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BLUEPRINT FOR CHANGE Division of Mental Health, Developmental Disabilities and Substance Abuse Services North Carolina’s plan for mental health, developmental disabilities and substance abuse services An Analysis of State Plans 2001 - 2005 North Carolina Department of Health and Human Services State Plan 2006 State Plan 2006: Analysis of State Plans 2001-2005 i North Carolina DHHS - DMH/DD/SAS Table of Contents CHAPTER I. INTRODUCTION................................................................................................1 Legislative Requirements for State Plan 2006.......................................................................................................................1 Reform as a National Effort.......................................................................................................................................................2 Table 1. Principles and goals of national mental health, developmental disabilities & substance abuse system reform..........................................................................................................................................................................................3 CHAPTER 2. ORIGINAL PROVISIONS OF REFORM........................................................5 Applicable Provisions from the Reform Legislation ............................................................................................................5 Vision ..........................................................................................................................................................................................6 Mission........................................................................................................................................................................................6 Guiding Principles .....................................................................................................................................................................6 Design of the Transformed Service Delivery System..........................................................................................................6 Figure 1. Key Components of an Effective Community-Based Human Service System.............................................7 Applicable Provisions from Prior State Plans .......................................................................................................................8 Table 2. Primary Provisions of Reform Legislation and Prior State Plans .....................................................................9 CHAPTER 3. THE COMMUNITY OF PEOPLE TO BE SERVED....................................13 CHAPTER 4. GOVERNANCE OF THE SYSTEM...............................................................17 Local Level....................................................................................................................................................................................17 County Commissioners and Area Boards ............................................................................................................................ 17 Local Consumer and Family Advisory Committees .......................................................................................................... 17 Human Rights Committees.................................................................................................................................................... 18 State Level.....................................................................................................................................................................................18 The Department of Health and Human Services and the Division of Mental Health, Developmental Disabilities and Substance Abuse Services .............................................................................................................................................. 18 State Consumer and Family Advisory Committee ............................................................................................................. 20 CHAPTER 5. FUNDING OF THE SYSTEM.........................................................................21 Finance Strategy.........................................................................................................................................................................22 Standardization...........................................................................................................................................................................23 Total Public Mental Health, Developmental Disabilities and Substance Abuse Services System Funding ........24 Figure 2. SFY 2006 Sources of Funding of the Public MH/DD/SAS System............................................................... 24 Figure 3. SFY 2006 Funding of the Public MH/DD/SAS System by Setting ............................................................... 25 CHAPTER 6. PERFORMANCE GOALS AND ACCOUNTABILITY FOR EFFECTIVENESS AND COSTS.............................................................................................27 State Plan 2006: Analysis of State Plans 2001-2005 ii North Carolina DHHS - DMH/DD/SAS Effective Outcomes for Consumers and their Families.....................................................................................................27 System Performance ..................................................................................................................................................................29 Quality Management............................................................................................................................................................... 29 The DHHS – LME Performance Contract.......................................................................................................................... 29 Long-Term System Goals ...................................................................................................................................................... 30 Service Monitoring .....................................................................................................................................................................30 CHAPTER 7. THE LOCAL MANAGEMENT OF THE SYSTEM......................................33 Local Business Plans (LBP) .....................................................................................................................................................34 The DHHS - LME Performance Contract...........................................................................................................................34 Core Functions of a Local Management Entity ..................................................................................................................35 Access, Uniform Portal, Screening, Triage and Referral.................................................................................................. 36 Endorsement of Providers ...................................................................................................................................................... 37 Utilization Management for State funds.............................................................................................................................. 38 Accreditation of Local Management Entities ......................................................................................................................39 Building Community Capacity ...............................................................................................................................................40 Provider Action Agenda......................................................................................................................................................... 40 CHAPTER 8. THE DELIVERY OF SERVICES...................................................................43 Figure 4. General Flow Chart for New Consumers ........................................................................................................... 44 Person-Centered Planning .......................................................................................................................................................45 Array/Continuum of Services..................................................................................................................................................46 Services for People with Developmental Disabilities ........................................................................................................ 47 Services for Children and Adolescents with Mental Health or Substance Abuse Needs............................................. 48 Services for Adults with Substance Abuse Service Needs................................................................................................ 48 Emergency Services ................................................................................................................................................................ 49 Prevention, education and consultation............................................................................................................................... 49 State Operated Facilities...........................................................................................................................................................50 Practice Improvement Collaborative ....................................................................................................................................51 Workforce Development ...........................................................................................................................................................52 APPENDICES………………………………………………………………………………….53 Applicable Provisions from Legislation Glossary Index to State Plans 2001-2005 by Topic Detailed Tasks and Status from Prior State Plans State Plan 2006: Analysis of State Plans 2001-2005 1 North Carolina DHHS - DMH/DD/SAS Chapter I. Introduction The transformation of the public system of mental health, developmental disabilities and substance abuse services began in the fall of 2001 after the North Carolina General Assembly enacted legislation for the reform of the system.1 That legislation instructed the State to publish an annual State Plan to address how reform would be implemented. The Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) published the first State Plan in November 2001 and since that time has published an annual plan on July 1 of each State fiscal year.2 This document provides an analysis of the five previous State Plans and serves as the State Plan for State fiscal year 2006-2007 and thereby meets the requirements of legislation passed in July 2006. Legislative Requirements for State Plan 2006 Session Law 2006-142, House Bill 2077, Section 2.(b) states3: “The North Carolina Department of Health and Human Services (DHHS) shall review all State Plans for Mental Health, Developmental Disabilities and Substance Abuse Services, implemented after July 1, 2001, and before the effective date of this act and produce a single document that contains a cumulative statement of all still applicable provisions of those Plans. This cumulative document shall constitute the State Plan until July 1, 2007.” House Bill 2077 also specifies that beginning July 1, 2007, the State Plan will be issued every three years as a strategic plan that identifies specific goals and benchmarks for determining progress. To support that aim, Session Law 2006-66, Senate Bill 1741, Section 10.28 entitled “Changes to the State Plan for Mental Health, Developmental Disabilities, and Substance Abuse Services” is written as follows. “Section 10.28. Independent consultants hired by the Department from funds appropriated in this act for this purpose shall undertake the following tasks: (1) Assist DHHS with the strategic planning necessary to develop the revised State Plan as required under G.S. 122C-102. The State Plan shall be coordinated with local and regional crisis service plans by area authorities and county programs.” 1 See North Carolina Session Law 2001-437, House Bill 381, Section 1.5. 2 The previous State Plans can be found on the Division’s web site: http://www.dhhs.state.nc.us/mhddsas/stateplanimplementation/index.htm 3 See the Division’s Communication Bulletin #059 entitled “Session Law 2006-142 House Bill 2077” and Communication Bulletin #057 entitled: “Modified Timing of State Plan 2006.” State Plan 2006: Analysis of State Plans 2001-2005 2 North Carolina DHHS - DMH/DD/SAS Therefore, this document provides an analysis of past efforts to transform the public mental health, developmental disabilities and substance abuse services system, clarifies the work to be accomplished in State fiscal year 2006-2007 and lays the groundwork for the upcoming three-year strategic plan to be developed for 2007-2010. Reform as a National Effort As the federal government and other states engage in the development of a more coherent, coordinated and effective plan and strategy for reform of mental health, developmental disabilities and substance abuse services, so has North Carolina committed to a transformation designed to be responsive to all stakeholders. Table 1 illustrates how the Division’s vision, mission and guiding principles complement national and federal goals and actions for reform of the public mental health, developmental disabilities and substance abuse services and supports. State Plan 2006: Analysis of State Plans 2001-2005 3 North Carolina DHHS - DMH/DD/SAS Table 1. Principles and goals of national mental health, developmental disabilities & substance abuse system reform PRINCIPLES GUIDING NATIONAL AND STATE MH/DD/SAS REFORM President’s New Freedom Commission on Mental Health “Achieving the Promise: Transforming Mental Health Care in America” (July 2003) & SAMHSA’s: Federal Action Agenda - (2005) The President��s Committee for People with Intellectual Disabilities “A Charge We Have To Keep: A Road Map to Personal and Economic Freedom for Persons with Intellectual Disabilities in the 21st Century” - (2004) Federal Center for Medicare & Medicaid Services (CMS) “Quality Framework” - (2002) v Assure that the system is person-centered – “Participant” refers to persons who are seeking assistance in overcoming or adjusting to life situations that involve MH/DD/SA issues and is inclusive of the terms “consumers,” “family members, “ “clients” and “patients”. · Mental health care is consumer and family driven. · Focus on the desired outcomes of mental health care including employment, self-care, interpersonal relationships and community participation. · A new road map is required, one that aligns a public rhetoric to desired outcomes. It needs to be based on the principles of self-determination. · Participant centered service planning and delivery: Services and supports are planned and effectively implemented in accordance with each participant’s unique needs, expressed preferences and decisions concerning his/her life in the community. · Participant outcomes and satisfaction. · Participants have the authority and are supported to manage their own supports . v Focus on community level models of care that effectively and efficiently coordinate treatment and the delivery of services. · Community-level models of care that coordinate multiple health and human service providers and private and public payers. · Focus on community-level models of care that efficiently coordinate the multiple heath and human service providers and public and private payers involved in mental health, developmental disabilities and substance abuse treatment and delivery of services. · People to have the freedom to live a meaningful life in the community. · Examine provider attitudes, behaviors relative to inclusion of persons with intellectual disabilities in community-based and private practice settings. · Provider capacity and capabilities: There are sufficient quality agency and individual providers to meet the needs of participants in their communities. · Participant access. · Individuals and families can readily obtain information concerning the availability of Home and Community Based Services, how to apply and, if desired, offered a referral. vThe utilization of information technology and early screening, assessment, referral to services is common practice and is valued as essential to overall health. · Early mental health screening, assessment and referral to services are common practice. · Advance and implement a national campaign to reduce the stigma of seeking care, providing facts and a national strategy for suicide prevention · American citizens with intellectual disabilities will have access to a complete range of health care services and supports from medical, dental and other health professional providers · Participants have continuous access to assistance as needed to obtain and coordinate services and promptly address issues. · Regular, systematic and objective methods-including obtaining the participant’s feedback -are used to monitor the individual’s well being, health status and the effectiveness of services in enabling the individual to achieve his or her personal goals. Prevention Focused Participant Driven Community-Based State Plan 2006: Analysis of State Plans 2001-2005 4 North Carolina DHHS - DMH/DD/SAS PRINCIPLES GUIDING NATIONAL AND STATE MH/DD/SAS REFORM President’s New Freedom Commission on Mental Health, “Achieving the Promise: Transforming Mental Health Care in America” – (July 2003) & SAMHSA’s: Federal Action Agenda - (2005) The President’s Committee for People with Intellectual Disabilities. “A Charge We Have To Keep: A Road Map to Personal and Economic Freedom for Persons with Intellectual Disabilities in the 21st Century” - (2004) Federal Center for Medicare & Medicaid Services (CMS) “Quality Framework” - (2002) v System elements will be seamless: consumers, families, policymakers, advocates and qualified providers will unite in a common approach that emphasizes support, education/training, rehabilitation and recovery. · Involve consumers and families fully in orienting the mental health system toward recovery. · Excellent mental health care is delivered and research is accelerated. · Utilize data and quality information to engage in actions that lead to continuous improvement in the Home and Community Based Services. · Developmeaningful assessments and accountability by establishing an Intra- Agency Task Force, which would be facilitated by the U.S. Department of Education and include national experts, to provide ongoing guidance to states on universally relevant standards and appropriate assessments for students with intellectual disabilities under the No Child Left Behind Act. · The service system promotes the effective and efficient provision of services and supports by engaging in systematic data collection and analysis of program performance and impact. v Use mental health research findings deemed to be “Evidenced-Based Best Practice” to influence the delivery of services. · Advance evidence -based practices using dissemination and demonstration projects and create a public-private partnerships to guide their implementation. · Use Mental Health Research Findings to Influence the Delivery of Services · Align relevant Federal programs to improve access and accountability for mental health services. · Create a Comprehensive State Mental Health Plan. · Disparities in Mental Health Services are Eliminated. · Partner to create a set of practical performance measures for agencies that administer federal programs that have an impact on people with intellectual disabilities to hold them accountable for the advancement of outcomes that improve personal and economic freedom. These measures and performance indicators should be comprehensive, consistent, and complementary. · Quality initiatives to focus on best practices. · Focus on state collections and analysis of data to be used to remediate and improve services and supports. vServices for persons with mental illness, developmental disabilities and substance abuse problems will be cost effective and will optimize available resources. · Focus on those policies that maximize the utility of existing resources by Increasing Cost Effectiveness and Reducing Unnecessary and Burdensome Regulatory Barriers. · Ensure Innovative, Flexibility, and Accountability at All Levels of Government and Respect the Constitutional Role of the States and Indian Tribes. · Ensure authority over dollars needed for support. · Support to organize resources in ways that are life-enhancing and meaningful. · Take responsibility for the wise use of public dollars. · Commission longitudinal studies to: 1) design new financing options and assess their impact on service access and delivery to persons with intellectual disabilities. · Financial accountability is assured and payments are made promptly in accordance with program requirements. Best-Practice Based Cost Effective Recovery Oriented State Plan 2006: Analysis of State Plans 2001-2005 5 North Carolina DHHS - DMH/DD/SAS Chapter 2. Original Provisions of Reform This chapter identifies the provisions of the reform legislation HB381 that represent the original intention and conceptual basis for transformation of the mental health, developmental disabilities and substance abuse services system. Further, it identifies the provisions from State Plan 2001 through State Plan 2005 that are still applicable. Finally, this chapter provides the means to organize and assess these provisions and to structure the remainder of the document. Applicable Provisions from the Reform Legislation Session Law 2001-437, HB 381 specified the provisions for reform and the contents for the State Plan for implementing reform. Appendix A provides excerpts from HB 381 and highlights provisions as key words. The reform legislation clearly lays out the basic values and requirements for the delivery of services for the people of North Carolina who experience mental health issues, developmental disabilities and/or substance abuse problems. The original reform legislation called for: · A delivery system designed to meet the needs of consumers in the least restrictive, therapeutically most appropriate setting available and to maximize their quality of life. · Community-based services when such services are appropriate, unopposed by the affected individuals, and can be reasonably accommodated within available resources, taking into account the needs of others. · A unified system of services centered in area authorities or county programs and where the area authority or county program is the locus of coordination. · A continuum of services for clients inclusive of area authorities, county programs, local providers and State facilities while considering the availability of services in the private sector. · Core services that are available for all individuals including screening, assessment, and referral; emergency services; service coordination; and consultation, prevention, and education. · Targeted populations, meaning those individuals given service priority under the State Plan. · Services provided within available resources. · Protection of the rights of consumers . State Plan 2006: Analysis of State Plans 2001-2005 6 North Carolina DHHS - DMH/DD/SAS The Division’s mission, vision and guiding principles capture the essence of these values. Each State plan published by the Division has included these statements.4 Vision North Carolina residents with mental health, developmental disabilities and substance abuse service needs will have prompt access to evidence-based, culturally competent services in their communities to support them in achieving their goals in life. Mission North Carolina will provide people with, or at risk of, mental illness, developmental disabilities, and substance abuse problems and their families the necessary prevention, intervention, treatment services and supports they need to live successfully in communities of their choice. Guiding Principles · Participant driven. · Community based. · Prevention focused. · Recovery outcome oriented. · Reflect best treatment/support practices. · Cost effective. Design of the Transformed Service Delivery System There are two fundamental requirements that underlie the design of the community-based system of services. 1. The system must be concerned with both effectiveness and cost. 2. The effects of the system must be specified by the community members it is intended to serve. Given the values stated above and these two requirements, the design of the community service delivery system is concerned with six essential elements and their relationships. As shown in figure 1, these essential elements are: · The community of people to be served. · The governance of the system. · Funding of the system. · Performance goals and accountability for effectiveness and costs. · The local management of the system. · The delivery of services. 4 The Division revised its Vision in July 2006 to more clearly align with the Vision and business plan of the Department of Health and Human Services. State Plan 2006: Analysis of State Plans 2001-2005 7 North Carolina DHHS - DMH/DD/SAS Figure 1. Key Components of an Effective Community-Based Human Service System Governance Local System Management The Delivery of Service The Community of People to be Served Funding Consumer Needs met Performance Goals & Accountability for Effectiveness & Costs State Plan 2006: Analysis of State Plans 2001-2005 8 North Carolina DHHS - DMH/DD/SAS Applicable Provisions from Prior State Plans Beginning with State Plan 2001: A Blueprint for Change, the Division published annual State plans as cumulative documentation of the Division’s interpretation and conception of the legislation and its plans to transform the old service delivery system into a community-based system. These documents contain descriptions of various parts of the system and specific tasks to be accomplished to implement the system. The Division has conducted an analysis of these five documents, as required by House Bill 2077, which points out the complexity of the ove rall undertaking. This analysis is two- fold: 1. An assessment of the topics covered in the five State plans by year and cumulatively organized by the primary provisions of the reform legislation. 