NAMI NC/Legislative Reform Talking Points

NAMI North Carolina Talking Points for System Reform: A Response to the State Auditor/PCG Report on the Mental Health System

Governance

NAMI North Carolina supports the recommendation to move responsibility for the MH/DD/SA system to county government if the following concern is addressed. We recognize that county government can provide a strong management capability, but we have serious concerns whether county leaders have the background to provide the fiscal and programmatic commitment to ensure success. North Carolina county government does not have a strong history of involvement in mental health services, particularly in multi-county area programs. There is tremendous ignorance and stigma that surround mental illness and support for treatment services has not been a priority. Support for mental health services has stayed the same or actually decreased for most counties. The state must put into place mechanisms to ensure that county leaders meet fiscal and programmatic commitments to the service system.

Area Programs

PCG recommends the elimination of the current area board structure and the establishment of disability specific advisory committees. Consumers and family members have tremendous expertise on the services necessary to support people with mental illness and the quality elements that must be in place. Families and consumers have a strong role to play in client rights issues. We believe that local citizen advocacy organizations should appoint a significant number of members to the disability specific committees. These organizations are generally comprised of consumers and family members and, as organizations, have made a commitment to represent and work on behalf of their constituent members.

Client Rights activities should be strengthened at all levels of the service system. The authority of the Client Rights Committee should be increased and play a central role in monitoring services. The active involvement of consumers and families on these committees should be required.

The advisory nature of these committees is of concern and steps should be taken to strengthen their authority. We recommend that these committees be charged with developing a disability specific plan for consideration by the county board as part of the plan that must be submitted as part of the contract with the state. A formal endorsement of the final plan by these committees prior to submission to the state should be required. These committees should have a role in monitoring quality and receive reports from clients rights committees.

County Contributions

The current deficit of services is several hundred million dollars. Simply shifting management responsibility to counties will not eliminate that deficit. We are in great danger of establishing a huge unfunded mandate for the counties. The state should consider a minimum contribution from the counties. While incentives are preferable to encourage participation and support, the state needs to establish minimum participation levels and targets to increase participation over time. Incentives should be provided to reaching these targets.

There are some low-wealth counties that will have considerable difficulty participating and other counties that do not have the history nor desire to support mental health. The lack of participation, for whatever reason, should be viewed by the state as a lack of capacity or willingness to contract with the state to provide mental health services.

The state should recognize, however, that increasing county contributions will not be sufficient to fund the needs of the system. The state has neglected its responsibility to provide adequate funding for services and in fact there have been recent service reductions at the community level. A commitment must be made at the state level to replace lost funding and to provide the necessary funding for service expansion.

NAMI North Carolina believes that new money should be provided to fund services in the basic benefit package and for target populations in the county. This should be the priority and we believe this will provide the accountability commissioners are seeking. Only if the funding needs of the basic benefit package and target populations are met should counties be allowed to spend new funds on other mental health priorities.

State Hospitals

No one should be moved from an institution until an appropriate community services are available and funds have been identified and committed to provide that service for the individual on an ongoing basis. The state must commit adequate bridge funding to ensure the development of community services.

PCG recommends the reduction of 667 beds in state psychiatric hospitals. To reach this goal, PCG recommends closing Dorothea Dix hospital. The projection of bed use/need is a very top down approach, using rates in other states and projected county capacity. It also does not take into account the dramatic reduction in hospital beds in the private sector, at children’s residential facilities, and at the state’s VA hospitals. Before reductions at the state institutions are enacted, we recommend a broader analysis of hospital capacity in the state. We also recommend an actual assessment of need be completed on those individuals currently in hospital settings, those who have a history of using institutions, or those who are at risk for needing institutionalization. This assessment, or survey of need, must be completed to assist the state in planning for compliance with the US Supreme Court Olmstead decision. The information gathered should be used to project actual need as well as to assist with planning during the proposed five-year transition period.

NAMI North Carolina believes that further analysis needs to be done before closing Dix Hospital and that all options should be considered. NAMI North Carolina believes strong consideration should be given to achieving bed reduction and savings by building four smaller but new state facilities at their present locations. While the cost savings may not be as great, over the long-term the difference is not significant. Smaller facilities will enhance quality of care and allow consumers to stay closer to their communities.

Area Program Services

The effort to expand community services must begin immediately as it has profound implications on the success of supporting people in communities instead of institutions and in determining the amount of funding necessary to provide needed support. It is likely that the implementation of the recommended basic benefit package will substantially increase usage, especially from individuals who have not previously received services through the public system. At the present time services are not available to accommodate the increased demand. Significant capital and bridge funding will be required.

We are very concerned that while cost projections have been made for the basic package, no projections have been made for special populations. A meaningful discussion with legislators and counties cannot take place until the full cost of this reform effort is projected.

We believe that the targeted groups should be priority populations, receiving priority funding. Care should be taken to ensure that the basic benefit package does not bankrupt resources for the target populations. The system was created for these individuals and it frequently is the only treatment option available. We know what services are necessary for people with SPMI and have well documented best practice models. We do not need to spend time and money piloting these efforts. Services should be flexible and meet individual needs. Benefits should not be terminated if an individual stabilizes.

For individuals determined by treating professionals to be SPMI based on diagnosis, history, and functioning level, the following services need to be available:

Case management
        Periodic
        Intensive
        Outreach
Individual and Group Therapy
Medication Management and Education, including access to new medications
Crisis Services
Inpatient Hospital
Assertive Community Treatment Teams (ACTT), following national (PACT) Standards
Rehabilitation Services
Psychosocial Clubhouse Programs
Partial Hospital Programs
Supported Housing
Supported Employment
Transportation Services

A strong mechanism for quality control and monitoring must be an integral part of providing community services. The state, as contractor with the counties, should be responsible for ensuring that such mechanisms are in place.

The development of a continuum of care for children in our communities must be a priority. At present, treatment options for children with serious emotional disorders are very limited. We recommend targeted funding (bridge funding) to develop crisis services, respite, residential, in-home, and school-based services.

Participation of consumers and families should be a requirement for contracting with the state. The state too, should commit to consumer and family involvement. Involvement must be meaningful, not token, and efforts should be made to ensure participation, including training if needed, transportation costs, and compensation for time.