperwork and duplication for providers. She is committed to ensuring a continuum of quality services. It appears that she believes the best way to achieve this, at least in the short run, is for the state to take a more active role.

NAMI North Carolina supports the vision of mental health services and management contained in the proposed MH/DD/SA State Plan. But such a comprehensive initiative, as proposed in the State Plan, often raises as many questions as it answers. Below are some questions and concerns identified by NAMI North Carolina that need to be addressed to make reform efforts successful:

• Questions have been raised about assuring confidentiality in a system that shares information across multiple agencies. Simply signing a release is not enough. Safeguards must be built into the system to protect consumers and families.
• The plan talks about providing "interim care" if services needed are not available or funded. But "interim care" is never defined. This is especially important during the transition when many services will not be available. There must be a process by which needed services are acquired so that individuals do not languish on waiting lists or in "interim care".
• Concerns have been raised about what, if any, services will be available for people who need some assistance but do not meet criteria for a target population. The state should be responsible for developing a comprehensive information and referral database to connect individuals in need with available resources.

• NAMI North Carolina supports the target populations identified for children, adolescents, and adults.

• Any time you target services to populations of people, concerns are raised on behalf of those not in the targeted populations. A right to appeal will be critical to protect individuals who are denied services based on an assessment that determines they are not part of a target population or who are part of the target population but determined to be ineligible for particular services. The plan alludes to a right to appeal but this process must be clearly articulated.

• NAMI North Carolina supports centralized utilization management, especially during the transition, in order to increase consistency across the state.
• While the state sees UM as a centralized function, other parts of plan also identify utilization management as a function of the LME. A clarification of roles is needed.
• Centralized UM must not result in depersonalized care. The UM system must support individualized person-centered planning and services.
• Strong controls and monitoring are critical to ensure that UM does not simply serve to deny services. Utilization criteria should be carefully considered and developed to allow flexible services and approval of treatment plans. Criteria should not include restrictive medication formularies that deny access to newer, more effective medications. UM must ensure that care is coordinated across services instead of increasing fragmentation.
• Concerns have been raised about how the LME can be a management entity if it doesn’t have control over utilization management. There should be a review and assessment of these concerns based on the experience of the first group of LMEs and, if necessary, changes should be considered.
• It is somewhat confusing that the state plan proposed centralized utilization management when the Division of Medical Assistance has already contracted with a vendor to provide this service for several programs. It is unclear how and whether this contract will be modified to bring it in line with the state plan.
• The state plan also requires that every LME and service provider develop and implement its own internal utilization management processes in coordination with the State system. It is not entirely clear what this would involve and how it would be different from the state system. The state plan suggests it would involve client-specific treatment planning, internal review and development of services and service management. But this needs much more clarification before it is implemented.

• NAMI North Carolina is very supportive of the service continuum proposed in the state plan and of the system of care approach for child/adolescent services.
• The plan frequently references requiring "best practice" services. We are very supportive of this approach. More work is needed to require that services adhere to best practice standards in order to improve quality and consistency of services.

• NAMI North Carolina supports the move to expand services through the growth of private/non-profit provider networks.
• The degree to which LMEs are allowed to provide services and under what circumstances continues to be debated. We believe that to a large extent this debate will be resolved through an open and comprehensive local plan process.
• The state plan says that the Division of MH/DD/SA will determine whether LMEs have developed "adequate" provider networks. Adequacy will involve such things as degree of consumer choice, timely access to services, geographical access to services, and access to quality services. Criteria to quantify "adequate" must be developed.
• Planning so as not to disrupt services needs more attention. Already consumers and families are dealing with "transition" issues as staff leave area programs, services are shut down, and area programs fail to recruit staff. The state will need to take a proactive approach immediately to ensure continuity of care.

• While we support the move toward greater privatization in service delivery, there are too many examples of services currently being provided by private/non-profit enterprises that are inappropriate or of poor quality. In moving toward greater privatization, the responsibility of the state and LMEs to ensure quality of service becomes paramount.
• More work needs to be done to define treatment outcomes and how to measure and collect data on those outcomes. In general, more detail is needed on a system to monitor these outcomes.
• Further clarification is needed regarding the monitoring roles between the state (DFS) and the LMEs. It is doubtful that DFS will have the staff necessary to review every facility and program in the state. DFS staff also must have qualifications to review the programmatic aspects of services. The LME could play a monitoring role but its authority to do so is unclear.
• NAMI North Carolina is very concerned at the neglect in the plan regarding human rights committees. Much more work needs to be done to ensure that these committees are empowered to protect consumers and families and become an integral part of the monitoring system.
• NAMI North Carolina applauds the effort to clarify and standardize staff competency requirements across the state. We also are very supportive of the effort to tie the ability to directly bill the state with licensure, competencies, and outcome measures.
• NAMI North Carolina has considerable concerns regarding the availability of trained and competent staff to provide services. As noted above, this is a current crisis, not an impending one. The state needs to immediately develop a plan to ensure adequate trained staff to provide services now, during the transition, and for the long term. The state should also develop a comprehensive plan to retrain and place displaced state hospital personnel. These individuals are knowledgeable and committed and their expertise is needed in our communities.