2. A determination of the current status of each of the detailed tasks listed in each of the five State Plans. Appendix D lists these detailed tasks and the status of each, with explanation if necessary. Table 2 identifies the provisions that are still applicable from both the reform legislation and prior state pla ns. These provisions are organized according to the essential elements of the community-based service delivery system shown in figure 1. The chapters that follow are also organized by the essential elements of a community-based system. Each chapter id entifies those provisions of the legislation and prior state plans that are still applicable, provides an analysis of prior tasks and summarizes what has been accomplished over the past five years and the current status of the system. State Plan 2006: Analysis of State Plans 2001-2005 9 North Carolina DHHS - DMH/DD/SAS Table 2. Primary Provisions of Reform Legislation and Prior State Plans Elements of Community-Based System Provisions of HB 381 Related Provisions of State Plans 2001-2005 THECOMMUNITY OF PEOPLE TO BE SERVED Targeted populations · Target populations (2001, 2002, 2003, 2004, 2005) · Summary of community needs (2002) · Child mental health plan (2004, 2005) Area boards and county commissioners Local Consumer Advocacy Programs (Local CFAC) · Local consumer and family advisory committees (2003) · LME-CFAC agreement (2003) Human rights committees · Appeals, grievances, human rights, consumer advocacy (2002) Role and responsibilities of the Secretary of DHHS-the Division of Mental Health, Developmental Disabilities and Substance Abuse Services · Infrastructure of system (2001, 2002) · National & federal policies (2002) · System transition issues (2002) · Reorganization of the Division (2002, 2003, 2004, 2005) GOVERNANCE OF THE SYSTEM State consumer advocacy programs (State CFAC) · State CFACs (2001, 2002, 2003, 2004, 2005) · Transformation of consumer and family participation in reform (2005) FUNDING OF THE SYSTEM Funding within available resources · Total system financing (2001) · Integrated Payment and Reporting System (2002) · Finance strategy (2002, 2004, 2005) Administrative Rules · Rules & statutes (2001, 2002, 2004, 2005) PERFORMANCE GOALS & ACCOUNTABILITY FOR EFFECTIVENESS & COSTS Role and responsibilities of the Secretary of Department of Health and Human Services and the Division of Mental Health, Developmental Disabilities and Substance Abuse Services · Federal policies & social trends & policies (2002) · Quality management (2005) · Cultural competence (2001, 2003, 2005) · Technical assistance (2002) · Data collection & analysis (2001, 2002, 2003, 2004, 2005) State Plan 2006: Analysis of State Plans 2001-2005 10 North Carolina DHHS - DMH/DD/SAS Elements of Community-Based System Provisions of HB 381 Related Provisions of State Plans 2001-2005 · Licensing and monitoring (2001, 2002, 2005) Roles and responsibilities of Local Management Entities (LMEs) · Local Management Entities (2001, 2003) · LME-provider contracts (2001, 2002, 2003, 2004, 2005) · Role and functions of LMEs (2002) · Performance contract (2002, 2005) LME local business plans & certification · Local business plans, (2001, 2002, 2003, 2004, 2005) · Consolidation, certification and accreditation (2002, 2004, 2005) THE LOCAL MANAGEMENT OF THE SYSTEM Core services · Uniform portal (2001) · Core functions (2002, 2003, 2004, 2005) · System access (2002) · Screening, triage, referral (2001, 2002, 2003) · Prevention (2001, 2002, 2003, 2004, 2005) A delivery system of mental health, developmental disability and substance abuse services · New system design (2001) · Self-determination & Recovery (2002) · Person-centered planning (2002, 2003) · Staff competencies, education and training (2002, 2005) Community-based services · Community services (2002) · Community capacity (2002, 2005) · Key system characteristics (2003) · CAP-MR/DD (2005) · LME providing direct services (2002, 2003) THE DELIVERY OF SERVICES A unified system of services · Qualified service providers (2001, 2002, 2003) · Documentation (2001, 2002) · Utilization management (2001, 2002, 2003, 2004, 2005) State Plan 2006: Analysis of State Plans 2001-2005 11 North Carolina DHHS - DMH/DD/SAS Elements of Community-Based System Provisions of HB 381 Related Provisions of State Plans 2001-2005 A continuum of services · Array of services (2001, 2002, 2004, 2005) · Assessment (2001, 2002) · Best practices (2003, 2005) · Care coordination, case management. Service coordination (2002, 2003) · Systems development (2003) · Emergency services (2001, 2002, 2003, 2005) · Crisis stabilization services (2005) · Enhanced benefits package (2005) · Justice system innovations (2005) · Employment/vocational services (2004) State facilities · Downsizing (2002, 2004) · Consolidated hospital (2002, 2004) · Olmstead plan (2004) · Bed day allocation plan (2004) · Transformation of state facilities (2005) · State facility regions (2005) State Plan 2006: Analysis of State Plans 2001-2005 12 North Carolina DHHS - DMH/DD/SAS This page left blank intentionally. State Plan 2006: Analysis of State Plans 2001-2005 13 North Carolina DHHS - DMH/DD/SAS Chapter 3. The Community of People to be Served The members of the community to be served by the public system of mental health, developmental disabilities and substance abuse services and supports must be unambiguously identified. While the primary focus of the transformed system is to provide services for individuals with the most severe disabilities and in the greatest need (defined as target populations), the community-based service system is also designed to be responsive to individuals in crisis. As required by legislation, any individual is eligible for screening and referral and for services in the event of a crisis. In addition, the community system is concerned with education and prevention of problems among its general population. The reform legislation states that within available resources the State shall provide funding to support services to targeted populations. This means individuals with the greatest need who are eligible according to specific criteria. As legislatively directed, the Division established appropriate criteria to identify individuals with various disabilities. Target populations were first established and described in detail in State Plan 2001 and have been included in each subsequent State Plan. These target populations are specifically described by both age (child and adult) and disability (mental health, developmental disabilities or substance abuse) and includes those populations who experience co-occurring disabilities. Estimates of the prevalence of problems for each age/disability group were first provided in State Plan 2002. Since the beginning of reform, the Division has continuously evaluated the definitions of the target populations to assure that we respond to evolving needs in a timely way. A complete and current listing of the target populations is maintained on the Division’s web site.5 Some changes have occurred since the original State Plan was published in November 2001. · State Plan 2002 added target populations in each age and disability category for individuals who are deaf or hard of hearing. · Communication Bulletin #003, dated October 28, 2002, clarified the management of resources in serving State Plan target and non-target populations during the transition. 5 See the Division’s web site for the most current description of the targeted populations at: http://www.dhhs.state.nc.us/mhddsas/iprsmenu/index.htm. Click on each age disability category for a detailed description of each. State Plan 2006: Analysis of State Plans 2001-2005 14 North Carolina DHHS - DMH/DD/SAS · State Plan 2003 clarified that those individuals who are eligible for Medicaid are entitled to services whether or not they meet the specific criteria of the target populations. Those individuals who are not eligible for Medicaid must meet the specific criteria of a target population to received State- funded services. This is primarily due to the fact that services paid by State dollars are not an entitlement. · In September 2005 the use of Child and Adolescent Functional Assessment Scale (CAFAS) was removed from the criteria for child populations when the Division elected to not upgrade to the most recent version as required by the developer.6 · Also in 2005, the Division expanded the definition of Substance Abuse High Management to include detoxification and consumers with stimulant disorders. · In 2006, the Division added two target populations, the Adult Mental Health Stable Recovery population (AMSRE) and Assessment Only (AO) for each age/disability population. · The Division is emphasizing crisis services during State fiscal year 2006-2007 and is defining a new target population for people in need of crisis services. The Division will draft a rule to specify the criteria for defining target populations during State fiscal year 2006-2007. Once adopted, the mental health, developmental disabilities and substance abuse service system must serve individuals who currently or in the future meet those criteria within available State resources. Regarding target populations for children, a Division workgroup studied the Child Mental Health Plan that was prepared by the Division and the State Collaborative in September 2003. This workgroup represented the needs of children and families in the Division’s overall design and development of the transformed system.7 The principles of System of Care were emphasized in this process, including the importance of child and family teams for the development and monitoring of a person-centered plan and the importance of a local community collaboratives in coordinating the services for children and their families across agencies. These efforts focused attention on identifying and serving children with severe impairments and their families. A five- year System of Care federal grant that demonstrated the success of that approach was completed in 2006. In support of the further development and implementation of System of Care across the entire state, the Division earmarked new funds in State fiscal year 2005-2006 in each local management entity to establish one full- time equivalent staff as System of Care Coordinator to provide local community leadership, training and technical assistance. A dedicated staff member of the Division provides support to these new local positions in working with child target populations. 6 See this announcement on the Division’s web site at: http://www.dhhs.state.nc.us/mhddsas/announce/cafasdeletion-iprstargetpopcriteria9-26-05a-2.pdf 7 See Communication Bulletin # 11: Child Mental Health Plan; and Communication Bulletin # 25: Child Mental Health Plan Implementation Update. State Plan 2006: Analysis of State Plans 2001-2005 15 North Carolina DHHS - DMH/DD/SAS Efforts to work with child target populations continue through the collaboration of the Division and the Department of Public Instruction to facilitate the coordination of educational and behavioral health services for children in public schools.8 In addition, the Division is participating in the Governor’s School-Based Child and Family Support Team initiative by providing funding to designated local management entities to hire care coordinators to work with child and family teams. The care coordinators will: · Serve as the primary contact for the schools in their catchment area for children and families identified as having behavioral health issues. · Receive and coordinate all school referrals for all school age children and assure that children referred are screened, assessed and connected with services and supports. · Work with the schools, especially the social worker/school nurse teams, to discuss treatment options with the child and family and assist in connecting them to the local management entity and treatment providers, clinical home with medical home and other supports within the community System of Care. In addition to defining new target populations in each age and disability category for people who are deaf or hard of hearing, the Division has funded the continued employment of deaf and hard of hearing specialists by local management entities (LMEs) to ensure continued support for children and adults across the State.9 There are numerous advocacy, consumer and professional organizations and individual advocates that work to increase the awareness of the needs of individuals with disabilities. These stakeholders represent consumers to governance and on governance bodies and bring attention to the need for system reform, for best practices and for increased funding. 8 See “The Transition to Community Support Services for Children in Public Schools” workbook and DVD on the Division’s web site: http://www.dhhs.state.nc.us/mhddsas/childandfamily/index-new.htm 9 See Communication Bulletin # 58: Services to Consumers who are Deaf, Hard of Hearing or Deaf-Blind. State Plan 2006: Analysis of State Plans 2001-2005 16 North Carolina DHHS - DMH/DD/SAS This page left blank intentionally. State Plan 2006: Analysis of State Plans 2001-2005 17 North Carolina DHHS - DMH/DD/SAS Chapter 4. Governance of the System Governance is the means that charts the course for the system and by which the system is held accountable for meeting the needs of people according to performance standards and available resources. In order to satisfy the requirement for accountability for effectiveness and costs and the requirement that the system be participant driven, there must be a governance body to speak for the people who are served and act on their behalf. Governing bodies set performance expectations and require that the system conform to its standards and report to it on a regular basis. For the North Carolina statewide system, governance primarily occurs at two levels. This chapter provides the State’s analysis of progress with this element of the system. Local Level At the local level, governance is provided by an area board and county commissioners with advice and input from the local consumer and family advisory committee (CFAC) and the local human rights committee. County Commissioners and Area Boards North Carolina’s Session Law 2001-437 and Session Law 2006-142 speak directly to the structure and duties and responsibilities of counties and area boards with regard to the public mental health, developmental disabilities and substance abuse service system. Briefly, legislation requires that counties appropriate funds to support local programs and specifies the structure and organization of area boards and responsibilities for finance. Local Consumer and Family Advisory Committees Legislation also calls for the formation and operation of local consumer and family advisory committees (CFACs) and specifies their roles and responsibilities. These are self-governing and self-directed organizations that advise the local management of the system regarding the planning and management of the local public mental health, developmental disabilities and substance abuse service system. At the request of either one, the local governing board or the local consumer and family advisory committee may execute an agreement that identifies their roles and responsibilities, channels of communication between them and a process for resolving disputes. In order to address the consumer involvement requirements of HB 381, the initial State Plan directed each LME to create a consumer and family advisory committee (CFAC).10 The consumer and family advisory committee, comprised of adult consumers and family 10 See the Division’s Communication Bulletin #031 entitled “LME/CFAC Relational Agreement.” State Plan 2006: Analysis of State Plans 2001-2005 18 North Carolina DHHS - DMH/DD/SAS members, is to advise the LME. During the last four years local consumer and family advisory committees have been established and operational for every local management entity. As specified in Session Law 2006-142, House Bill 2077, Section 5, a consumer and family advisory committee’s duties include: · Reviewing, commenting on and monitoring the implementation of the local business plan. · Identifying service gaps and underserved populations. · Making recommendations regarding the service array and monitoring the development of additional services. · Reviewing and commenting on the area authority or county program budget. · Participating in all quality improvement measures and performance indicators. · Submitting to the State consumer and family advisory committee their findings and recommendations regarding ways to improve the delivery of mental health, developmental disabilities and substance abuse services. Human Rights Committees Session Law 2001-437, House Bill 381, Section 1.3 requires the establishment of human rights committees at each State facility and for each area authority and county program. Rules specify the duties of these committees. Area authorities and county programs as local management entities oversee consumer rights for their catchment areas. In addition, providers who use restrictive interventions must have an Intervention Advisory Committee to review the interventions as required by statute 10A NCAC 27E.0106. State Level At the State level, the North Carolina General Assembly serves to represent and speak for communities and residents of the State including the people served by the public mental health, developmental disabilities and substance abuse services system. Reform of the MH/DD/SA services system was initiated by the General Assembly with Session Law 2001-437. The General Assembly established the Legislative Oversight Committee to which the Department and Division report on a quarterly basis on progress of reform.11 The Department of Health and Human Services and the Division of Mental Health, Developmental Disabilities and Substance Abuse Services The Secretary of the Department of Health and Human Services and its Division of Mental Health, Developmental Disabilities and Substance Abuse Services are responsible for administering and enforcing the reform statute and other statutes related to the public 11The quarterly reports to the Legislative Oversight Committee can be found on the Division’s web site. See http://www.dhhs.state.nc.us/mhddsas/stateplanimplementation/index.htm State Plan 2006: Analysis of State Plans 2001-2005 19 North Carolina DHHS - DMH/DD/SAS mental health, developmental disabilities and substance abuse services system. In addition to the development of policy guidance and provision of technical assistance, the development and adoption of rules is a primary means for carrying out this responsibility. In addition to rules, the State is bound by federal regulations (such as the Code of Federal Regulations 42CFR that speaks to confidentiality) and federal funding requirements (such as those from the Substance Abuse and Mental Health Services Administration and the Centers of Medicare and Medicaid) to which the Department and the Division must ensure that the system adheres. The federal government sets an agenda and provides major funding for services through block grants and Medicaid. The State must follow guidelines to qualify and utilize these funds. One of the first steps taken by the Division following the passage of HB381 was to meet with the North Carolina Association of County Commissioners to discuss and clarify the intentions and implications for change activated by the reform legislation. Division leadership conducted town hall meetings and broadcast videoconferences across the State to increase public awareness of the goals and impact of reform. These vehicles enabled the Division to communicate new developments related to reform and to hear the concerns of consumers and their families and other stakeholders. Another method of communication is the rights and empowerment conference for consumers held by the Division each year. During 2006 this conference focused on the power of change and sessio ns addressed accessing services, choice of providers, protection of rights and advocacy. In addition, the Division implemented a series of communication bulletins in 2002 and enhanced services implementation updates in 2006 to provide policy and technical guidance to local governance and management of services. References to such applicable communications are made throughout this document. The Division’s web site has recently been enhanced to increase access to publications and documents by consumers and families, providers, governance and management. All announcements, communication bulletins, implementation updates and other materials related to reform are available on the Division’s web site. In order to carry out its responsibilities for the transformation and operation of mental health, developmental disabilities and substance abuse services, the Division collaborates with other divisions of the Department of Health and Human Services such as the Division of Social Services, Division of Public Health, Division of Medical Assistance and the Division of Facility Services, and with other departments of State government such as the Department of Juvenile Justice and Delinquency Prevention and the Department of Public Instruction. Since 2001, the Division has renewed interagency memoranda of agreement and developed new agreements and procedures with these state agencies to facilitate operations at the local level. The Division has worked closely with the Division of Medical Assistance to develop the new enhanced service definitions and the new Community Alternative Program for Developmental Disabilities (often referred to as the CAP-MR/DD waiver). In addition, State Plan 2006: Analysis of State Plans 2001-2005 20 North Carolina DHHS - DMH/DD/SAS the two divisions have collaborated in the enrollment of providers of services in the Medicaid system. The Division has worked closely with the Division of Facility Services to coordinate oversight activities of licensed facilities. The Department and the Division are responsible for reporting progress to the Legislative Oversight Committee of the General Assembly. Local management is responsible for reporting to its local governance bodies as well as to the Division. State Consumer and Family Advisory Committee Session Law 2001-437 and Session Law 2006-142 also required the establishment of a State Consumer and Family Advisory Committee (CFAC) to advise the Department, the Division and the General Assembly on the planning and management of the State’s public mental health, developmental disabilities and substance abuse services system. The Division’s Communication Bulletin #059 noted that both the State and local consumer and family advisory committees are now codified in statute. The fact that State and local consumer and family advisory committees are now in statute speaks to North Carolina’s commitment to and regard for the perspective of consumers and family members in the mental health, developmental disabilities and substance abuse service system. The first meeting of the State Consumer and Family Advisory Committee was May 5, 2004. The Division is currently working to implement changes as they relate to the State Consumer and Family Advisory Committee in order to accommodate the requirements outlined in the 2006 statute. The Division will provide assistance to the local consumer and family advisory committees as far as any changes they may need to make given the new statutory guidelines. State Plan 2006: Analysis of State Plans 2001-2005 21 North Carolina DHHS - DMH/DD/SAS Chapter 5. Funding of the System An effective public mental health, developmental disabilities and substance abuse services system requires a true partnership among consumers, family members, local management entities, providers, counties and the State and federal governments. As the major financing source for the public system, the State, federal government and counties have a responsibility to support the provision of services to individuals with, or ask risk of, mental illness, developmental disabilities and substance abuse problems. Concurrently, these entities have the fiduciary responsibility to ensure that public funds that they appropriate are utilized in a cost effective manner to support positive outcomes for consumers. As local managers of the public mental health, developmental disabilities and substance abuse services system, local management entities play a critical role in ensuring a partnership among stakeholders and as the focal point for local financial management and accountability. With finite resources, it is recognized that State- funded services must be provided within available resources. In State fiscal year 2007, the Division receives over $650,000,000 in State funds on a recurring basis for State-funded institution and community-based services, as compared to approximately $593.8 million in State fiscal year 2006. However, additional resources are needed to meet the needs of all consumers who are not eligible for Medicaid or Health Choice or do not have third party insurance coverage. While all resources must be appropriately managed, local management entities have a unique role and challenge in managing limited State and county funds to address the needs of their local residents. Since the majority of funding (61 percent or $1.42 billion) for the public mental health, developmental disabilities and substance abuse service system is derived from Medicaid receipts, the Division works collaboratively with the Division of Medical Assistance to assure that services provided are approved by the federal Centers of Medicare and Medicaid. Likewise, Health Choice is a system of insurance funding for children of North Carolina who are not covered by insurance. In addition to efforts to increase Medicaid receipts and additional funding made available by the North Carolina General Assembly, funding is being shifted from State facilities to increase community service capacity as State facilities are downsized. Between State fiscal year 2002 and State fiscal year 2006, State facilities eliminated 413.25 positions and related operating cost, with over $15.5 million in State appropriations transferred from State facilities to funding for community-based services. An additional $1.1 million in Medicaid receipts have been realigned within the Division of Medical Assistance’s budget from State institution funding to support services provided via the community-based Community Alternative Program for Developmental Disabilities (CAP-MR/DD) wavier. State Plan 2006: Analysis of State Plans 2001-2005 22 North Carolina DHHS - DMH/DD/SAS The General Assembly also appropriated over $105,000,000 for the Mental Health Trust Fund to support implementation of system transformation and increasing community-based service capacity. In addition, the State General Assembly has designated non-recurring funds for hiring consultants to assist DHHS and the Division with specific tasks during State fiscal years 2007 and 2008. Finance Strategy In order to ensure that a financing strategy for the public mental health, developmental disabilities and substance abuse services system is in place to effectively address needs and resources, the Division has undertaken a comprehensive assessment of service needs, service resources, service gaps and cost modeling. These efforts are closely linked through two initiatives initiated in SFY 06. First, the Division issued a competitively bid contract for the development of a long range planning model that will predict the overall cost of services needed at the community level. The long range planning model is based on assumptions associated with movement to evidence based practices and provides information regarding service needs, current service resources, identification of service gaps and service constructs that focus on positive consumer outcomes. Secondly, the Division awarded another competitively bid contract to develop a funding cost model for services. This model factors in variables such as the number of Medicaid eligible and non-eligible consumers, current penetration rates for Medicaid and non- Medicaid consumers, available resources and potential earning capacity for additional resources. Once service costs are estimated by the long range planning model, the costs of such services will be entered into the finance model. The finance model will render estimates of additional Medicaid resources that may be earned, availability of county funds and funding needs for non-Medicaid consumers or non-Medicaid covered services. This information will assist the Division in allocating existing State resources on an equitable basis to help ensure the availability of services in all communities throughout the State. It will also provide, in a quantifiable manner, additional resources that would be needed to achieve varying levels of evidence based practices implementation. Both models described above will be delivered to the Division in State fiscal year 2007 and will be operational in State fiscal year 2008 for use in determining funding needs and resource distribution. Another key element for improvement in the overall finance strategy for the public mental health, developmental disabilities and substance abuse system is the continued refinement and updating of service definitions. Effective March 20, 2006, the federal Centers for Medicare and Medicaid Services approved an array of new and improved Medicaid service definitions that the Division considered a critical milestone in overall State Plan 2006: Analysis of State Plans 2001-2005 23 North Carolina DHHS - DMH/DD/SAS system transformation. Approval of these services by the Centers for Medicare and Medicaid Services, coupled with the new Community Alternatives Program waiver that was effective September 1, 2005, provides the clinical foundation for transforming the community service array and providing more effective services to consumers. Each of these initiatives is included within the overall financing strategies described above. Standardization In response to action taken by the General Assembly and in concert with activities currently being conducted by the Division, the Division is pursuing a Request for Proposals in State fiscal year 2007 that, among other activities, will focus on the standardization of forms, contracts, processes and procedures at the local level. Standardization of functions and processes will aid providers by creating a relatively uniform business environment, regardless of which area authority or county program the provider contracts with for the provision of services. This will in turn, and more importantly, benefit consumers and family members by contributing to the development and stabilization of community-based resources provided by a wide array of providers throughout the State. Activities to be addressed in this process to improve standardization include, but are not limited to, the following: · Standard Forms - Consideration of the standardization of forms required of providers by area authorities or county programs. · Standard Contracts - Review of current standard contract content for Medicaid and State- funded services currently in place for any recommended improvements. · Standard Processes and Procedures – Assessment of local functions associated with the provider monitoring for the standardization of processes and procedures. · Standard Denial Codes – Consideration of standardized denial codes at the local level prior to service units being billed to Medicaid or the Division’s Integrated Payment and Reporting System (known as IPRS). · Coordination of Benefits – More effective procedures for the coordination of benefits to optimize resources at the local level. · Standard Definition of a “Clean Claim” - Ensure a standardized definition and process among local management entities and providers in determining a “clean claim”. · Area Authority and County Program Management Information Systems - Assessment and potential changes of local management information systems in order to improve the delivery of services to consumers and family members through a more effective methodology for securing and accessing information. State Plan 2006: Analysis of State Plans 2001-2005 24 North Carolina DHHS - DMH/DD/SAS · Feasibility of a Standard Electronic Health Record - The Division’s strategic vision includes continuity of care across all settings, including the community and State facilities. Total Public Mental Health, Developmental Disabilities and Substance Abuse Services System Funding During State fiscal year 2006, total funding within the public service system was approximately $2.3 billion dollars, inclusive of all funding sources for the Division’s State operated facilities, community-based services and the Division’s central administration. 