The Mental Health System: Organization and Resources by Beth ...

Mental Health Reform in North Carolina

March 9, 2006Beth Melcher, Ph.D.

Where We’ve Been

Overuse of Institutional Care - Durham had twice as many admissions per capita

Lack of Community Inpatient Care & Inpatient Alternatives

Lack of Accountability - Direct Service Provider and manager of funds; no emphasis on the use of “best-practices”

Inadequate Access Tremendous variation in quality across the

state

State Context 2000 State Auditor’s Study of the State Psychiatric

Hospitals and the Area Mental Health Programs. - Define specific target populations requiring Define specific target populations requiring

specialized services that matched the needs of specialized services that matched the needs of the targeted group the targeted group

- Require the development of new community-Require the development of new community-based capacities based capacities

- Make changes in the structure of how services Make changes in the structure of how services provided and managedprovided and managed

- Change funding mechanisms (i.e. coordination Change funding mechanisms (i.e. coordination with Medicaid; establishment of “bridge” funding)with Medicaid; establishment of “bridge” funding)

Guiding Principles of Reform

Easy Access Consumer and family involvement Implementation of best practice Accountability for consumer outcomes Services and supports in the least

restrictive environment Collaboration with the greater community--

System of Care Expectation of system improvement

House Bill 381 Enhanced accountability and cooperation

between counties, area authorities and DHHS Require development of State and local

business plans Secretary to certify local programs Governance options Changes in area board authority Establish “target populations” and expectation

that “best practice” services be offered Must contract for services

What are the biggest changes? Public mental health programs have a different role - a

manager, not a provider of services (new role: assess, evaluate, refer, prevention, outreach, education, monitor quality, determine community service needs).

There are fewer public area programs Tighter eligibility criteria and clearer target population

(some people will no longer be eligible for service) Increased accountability through community planning,

performance agreements between state and local programs, and contracts between local programs and providers

Changing Role

Area Program to Local Management Entity (LME)- From Service Provider to Service Manager From Service Provider to Service Manager - Becoming Local Management Entity (LME)Becoming Local Management Entity (LME)

LME as the manager of public policy

Manager of Public Policy

Within Available Resources Provided by the Public and Private Sector

Individuals with Needs in the Target Population Will be Assisted

Services will be provided by qualified community providers

Least Restrictive, Therapeutically Most Appropriate Setting

To Maximize the Quality of Life Continually assess needs of the community

LME Core Functions

ScreeningScreening Assessment Assessment ReferralReferral Emergency servicesEmergency services Service coordinationService coordination ConsultationConsultation Prevention Prevention EducationEducation

What “Reform” means to the people we serve

Person-centered Plan Natural supports Crisis Plan Services are authorized Greater continuum of “best practice”

services Customer Services Quality Improvement Comprehensive Emergency Services

Target Populations

Adults with mental illness

Children with mental illness

People with developmental disabilities

People with substance abuse problems

Adult Mental Health

People with severe & persistent mental illness (SPMI)- Substantially interferes with capacity to Substantially interferes with capacity to

remain in the communityremain in the community

People with serious mental illness- Substantially interferes with life activitiesSubstantially interferes with life activities

Child Mental Health

Children with severe emotional and behavioral problems

Children with moderate mental health problems and their families

Children with mild mental health problems and their families

People with Developmental Disabilities

People who meet the state definition of developmental disability

AND

meet criteria for priority services using the Intensity and Urgency of Need Assessment

Substance Abuse Injecting drug users, those with

communicable disease risk and/or those on opioid maintenance therapy

Substance abusing women with children DSS involved parents who are substance

abusers High management adult substance

abusers Persons being served who are in the

criminal justice system DWI offenders

Services and Supports

Case Management and Coordination Emergency and Crisis Services Home-based services for families Housing and residential services Team-based wrap around services Employment and education services Substance abuse detox and treatment Medication management

Reform Implementation in Durham County

Durham Reform Implementation

Durham was certified as a Local Management Entity (LME) - July 1, 2004

Direct Services divested during FY 2003-04

Request for Proposal (RFP) Process Used

How are we doing? Centralized our access/screening (24/7). Walk-

in or phone call Fully developed Utilization Management Unit –

all services to be authorized Divested all services & programs since Jan 03 Significant Increases in numbers of people

served for all target population groups Significant increase in continuum of services

offered– over 165 provider organizations Significant reduction in hospitalization for adults

and out of home placements for children Development of housing resources

How are we doing? Durham Center Access - 24/7 Crisis/Emergency

Facility –impact reducing hospital admissions Rapid Response Homes (for children) All providers will be first point of crisis contact Court, hospital, jail, DSS, community liaisons Promotion of services based on Best Practice Care Review Customer Service Quality Management Fiscal management and accountability More responsive and accountable care of people

receiving our services.

Challenges

Developing a qualified provider community Capacity of provider community to meet

demand Limited resources, especially state funded

services Promoting and monitoring quality services

System of Care (SOC)Overview

• History of SOCHistory of SOC Fragmentation/Poor Results create need for reform Federal reform/Congressional Funding/National

Evaluation Implementation since 1992, nationwide and in NC Strong evidence of improved outcomes cited in National

Congressional Reports, President’s New Freedom Commission, Surgeon General’s Reports, etc.

SOC framework called for in States to improve MH service delivery for children with SED, for Child Welfare reform, consistent with Juvenile Justice Reform and Education Reform.

What is a System of Care?What is a System of Care?

A System of Care is an integrated network of community services and resources supported by collaboration among families, professionals, and the community.

