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.