12 At a summary level, total system funding is illustrated in figures 2 and 3 below. In figure 2, note that Medicaid funds include federal dollars plus State and county shares. Other sources of funds include block grants, Medicare, first party payments, insurance payments and other grants. In figure 3, note that Division central administration includes the operation of the Integrated Payment and Reporting System (IPRS) for the community based State-funded services. Figure 2. SFY 2006 Sources of Funding of the Public MH/DD/SAS System Medicaid $1,426,000,000 61.0% State Appropriations $593,800,000 25.4% Other Sources $208,000,000 8.9% County General $109,200,000 4.7% 12 Community-based services include intermediate care facilities for mentally retarded known as ICF-MR and the Community Alternative Program for Developmental Disabilities known as CAP-MR/DD. State Plan 2006: Analysis of State Plans 2001-2005 25 North Carolina DHHS - DMH/DD/SAS Figure 3. SFY 2006 Funding of the Public MH/DD/SAS System by Setting Division State Operated Facilities $558,500,000 23.9% Division Central Administration $35,700,000 1.5% Community- Based Public Services $1,742,800,000 74.6% State Plan 2006: Analysis of State Plans 2001-2005 26 North Carolina DHHS - DMH/DD/SAS This page left blank intentionally. State Plan 2006: Analysis of State Plans 2001-2005 27 North Carolina DHHS - DMH/DD/SAS Chapter 6. Performance Goals and Accountability for Effectiveness and Costs The primary goal of the community-based system is to provide effective mental health, developmental disabilities and substance abuse services and supports. Effective means that the services and supports produce the desired outcomes for individuals using best practices within the resources available. Achievement of this goal requires setting performance standards and measuring progress on a regular basis. This provides a feedback loop to for continuous improvement of the system. There are two types of performance goals: (1) outcomes for individuals served by the system, and (2) measures of how well the system is operating on an ongoing basis. By setting performance goals and monitoring progress, adjustments can be made over time to increase the quality of the service system. Using person-centered thinking, outcomes for consumers focus on what is important to the consumer, such as recovery, health, independence, community inclusion, safety, social support, housing, employment, daily activities and justice. System performance goals focus on what is important for the consumer, such as use of best practice models of care, person-centered planning, ease of access, choice of quality providers and continuous improvement of services. The first semi-annual Statewide System Performance Report for SFY 2006-2007 published October 2006 provides progress in both consumer outcomes and system performance. See the Division’s web site for a copy of this report.13 Effective Outcomes for Consumers and their Families On a personal level, consumer outcomes are tied to the goals of each consumer’s person-centered plan. These goals are defined by the individual and family members with the assistance of the professional staff of the system and written in the consumer’s person-centered plan. Assessment of progress toward those goals is made by those same people on a periodic basis. Success depends on the participation of the consumer and the quality of the professional services and supports provided. See the discussion of person-centered planning in chapter 8. 13 See the Division’s web site at: http://www.dhhs.state.nc.us/mhddsas/. State Plan 2006: Analysis of State Plans 2001-2005 28 North Carolina DHHS - DMH/DD/SAS On an aggregate level, consumer outcomes are defined by domains that are important to all individuals to enable control over one’s life, such as: · Safe stable housing. · Supportive relationships. · Meaningful daily activities. · Emotional well-being. · Justice. · Employment. · Respectful inclusion in a community of choice. · Freedom from addiction and disruptive symptoms. Such outcomes are identified by the State so it can determine how well all consumers are being served by the system. These outcomes are based on the National Outcome Measures being developed by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) and the Quality Framework developed by the federal Centers for Medicare and Medicaid Services. (Both of these are addressed in table 1.) Such consumer outcomes enable the State to assess the success of its service delivery system in comparison with other states and with national standards. Outcomes for consumers with diagnoses of mental illness and/or substance abuse are measured by the North Carolina Treatment Outcomes Program Performance System (NC-TOPPS). This system, initially implemented in 1995, was expanded in July 2005 to include all mental health and substance abuse consumers ages six and above.14 Initial data show that mental health and substance abuse consumers show marked improvement in a variety of areas after three months of treatment. Outcomes for consumers with a developmental disability are measured through the National Core Indicator Project. The national reports prepared by the Human Services Research Institute (HSRI) compare the data from participating states.15 North Carolina participates in the project through interviews with a sample of consumers and surveys of parents and guardians. Overall, North Carolina performs as well as or better than other states in measures for consumers with developmental disabilities’ participation in community life and meaningful activities. Consumers’ perceptions of their progress toward personal goals and the quality of the services they receive are critical barometers of the effectiveness of the service system. National Core Indicators Project surveys provide consumers and family members’ views for evaluating service quality. For consumers of mental health and substance abuse services, the State uses the Consumer Survey developed by the national Mental Health Statistical Improvement Project (MHSIP) and sponsored by SAMHSA.16 Both of these surveys allow rough comparisons to other states, in which North Carolina generally performs similarly to national averages. 14 A report of results for SFY 2005-2006 NC-TOPPS can be found at the following web site: http://www.ndri-nc.org/nc-topps_research_feedback.htm#0506 15 More information about Core Indicators is available at: http://www.hsri.org/nci/index.asp?id=reports. 16 See the annual consumer satisfaction reports for State fiscal years 2000 through 2003 on the Division’s web site at: http://www.dhhs.state.nc.us/mhddsas/statspublications/reports/index.htm State Plan 2006: Analysis of State Plans 2001-2005 29 North Carolina DHHS - DMH/DD/SAS System Performance Achievement of consumer outcomes depends on a service system that is operating with optimal efficiency and effectiveness. Quality Management System performance and service outcomes are basically quality management issues. Attention to quality must be integrated throughout the entire system with the participation of all stakeholders in designated roles. Quality management at all levels of the system includes specification of desired outcomes, identification of outcome indicators and measures, monitoring of service provision, development of measurement tools, data collection, periodic reporting of progress on key indicators of quality, review of information by management staff for decision making, evaluation of system performance, and use of data for focusing quality improvement efforts and quality assurance plans. Performance standards of the system are based on: · Federal and State statutes, rules, regulations, licensing and policies. · Memoranda of understanding and contracts among State agencies. · Requirements of national performance expectations. · Goals of State reform. System performance includes such issues as how quickly and effectively the local system responds to the needs of people, how well the system is managed and how well it meets quality standards. For example, how well does the system respond: · When an individual calls for the first time. · When a consumer is experiencing a crisis. · To develop a person-centered plan. · To stay within available resources. · To develop needed service capacity. · With fidelity to best practices. · To protect safety and rights. The DHHS – LME Performance Contract Performance standards for local system operations are contained in the performance based contract between the State and the local management of the system. In 1999, the performance contract process replaced the annual memorandum of agreement that was signed by each area authority/county program and the Division. This change demonstrated the Division’s focus on greater accountability for effectiveness and funding invested in the system by the General Assembly and the federal government. The process encourages a business relationship between the Division and local management entities by outlining specific requirements geared toward major program State Plan 2006: Analysis of State Plans 2001-2005 30 North Carolina DHHS - DMH/DD/SAS outcomes and standards for operations. The Division routinely monitors area authority/county program's fulfillment of the performance requirements. The current performance contract includes requirements for: · General administration and governance. · Access, triage and referral. · Service management. · Provider relations and support. · Customer services and consumer rights. · Quality management and outcomes evaluation. · Business management and accounting. · Information management, analysis and reporting. The Division publishes quarterly reports showing the progress of area authorities/county programs in satisfying the requirements.17 In November 2006, the Division will publish the first quarterly report on key indicators of local performance. Long-Term System Goals The Division may also set long-term goals for system operation or outcomes. By definition these are goals that cannot be accomplished in one or two years. Such goals may focus on implementation of aspects of the transformed system, such as downsizing the state facilities. Long-term goals may also be based on broad consumer outcomes such as reducing the number of children who start smoking cigarettes. Ultimately, long-term goals focus on the overall impact the service system has on the personal lives of children, families and adults. Further, these outcomes have an impact on the health and safety of the ir communities and on the health of the state. Service Monitoring System reform allows for a local and State partnership for monitoring the quality and appropriateness of mental health, developmental disabilities and substance abuse services through regular monitoring visits, review of critical incident reports and the aggregation of statewide data for trend analysis. Staff of the Division are responsible for performing independent complaint investigations and monitoring of all components of the public mental health, developmental disabilities and substance abuse services system. Local management entities are responsible for monitoring service providers in their catchment area. This monitoring – local and State – serves to assure that the funding appropriated for mental health, developmental disabilities and substance abuse services and supports is spent appropriately, and that consumers of services receive the highest quality care, in the most appropriate setting and in accordance with best practice. 17 Performance contract and quarterly progress reports can be seen on the Division’s web site at: http://www.dhhs.state.nc.us/mhddsas/performanceagreement/index.htm State Plan 2006: Analysis of State Plans 2001-2005 31 North Carolina DHHS - DMH/DD/SAS Public accountability is embedded in the overall system reform process – from initial planning for service delivery and administration through the actual delivery of services, follow up, monitoring and contracting. As the system has evolved, a clear and unbroken “chain of accountability” has emerged. This involves a public partner relationship between the leadership, support and oversight role of the State system and the management of public policy role of the local public system. In turn, a public-private partnership emerges between the local management of the system and providers of services. Additionally, the system continues to develop a more effective and efficient set of regulatory compliance requirements as system performance and consumer outcomes act as critical drivers of improvement efforts. The specification of performance standards provides a clear direction for system operations year after year. Further, clear measures of performance must be specified as part of the standards. These measures must be included in the performance-based contracts between the State and local management entities and between a local management entity and providers of services. The measures allow the means for recognizing how far the public mental health, developmental disabilities and substance abuse services system has come and where it needs to go next. State Plan 2006: Analysis of State Plans 2001-2005 32 North Carolina DHHS - DMH/DD/SAS This page left blank intentionally. State Plan 2006: Analysis of State Plans 2001-2005 33 North Carolina DHHS - DMH/DD/SAS Chapter 7. The Local Management of the System This element of the system provides for a single point of accountability for the performance of the system at the local level. In the North Carolina system, the area authority or county program18 must be certified by the Secretary of the Department of Health and Human Services to perform as a local management entity. The reform legislation obligated each county to decide on the form of local governance for management of mental health, developmental disabilities and substance abuse services. While a county can be part of an area authority, a single county program, or part of an inter- local agreement, the function of these organizations as local management entities is the same. Once established and certified, each public program is referred to as a local management entity or LME – a collective term that refers to the purpose and functional responsibilities of the public agency rather than describing its governance structure. In HB 381, area authorities and county programs were directed to become local management entities. Public services previously delivered directly by area authorities or county programs were to be divested to private providers. As the system transformation has progressed, it has been discerned that certain services are at times most efficiently and effectively delivered by the local management ent ity. In these cases, local management entities have returned to the provision of a narrow range of discreet services such as psychiatric care. In addition, legislation allows that an area authority or county program may relinquish its local management entity functional responsibilities and contract to provide services as long as that public program meets all provider qualifications and fair competition is practiced by the local management entity.19 In managing services, local management entities are expected to perform a series of functions sometimes not previously expected of the area authorities and county programs. These responsibilities include, but are not limited to: · Ensuring access, screening, triage and referral through a uniform portal of entry. · Utilization review and management. · Increased monitoring of services and providers. · Understanding community-based services and supports, as well as identifying service gaps. · Recruiting and endorsing as well as contracting with providers. · Establishing, supporting and working with a local Consumer and Family Advisory Committee. 18 General Statute 122C-3 defines “area authority” as the area mental health, developmental disabilities and substance abuse authority. A “county program” means a mental health, developmental disabilities and substance abuse services program established, operated and governed by a county pursuant to G.S. 122C-115.1. 19 See article 20 of NCGS 160A. State Plan 2006: Analysis of State Plans 2001-2005 34 North Carolina DHHS - DMH/DD/SAS The original State Plan 2001 contemplated full transformation to the system of local management entities by July 1, 2003. Currently, the number of area and county authorities has been reduced from 39 to 30 local management entities. In addition, each area authority or county program must respond to the requirements of its governance bodies. Local Business Plans (LBP) In order to achieve the transformation from service provider to management of services, the State Plan established a process and schedule for certifying newly created local management entities (LMEs). This process included the statutory requirement that counties develop local business plans for implementing and managing the transformed community behavioral healthcare system. The local business plan describes characteristics of the local management entity's catchment area, including the client base and service gaps, as well as addressing specific implementation of local management entity functions.20 The Secretary of the Department is responsible for the approval (or disapproval) of each three-year local business plan and certifying each local management entity. Once certified, the local management entity has a relations hip that is legally formed through a performance-based contract between the Department of Health and Human Services and the local management entity. The local management entities submit to the Division quarterly progress reports about their local business plans. In addition to addressing the targets of its local business plan, the local management entity must indicate actions taken in response to the Division’s communication bulletins. The Division is currently in the process of developing the format and content requirements of a revised three-year local business plan template. This template will specify the functions and activities of each local management entity for which the Division will provide funding. Each local management entity must develop their revised plan based on this template and submit it to the Secretary of the Department by March 31, 2007 for implementation on July 1, 2007. The DHHS - LME Performance Contract During State fiscal year 2005, the Department of Health and Human Services (including its divisions of Mental Health, Developmental Disabilities and Substance Abuse Services, Medical Assistance and the Office of the Controller), the N.C. Council of Community Program and the N.C. Association of County Commissioners (NCACC) negotiated a 20 See the Division’s Communication Bulletin #002 entitled “Local Business Plan Submission and LME Certification” and Communication Bulleting #004 entitled “Housing Resource Development and Local Business Plans.” State Plan 2006: Analysis of State Plans 2001-2005 35 North Carolina DHHS - DMH/DD/SAS statewide performance contact between the Department and the LMEs.21 This contract, which is anticipated to develop over time, currently contains each local management entity’s local business plan as the scope of work, statewide requirements, performance measures and financing requirements. Division staff worked with each local management entity to incorporate its local business plan into the final contract and secure signatures. While the contract did not address all issues that various stakeholders wished to see included, the Department and local management entities are committed to working on a development plan that will add requirements to the contract over the next several years as local management entities continue to transition to their role of managers of service and public policy at the local level. Core Functions of a Local Management Entity General Statute 122C-115.4 defines the primary functions of a local management entity to be: · Access for all citizens to core services, including 24/7/365 screening, triage and referral process and a uniform portal of entry into care. · Provider endorsement, monitoring, technical assistance, capacity development and quality control. · Utilization management/review and determination of the appropriate level and intensity of services, including review and approval of person-centered plans for consumers who receive State- funded services and concurrent review of person-centered plans for consumers who receive Medicaid funded services. · Authorization of the utilization of State operated services and authorization of eligibility determination requests for recipients under a CAP-MR/DD waiver. · Care coordination and quality management including the direct monitoring of the effectiveness of person-centered plans. · Community collaboration and consumer affairs, including a process to protect consumer rights, an appeals process and support of an effective consumer and family advisory committee.22 · Financial management/accountability for the use of State and local funds and information management for the delivery of publicly funded services. Session Law 2006-66, Senate Bill 1741, Section 10.32.(a) states that the Department of Health and Human Services shall allocate funds to LMEs to implement the functions described above. Access, provider endorsement and utilization review are described in the following sections. The review and monitoring of person-centered plans is discussed in chapter 8. 21 See Division’s Communication Bulletin #023 DHHS/LME Contract. 22 See the Division’s Communication Bulletin #038 (FINAL) “Policy for Consumer Complaints to Area/County Programs.” State Plan 2006: Analysis of State Plans 2001-2005 36 North Carolina DHHS - DMH/DD/SAS Access, Uniform Portal, Screening, Triage and Referral A critical component of the system reform effort includes establishing statewide consistency regarding access to services. Access is the method(s) through which individuals can enter a health care delivery system. The probability of an individual's entry into the health care system is influenced by the structure of the delivery system itself and the nature of the potential consumer’s wants, resources and needs. Uniform portal is a term used to describe a set of standardized processes and procedures that ensures that people throughout the state are provided consistent access. The pathways to access (screening, triage, referral, and emergency services) provide the framework for uniform portal activities. There are many access points in a community; however, standards must be consistent. The concept of “no wrong door” establishes the expectation that people are able to directly enter the mental health, developmental disabilities and substance abuse services system through different access points using the same process of screening, triage and referral. Screening is a brief standardized appraisal of an individual who is not currently being served within the system in order to determine: · The nature of the individual’s problem (that is whether the individual has a mental health, developmental disability or substance abuse need). · The individual’s level of need for services and supports. The screening process is not an evaluation or assessment. It is a structured interview conducted by a qualified professional either face-to- face or by telephone. During the interview the process determines provisionally whether the individual may meet the criteria for a target population and where and how the individual should enter the system. Basic financial and clinical information is gathered to determine the types of benefits for which the individual qualifies. Triage is the process for determining the level of the person’s need (that is if it is emergent, urgent or routine). Referral is the procedure by which the screening professional and the consumer choose a clinically appropriate provider and facilitate the consumer’s successful contact with that provider so that services can be initiated. The Division is currently implementing a standardized screening, triage and referral (STR) process that is used whether the individual first contacted the local management entity, a service provider or another agency. The service need, array of services and a list of potential providers are discussed with the individual so that a referral can be made to a service provider of the individual’s choice.23 23 See the Division’s Enhanced Services Implementation Update # 014 entitled “Uniform Screening and Registration.” State Plan 2006: Analysis of State Plans 2001-2005 37 North Carolina DHHS - DMH/DD/SAS One of the advantages of having a standardized system is to help create a statewide database system that will be able to track services requested, services received and service gaps. Such a statewide data system can reduce duplication of effort in the information gathering and tracking process. Another significant benefit is minimizing the number of times that an individual needs to provide personal information. Historically, access to the service system was not readily available 24-hours-a-day, seven-days-a-week (24/7/365) in all areas of the State. Much progress has been made over the last five years to ensure that access to services is standardized, reasonable, culturally sensitive and available 24-hours-a-day, seven-days-a-week through access and/or crisis phone lines or face-to-face. Ultimately, the Division intends to: · Continue to design and shape the statewide system of uniform portal (standardized process of access to services). · Monitor and strengthen access system performance indicators included in the quality management system for statewide reporting. · Refine reporting procedures regarding access – access reporting received quarterly and reported on statewide tracking reports. · Develop and issue periodic contract performance reports. Endorsement of Providers During SFY 05-06, a standardized process for endorsement of all providers of Medicaid covered enhanced benefit services was implemented.24 The purpose of this endorsement process is to assure that individuals receive services and supports from provider organizations that comply with State and federal laws and regulations and provide services in a manner consistent with the Division’s reform plan and the State Medicaid Plan. The endorsement process provides local management entities with objective criteria to determine the competency and quality of providers of approved Medicaid services. Endorsement by a local management entity and enrollment by the Division of Medical Assistance as a Medicaid provider is carried out on a service and site specific basis. The 24 See Communication Bulletin # 37: Provider Endorsement; Communication Bulletin # 44: Final Policy- Provider Endorsement; and Communication Bulletin # 47: Provider Endorsement Transition Plan; Communication Bulletin # 49: Letter of Support (Providers applying for licensure for a residential facility are required to seek a letter of support form the LME); Communication Bulletin # 55: New Phases for Provider Endorsement: Policy Amendment for Conditional Endorsement; Enhanced Services Implementation Update Memo # 1: CMS approval of Medicaid State Plan Amendment (SPA) to implement the Enhanced Benefit Services proposed under the Rehabilitation Option. (Provider Endorsement); Enhanced Services Implementation Update Memo # 6: Consumers’ Choice of Providers, Subcontracting, Caseload Ratios, & Questions and Answers. State Plan 2006: Analysis of State Plans 2001-2005 38 North Carolina DHHS - DMH/DD/SAS process is required for all enhanced benefit services prior to a provider being directly enrolled in the Medicaid program through the Division of Medical Assistance. As of June 20, 2006 the services of a total of 1,515 providers had been endorsed and directly enrolled with Medicaid as required. Utilization Management for State funds A significant component of North Carolina’s mental health, developmental disabilities and substance abuse services system is the process to regulate the provision of services in relation to the capacity of the system and the needs of consumers. The system’s overall strategy for managing service use by individuals and by the system as a whole was described in State Plan 2003 as including the functions of: · Eligibility determination. · Medical necessity. · Person-centered plan authorization. · Utilization review. This process ensures that services are necessary, appropriate and cost effective through pre-authorization of services for individuals, evaluation of the need for continued services and extended authorization as determined by that evaluation. 