the mental health system: organization and resources by beth
TRANSCRIPT
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?