• Financing of the state plan is absolutely critical yet this section of the plan is one of weakest and most vague. No cost projections have been done on the plan. Limited and poorly defined funding options are presented. The implementation plan indicates that a full financial plan will be completed by March 2002. NAMI North Carolina urges the state to seek innovative and progressive funding options to support the state plan. Without adequate and flexible funding, the state plan will do nothing to improve care.
• In the development of any financing plan care must be taken to ensure that individuals that are considered "indigent" receive care. We should not have a two-tiered system of care. Simply because an individual does not have a source such as Medicaid to pay for care should not be a reason to deny necessary care. The state has always been the "safety net" for those in need and without resources and must continue to play that role.

• Of the 174 tasks, most evident for adult mental health are those associated with closing hospital beds. Only one goal relates to the development of community services (crisis teams). It is imperative that goals for the development of community services and the achievement of particular outcomes be incorporated into the implementation plan. For example, require that ACTT teams be in place in each area program or LME by a certain date or that hospital admissions or homeless rates be reduced by a certain percentage by a particular date. In other words, the state should aggressively monitor and require the development of community services across state. We applaud the efforts of the child/adolescent section to set such goals.

• NAMI North Carolina supports the format and structure of the proposed local plan. The criteria begin to set clear and standardized expectations for services and management across the state.

   

NAMI North Carolina and others worked very hard to pass comprehensive legislation to reform the public MH/DD/SA system based on the belief that change HAD to happen. Below are issues that NAMI North Carolina has advocated for throughout its history and during the debate around the reform bill. We compare whether we believe the draft state plan is consistent with the reform legislation and whether it will move North Carolina toward achieving our longstanding goals:

The state plan articulates core service functions for all citizens and targets state resources to individuals with severe mental illnesses and children with emotional disturbances. For those targeted populations it also proposes a full continuum of services based on best practice standards.

The state plan maintains the current level of involvement and adds additional opportunities. These include citizen advisory boards at the state and local level, an Office of Consumer Affairs within the Division of MH/DD/SA, and the requirement that families and consumers be involved in the development of the local business plan. The Secretary has also announced that she will form a state level committee comprised entirely of families and consumers to oversee implementation of the state plan.

While the plan states that protection of rights is the responsibility of both the state and LME, there is very little detail on how this will be accomplished, how state and local levels will coordinate, and how human rights activities will be empowered and enforced. While the intent seems to be there, this area needs a lot of work. The Consumer Advocacy Program is listed as one of the implementation tasks but no detail is provided.

No financial projections have been completed. The plan is limited in articulating a vision of how adequate funding will be developed. The implementation plan indicates a full report on financing will be completed by March 2002. We know from the experience of other states that there are creative ways to finance services and develop flexible funding mechanisms to support very individualized services for consumers. The state should learn from these efforts and pursue creative options.

A strong emphasis of the plan is the development of an array of community-based services. Integration of Olmstead planning for people coming out of the hospital with the planning for the development of the broader array of community services is not well articulated. The plan focuses the role of the hospitals that may help improve planning and treatment programs. The plan does not address the critical physical plant and staffing needs currently facing the state hospitals. Until the issue of funding is fully dealt with it is unlikely the state will be able to successfully support the institutions and support individuals in community services.

The state plan makes it clear that the state intends to take a more prominent role in quality control and monitoring functions. But to be successful, the state will have to commit the resources and expertise to organizing effective quality and monitoring systems and clarify roles between the state and local programs.

The state plan is a good start toward clarifying roles and responsibilities. More work needs to be done, especially around monitoring, utilization management, and care coordination issues.

The state plan has made a very good start through the articulation of expectations for the local business plan. The plan must be approved by the state and implementation will be monitored.

The state plan has made a good start on articulating what services should be available to which populations across the state. It also makes a commitment to establishing service standards based on best practice. How to implement and monitor these services and standards will require additional work.

The growth of local provider networks is clearly the intent of the state plan. The plan also proposes that the role of local programs be to develop and monitor local provider networks. Local programs are expected to offer services in only limited circumstances.

The state plan takes a major step forward implementing reform of the North Carolina MH/DD/SA System. NAMI North Carolina looks forward to continuing work with the state and other stakeholder groups to further develop the plan and create a system of care of which we are proud of.

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