25 State Plan 2005 clarified that the process is intended to guard against under-utilization as well as over-utilization of services to assure that the frequency and type of services fit the needs of consumers. It is typically an externally imposed process based on clinically defined criteria. Such a decision- making process requires standards and criteria to ensure the most efficient and effective use of finite resources. From the beginning of reform, the Division’s intention has been to provide State-defined standards and criteria for utilization review and service authorization. Standardized criteria fall into three categories: Medicaid funded services, state funded services and utilization of the state psychiatric hospitals and other state facilities. · Criteria are specified in the State Medicaid Plan as part of the definition of each Medicaid funded service. The Division of Mental Health, Developmental Disabilities and Substance Abuse Services and the Division of Medical Assistance developed new and revised service definitions that are based on best practice and evidence based approaches to address the needs of consumers. These definitions were approved by the federal Centers for Medicare and Medicaid Services in December 2005 and became effective in March 20, 2006. Each definition specifies utilization criteria including entrance and continued stay criteria and provides information about the frequency or intensity of service that has been shown to lead to positive outcomes. 25 See the Division’s Enhanced Services Implementation Update #11, “Utilization Review.” State Plan 2006: Analysis of State Plans 2001-2005 39 North Carolina DHHS - DMH/DD/SAS The two divisions continue to work together to manage the utilization of Medicaid funds. · The Division is developing criteria for State- funded services with the assistance of a consultant to be finalized during State fiscal year 2007. The Division will ensure that State- funded services are defined in a way that is consistent with the State Medicaid Plan and best practices.26 · State Plan 2003 stated that utilization of the four state psychiatric hospitals would be determined based upon a Division approved bed day allocation plan. Through this plan, bed days would be allocated to each local management entity in the following categories: adult admissions, adult long-term, geriatric admissions and adolescent admissions. Each local management entity’s initial bed day allocation was based on its historical utilization during State fiscal years 2000 - 2002. State Plan 2004 implemented a revised bed day allocation stating that over the following three years, the number of bed days allocated for psychiatric beds tracks the downsizing schedule, so that fewer bed days are available after closure of beds at the end of the previous year. In addition, the basis for allocation of bed days changed from historical utilization to the popula tion of the local management entity. Accreditation of Local Management Entities Both local management entities and providers of mental health, developmental disabilities and substance abuse services are being required to achieve national accreditation by established accreditation agencies known for values and standards that support the direction of mental health, developmental disabilities and substance abuse services reform. 27 The requirement for national accreditation of local management entities has been in place since the current State and local management entity performance contract went into effect. The accreditation required of local management entities is different from the accreditation that was required of the area authority/county programs under the mental health, developmental disabilities and substance abuse services system prior to reform. The previous accreditation required was based on the role of area authorities and county programs as service providers rather than the current role as system managers. 26 See the Division’s Communication Bulletin #54 Standardized contract for State-funded Services, Guidance on Provider Billing requirements and Excel Billing Format. 27 See the Division’s Communication Bulletin #036 entitled “Approved List of Organizations Who (a) May Accredit Providers of MH/DD/SA Services, and (b) May Accredit LMEs for System Management”, and Communication Bulletin #050, entitled “Approved List of Agencies Who (a) May Accredit Providers of MH/DD/SA Services, and (b) May Accredit LMEs for System Management”. State Plan 2006: Analysis of State Plans 2001-2005 40 North Carolina DHHS - DMH/DD/SAS Accreditation required under reform is intended to assure the State that the local management entity is qualified as a systems manager. Rules are being written that will establish this requirement in administrative code. The requirement for national accreditation for providers of mental health, developmental disabilities and substance abuse services is established currently in the individual service definitions for the services that they provide. Building Community Capacity Key strategies for funding the development of community capacity include the downsizing of institutions and the transfer of institutional funding to the community. In order to successfully implement the downsizing plan for the psychiatric hospitals, the Division works with local management entities to develop sufficient community capacity to serve long-term residents of the hospitals. In addition, the Division is currently focused on transitioning residents to the community based on Olmstead plans.28 In building community capacity, a key element is housing. Expanding the availability of decent, safe and affordable housing for persons with mental illness, developmental disabilities and/or substance use disorders is an area where it is necessary to target resources – staff time, technical expertise and investment.29 Where individuals live is not an issue that can be addressed in isolation. It is directly related to the service system’s capacity to provide the depth and range of community based services needed to support persons with disabilities in the community. The housing needs of consumers of mental health, developmental disabilities and substance abuse services must be addressed with a range of housing and residential models. The pure supportive housing model with scattered sites and independent units with access to flexible support services tailored to individual needs and preferences is a recognized model of best practice. As described in chapter 5, the Division has contracted for the development of a long-term planning model that identifies gaps in services capacity and assesses alternative strategies for building capacity in the State. A final report will be presented to the Legislative Oversight Committee in December 2006. Provider Action Agenda In the fall of 2005, the Division Director initiated an accelerated focus on the provider system with an invitation to all providers to complete a web-based survey on the challenges facing them. Over 500 providers responded. The survey was followed up 28 See the Division’s Communication Bulletin #026 entitled “Draft 1915(c) Home and Community Based Waiver.” 29 See Communication Bulletin #004 Housing Resource Development and Local Business Plans. State Plan 2006: Analysis of State Plans 2001-2005 41 North Carolina DHHS - DMH/DD/SAS with two provider summits that enabled discussion between Division management and providers about the primary themes identified from the survey. As a result, the Division has established a Provider Action Agenda Committee with the overall goal to strengthen and enhance the provider community for the direct benefit to individuals and families who receive services. The committee has three primary objectives: · Standardization - The identification of additional areas of needed standardization. · Regulations and Reporting - An inventory of potentially overlapping regulation and reporting requirements. · Provider Improvement - Collaboration and support for provider initiatives such as provider fairs, small business technical assistance and identification of training needs. State Plan 2006: Analysis of State Plans 2001-2005 42 North Carolina DHHS - DMH/DD/SAS This page left blank intentionally. State Plan 2006: Analysis of State Plans 2001-2005 43 North Carolina DHHS - DMH/DD/SAS Chapter 8. The Delivery of Services Service delivery is the means by which the needs of people are met. The reform legislation clearly states expectations for the delivery of mental health, developmental disabilities and substance abuse services. It requires a continuum of services that is: · Community-based. · Regional as needed. · Based on best practices. · Recovery oriented. · Participant driven. · Cost-effective. · Prevention focused. · Performance based. A delivery system must include a pathway for any consumer to follow that will lead to a reduction or stabilization of problems and increase the ability ofa consumer to live successfully in the community. The general pathway or flow chart shown in figure 2 is the most likely way to produce the desired outcomes within a reasonable time at justifiable cost. Local management of the system must be concerned consumer-by-consumer because success for individual consumers is the way to achieve overall system performance. The professional staff that provides the clinical home for the consumer assists in the development and monitors the consumer’s person-centered plan. Data is required to determine and communicate the success or failure of implementing that plan as the individualized path for each consumer. To make the pathway more reliable, the system must have ways to detect “dropouts” or other ways in which the system fails to engage the consumer, so corrective action can be taken to ensure success for each consumer. Together, the providers of services and the local management entity build the success of the system for individual consumers and across all consumers served locally. To meet the needs of consumers in the most effective means, the legislature directed the State to provide services that are evidence-based or best practices. The assistance of researchers and experts in the fields of mental health, developmental disabilities and substance abuse are essential for the identification and recommendations of such practices to the Division. If selected as a best practice that Division management wants to implement, the Division must obtain approval from the Division of Medical Assistance and the federal Centers for Medicare and Medicaid Services (CMS) to include the practice as part of the enhanced benefit service package. State Plan 2006: Analysis of State Plans 2001-2005 44 North Carolina DHHS - DMH/DD/SAS Figure 4. General Flow Chart for New Consumers Access: 24 / 7 Initial Contact with the LME/Provider Telephonic or Face to face (uniform portal) MH/DD/SA problem? NO YES Triage: Emergent? Referral: another community service Member of a target population? NO Medicaid eligible? Directly enrolled provider for BASIC BENEFITS Crisis services Clinical evaluation 23-hour observation Community hospital ER Mobile crisis unit Detox (4 levels) Facility based crisis Brief intervention Inpatient hospitalization YES = Client Choice = Utilization review & authorization required NO YES Emergent = initiated w/in 1 hr. Face to face within 2 hrs. of contact UR UR NO YES Screening Basic demographics Brief clinical history Financial eligibility Rights & Consents Encourage LME to start natural community supports and/or county funded community-based programs 6/26/05 DMH/DD/SAS Diagnostic Assessment Community Support/Targeted Case Management Provider selected Person-Centered Plan UR including crisis plan Crisis services per crisis plan Enhanced Benefits per Person-Centered Plan Community Support, ACTT, or Targeted Case Management services Adult MH services Adult DD services Child MH services Child DD services Adult SA services CAP-MR/DD Child SA services ICF-MR State operated facility services and other services Natural& community supports Urgent = appt. within 48 hrs. Routine = appt. within 7 days State Plan 2006: Analysis of State Plans 2001-2005 45 North Carolina DHHS - DMH/DD/SAS Person-Centered Planning Person-centered planning is the process of determining the real- life outcomes that are important to individuals and of developing strategies to achieve those outcomes. The process supports strengths and recovery and applies to everyone supported and served in the system. Person-centered planning provides for the individual with the disability to assume an informed and in-command role for life planning and for treatment, service and support options. The individual with a disability and/or the legally responsible person directs the process and shares authority and responsibility with system professionals about the decisions made.30 The concept of person-centered planning and comprehensive care is the foundation of all system reform efforts and best practice models for individuals in need of mental health, developmental disabilities, and/or substance abuse services according to the President’s New Freedom Commission (see table 1). The national movement has included person-centered planning practices into the design and implementation of individualized services with consumers and their families. Equally so, the Division has established person-centered planning as a fundamental element in the reform of mental health, developmental disabilities and substance abuse service system. There has been much to suggest that a focus on person-centered planning will play an essential role in ensuring the positive experience of recovery and resilience for consumers and family members.31 The Division’s efforts to design and implement a system of person-centered planning are based on the following principles: § Person-centered planning builds on the individual’s and family’s strengths, gifts, skills and contributions. § Person-centered planning supports consumer empowerment and provides meaningful options for individuals and their families to express preferences and make informed choices in order to identify and achieve their hopes, goals and aspirations. § Person-centered planning is a framework for providing services, treatment and supports that meet the individual’s needs and that honors goals and aspirations for a lifestyle that promotes dignity, respect, interdependence, mastery and competence. § Person-centered planning supports a fair and equitable distribution of system resources. § Person-centered planning processes create community connections. They encourage the use of natural and community supports to assist in ending isolation, disconnection and disenfranchisement by engaging individuals and their families in the community, as they choose. 30 See the Division’s Communication Bulletin #034 entitled “Person-Centered Planning,” and Enhanced Services Implementation Updates #1 “CMS Approval of Medicaid State Plan Amendment to Implement the Enhanced Benefit Services Proposed under the Rehabilitation Option (Person-Centered Plans), #8 “Person-Centered Plan”, and #11 “Person-Centered Planning Template.” 31 See the Division’s Enhanced Services Implementation Update #4 “Transition of Services Authorization, Service Orders, Additional Crosswalks,” and #11 “Service Orders.” State Plan 2006: Analysis of State Plans 2001-2005 46 North Carolina DHHS - DMH/DD/SAS § Person-centered planning sees individuals in the context of their culture, ethnicity, religion and gender. All the elements that compose a person’s individuality are acknowledged and valued in the planning process. § Person-centered planning supports mutually respectful and partnering relationships between providers/professionals and individuals/families, acknowledging the legitimate contributions of all parties. In March 2005, the Division announced guidelines for person-centered planning.32 These guidelines address the underlying values and principles, the essential elements, the required documentation elements and indicators to demonstrate that person-centered planning has occurred.33 One of the essential elements of the person-centered plan is a crisis plan. Information is to be included concerning proactive steps to prevent crisis from occurring, and processes or procedures to be followed should a crisis event or emergency situation occur. In April of 2006, person-centered planning became a fundamental part of implementing North Carolina’s new service array for people receiving mental health, developmental disabilities and substance abuse services.34 A standardized format and instructions for developing a person-centered plan (PCP) were distributed for all providers who facilitate plan development for consumers receiving enhanced benefit services. The required standardized format was designed to align with the approved utilization review and authorization processes. The implementation of this person-centered plan and its components has set the stage for influencing and supporting person-centered thinking and planning for all individuals being served in the system. Array/Continuum of Services The continuum of services includes private sector services, community-based public sector services, regionally-based public sector services, and State operated facility services. Ongoing development of local capacity to provide services is a task of the local management entity and, in the long run, will enable the reduced use of state facilities. At the same time, upgrading or replacement of aging state facilities is necessary for those consumers whose needs are beyond the cost-effectiveness at every local level. There are a considerable number of Division publications that address the service array, including communication bulletins and enhanced services implementation updates.35 Refer to those documents for detailed policy and guidance. 32 See the Division’s Communication Bulletin #034. 33 See Enhanced Services Implementation Update Memo # 12: Value Options Implementation; and Enhanced Services Implementation Update Memo # 15: Targeted Case Management and Services Authorization through Value Options. 34 See the Division’s Enhanced Services Implementation Update # 8. 35 See Communication Bulletins and Enhanced Services Implementation Update Memos for additional details on the Division’s web site: http://www.dhhs.state.nc.us/mhddsas/announce/index.htm State Plan 2006: Analysis of State Plans 2001-2005 47 North Carolina DHHS - DMH/DD/SAS Services for People with Developmental Disabilities The services for people with developmental disabilities include an array of habilitation and support services that are available to individuals who qualify for the level of services referred to as Intermediate Care Facilities – Mentally Retarded (referred to as ICF-MR) that are funded by Medicaid. Eligible individuals, who choose community services rather than in an ICF-MR facility, may receive services that are funded by the Community Alternative Program for Developmental Disabilities. This is most often referred to as the CAP-MR/DD waiver. The CAP-MR/DD waiver offers specific services that promote community living and thereby avoid institutionalization. Waiver services compliment and/or supplement services available through the State Medicaid Plan and other State, local and federal programs.36 North Carolina’s most recent Community Alternative Program for Developmental Disabilities waiver went into effect in September 2005. The specific services that an individual receives under the waiver are based on the person-centered planning process and the identification of the individual’s needs. Examples of the types of service that an individual might receive include Day Supports provided in a licensed day setting, Home and Community Supports provided in an individual’s home or in the community, Personal Care and Respite. Other services include tangible supports such Augmentative Communication Devices, Home Modifications and Vehicle Adaptations. Individuals who receive waiver funding and live in licensed residential settings such as a group home are supported under the service definition of Residential Supports to meet their habilitation needs in the residential setting. State funds are also used in these settings to address some support, supervision and care needs. Targeted Case Management is a required service for individuals participating in the waiver. These case managers provide a variety of functions to individuals on the waiver including facilitation of the person-centered planning process and identification of needed waiver services, locating and coordinating those services, as well as monitoring of services to assure services are delivered appropriately to insure the health and safety of the waiver recipient. For individuals who do not meet the ICF-MR level of care and/or are not CAP-MR/DD waiver recipients, there are a variety of State- funded services. These services are available to individuals who are ineligible for Medicaid and are not CAP recipients, or to individuals who receive Medicaid but are not CAP recipients. Some State-funded 36 For more about the CAP-MR/DD Waiver, see the Division’s Communication Bulletins: # 024: CAP/MRDD Waiver Team. # 042: Revised Implementation for New CAP-MR/DD Waiver. # 045: Approval of CAP-MR/DD Waiver. And Enhanced Services Implementation Update Memos: # 2: CAP-MR/DD Waiver. # 13: CAP-MR/DD. # 15: CAP-MR/DD and Targeted Case Management. State Plan 2006: Analysis of State Plans 2001-2005 48 North Carolina DHHS - DMH/DD/SAS services are available to individuals who are CAP recipients to pay for things the waiver does not cover, such as room and board in a group home. Services for Children and Adolescents with Mental Health or Substance Abuse Needs The new and revised services that were approved for both Medicaid covered services and for State funding include Community Support services that are often a consumer’s clinical home. Interventions that are delivered by Community Support providers include coordination of assessments, the involvement of the child and family team in developing the individual’s person-centered plan and the functions of linking the child and his/her family with other needed services or resources. In addition, Community Support providers can provide, for example, training for caregivers, preventive and therapeutic activities that will assist with skill building and development of skills that enable the child and family to have positive relationships with others. Examples of other more intensive services for children and adolescents that were made available in March 2006 are Intensive In-Home Services and Multisystemic Therapy (MST), Day Treatment and Substance Abuse Intensive Outpatient services. Several types of residential treatment continue to be available at varying levels of support and intensity. The delivery of services for individual children and adolescents is based on person-centered planning by a child and family team.37 The organizing principle for these services is for communities to have a “system of care.” The purpose of a system of care is to make comprehensive, flexible and effective support available for children, youth and families throughout the community and through this assistance make the community a better place to live. Services for Adults with Substance Abuse Service Needs The enhanced services implemented in March 2006 include a full continuum of substance abuse services based on the levels of care recognized by the American Society of Addiction Medicine. The service continuum includes Community Support, Mobile Crisis Management, Substance Abuse Intensive Outpatient Program, Substance Abuse Comprehensive Outpatient Program, Residential Treatment services and Detoxification services. Consumers are able to move from level of care to another base on their level of need and medical necessity. These services are designed to assist individuals with a primary substance abuse disorder to achieve positive life outcomes that support stable and ongoing recovery. 37 See Enhanced Services Implementation Update Memo # 3: Crosswalk from Old Services to New and Children’s Services Issues; Enhanced Services Implementation Update Memo # 5: Developmental Therapy; and Enhanced Services Implementation Update Memo # 11: Children’s Residential Treatment Facility Services/EPSDT. State Plan 2006: Analysis of State Plans 2001-2005 49 North Carolina DHHS - DMH/DD/SAS Services for Adults with Serious Mental Illness As is the case for children and adolescents, the Community Support service is the clinical home for many adults. Other adults may receive more intensive community services such as Assertive Community Treatment Team (ACTT) that comprehensively addresses the needs of adults who have had multiple hospitalizations or other serious functional difficulties related to living successfully in the community. Other adults with mental illness who are on the path to rehabilitation and recovery may need services such as Supported Employment, Psychosocial Rehabilitation Day Services, and/or affordable housing with appropriate levels of support from mental health service providers or other community agencies.38 Emergency Services During State fiscal year 2007, the Division will assist local management entities with the development of a model for a continuum for crisis services for both urban and rural areas with the assistance of a consultant. The model will include: · 24/7/365 crisis access to services (telephone, walk- in, mobile response, crisis outreach). · Regional crisis facilities (respite, observation and stabilization units). · Inpatient facilities (with options for voluntary admission to a psychiatric hospital). · Transportation. The development of the continuum will be based upon the findings and recommendations from the Division after conducting an assessment of crisis services and needs throughout the State.39 Prevention, education and consultation House Bill 381 refers to consultation, prevention and education as core services that shall be made available by State and local governments to individuals with mental health, developmental disabilities and substance abuse needs within available resources. The mission of the Division states it will provide the necessary prevention, intervention, treatment, services and supports that individuals need to live successfully in communities of their choice. Prevention programs are reaching a new level of sophistication that includes evidence-based practices, outcome evaluations and cost/benefit considerations. In recent years, developing and delivering prevention services and programs has become a specialty in its own right. 38 See the Division’s Communication Bulletin #007 “Best Practice-Adult Mental Health.” 