A System of Care links education, juvenile justice, health, mental health, child welfare, family court and other helping agencies with families to assure that children with significant health, mental health, education, and safety issues have access to the services and supports they need to be successful at home, in school, and in the community

SOC Principles

• System’s of Care provide for: prevention and early identification and intervention; service coordination or case management; smooth transitions among agencies, providers, and to adult

system; human rights protection and advocacy; nondiscrimination in access to services; a comprehensive array of services and supports; individualized service planning; services in the least restrictive environment; family participation in ALL aspects of planning, service delivery,

and evaluation; and integrated services with coordinated planning across the child-

serving systems.

Traditional vs. SOC

Services/PracticeServices/Practice “1 size fits all” IndividualizedService Pieces One Family/One PlanSeparate Delivery Collaborative CFTeamSpecialty Training Cross -Training

FamilyFamily

Recipient Full & Active Partner

Root of Problem Core of SolutionDependent Self-Reliant

Development of SOC in Durham

• Initial Issues of ConcernOver utilization of out of home placements (~

50%)Lack of community servicesLack of best practices reflected in community

servicesFragmentation and lack of agency

cooperation in service Delivery (court ordered placements, etc.)

Lack of continuity of care in service delivery

How does SOC work ?

Services, supervision of services, program development and policy development are already occurring in all agencies & sectors. SOC does not add on this work, it simply integrates it by developing team-based decision-making.

Each agency maintains its mandates and ultimate decision-making authority, but by working together, fragmentation & duplication are reduced and consumer outcomes are significantly improved.

How does SOC work, con’t ?

All participating agencies, families and the community must work together in teams in order to achieve outcomes for consumers with complex needs:• Child and Family TeamsChild and Family Teams – wraparound svc – wraparound svc

delivery/integrationdelivery/integration• Strong Families DurhamStrong Families Durham – families advocating and – families advocating and

supporting each othersupporting each other• Care Review TeamsCare Review Teams – supervisors working together/QI – supervisors working together/QI• Community CollaborativeCommunity Collaborative – program administrators working – program administrators working

togethertogether• Durham DeputiesDurham Deputies – policy implementers working together – policy implementers working together• Durham DirectorsDurham Directors – policy makers working together – policy makers working together

Child and Family Team BasicsChild and Family Team Basics1 Family/1 Team/1 Plan1 Family/1 Team/1 Plan

A CFT is built around each child and family A CFT is built around each child and family who needs help from more than one sourcewho needs help from more than one source

A strong CFT has a mix of family members, A strong CFT has a mix of family members, friends, community members and service friends, community members and service providersproviders

Goal - Family, friends and community Goal - Family, friends and community members make up at least half of the team.members make up at least half of the team.

CFT size – no set number, usually 6-10 CFT size – no set number, usually 6-10 people, depending on what the family people, depending on what the family wants/needswants/needs

Child and Family Team BasicsChild and Family Team Basics1 Family/1 Team/1 Plan, con’t1 Family/1 Team/1 Plan, con’t

Team membership can change over time – members Team membership can change over time – members leave when their help is no longer needed – new leave when their help is no longer needed – new members taker their places to address different members taker their places to address different needsneeds

Members typically include:Members typically include:– FamilyFamily– Child, if age appropriateChild, if age appropriate– Local service providers involved with family’s care, child’s custody, Local service providers involved with family’s care, child’s custody,

education and treatmenteducation and treatment– Court, DSS, School membersCourt, DSS, School members– Others significant in the daily lives of the child/familyOthers significant in the daily lives of the child/family

Child & Family Teams @ the Point of Child & Family Teams @ the Point of Service: Service: 1 Family/1 Team/1 Plan1 Family/1 Team/1 Plan

Job Coach

DSSProfessional

Housing Authority

MH /DD/SA Professional

Friends

Parks/Rec

CourtsJJ Professional

Primary Care Phy.Health Dept. Nurse

Consumer Credit

LEATeacher

CFT Facilitator & Family Lead Role

Neighbors

Pastor

Advocate

Wraparound Approach across Life Domains

SOC IS EFFECTIVESOC IS EFFECTIVE

Reduces duplicationReduces duplicationpooling resources & unifying services

Helps keep children and families together - Helps keep children and families together - reduces costly out of home placement for treatment or incarceration

Provides incentives for communities to engineer enduring Provides incentives for communities to engineer enduring positive changepositive changeEstablishes a system that promotes Establishes a system that promotes

family strengths, greater self-reliance and less dependence on the system, and children who will grow up in success

Number of children/families served more than tripledOut of home placements (CTSP) drop from 50% to 30%Cross-agency training and education in best practicesAgency cooperation/direct participation in service deliveryAgency Directors, Deputy Directors and supervisors working together Significant drop in county funded court ordered placements (from $700 K to $0)County Commissioners invest $225,000 in SOC Community Support positions via cross-agency advocacyContinuity of care via CFTs for over 500 children/familiesNew services identified, recruited via cross-agency RFI processFunds braided to support new services & new positions: DSS/Court/MH Liaison, DJJ/Court/MH Liaison (e.g., DSS + DJJ + MH)2004 Ketner Award - NC County Commissioners Association2004 Programs of Excellence Award - NC Council of Community Programs

Results of SOC Implementation in Durham to Datein Durham to Date

We Got There Through . . .We Got There Through . . .

A collective commitment of public & private agencies and community partners to make the System of Care work in Durham County.

1 Family/1 Plan/1 Team1 Family/1 Plan/1 Team

More Information

www.dhhs.state.nc.us www.dhhs.state.nc.us/mhddsas www.ncleg.net www.durhamcenter.org

Questions?