39 See the Division’s Communication Bulletin #035 entitled “Policy Guidance (Provision of Local Crisis Services), Communication Bulletin #048 “Service Transition Guidance: How to Use Existing Definitions in Transition-Mobile Crisis Management” and Co mmunication Bulletin #061 “Partners for Planning Regional Crisis Services.” State Plan 2006: Analysis of State Plans 2001-2005 50 North Carolina DHHS - DMH/DD/SAS Prevention implies taking advance measures against something possible or probable. Within the Division, prevention may be designed to inform and teach individuals, various groups or the population at large about the insights and skills related to healt hy living. Prevention may also support policies that prevent undesired consequences, such as death or injury due to driving while intoxicated. Local business plans must address how prevention will be provided in the catchment area. Education is defined as a practice of developing mentally, morally or aesthetically, especially by instruction or to provide with information. Within the Division, education is designed to inform and teach various groups including persons being served, families, schools, bus inesses, churches, industries, civic and other community groups about the nature of mental illness, developmental disabilities and substance abuse and the services and supports in the state and community. Local business plans must outline how education will be provided. Consultation is defined as professional advice or services. Within the Division, these services are provided to other agencies, groups, or organizations and to individual practitioners to promote planning and development of services. Training and technical assistance may be offered directly, or by a contracted consultant, regarding the development of practices, tools, and resources. Local management entities may provide consultation to their providers in an effort to maintain continuity. Local business plans must outline how they will provide this service to the community. Past methods of prevention within the Division and its contract providers have mainly focused on substance abuse prevention, working with the federal Center for Substance Abuse Prevention (CSAP) and other nationally known prevention agencies. New prevention and intervention methods are crossing disability categories. The Division is currently developing and creating a comprehensive prevention plan that will be culturally competent, utilize evidence-based techniques and involve best practice. This plan will guide the Division, local management entities, providers, consumers, advocates and other stakeholders to engage in prevention and early intervention practices throughout the State. State Operated Facilities The Department of Health and Human Services has committed to the construction of a new regional psychiatric hospital in Butner, North Carolina. The 432 bed facility will serve persons who need inpatient psychiatric services in both the north and south central regions of the state. Dorothea Dix Hospital in Raleigh and John Umstead Hospital in Butner continue to provide services until remaining patients and admissions can be accommodated in the new facility. Construction is expected to be completed by late summer of 2007. The General Assembly has also approved construction of new facilities to replace Cherry and Broughton Hospitals within the next eight years. State Plan 2006: Analysis of State Plans 2001-2005 51 North Carolina DHHS - DMH/DD/SAS Between State fiscal year 2002 and State fiscal year 2005 the psychiatric hospitals engaged in efforts to downsize. Target reductions were met for skilled nursing and adult long-term units. The number of gero-psychiatric beds was also reduced, although current census exceeds the target capacity. Due to increased admissions and census, no adult admission units have been downsized. Downsizing the hospitals continues to be a goal and the Division is developing a new plan to address further downsizing of the admissions units. The Division is transforming the alcohol and drug abuse treatment centers (ADATCs) to increase acute capacity in order to serve individuals with substance abuse disorders who are involuntarily committed. This increased capacity will divert involuntary substance abuse commitments from the state psychiatric hospitals and provide immediate access for individuals needing inpatient substance abuse treatment interventions. Strategic planning is ongoing with the ADATCs to operationalize their new mission to provide medically monitored detoxification, crisis stabilization and short-term treatment to prepare adults with substance abuse problems for ongoing community-based recovery services. The ADATCs are in the process of implementing a redesigned evidence based treatment model for individuals who require inpatient treatment in order to initiate recovery before returning to ongoing treatment in the community. The Division continues its efforts to downsize the developmental centers by working closely with consumers who are interested in receiving community services, their guardians, local management entities and providers. Specialized programs have been established at the developmental centers to provide time-limited active treatment for individuals meeting specific admission criteria and who have been unsuccessful in the community. The specialized services at the developmental centers have either not been available in the individuals’ home communities or have not been sufficient to meet intensive, complex needs. The goal of the specialized programs is to provide individualized, multi-disciplinary services, while working in partnership with local management entities to prepare individuals for successful transition back to their communities. Practice Improvement Collaborative While a first foundation of services has been approved by the federal Centers for Medicare and Medicaid Services and was implemented in March 2006, the ongoing North Carolina Practice Improvement Collaborative (PIC) continues to monitor research and development of promising best practices for possible adoption by North Carolina. The mission for the Practice Improvement Collaborative is to ensure that each time any North Carolinian comes into contact with the mental health, developmental disabilities and substance abuse services system he or she will receive excellent care that is consistent with the scientific understanding of what works. State Plan 2006: Analysis of State Plans 2001-2005 52 North Carolina DHHS - DMH/DD/SAS Comprised of representatives specializing in all three disabilities, the Practice Improvement Collaborative meets quarterly to review and discuss relevant programs. Annually, the group presents a report of prioritized program recommendations to the Division Director at a public forum. This forum, defined as the North Carolina Practice Improvement Congress, will feature brief educational descriptions of the practices being recommended by the Practice Improvement Collaborative in its report. Workforce Development Early in the process of system reform, the Division recognized that development of the workforce would be a significant and complex issue to ensure the success of transformation. This issue involves professional standards, the requirements of service definitions, determination and measurement of competencies, availability of curricula and educational opportunities, and the development and implementation of strategies to build a statewide workforce. The Division recognizes that workforce development for the system is part of a much greater situation for the entire State. The Division is participating in the Department’s initiative to address workforce issues in all of human services.40 In 2001, the Division identified some specific strategies, such as the establishment of regional training facilities that were later eliminated due to the lack of sufficient Division infrastructure to operate. The 2001 tasks that focused on the reasonable compensation of the workforce have also been deleted because these are beyond the scope of the Department. While the State establishes rates paid for services and requires certain types and levels of training as a compliance measure, market forces actually control the rates paid by private providers to staff. During 2002-2003, initial training was begun along with technical assistance to local management entities in collaboration with the North Carolina Council for Community Programs. Workshops were held on person-centered planning and the new service definitions. In depth training has evolved and is ongoing. The North Carolina Commission for Mental Health, Developmental Disabilities and Substance Abuse Services in conjunction with the Division has undertaken workforce development as a priority initiative for State fiscal year 2007. 40 See Communication Bulletin # 22: Workforce Development Plan (Final); Communication Bulletin # 33: Clinical Skills Series (Faculty Application); Enhanced Services Implementation Update Memo # 1: CMS approval of Medicaid State Plan Amendment (SPA) to implement the Enhanced Benefit Services proposed under the Rehabilitation Option. (Training); and Enhanced Services Implementation Update Memo # 10: Courses which Satisfy the Training Requirements for Service Definitions; and Communication Bulletin # 51: (DRAFT) Cultural and Linguistic Competency Action Plan. State Plan 2006: Analysis of State Plans 2001-2005 53 North Carolina DHHS – DMH/DD/SAS Appendices A. Applicable provisions from legislation. B. Glossary. C. Index to State Plans 2001 through 2005 by topic. D. Detailed tasks and status of tasks from prior State Plans. State Plan 2006: Analysis of State Plans 2001-2005 54 North Carolina DHHS – DMH/DD/SAS State Pla
Object Description
Description
Title | State plan... : blueprint for change |
Date | 2006 |
Description | 2006 |
Digital Characteristics-A | 490 KB; 121 p. |
Digital Format | application/pdf |
Full Text | BLUEPRINT FOR CHANGE Division of Mental Health, Developmental Disabilities and Substance Abuse Services North Carolina’s plan for mental health, developmental disabilities and substance abuse services An Analysis of State Plans 2001 - 2005 North Carolina Department of Health and Human Services State Plan 2006 State Plan 2006: Analysis of State Plans 2001-2005 i North Carolina DHHS - DMH/DD/SAS Table of Contents CHAPTER I. INTRODUCTION................................................................................................1 Legislative Requirements for State Plan 2006.......................................................................................................................1 Reform as a National Effort.......................................................................................................................................................2 Table 1. Principles and goals of national mental health, developmental disabilities & substance abuse system reform..........................................................................................................................................................................................3 CHAPTER 2. ORIGINAL PROVISIONS OF REFORM........................................................5 Applicable Provisions from the Reform Legislation ............................................................................................................5 Vision ..........................................................................................................................................................................................6 Mission........................................................................................................................................................................................6 Guiding Principles .....................................................................................................................................................................6 Design of the Transformed Service Delivery System..........................................................................................................6 Figure 1. Key Components of an Effective Community-Based Human Service System.............................................7 Applicable Provisions from Prior State Plans .......................................................................................................................8 Table 2. Primary Provisions of Reform Legislation and Prior State Plans .....................................................................9 CHAPTER 3. THE COMMUNITY OF PEOPLE TO BE SERVED....................................13 CHAPTER 4. GOVERNANCE OF THE SYSTEM...............................................................17 Local Level....................................................................................................................................................................................17 County Commissioners and Area Boards ............................................................................................................................ 17 Local Consumer and Family Advisory Committees .......................................................................................................... 17 Human Rights Committees.................................................................................................................................................... 18 State Level.....................................................................................................................................................................................18 The Department of Health and Human Services and the Division of Mental Health, Developmental Disabilities and Substance Abuse Services .............................................................................................................................................. 18 State Consumer and Family Advisory Committee ............................................................................................................. 20 CHAPTER 5. FUNDING OF THE SYSTEM.........................................................................21 Finance Strategy.........................................................................................................................................................................22 Standardization...........................................................................................................................................................................23 Total Public Mental Health, Developmental Disabilities and Substance Abuse Services System Funding ........24 Figure 2. SFY 2006 Sources of Funding of the Public MH/DD/SAS System............................................................... 24 Figure 3. SFY 2006 Funding of the Public MH/DD/SAS System by Setting ............................................................... 25 CHAPTER 6. PERFORMANCE GOALS AND ACCOUNTABILITY FOR EFFECTIVENESS AND COSTS.............................................................................................27 State Plan 2006: Analysis of State Plans 2001-2005 ii North Carolina DHHS - DMH/DD/SAS Effective Outcomes for Consumers and their Families.....................................................................................................27 System Performance ..................................................................................................................................................................29 Quality Management............................................................................................................................................................... 29 The DHHS – LME Performance Contract.......................................................................................................................... 29 Long-Term System Goals ...................................................................................................................................................... 30 Service Monitoring .....................................................................................................................................................................30 CHAPTER 7. THE LOCAL MANAGEMENT OF THE SYSTEM......................................33 Local Business Plans (LBP) .....................................................................................................................................................34 The DHHS - LME Performance Contract...........................................................................................................................34 Core Functions of a Local Management Entity ..................................................................................................................35 Access, Uniform Portal, Screening, Triage and Referral.................................................................................................. 36 Endorsement of Providers ...................................................................................................................................................... 37 Utilization Management for State funds.............................................................................................................................. 38 Accreditation of Local Management Entities ......................................................................................................................39 Building Community Capacity ...............................................................................................................................................40 Provider Action Agenda......................................................................................................................................................... 40 CHAPTER 8. THE DELIVERY OF SERVICES...................................................................43 Figure 4. General Flow Chart for New Consumers ........................................................................................................... 44 Person-Centered Planning .......................................................................................................................................................45 Array/Continuum of Services..................................................................................................................................................46 Services for People with Developmental Disabilities ........................................................................................................ 47 Services for Children and Adolescents with Mental Health or Substance Abuse Needs............................................. 48 Services for Adults with Substance Abuse Service Needs................................................................................................ 48 Emergency Services ................................................................................................................................................................ 49 Prevention, education and consultation............................................................................................................................... 49 State Operated Facilities...........................................................................................................................................................50 Practice Improvement Collaborative ....................................................................................................................................51 Workforce Development ...........................................................................................................................................................52 APPENDICES………………………………………………………………………………….53 Applicable Provisions from Legislation Glossary Index to State Plans 2001-2005 by Topic Detailed Tasks and Status from Prior State Plans State Plan 2006: Analysis of State Plans 2001-2005 1 North Carolina DHHS - DMH/DD/SAS Chapter I. Introduction The transformation of the public system of mental health, developmental disabilities and substance abuse services began in the fall of 2001 after the North Carolina General Assembly enacted legislation for the reform of the system.1 That legislation instructed the State to publish an annual State Plan to address how reform would be implemented. The Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) published the first State Plan in November 2001 and since that time has published an annual plan on July 1 of each State fiscal year.2 This document provides an analysis of the five previous State Plans and serves as the State Plan for State fiscal year 2006-2007 and thereby meets the requirements of legislation passed in July 2006. Legislative Requirements for State Plan 2006 Session Law 2006-142, House Bill 2077, Section 2.(b) states3: “The North Carolina Department of Health and Human Services (DHHS) shall review all State Plans for Mental Health, Developmental Disabilities and Substance Abuse Services, implemented after July 1, 2001, and before the effective date of this act and produce a single document that contains a cumulative statement of all still applicable provisions of those Plans. This cumulative document shall constitute the State Plan until July 1, 2007.” House Bill 2077 also specifies that beginning July 1, 2007, the State Plan will be issued every three years as a strategic plan that identifies specific goals and benchmarks for determining progress. To support that aim, Session Law 2006-66, Senate Bill 1741, Section 10.28 entitled “Changes to the State Plan for Mental Health, Developmental Disabilities, and Substance Abuse Services” is written as follows. “Section 10.28. Independent consultants hired by the Department from funds appropriated in this act for this purpose shall undertake the following tasks: (1) Assist DHHS with the strategic planning necessary to develop the revised State Plan as required under G.S. 122C-102. The State Plan shall be coordinated with local and regional crisis service plans by area authorities and county programs.” 1 See North Carolina Session Law 2001-437, House Bill 381, Section 1.5. 2 The previous State Plans can be found on the Division’s web site: http://www.dhhs.state.nc.us/mhddsas/stateplanimplementation/index.htm 3 See the Division’s Communication Bulletin #059 entitled “Session Law 2006-142 House Bill 2077” and Communication Bulletin #057 entitled: “Modified Timing of State Plan 2006.” State Plan 2006: Analysis of State Plans 2001-2005 2 North Carolina DHHS - DMH/DD/SAS Therefore, this document provides an analysis of past efforts to transform the public mental health, developmental disabilities and substance abuse services system, clarifies the work to be accomplished in State fiscal year 2006-2007 and lays the groundwork for the upcoming three-year strategic plan to be developed for 2007-2010. Reform as a National Effort As the federal government and other states engage in the development of a more coherent, coordinated and effective plan and strategy for reform of mental health, developmental disabilities and substance abuse services, so has North Carolina committed to a transformation designed to be responsive to all stakeholders. Table 1 illustrates how the Division’s vision, mission and guiding principles complement national and federal goals and actions for reform of the public mental health, developmental disabilities and substance abuse services and supports. State Plan 2006: Analysis of State Plans 2001-2005 3 North Carolina DHHS - DMH/DD/SAS Table 1. Principles and goals of national mental health, developmental disabilities & substance abuse system reform PRINCIPLES GUIDING NATIONAL AND STATE MH/DD/SAS REFORM President’s New Freedom Commission on Mental Health “Achieving the Promise: Transforming Mental Health Care in America” (July 2003) & SAMHSA’s: Federal Action Agenda - (2005) The President��s Committee for People with Intellectual Disabilities “A Charge We Have To Keep: A Road Map to Personal and Economic Freedom for Persons with Intellectual Disabilities in the 21st Century” - (2004) Federal Center for Medicare & Medicaid Services (CMS) “Quality Framework” - (2002) v Assure that the system is person-centered – “Participant” refers to persons who are seeking assistance in overcoming or adjusting to life situations that involve MH/DD/SA issues and is inclusive of the terms “consumers,” “family members, “ “clients” and “patients”. · Mental health care is consumer and family driven. · Focus on the desired outcomes of mental health care including employment, self-care, interpersonal relationships and community participation. · A new road map is required, one that aligns a public rhetoric to desired outcomes. It needs to be based on the principles of self-determination. · Participant centered service planning and delivery: Services and supports are planned and effectively implemented in accordance with each participant’s unique needs, expressed preferences and decisions concerning his/her life in the community. · Participant outcomes and satisfaction. · Participants have the authority and are supported to manage their own supports . v Focus on community level models of care that effectively and efficiently coordinate treatment and the delivery of services. · Community-level models of care that coordinate multiple health and human service providers and private and public payers. · Focus on community-level models of care that efficiently coordinate the multiple heath and human service providers and public and private payers involved in mental health, developmental disabilities and substance abuse treatment and delivery of services. · People to have the freedom to live a meaningful life in the community. · Examine provider attitudes, behaviors relative to inclusion of persons with intellectual disabilities in community-based and private practice settings. · Provider capacity and capabilities: There are sufficient quality agency and individual providers to meet the needs of participants in their communities. · Participant access. · Individuals and families can readily obtain information concerning the availability of Home and Community Based Services, how to apply and, if desired, offered a referral. vThe utilization of information technology and early screening, assessment, referral to services is common practice and is valued as essential to overall health. · Early mental health screening, assessment and referral to services are common practice. · Advance and implement a national campaign to reduce the stigma of seeking care, providing facts and a national strategy for suicide prevention · American citizens with intellectual disabilities will have access to a complete range of health care services and supports from medical, dental and other health professional providers · Participants have continuous access to assistance as needed to obtain and coordinate services and promptly address issues. · Regular, systematic and objective methods-including obtaining the participant’s feedback -are used to monitor the individual’s well being, health status and the effectiveness of services in enabling the individual to achieve his or her personal goals. Prevention Focused Participant Driven Community-Based State Plan 2006: Analysis of State Plans 2001-2005 4 North Carolina DHHS - DMH/DD/SAS PRINCIPLES GUIDING NATIONAL AND STATE MH/DD/SAS REFORM President’s New Freedom Commission on Mental Health, “Achieving the Promise: Transforming Mental Health Care in America” – (July 2003) & SAMHSA’s: Federal Action Agenda - (2005) The President’s Committee for People with Intellectual Disabilities. “A Charge We Have To Keep: A Road Map to Personal and Economic Freedom for Persons with Intellectual Disabilities in the 21st Century” - (2004) Federal Center for Medicare & Medicaid Services (CMS) “Quality Framework” - (2002) v System elements will be seamless: consumers, families, policymakers, advocates and qualified providers will unite in a common approach that emphasizes support, education/training, rehabilitation and recovery. · Involve consumers and families fully in orienting the mental health system toward recovery. · Excellent mental health care is delivered and research is accelerated. · Utilize data and quality information to engage in actions that lead to continuous improvement in the Home and Community Based Services. · Developmeaningful assessments and accountability by establishing an Intra- Agency Task Force, which would be facilitated by the U.S. Department of Education and include national experts, to provide ongoing guidance to states on universally relevant standards and appropriate assessments for students with intellectual disabilities under the No Child Left Behind Act. · The service system promotes the effective and efficient provision of services and supports by engaging in systematic data collection and analysis of program performance and impact. v Use mental health research findings deemed to be “Evidenced-Based Best Practice” to influence the delivery of services. · Advance evidence -based practices using dissemination and demonstration projects and create a public-private partnerships to guide their implementation. · Use Mental Health Research Findings to Influence the Delivery of Services · Align relevant Federal programs to improve access and accountability for mental health services. · Create a Comprehensive State Mental Health Plan. · Disparities in Mental Health Services are Eliminated. · Partner to create a set of practical performance measures for agencies that administer federal programs that have an impact on people with intellectual disabilities to hold them accountable for the advancement of outcomes that improve personal and economic freedom. These measures and performance indicators should be comprehensive, consistent, and complementary. · Quality initiatives to focus on best practices. · Focus on state collections and analysis of data to be used to remediate and improve services and supports. vServices for persons with mental illness, developmental disabilities and substance abuse problems will be cost effective and will optimize available resources. · Focus on those policies that maximize the utility of existing resources by Increasing Cost Effectiveness and Reducing Unnecessary and Burdensome Regulatory Barriers. · Ensure Innovative, Flexibility, and Accountability at All Levels of Government and Respect the Constitutional Role of the States and Indian Tribes. · Ensure authority over dollars needed for support. · Support to organize resources in ways that are life-enhancing and meaningful. · Take responsibility for the wise use of public dollars. · Commission longitudinal studies to: 1) design new financing options and assess their impact on service access and delivery to persons with intellectual disabilities. · Financial accountability is assured and payments are made promptly in accordance with program requirements. Best-Practice Based Cost Effective Recovery Oriented State Plan 2006: Analysis of State Plans 2001-2005 5 North Carolina DHHS - DMH/DD/SAS Chapter 2. Original Provisions of Reform This chapter identifies the provisions of the reform legislation HB381 that represent the original intention and conceptual basis for transformation of the mental health, developmental disabilities and substance abuse services system. Further, it identifies the provisions from State Plan 2001 through State Plan 2005 that are still applicable. Finally, this chapter provides the means to organize and assess these provisions and to structure the remainder of the document. Applicable Provisions from the Reform Legislation Session Law 2001-437, HB 381 specified the provisions for reform and the contents for the State Plan for implementing reform. Appendix A provides excerpts from HB 381 and highlights provisions as key words. The reform legislation clearly lays out the basic values and requirements for the delivery of services for the people of North Carolina who experience mental health issues, developmental disabilities and/or substance abuse problems. The original reform legislation called for: · A delivery system designed to meet the needs of consumers in the least restrictive, therapeutically most appropriate setting available and to maximize their quality of life. · Community-based services when such services are appropriate, unopposed by the affected individuals, and can be reasonably accommodated within available resources, taking into account the needs of others. · A unified system of services centered in area authorities or county programs and where the area authority or county program is the locus of coordination. · A continuum of services for clients inclusive of area authorities, county programs, local providers and State facilities while considering the availability of services in the private sector. · Core services that are available for all individuals including screening, assessment, and referral; emergency services; service coordination; and consultation, prevention, and education. · Targeted populations, meaning those individuals given service priority under the State Plan. · Services provided within available resources. · Protection of the rights of consumers . State Plan 2006: Analysis of State Plans 2001-2005 6 North Carolina DHHS - DMH/DD/SAS The Division’s mission, vision and guiding principles capture the essence of these values. Each State plan published by the Division has included these statements.4 Vision North Carolina residents with mental health, developmental disabilities and substance abuse service needs will have prompt access to evidence-based, culturally competent services in their communities to support them in achieving their goals in life. Mission North Carolina will provide people with, or at risk of, mental illness, developmental disabilities, and substance abuse problems and their families the necessary prevention, intervention, treatment services and supports they need to live successfully in communities of their choice. Guiding Principles · Participant driven. · Community based. · Prevention focused. · Recovery outcome oriented. · Reflect best treatment/support practices. · Cost effective. Design of the Transformed Service Delivery System There are two fundamental requirements that underlie the design of the community-based system of services. 1. The system must be concerned with both effectiveness and cost. 2. The effects of the system must be specified by the community members it is intended to serve. Given the values stated above and these two requirements, the design of the community service delivery system is concerned with six essential elements and their relationships. As shown in figure 1, these essential elements are: · The community of people to be served. · The governance of the system. · Funding of the system. · Performance goals and accountability for effectiveness and costs. · The local management of the system. · The delivery of services. 4 The Division revised its Vision in July 2006 to more clearly align with the Vision and business plan of the Department of Health and Human Services. State Plan 2006: Analysis of State Plans 2001-2005 7 North Carolina DHHS - DMH/DD/SAS Figure 1. Key Components of an Effective Community-Based Human Service System Governance Local System Management The Delivery of Service The Community of People to be Served Funding Consumer Needs met Performance Goals & Accountability for Effectiveness & Costs State Plan 2006: Analysis of State Plans 2001-2005 8 North Carolina DHHS - DMH/DD/SAS Applicable Provisions from Prior State Plans Beginning with State Plan 2001: A Blueprint for Change, the Division published annual State plans as cumulative documentation of the Division’s interpretation and conception of the legislation and its plans to transform the old service delivery system into a community-based system. These documents contain descriptions of various parts of the system and specific tasks to be accomplished to implement the system. The Division has conducted an analysis of these five documents, as required by House Bill 2077, which points out the complexity of the ove rall undertaking. This analysis is two- fold: 1. An assessment of the topics covered in the five State plans by year and cumulatively organized by the primary provisions of the reform legislation. 2. A determination of the current status of each of the detailed tasks listed in each of the five State Plans. Appendix D lists these detailed tasks and the status of each, with explanation if necessary. Table 2 identifies the provisions that are still applicable from both the reform legislation and prior state pla ns. These provisions are organized according to the essential elements of the community-based service delivery system shown in figure 1. The chapters that follow are also organized by the essential elements of a community-based system. Each chapter id entifies those provisions of the legislation and prior state plans that are still applicable, provides an analysis of prior tasks and summarizes what has been accomplished over the past five years and the current status of the system. State Plan 2006: Analysis of State Plans 2001-2005 9 North Carolina DHHS - DMH/DD/SAS Table 2. Primary Provisions of Reform Legislation and Prior State Plans Elements of Community-Based System Provisions of HB 381 Related Provisions of State Plans 2001-2005 THECOMMUNITY OF PEOPLE TO BE SERVED Targeted populations · Target populations (2001, 2002, 2003, 2004, 2005) · Summary of community needs (2002) · Child mental health plan (2004, 2005) Area boards and county commissioners Local Consumer Advocacy Programs (Local CFAC) · Local consumer and family advisory committees (2003) · LME-CFAC agreement (2003) Human rights committees · Appeals, grievances, human rights, consumer advocacy (2002) Role and responsibilities of the Secretary of DHHS-the Division of Mental Health, Developmental Disabilities and Substance Abuse Services · Infrastructure of system (2001, 2002) · National & federal policies (2002) · System transition issues (2002) · Reorganization of the Division (2002, 2003, 2004, 2005) GOVERNANCE OF THE SYSTEM State consumer advocacy programs (State CFAC) · State CFACs (2001, 2002, 2003, 2004, 2005) · Transformation of consumer and family participation in reform (2005) FUNDING OF THE SYSTEM Funding within available resources · Total system financing (2001) · Integrated Payment and Reporting System (2002) · Finance strategy (2002, 2004, 2005) Administrative Rules · Rules & statutes (2001, 2002, 2004, 2005) PERFORMANCE GOALS & ACCOUNTABILITY FOR EFFECTIVENESS & COSTS Role and responsibilities of the Secretary of Department of Health and Human Services and the Division of Mental Health, Developmental Disabilities and Substance Abuse Services · Federal policies & social trends & policies (2002) · Quality management (2005) · Cultural competence (2001, 2003, 2005) · Technical assistance (2002) · Data collection & analysis (2001, 2002, 2003, 2004, 2005) State Plan 2006: Analysis of State Plans 2001-2005 10 North Carolina DHHS - DMH/DD/SAS Elements of Community-Based System Provisions of HB 381 Related Provisions of State Plans 2001-2005 · Licensing and monitoring (2001, 2002, 2005) Roles and responsibilities of Local Management Entities (LMEs) · Local Management Entities (2001, 2003) · LME-provider contracts (2001, 2002, 2003, 2004, 2005) · Role and functions of LMEs (2002) · Performance contract (2002, 2005) LME local business plans & certification · Local business plans, (2001, 2002, 2003, 2004, 2005) · Consolidation, certification and accreditation (2002, 2004, 2005) THE LOCAL MANAGEMENT OF THE SYSTEM Core services · Uniform portal (2001) · Core functions (2002, 2003, 2004, 2005) · System access (2002) · Screening, triage, referral (2001, 2002, 2003) · Prevention (2001, 2002, 2003, 2004, 2005) A delivery system of mental health, developmental disability and substance abuse services · New system design (2001) · Self-determination & Recovery (2002) · Person-centered planning (2002, 2003) · Staff competencies, education and training (2002, 2005) Community-based services · Community services (2002) · Community capacity (2002, 2005) · Key system characteristics (2003) · CAP-MR/DD (2005) · LME providing direct services (2002, 2003) THE DELIVERY OF SERVICES A unified system of services · Qualified service providers (2001, 2002, 2003) · Documentation (2001, 2002) · Utilization management (2001, 2002, 2003, 2004, 2005) State Plan 2006: Analysis of State Plans 2001-2005 11 North Carolina DHHS - DMH/DD/SAS Elements of Community-Based System Provisions of HB 381 Related Provisions of State Plans 2001-2005 A continuum of services · Array of services (2001, 2002, 2004, 2005) · Assessment (2001, 2002) · Best practices (2003, 2005) · Care coordination, case management. Service coordination (2002, 2003) · Systems development (2003) · Emergency services (2001, 2002, 2003, 2005) · Crisis stabilization services (2005) · Enhanced benefits package (2005) · Justice system innovations (2005) · Employment/vocational services (2004) State facilities · Downsizing (2002, 2004) · Consolidated hospital (2002, 2004) · Olmstead plan (2004) · Bed day allocation plan (2004) · Transformation of state facilities (2005) · State facility regions (2005) State Plan 2006: Analysis of State Plans 2001-2005 12 North Carolina DHHS - DMH/DD/SAS This page left blank intentionally. State Plan 2006: Analysis of State Plans 2001-2005 13 North Carolina DHHS - DMH/DD/SAS Chapter 3. The Community of People to be Served The members of the community to be served by the public system of mental health, developmental disabilities and substance abuse services and supports must be unambiguously identified. While the primary focus of the transformed system is to provide services for individuals with the most severe disabilities and in the greatest need (defined as target populations), the community-based service system is also designed to be responsive to individuals in crisis. As required by legislation, any individual is eligible for screening and referral and for services in the event of a crisis. In addition, the community system is concerned with education and prevention of problems among its general population. The reform legislation states that within available resources the State shall provide funding to support services to targeted populations. This means individuals with the greatest need who are eligible according to specific criteria. As legislatively directed, the Division established appropriate criteria to identify individuals with various disabilities. Target populations were first established and described in detail in State Plan 2001 and have been included in each subsequent State Plan. These target populations are specifically described by both age (child and adult) and disability (mental health, developmental disabilities or substance abuse) and includes those populations who experience co-occurring disabilities. Estimates of the prevalence of problems for each age/disability group were first provided in State Plan 2002. Since the beginning of reform, the Division has continuously evaluated the definitions of the target populations to assure that we respond to evolving needs in a timely way. A complete and current listing of the target populations is maintained on the Division’s web site.5 Some changes have occurred since the original State Plan was published in November 2001. · State Plan 2002 added target populations in each age and disability category for individuals who are deaf or hard of hearing. · Communication Bulletin #003, dated October 28, 2002, clarified the management of resources in serving State Plan target and non-target populations during the transition. 5 See the Division’s web site for the most current description of the targeted populations at: http://www.dhhs.state.nc.us/mhddsas/iprsmenu/index.htm. Click on each age disability category for a detailed description of each. State Plan 2006: Analysis of State Plans 2001-2005 14 North Carolina DHHS - DMH/DD/SAS · State Plan 2003 clarified that those individuals who are eligible for Medicaid are entitled to services whether or not they meet the specific criteria of the target populations. Those individuals who are not eligible for Medicaid must meet the specific criteria of a target population to received State- funded services. This is primarily due to the fact that services paid by State dollars are not an entitlement. · In September 2005 the use of Child and Adolescent Functional Assessment Scale (CAFAS) was removed from the criteria for child populations when the Division elected to not upgrade to the most recent version as required by the developer.6 · Also in 2005, the Division expanded the definition of Substance Abuse High Management to include detoxification and consumers with stimulant disorders. · In 2006, the Division added two target populations, the Adult Mental Health Stable Recovery population (AMSRE) and Assessment Only (AO) for each age/disability population. · The Division is emphasizing crisis services during State fiscal year 2006-2007 and is defining a new target population for people in need of crisis services. The Division will draft a rule to specify the criteria for defining target populations during State fiscal year 2006-2007. Once adopted, the mental health, developmental disabilities and substance abuse service system must serve individuals who currently or in the future meet those criteria within available State resources. Regarding target populations for children, a Division workgroup studied the Child Mental Health Plan that was prepared by the Division and the State Collaborative in September 2003. This workgroup represented the needs of children and families in the Division’s overall design and development of the transformed system.7 The principles of System of Care were emphasized in this process, including the importance of child and family teams for the development and monitoring of a person-centered plan and the importance of a local community collaboratives in coordinating the services for children and their families across agencies. These efforts focused attention on identifying and serving children with severe impairments and their families. A five- year System of Care federal grant that demonstrated the success of that approach was completed in 2006. In support of the further development and implementation of System of Care across the entire state, the Division earmarked new funds in State fiscal year 2005-2006 in each local management entity to establish one full- time equivalent staff as System of Care Coordinator to provide local community leadership, training and technical assistance. A dedicated staff member of the Division provides support to these new local positions in working with child target populations. 6 See this announcement on the Division’s web site at: http://www.dhhs.state.nc.us/mhddsas/announce/cafasdeletion-iprstargetpopcriteria9-26-05a-2.pdf 7 See Communication Bulletin # 11: Child Mental Health Plan; and Communication Bulletin # 25: Child Mental Health Plan Implementation Update. State Plan 2006: Analysis of State Plans 2001-2005 15 North Carolina DHHS - DMH/DD/SAS Efforts to work with child target populations continue through the collaboration of the Division and the Department of Public Instruction to facilitate the coordination of educational and behavioral health services for children in public schools.8 In addition, the Division is participating in the Governor’s School-Based Child and Family Support Team initiative by providing funding to designated local management entities to hire care coordinators to work with child and family teams. The care coordinators will: · Serve as the primary contact for the schools in their catchment area for children and families identified as having behavioral health issues. · Receive and coordinate all school referrals for all school age children and assure that children referred are screened, assessed and connected with services and supports. · Work with the schools, especially the social worker/school nurse teams, to discuss treatment options with the child and family and assist in connecting them to the local management entity and treatment providers, clinical home with medical home and other supports within the community System of Care. In addition to defining new target populations in each age and disability category for people who are deaf or hard of hearing, the Division has funded the continued employment of deaf and hard of hearing specialists by local management entities (LMEs) to ensure continued support for children and adults across the State.9 There are numerous advocacy, consumer and professional organizations and individual advocates that work to increase the awareness of the needs of individuals with disabilities. These stakeholders represent consumers to governance and on governance bodies and bring attention to the need for system reform, for best practices and for increased funding. 8 See “The Transition to Community Support Services for Children in Public Schools” workbook and DVD on the Division’s web site: http://www.dhhs.state.nc.us/mhddsas/childandfamily/index-new.htm 9 See Communication Bulletin # 58: Services to Consumers who are Deaf, Hard of Hearing or Deaf-Blind. State Plan 2006: Analysis of State Plans 2001-2005 16 North Carolina DHHS - DMH/DD/SAS This page left blank intentionally. State Plan 2006: Analysis of State Plans 2001-2005 17 North Carolina DHHS - DMH/DD/SAS Chapter 4. Governance of the System Governance is the means that charts the course for the system and by which the system is held accountable for meeting the needs of people according to performance standards and available resources. In order to satisfy the requirement for accountability for effectiveness and costs and the requirement that the system be participant driven, there must be a governance body to speak for the people who are served and act on their behalf. Governing bodies set performance expectations and require that the system conform to its standards and report to it on a regular basis. For the North Carolina statewide system, governance primarily occurs at two levels. This chapter provides the State’s analysis of progress with this element of the system. Local Level At the local level, governance is provided by an area board and county commissioners with advice and input from the local consumer and family advisory committee (CFAC) and the local human rights committee. County Commissioners and Area Boards North Carolina’s Session Law 2001-437 and Session Law 2006-142 speak directly to the structure and duties and responsibilities of counties and area boards with regard to the public mental health, developmental disabilities and substance abuse service system. Briefly, legislation requires that counties appropriate funds to support local programs and specifies the structure and organization of area boards and responsibilities for finance. Local Consumer and Family Advisory Committees Legislation also calls for the formation and operation of local consumer and family advisory committees (CFACs) and specifies their roles and responsibilities. These are self-governing and self-directed organizations that advise the local management of the system regarding the planning and management of the local public mental health, developmental disabilities and substance abuse service system. At the request of either one, the local governing board or the local consumer and family advisory committee may execute an agreement that identifies their roles and responsibilities, channels of communication between them and a process for resolving disputes. In order to address the consumer involvement requirements of HB 381, the initial State Plan directed each LME to create a consumer and family advisory committee (CFAC).10 The consumer and family advisory committee, comprised of adult consumers and family 10 See the Division’s Communication Bulletin #031 entitled “LME/CFAC Relational Agreement.” State Plan 2006: Analysis of State Plans 2001-2005 18 North Carolina DHHS - DMH/DD/SAS members, is to advise the LME. During the last four years local consumer and family advisory committees have been established and operational for every local management entity. As specified in Session Law 2006-142, House Bill 2077, Section 5, a consumer and family advisory committee’s duties include: · Reviewing, commenting on and monitoring the implementation of the local business plan. · Identifying service gaps and underserved populations. · Making recommendations regarding the service array and monitoring the development of additional services. · Reviewing and commenting on the area authority or county program budget. · Participating in all quality improvement measures and performance indicators. · Submitting to the State consumer and family advisory committee their findings and recommendations regarding ways to improve the delivery of mental health, developmental disabilities and substance abuse services. Human Rights Committees Session Law 2001-437, House Bill 381, Section 1.3 requires the establishment of human rights committees at each State facility and for each area authority and county program. Rules specify the duties of these committees. Area authorities and county programs as local management entities oversee consumer rights for their catchment areas. In addition, providers who use restrictive interventions must have an Intervention Advisory Committee to review the interventions as required by statute 10A NCAC 27E.0106. State Level At the State level, the North Carolina General Assembly serves to represent and speak for communities and residents of the State including the people served by the public mental health, developmental disabilities and substance abuse services system. Reform of the MH/DD/SA services system was initiated by the General Assembly with Session Law 2001-437. The General Assembly established the Legislative Oversight Committee to which the Department and Division report on a quarterly basis on progress of reform.11 The Department of Health and Human Services and the Division of Mental Health, Developmental Disabilities and Substance Abuse Services The Secretary of the Department of Health and Human Services and its Division of Mental Health, Developmental Disabilities and Substance Abuse Services are responsible for administering and enforcing the reform statute and other statutes related to the public 11The quarterly reports to the Legislative Oversight Committee can be found on the Division’s web site. See http://www.dhhs.state.nc.us/mhddsas/stateplanimplementation/index.htm State Plan 2006: Analysis of State Plans 2001-2005 19 North Carolina DHHS - DMH/DD/SAS mental health, developmental disabilities and substance abuse services system. In addition to the development of policy guidance and provision of technical assistance, the development and adoption of rules is a primary means for carrying out this responsibility. In addition to rules, the State is bound by federal regulations (such as the Code of Federal Regulations 42CFR that speaks to confidentiality) and federal funding requirements (such as those from the Substance Abuse and Mental Health Services Administration and the Centers of Medicare and Medicaid) to which the Department and the Division must ensure that the system adheres. The federal government sets an agenda and provides major funding for services through block grants and Medicaid. The State must follow guidelines to qualify and utilize these funds. One of the first steps taken by the Division following the passage of HB381 was to meet with the North Carolina Association of County Commissioners to discuss and clarify the intentions and implications for change activated by the reform legislation. Division leadership conducted town hall meetings and broadcast videoconferences across the State to increase public awareness of the goals and impact of reform. These vehicles enabled the Division to communicate new developments related to reform and to hear the concerns of consumers and their families and other stakeholders. Another method of communication is the rights and empowerment conference for consumers held by the Division each year. During 2006 this conference focused on the power of change and sessio ns addressed accessing services, choice of providers, protection of rights and advocacy. In addition, the Division implemented a series of communication bulletins in 2002 and enhanced services implementation updates in 2006 to provide policy and technical guidance to local governance and management of services. References to such applicable communications are made throughout this document. The Division’s web site has recently been enhanced to increase access to publications and documents by consumers and families, providers, governance and management. All announcements, communication bulletins, implementation updates and other materials related to reform are available on the Division’s web site. In order to carry out its responsibilities for the transformation and operation of mental health, developmental disabilities and substance abuse services, the Division collaborates with other divisions of the Department of Health and Human Services such as the Division of Social Services, Division of Public Health, Division of Medical Assistance and the Division of Facility Services, and with other departments of State government such as the Department of Juvenile Justice and Delinquency Prevention and the Department of Public Instruction. Since 2001, the Division has renewed interagency memoranda of agreement and developed new agreements and procedures with these state agencies to facilitate operations at the local level. The Division has worked closely with the Division of Medical Assistance to develop the new enhanced service definitions and the new Community Alternative Program for Developmental Disabilities (often referred to as the CAP-MR/DD waiver). In addition, State Plan 2006: Analysis of State Plans 2001-2005 20 North Carolina DHHS - DMH/DD/SAS the two divisions have collaborated in the enrollment of providers of services in the Medicaid system. The Division has worked closely with the Division of Facility Services to coordinate oversight activities of licensed facilities. The Department and the Division are responsible for reporting progress to the Legislative Oversight Committee of the General Assembly. Local management is responsible for reporting to its local governance bodies as well as to the Division. State Consumer and Family Advisory Committee Session Law 2001-437 and Session Law 2006-142 also required the establishment of a State Consumer and Family Advisory Committee (CFAC) to advise the Department, the Division and the General Assembly on the planning and management of the State’s public mental health, developmental disabilities and substance abuse services system. The Division’s Communication Bulletin #059 noted that both the State and local consumer and family advisory committees are now codified in statute. The fact that State and local consumer and family advisory committees are now in statute speaks to North Carolina’s commitment to and regard for the perspective of consumers and family members in the mental health, developmental disabilities and substance abuse service system. The first meeting of the State Consumer and Family Advisory Committee was May 5, 2004. The Division is currently working to implement changes as they relate to the State Consumer and Family Advisory Committee in order to accommodate the requirements outlined in the 2006 statute. The Division will provide assistance to the local consumer and family advisory committees as far as any changes they may need to make given the new statutory guidelines. State Plan 2006: Analysis of State Plans 2001-2005 21 North Carolina DHHS - DMH/DD/SAS Chapter 5. Funding of the System An effective public mental health, developmental disabilities and substance abuse services system requires a true partnership among consumers, family members, local management entities, providers, counties and the State and federal governments. As the major financing source for the public system, the State, federal government and counties have a responsibility to support the provision of services to individuals with, or ask risk of, mental illness, developmental disabilities and substance abuse problems. Concurrently, these entities have the fiduciary responsibility to ensure that public funds that they appropriate are utilized in a cost effective manner to support positive outcomes for consumers. As local managers of the public mental health, developmental disabilities and substance abuse services system, local management entities play a critical role in ensuring a partnership among stakeholders and as the focal point for local financial management and accountability. With finite resources, it is recognized that State- funded services must be provided within available resources. In State fiscal year 2007, the Division receives over $650,000,000 in State funds on a recurring basis for State-funded institution and community-based services, as compared to approximately $593.8 million in State fiscal year 2006. However, additional resources are needed to meet the needs of all consumers who are not eligible for Medicaid or Health Choice or do not have third party insurance coverage. While all resources must be appropriately managed, local management entities have a unique role and challenge in managing limited State and county funds to address the needs of their local residents. Since the majority of funding (61 percent or $1.42 billion) for the public mental health, developmental disabilities and substance abuse service system is derived from Medicaid receipts, the Division works collaboratively with the Division of Medical Assistance to assure that services provided are approved by the federal Centers of Medicare and Medicaid. Likewise, Health Choice is a system of insurance funding for children of North Carolina who are not covered by insurance. In addition to efforts to increase Medicaid receipts and additional funding made available by the North Carolina General Assembly, funding is being shifted from State facilities to increase community service capacity as State facilities are downsized. Between State fiscal year 2002 and State fiscal year 2006, State facilities eliminated 413.25 positions and related operating cost, with over $15.5 million in State appropriations transferred from State facilities to funding for community-based services. An additional $1.1 million in Medicaid receipts have been realigned within the Division of Medical Assistance’s budget from State institution funding to support services provided via the community-based Community Alternative Program for Developmental Disabilities (CAP-MR/DD) wavier. State Plan 2006: Analysis of State Plans 2001-2005 22 North Carolina DHHS - DMH/DD/SAS The General Assembly also appropriated over $105,000,000 for the Mental Health Trust Fund to support implementation of system transformation and increasing community-based service capacity. In addition, the State General Assembly has designated non-recurring funds for hiring consultants to assist DHHS and the Division with specific tasks during State fiscal years 2007 and 2008. Finance Strategy In order to ensure that a financing strategy for the public mental health, developmental disabilities and substance abuse services system is in place to effectively address needs and resources, the Division has undertaken a comprehensive assessment of service needs, service resources, service gaps and cost modeling. These efforts are closely linked through two initiatives initiated in SFY 06. First, the Division issued a competitively bid contract for the development of a long range planning model that will predict the overall cost of services needed at the community level. The long range planning model is based on assumptions associated with movement to evidence based practices and provides information regarding service needs, current service resources, identification of service gaps and service constructs that focus on positive consumer outcomes. Secondly, the Division awarded another competitively bid contract to develop a funding cost model for services. This model factors in variables such as the number of Medicaid eligible and non-eligible consumers, current penetration rates for Medicaid and non- Medicaid consumers, available resources and potential earning capacity for additional resources. Once service costs are estimated by the long range planning model, the costs of such services will be entered into the finance model. The finance model will render estimates of additional Medicaid resources that may be earned, availability of county funds and funding needs for non-Medicaid consumers or non-Medicaid covered services. This information will assist the Division in allocating existing State resources on an equitable basis to help ensure the availability of services in all communities throughout the State. It will also provide, in a quantifiable manner, additional resources that would be needed to achieve varying levels of evidence based practices implementation. Both models described above will be delivered to the Division in State fiscal year 2007 and will be operational in State fiscal year 2008 for use in determining funding needs and resource distribution. Another key element for improvement in the overall finance strategy for the public mental health, developmental disabilities and substance abuse system is the continued refinement and updating of service definitions. Effective March 20, 2006, the federal Centers for Medicare and Medicaid Services approved an array of new and improved Medicaid service definitions that the Division considered a critical milestone in overall State Plan 2006: Analysis of State Plans 2001-2005 23 North Carolina DHHS - DMH/DD/SAS system transformation. Approval of these services by the Centers for Medicare and Medicaid Services, coupled with the new Community Alternatives Program waiver that was effective September 1, 2005, provides the clinical foundation for transforming the community service array and providing more effective services to consumers. Each of these initiatives is included within the overall financing strategies described above. Standardization In response to action taken by the General Assembly and in concert with activities currently being conducted by the Division, the Division is pursuing a Request for Proposals in State fiscal year 2007 that, among other activities, will focus on the standardization of forms, contracts, processes and procedures at the local level. Standardization of functions and processes will aid providers by creating a relatively uniform business environment, regardless of which area authority or county program the provider contracts with for the provision of services. This will in turn, and more importantly, benefit consumers and family members by contributing to the development and stabilization of community-based resources provided by a wide array of providers throughout the State. Activities to be addressed in this process to improve standardization include, but are not limited to, the following: · Standard Forms - Consideration of the standardization of forms required of providers by area authorities or county programs. · Standard Contracts - Review of current standard contract content for Medicaid and State- funded services currently in place for any recommended improvements. · Standard Processes and Procedures – Assessment of local functions associated with the provider monitoring for the standardization of processes and procedures. · Standard Denial Codes – Consideration of standardized denial codes at the local level prior to service units being billed to Medicaid or the Division’s Integrated Payment and Reporting System (known as IPRS). · Coordination of Benefits – More effective procedures for the coordination of benefits to optimize resources at the local level. · Standard Definition of a “Clean Claim” - Ensure a standardized definition and process among local management entities and providers in determining a “clean claim”. · Area Authority and County Program Management Information Systems - Assessment and potential changes of local management information systems in order to improve the delivery of services to consumers and family members through a more effective methodology for securing and accessing information. State Plan 2006: Analysis of State Plans 2001-2005 24 North Carolina DHHS - DMH/DD/SAS · Feasibility of a Standard Electronic Health Record - The Division’s strategic vision includes continuity of care across all settings, including the community and State facilities. Total Public Mental Health, Developmental Disabilities and Substance Abuse Services System Funding During State fiscal year 2006, total funding within the public service system was approximately $2.3 billion dollars, inclusive of all funding sources for the Division’s State operated facilities, community-based services and the Division’s central administration. 12 At a summary level, total system funding is illustrated in figures 2 and 3 below. In figure 2, note that Medicaid funds include federal dollars plus State and county shares. Other sources of funds include block grants, Medicare, first party payments, insurance payments and other grants. In figure 3, note that Division central administration includes the operation of the Integrated Payment and Reporting System (IPRS) for the community based State-funded services. Figure 2. SFY 2006 Sources of Funding of the Public MH/DD/SAS System Medicaid $1,426,000,000 61.0% State Appropriations $593,800,000 25.4% Other Sources $208,000,000 8.9% County General $109,200,000 4.7% 12 Community-based services include intermediate care facilities for mentally retarded known as ICF-MR and the Community Alternative Program for Developmental Disabilities known as CAP-MR/DD. State Plan 2006: Analysis of State Plans 2001-2005 25 North Carolina DHHS - DMH/DD/SAS Figure 3. SFY 2006 Funding of the Public MH/DD/SAS System by Setting Division State Operated Facilities $558,500,000 23.9% Division Central Administration $35,700,000 1.5% Community- Based Public Services $1,742,800,000 74.6% State Plan 2006: Analysis of State Plans 2001-2005 26 North Carolina DHHS - DMH/DD/SAS This page left blank intentionally. State Plan 2006: Analysis of State Plans 2001-2005 27 North Carolina DHHS - DMH/DD/SAS Chapter 6. Performance Goals and Accountability for Effectiveness and Costs The primary goal of the community-based system is to provide effective mental health, developmental disabilities and substance abuse services and supports. Effective means that the services and supports produce the desired outcomes for individuals using best practices within the resources available. Achievement of this goal requires setting performance standards and measuring progress on a regular basis. This provides a feedback loop to for continuous improvement of the system. There are two types of performance goals: (1) outcomes for individuals served by the system, and (2) measures of how well the system is operating on an ongoing basis. By setting performance goals and monitoring progress, adjustments can be made over time to increase the quality of the service system. Using person-centered thinking, outcomes for consumers focus on what is important to the consumer, such as recovery, health, independence, community inclusion, safety, social support, housing, employment, daily activities and justice. System performance goals focus on what is important for the consumer, such as use of best practice models of care, person-centered planning, ease of access, choice of quality providers and continuous improvement of services. The first semi-annual Statewide System Performance Report for SFY 2006-2007 published October 2006 provides progress in both consumer outcomes and system performance. See the Division’s web site for a copy of this report.13 Effective Outcomes for Consumers and their Families On a personal level, consumer outcomes are tied to the goals of each consumer’s person-centered plan. These goals are defined by the individual and family members with the assistance of the professional staff of the system and written in the consumer’s person-centered plan. Assessment of progress toward those goals is made by those same people on a periodic basis. Success depends on the participation of the consumer and the quality of the professional services and supports provided. See the discussion of person-centered planning in chapter 8. 13 See the Division’s web site at: http://www.dhhs.state.nc.us/mhddsas/. State Plan 2006: Analysis of State Plans 2001-2005 28 North Carolina DHHS - DMH/DD/SAS On an aggregate level, consumer outcomes are defined by domains that are important to all individuals to enable control over one’s life, such as: · Safe stable housing. · Supportive relationships. · Meaningful daily activities. · Emotional well-being. · Justice. · Employment. · Respectful inclusion in a community of choice. · Freedom from addiction and disruptive symptoms. Such outcomes are identified by the State so it can determine how well all consumers are being served by the system. These outcomes are based on the National Outcome Measures being developed by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) and the Quality Framework developed by the federal Centers for Medicare and Medicaid Services. (Both of these are addressed in table 1.) Such consumer outcomes enable the State to assess the success of its service delivery system in comparison with other states and with national standards. Outcomes for consumers with diagnoses of mental illness and/or substance abuse are measured by the North Carolina Treatment Outcomes Program Performance System (NC-TOPPS). This system, initially implemented in 1995, was expanded in July 2005 to include all mental health and substance abuse consumers ages six and above.14 Initial data show that mental health and substance abuse consumers show marked improvement in a variety of areas after three months of treatment. Outcomes for consumers with a developmental disability are measured through the National Core Indicator Project. The national reports prepared by the Human Services Research Institute (HSRI) compare the data from participating states.15 North Carolina participates in the project through interviews with a sample of consumers and surveys of parents and guardians. Overall, North Carolina performs as well as or better than other states in measures for consumers with developmental disabilities’ participation in community life and meaningful activities. Consumers’ perceptions of their progress toward personal goals and the quality of the services they receive are critical barometers of the effectiveness of the service system. National Core Indicators Project surveys provide consumers and family members’ views for evaluating service quality. For consumers of mental health and substance abuse services, the State uses the Consumer Survey developed by the national Mental Health Statistical Improvement Project (MHSIP) and sponsored by SAMHSA.16 Both of these surveys allow rough comparisons to other states, in which North Carolina generally performs similarly to national averages. 14 A report of results for SFY 2005-2006 NC-TOPPS can be found at the following web site: http://www.ndri-nc.org/nc-topps_research_feedback.htm#0506 15 More information about Core Indicators is available at: http://www.hsri.org/nci/index.asp?id=reports. 16 See the annual consumer satisfaction reports for State fiscal years 2000 through 2003 on the Division’s web site at: http://www.dhhs.state.nc.us/mhddsas/statspublications/reports/index.htm State Plan 2006: Analysis of State Plans 2001-2005 29 North Carolina DHHS - DMH/DD/SAS System Performance Achievement of consumer outcomes depends on a service system that is operating with optimal efficiency and effectiveness. Quality Management System performance and service outcomes are basically quality management issues. Attention to quality must be integrated throughout the entire system with the participation of all stakeholders in designated roles. Quality management at all levels of the system includes specification of desired outcomes, identification of outcome indicators and measures, monitoring of service provision, development of measurement tools, data collection, periodic reporting of progress on key indicators of quality, review of information by management staff for decision making, evaluation of system performance, and use of data for focusing quality improvement efforts and quality assurance plans. Performance standards of the system are based on: · Federal and State statutes, rules, regulations, licensing and policies. · Memoranda of understanding and contracts among State agencies. · Requirements of national performance expectations. · Goals of State reform. System performance includes such issues as how quickly and effectively the local system responds to the needs of people, how well the system is managed and how well it meets quality standards. For example, how well does the system respond: · When an individual calls for the first time. · When a consumer is experiencing a crisis. · To develop a person-centered plan. · To stay within available resources. · To develop needed service capacity. · With fidelity to best practices. · To protect safety and rights. The DHHS – LME Performance Contract Performance standards for local system operations are contained in the performance based contract between the State and the local management of the system. In 1999, the performance contract process replaced the annual memorandum of agreement that was signed by each area authority/county program and the Division. This change demonstrated the Division’s focus on greater accountability for effectiveness and funding invested in the system by the General Assembly and the federal government. The process encourages a business relationship between the Division and local management entities by outlining specific requirements geared toward major program State Plan 2006: Analysis of State Plans 2001-2005 30 North Carolina DHHS - DMH/DD/SAS outcomes and standards for operations. The Division routinely monitors area authority/county program's fulfillment of the performance requirements. The current performance contract includes requirements for: · General administration and governance. · Access, triage and referral. · Service management. · Provider relations and support. · Customer services and consumer rights. · Quality management and outcomes evaluation. · Business management and accounting. · Information management, analysis and reporting. The Division publishes quarterly reports showing the progress of area authorities/county programs in satisfying the requirements.17 In November 2006, the Division will publish the first quarterly report on key indicators of local performance. Long-Term System Goals The Division may also set long-term goals for system operation or outcomes. By definition these are goals that cannot be accomplished in one or two years. Such goals may focus on implementation of aspects of the transformed system, such as downsizing the state facilities. Long-term goals may also be based on broad consumer outcomes such as reducing the number of children who start smoking cigarettes. Ultimately, long-term goals focus on the overall impact the service system has on the personal lives of children, families and adults. Further, these outcomes have an impact on the health and safety of the ir communities and on the health of the state. Service Monitoring System reform allows for a local and State partnership for monitoring the quality and appropriateness of mental health, developmental disabilities and substance abuse services through regular monitoring visits, review of critical incident reports and the aggregation of statewide data for trend analysis. Staff of the Division are responsible for performing independent complaint investigations and monitoring of all components of the public mental health, developmental disabilities and substance abuse services system. Local management entities are responsible for monitoring service providers in their catchment area. This monitoring – local and State – serves to assure that the funding appropriated for mental health, developmental disabilities and substance abuse services and supports is spent appropriately, and that consumers of services receive the highest quality care, in the most appropriate setting and in accordance with best practice. 17 Performance contract and quarterly progress reports can be seen on the Division’s web site at: http://www.dhhs.state.nc.us/mhddsas/performanceagreement/index.htm State Plan 2006: Analysis of State Plans 2001-2005 31 North Carolina DHHS - DMH/DD/SAS Public accountability is embedded in the overall system reform process – from initial planning for service delivery and administration through the actual delivery of services, follow up, monitoring and contracting. As the system has evolved, a clear and unbroken “chain of accountability” has emerged. This involves a public partner relationship between the leadership, support and oversight role of the State system and the management of public policy role of the local public system. In turn, a public-private partnership emerges between the local management of the system and providers of services. Additionally, the system continues to develop a more effective and efficient set of regulatory compliance requirements as system performance and consumer outcomes act as critical drivers of improvement efforts. The specification of performance standards provides a clear direction for system operations year after year. Further, clear measures of performance must be specified as part of the standards. These measures must be included in the performance-based contracts between the State and local management entities and between a local management entity and providers of services. The measures allow the means for recognizing how far the public mental health, developmental disabilities and substance abuse services system has come and where it needs to go next. State Plan 2006: Analysis of State Plans 2001-2005 32 North Carolina DHHS - DMH/DD/SAS This page left blank intentionally. State Plan 2006: Analysis of State Plans 2001-2005 33 North Carolina DHHS - DMH/DD/SAS Chapter 7. The Local Management of the System This element of the system provides for a single point of accountability for the performance of the system at the local level. In the North Carolina system, the area authority or county program18 must be certified by the Secretary of the Department of Health and Human Services to perform as a local management entity. The reform legislation obligated each county to decide on the form of local governance for management of mental health, developmental disabilities and substance abuse services. While a county can be part of an area authority, a single county program, or part of an inter- local agreement, the function of these organizations as local management entities is the same. Once established and certified, each public program is referred to as a local management entity or LME – a collective term that refers to the purpose and functional responsibilities of the public agency rather than describing its governance structure. In HB 381, area authorities and county programs were directed to become local management entities. Public services previously delivered directly by area authorities or county programs were to be divested to private providers. As the system transformation has progressed, it has been discerned that certain services are at times most efficiently and effectively delivered by the local management ent ity. In these cases, local management entities have returned to the provision of a narrow range of discreet services such as psychiatric care. In addition, legislation allows that an area authority or county program may relinquish its local management entity functional responsibilities and contract to provide services as long as that public program meets all provider qualifications and fair competition is practiced by the local management entity.19 In managing services, local management entities are expected to perform a series of functions sometimes not previously expected of the area authorities and county programs. These responsibilities include, but are not limited to: · Ensuring access, screening, triage and referral through a uniform portal of entry. · Utilization review and management. · Increased monitoring of services and providers. · Understanding community-based services and supports, as well as identifying service gaps. · Recruiting and endorsing as well as contracting with providers. · Establishing, supporting and working with a local Consumer and Family Advisory Committee. 18 General Statute 122C-3 defines “area authority” as the area mental health, developmental disabilities and substance abuse authority. A “county program” means a mental health, developmental disabilities and substance abuse services program established, operated and governed by a county pursuant to G.S. 122C-115.1. 19 See article 20 of NCGS 160A. State Plan 2006: Analysis of State Plans 2001-2005 34 North Carolina DHHS - DMH/DD/SAS The original State Plan 2001 contemplated full transformation to the system of local management entities by July 1, 2003. Currently, the number of area and county authorities has been reduced from 39 to 30 local management entities. In addition, each area authority or county program must respond to the requirements of its governance bodies. Local Business Plans (LBP) In order to achieve the transformation from service provider to management of services, the State Plan established a process and schedule for certifying newly created local management entities (LMEs). This process included the statutory requirement that counties develop local business plans for implementing and managing the transformed community behavioral healthcare system. The local business plan describes characteristics of the local management entity's catchment area, including the client base and service gaps, as well as addressing specific implementation of local management entity functions.20 The Secretary of the Department is responsible for the approval (or disapproval) of each three-year local business plan and certifying each local management entity. Once certified, the local management entity has a relations hip that is legally formed through a performance-based contract between the Department of Health and Human Services and the local management entity. The local management entities submit to the Division quarterly progress reports about their local business plans. In addition to addressing the targets of its local business plan, the local management entity must indicate actions taken in response to the Division’s communication bulletins. The Division is currently in the process of developing the format and content requirements of a revised three-year local business plan template. This template will specify the functions and activities of each local management entity for which the Division will provide funding. Each local management entity must develop their revised plan based on this template and submit it to the Secretary of the Department by March 31, 2007 for implementation on July 1, 2007. The DHHS - LME Performance Contract During State fiscal year 2005, the Department of Health and Human Services (including its divisions of Mental Health, Developmental Disabilities and Substance Abuse Services, Medical Assistance and the Office of the Controller), the N.C. Council of Community Program and the N.C. Association of County Commissioners (NCACC) negotiated a 20 See the Division’s Communication Bulletin #002 entitled “Local Business Plan Submission and LME Certification” and Communication Bulleting #004 entitled “Housing Resource Development and Local Business Plans.” State Plan 2006: Analysis of State Plans 2001-2005 35 North Carolina DHHS - DMH/DD/SAS statewide performance contact between the Department and the LMEs.21 This contract, which is anticipated to develop over time, currently contains each local management entity’s local business plan as the scope of work, statewide requirements, performance measures and financing requirements. Division staff worked with each local management entity to incorporate its local business plan into the final contract and secure signatures. While the contract did not address all issues that various stakeholders wished to see included, the Department and local management entities are committed to working on a development plan that will add requirements to the contract over the next several years as local management entities continue to transition to their role of managers of service and public policy at the local level. Core Functions of a Local Management Entity General Statute 122C-115.4 defines the primary functions of a local management entity to be: · Access for all citizens to core services, including 24/7/365 screening, triage and referral process and a uniform portal of entry into care. · Provider endorsement, monitoring, technical assistance, capacity development and quality control. · Utilization management/review and determination of the appropriate level and intensity of services, including review and approval of person-centered plans for consumers who receive State- funded services and concurrent review of person-centered plans for consumers who receive Medicaid funded services. · Authorization of the utilization of State operated services and authorization of eligibility determination requests for recipients under a CAP-MR/DD waiver. · Care coordination and quality management including the direct monitoring of the effectiveness of person-centered plans. · Community collaboration and consumer affairs, including a process to protect consumer rights, an appeals process and support of an effective consumer and family advisory committee.22 · Financial management/accountability for the use of State and local funds and information management for the delivery of publicly funded services. Session Law 2006-66, Senate Bill 1741, Section 10.32.(a) states that the Department of Health and Human Services shall allocate funds to LMEs to implement the functions described above. Access, provider endorsement and utilization review are described in the following sections. The review and monitoring of person-centered plans is discussed in chapter 8. 21 See Division’s Communication Bulletin #023 DHHS/LME Contract. 22 See the Division’s Communication Bulletin #038 (FINAL) “Policy for Consumer Complaints to Area/County Programs.” State Plan 2006: Analysis of State Plans 2001-2005 36 North Carolina DHHS - DMH/DD/SAS Access, Uniform Portal, Screening, Triage and Referral A critical component of the system reform effort includes establishing statewide consistency regarding access to services. Access is the method(s) through which individuals can enter a health care delivery system. The probability of an individual's entry into the health care system is influenced by the structure of the delivery system itself and the nature of the potential consumer’s wants, resources and needs. Uniform portal is a term used to describe a set of standardized processes and procedures that ensures that people throughout the state are provided consistent access. The pathways to access (screening, triage, referral, and emergency services) provide the framework for uniform portal activities. There are many access points in a community; however, standards must be consistent. The concept of “no wrong door” establishes the expectation that people are able to directly enter the mental health, developmental disabilities and substance abuse services system through different access points using the same process of screening, triage and referral. Screening is a brief standardized appraisal of an individual who is not currently being served within the system in order to determine: · The nature of the individual’s problem (that is whether the individual has a mental health, developmental disability or substance abuse need). · The individual’s level of need for services and supports. The screening process is not an evaluation or assessment. It is a structured interview conducted by a qualified professional either face-to- face or by telephone. During the interview the process determines provisionally whether the individual may meet the criteria for a target population and where and how the individual should enter the system. Basic financial and clinical information is gathered to determine the types of benefits for which the individual qualifies. Triage is the process for determining the level of the person’s need (that is if it is emergent, urgent or routine). Referral is the procedure by which the screening professional and the consumer choose a clinically appropriate provider and facilitate the consumer’s successful contact with that provider so that services can be initiated. The Division is currently implementing a standardized screening, triage and referral (STR) process that is used whether the individual first contacted the local management entity, a service provider or another agency. The service need, array of services and a list of potential providers are discussed with the individual so that a referral can be made to a service provider of the individual’s choice.23 23 See the Division’s Enhanced Services Implementation Update # 014 entitled “Uniform Screening and Registration.” State Plan 2006: Analysis of State Plans 2001-2005 37 North Carolina DHHS - DMH/DD/SAS One of the advantages of having a standardized system is to help create a statewide database system that will be able to track services requested, services received and service gaps. Such a statewide data system can reduce duplication of effort in the information gathering and tracking process. Another significant benefit is minimizing the number of times that an individual needs to provide personal information. Historically, access to the service system was not readily available 24-hours-a-day, seven-days-a-week (24/7/365) in all areas of the State. Much progress has been made over the last five years to ensure that access to services is standardized, reasonable, culturally sensitive and available 24-hours-a-day, seven-days-a-week through access and/or crisis phone lines or face-to-face. Ultimately, the Division intends to: · Continue to design and shape the statewide system of uniform portal (standardized process of access to services). · Monitor and strengthen access system performance indicators included in the quality management system for statewide reporting. · Refine reporting procedures regarding access – access reporting received quarterly and reported on statewide tracking reports. · Develop and issue periodic contract performance reports. Endorsement of Providers During SFY 05-06, a standardized process for endorsement of all providers of Medicaid covered enhanced benefit services was implemented.24 The purpose of this endorsement process is to assure that individuals receive services and supports from provider organizations that comply with State and federal laws and regulations and provide services in a manner consistent with the Division’s reform plan and the State Medicaid Plan. The endorsement process provides local management entities with objective criteria to determine the competency and quality of providers of approved Medicaid services. Endorsement by a local management entity and enrollment by the Division of Medical Assistance as a Medicaid provider is carried out on a service and site specific basis. The 24 See Communication Bulletin # 37: Provider Endorsement; Communication Bulletin # 44: Final Policy- Provider Endorsement; and Communication Bulletin # 47: Provider Endorsement Transition Plan; Communication Bulletin # 49: Letter of Support (Providers applying for licensure for a residential facility are required to seek a letter of support form the LME); Communication Bulletin # 55: New Phases for Provider Endorsement: Policy Amendment for Conditional Endorsement; Enhanced Services Implementation Update Memo # 1: CMS approval of Medicaid State Plan Amendment (SPA) to implement the Enhanced Benefit Services proposed under the Rehabilitation Option. (Provider Endorsement); Enhanced Services Implementation Update Memo # 6: Consumers’ Choice of Providers, Subcontracting, Caseload Ratios, & Questions and Answers. State Plan 2006: Analysis of State Plans 2001-2005 38 North Carolina DHHS - DMH/DD/SAS process is required for all enhanced benefit services prior to a provider being directly enrolled in the Medicaid program through the Division of Medical Assistance. As of June 20, 2006 the services of a total of 1,515 providers had been endorsed and directly enrolled with Medicaid as required. Utilization Management for State funds A significant component of North Carolina’s mental health, developmental disabilities and substance abuse services system is the process to regulate the provision of services in relation to the capacity of the system and the needs of consumers. The system’s overall strategy for managing service use by individuals and by the system as a whole was described in State Plan 2003 as including the functions of: · Eligibility determination. · Medical necessity. · Person-centered plan authorization. · Utilization review. This process ensures that services are necessary, appropriate and cost effective through pre-authorization of services for individuals, evaluation of the need for continued services and extended authorization as determined by that evaluation. 25 State Plan 2005 clarified that the process is intended to guard against under-utilization as well as over-utilization of services to assure that the frequency and type of services fit the needs of consumers. It is typically an externally imposed process based on clinically defined criteria. Such a decision- making process requires standards and criteria to ensure the most efficient and effective use of finite resources. From the beginning of reform, the Division’s intention has been to provide State-defined standards and criteria for utilization review and service authorization. Standardized criteria fall into three categories: Medicaid funded services, state funded services and utilization of the state psychiatric hospitals and other state facilities. · Criteria are specified in the State Medicaid Plan as part of the definition of each Medicaid funded service. The Division of Mental Health, Developmental Disabilities and Substance Abuse Services and the Division of Medical Assistance developed new and revised service definitions that are based on best practice and evidence based approaches to address the needs of consumers. These definitions were approved by the federal Centers for Medicare and Medicaid Services in December 2005 and became effective in March 20, 2006. Each definition specifies utilization criteria including entrance and continued stay criteria and provides information about the frequency or intensity of service that has been shown to lead to positive outcomes. 25 See the Division’s Enhanced Services Implementation Update #11, “Utilization Review.” State Plan 2006: Analysis of State Plans 2001-2005 39 North Carolina DHHS - DMH/DD/SAS The two divisions continue to work together to manage the utilization of Medicaid funds. · The Division is developing criteria for State- funded services with the assistance of a consultant to be finalized during State fiscal year 2007. The Division will ensure that State- funded services are defined in a way that is consistent with the State Medicaid Plan and best practices.26 · State Plan 2003 stated that utilization of the four state psychiatric hospitals would be determined based upon a Division approved bed day allocation plan. Through this plan, bed days would be allocated to each local management entity in the following categories: adult admissions, adult long-term, geriatric admissions and adolescent admissions. Each local management entity’s initial bed day allocation was based on its historical utilization during State fiscal years 2000 - 2002. State Plan 2004 implemented a revised bed day allocation stating that over the following three years, the number of bed days allocated for psychiatric beds tracks the downsizing schedule, so that fewer bed days are available after closure of beds at the end of the previous year. In addition, the basis for allocation of bed days changed from historical utilization to the popula tion of the local management entity. Accreditation of Local Management Entities Both local management entities and providers of mental health, developmental disabilities and substance abuse services are being required to achieve national accreditation by established accreditation agencies known for values and standards that support the direction of mental health, developmental disabilities and substance abuse services reform. 27 The requirement for national accreditation of local management entities has been in place since the current State and local management entity performance contract went into effect. The accreditation required of local management entities is different from the accreditation that was required of the area authority/county programs under the mental health, developmental disabilities and substance abuse services system prior to reform. The previous accreditation required was based on the role of area authorities and county programs as service providers rather than the current role as system managers. 26 See the Division’s Communication Bulletin #54 Standardized contract for State-funded Services, Guidance on Provider Billing requirements and Excel Billing Format. 27 See the Division’s Communication Bulletin #036 entitled “Approved List of Organizations Who (a) May Accredit Providers of MH/DD/SA Services, and (b) May Accredit LMEs for System Management”, and Communication Bulletin #050, entitled “Approved List of Agencies Who (a) May Accredit Providers of MH/DD/SA Services, and (b) May Accredit LMEs for System Management”. State Plan 2006: Analysis of State Plans 2001-2005 40 North Carolina DHHS - DMH/DD/SAS Accreditation required under reform is intended to assure the State that the local management entity is qualified as a systems manager. Rules are being written that will establish this requirement in administrative code. The requirement for national accreditation for providers of mental health, developmental disabilities and substance abuse services is established currently in the individual service definitions for the services that they provide. Building Community Capacity Key strategies for funding the development of community capacity include the downsizing of institutions and the transfer of institutional funding to the community. In order to successfully implement the downsizing plan for the psychiatric hospitals, the Division works with local management entities to develop sufficient community capacity to serve long-term residents of the hospitals. In addition, the Division is currently focused on transitioning residents to the community based on Olmstead plans.28 In building community capacity, a key element is housing. Expanding the availability of decent, safe and affordable housing for persons with mental illness, developmental disabilities and/or substance use disorders is an area where it is necessary to target resources – staff time, technical expertise and investment.29 Where individuals live is not an issue that can be addressed in isolation. It is directly related to the service system’s capacity to provide the depth and range of community based services needed to support persons with disabilities in the community. The housing needs of consumers of mental health, developmental disabilities and substance abuse services must be addressed with a range of housing and residential models. The pure supportive housing model with scattered sites and independent units with access to flexible support services tailored to individual needs and preferences is a recognized model of best practice. As described in chapter 5, the Division has contracted for the development of a long-term planning model that identifies gaps in services capacity and assesses alternative strategies for building capacity in the State. A final report will be presented to the Legislative Oversight Committee in December 2006. Provider Action Agenda In the fall of 2005, the Division Director initiated an accelerated focus on the provider system with an invitation to all providers to complete a web-based survey on the challenges facing them. Over 500 providers responded. The survey was followed up 28 See the Division’s Communication Bulletin #026 entitled “Draft 1915(c) Home and Community Based Waiver.” 29 See Communication Bulletin #004 Housing Resource Development and Local Business Plans. State Plan 2006: Analysis of State Plans 2001-2005 41 North Carolina DHHS - DMH/DD/SAS with two provider summits that enabled discussion between Division management and providers about the primary themes identified from the survey. As a result, the Division has established a Provider Action Agenda Committee with the overall goal to strengthen and enhance the provider community for the direct benefit to individuals and families who receive services. The committee has three primary objectives: · Standardization - The identification of additional areas of needed standardization. · Regulations and Reporting - An inventory of potentially overlapping regulation and reporting requirements. · Provider Improvement - Collaboration and support for provider initiatives such as provider fairs, small business technical assistance and identification of training needs. State Plan 2006: Analysis of State Plans 2001-2005 42 North Carolina DHHS - DMH/DD/SAS This page left blank intentionally. State Plan 2006: Analysis of State Plans 2001-2005 43 North Carolina DHHS - DMH/DD/SAS Chapter 8. The Delivery of Services Service delivery is the means by which the needs of people are met. The reform legislation clearly states expectations for the delivery of mental health, developmental disabilities and substance abuse services. It requires a continuum of services that is: · Community-based. · Regional as needed. · Based on best practices. · Recovery oriented. · Participant driven. · Cost-effective. · Prevention focused. · Performance based. A delivery system must include a pathway for any consumer to follow that will lead to a reduction or stabilization of problems and increase the ability ofa consumer to live successfully in the community. The general pathway or flow chart shown in figure 2 is the most likely way to produce the desired outcomes within a reasonable time at justifiable cost. Local management of the system must be concerned consumer-by-consumer because success for individual consumers is the way to achieve overall system performance. The professional staff that provides the clinical home for the consumer assists in the development and monitors the consumer’s person-centered plan. Data is required to determine and communicate the success or failure of implementing that plan as the individualized path for each consumer. To make the pathway more reliable, the system must have ways to detect “dropouts” or other ways in which the system fails to engage the consumer, so corrective action can be taken to ensure success for each consumer. Together, the providers of services and the local management entity build the success of the system for individual consumers and across all consumers served locally. To meet the needs of consumers in the most effective means, the legislature directed the State to provide services that are evidence-based or best practices. The assistance of researchers and experts in the fields of mental health, developmental disabilities and substance abuse are essential for the identification and recommendations of such practices to the Division. If selected as a best practice that Division management wants to implement, the Division must obtain approval from the Division of Medical Assistance and the federal Centers for Medicare and Medicaid Services (CMS) to include the practice as part of the enhanced benefit service package. State Plan 2006: Analysis of State Plans 2001-2005 44 North Carolina DHHS - DMH/DD/SAS Figure 4. General Flow Chart for New Consumers Access: 24 / 7 Initial Contact with the LME/Provider Telephonic or Face to face (uniform portal) MH/DD/SA problem? NO YES Triage: Emergent? Referral: another community service Member of a target population? NO Medicaid eligible? Directly enrolled provider for BASIC BENEFITS Crisis services Clinical evaluation 23-hour observation Community hospital ER Mobile crisis unit Detox (4 levels) Facility based crisis Brief intervention Inpatient hospitalization YES = Client Choice = Utilization review & authorization required NO YES Emergent = initiated w/in 1 hr. Face to face within 2 hrs. of contact UR UR NO YES Screening Basic demographics Brief clinical history Financial eligibility Rights & Consents Encourage LME to start natural community supports and/or county funded community-based programs 6/26/05 DMH/DD/SAS Diagnostic Assessment Community Support/Targeted Case Management Provider selected Person-Centered Plan UR including crisis plan Crisis services per crisis plan Enhanced Benefits per Person-Centered Plan Community Support, ACTT, or Targeted Case Management services Adult MH services Adult DD services Child MH services Child DD services Adult SA services CAP-MR/DD Child SA services ICF-MR State operated facility services and other services Natural& community supports Urgent = appt. within 48 hrs. Routine = appt. within 7 days State Plan 2006: Analysis of State Plans 2001-2005 45 North Carolina DHHS - DMH/DD/SAS Person-Centered Planning Person-centered planning is the process of determining the real- life outcomes that are important to individuals and of developing strategies to achieve those outcomes. The process supports strengths and recovery and applies to everyone supported and served in the system. Person-centered planning provides for the individual with the disability to assume an informed and in-command role for life planning and for treatment, service and support options. The individual with a disability and/or the legally responsible person directs the process and shares authority and responsibility with system professionals about the decisions made.30 The concept of person-centered planning and comprehensive care is the foundation of all system reform efforts and best practice models for individuals in need of mental health, developmental disabilities, and/or substance abuse services according to the President’s New Freedom Commission (see table 1). The national movement has included person-centered planning practices into the design and implementation of individualized services with consumers and their families. Equally so, the Division has established person-centered planning as a fundamental element in the reform of mental health, developmental disabilities and substance abuse service system. There has been much to suggest that a focus on person-centered planning will play an essential role in ensuring the positive experience of recovery and resilience for consumers and family members.31 The Division’s efforts to design and implement a system of person-centered planning are based on the following principles: § Person-centered planning builds on the individual’s and family’s strengths, gifts, skills and contributions. § Person-centered planning supports consumer empowerment and provides meaningful options for individuals and their families to express preferences and make informed choices in order to identify and achieve their hopes, goals and aspirations. § Person-centered planning is a framework for providing services, treatment and supports that meet the individual’s needs and that honors goals and aspirations for a lifestyle that promotes dignity, respect, interdependence, mastery and competence. § Person-centered planning supports a fair and equitable distribution of system resources. § Person-centered planning processes create community connections. They encourage the use of natural and community supports to assist in ending isolation, disconnection and disenfranchisement by engaging individuals and their families in the community, as they choose. 30 See the Division’s Communication Bulletin #034 entitled “Person-Centered Planning,” and Enhanced Services Implementation Updates #1 “CMS Approval of Medicaid State Plan Amendment to Implement the Enhanced Benefit Services Proposed under the Rehabilitation Option (Person-Centered Plans), #8 “Person-Centered Plan”, and #11 “Person-Centered Planning Template.” 31 See the Division’s Enhanced Services Implementation Update #4 “Transition of Services Authorization, Service Orders, Additional Crosswalks,” and #11 “Service Orders.” State Plan 2006: Analysis of State Plans 2001-2005 46 North Carolina DHHS - DMH/DD/SAS § Person-centered planning sees individuals in the context of their culture, ethnicity, religion and gender. All the elements that compose a person’s individuality are acknowledged and valued in the planning process. § Person-centered planning supports mutually respectful and partnering relationships between providers/professionals and individuals/families, acknowledging the legitimate contributions of all parties. In March 2005, the Division announced guidelines for person-centered planning.32 These guidelines address the underlying values and principles, the essential elements, the required documentation elements and indicators to demonstrate that person-centered planning has occurred.33 One of the essential elements of the person-centered plan is a crisis plan. Information is to be included concerning proactive steps to prevent crisis from occurring, and processes or procedures to be followed should a crisis event or emergency situation occur. In April of 2006, person-centered planning became a fundamental part of implementing North Carolina’s new service array for people receiving mental health, developmental disabilities and substance abuse services.34 A standardized format and instructions for developing a person-centered plan (PCP) were distributed for all providers who facilitate plan development for consumers receiving enhanced benefit services. The required standardized format was designed to align with the approved utilization review and authorization processes. The implementation of this person-centered plan and its components has set the stage for influencing and supporting person-centered thinking and planning for all individuals being served in the system. Array/Continuum of Services The continuum of services includes private sector services, community-based public sector services, regionally-based public sector services, and State operated facility services. Ongoing development of local capacity to provide services is a task of the local management entity and, in the long run, will enable the reduced use of state facilities. At the same time, upgrading or replacement of aging state facilities is necessary for those consumers whose needs are beyond the cost-effectiveness at every local level. There are a considerable number of Division publications that address the service array, including communication bulletins and enhanced services implementation updates.35 Refer to those documents for detailed policy and guidance. 32 See the Division’s Communication Bulletin #034. 33 See Enhanced Services Implementation Update Memo # 12: Value Options Implementation; and Enhanced Services Implementation Update Memo # 15: Targeted Case Management and Services Authorization through Value Options. 34 See the Division’s Enhanced Services Implementation Update # 8. 35 See Communication Bulletins and Enhanced Services Implementation Update Memos for additional details on the Division’s web site: http://www.dhhs.state.nc.us/mhddsas/announce/index.htm State Plan 2006: Analysis of State Plans 2001-2005 47 North Carolina DHHS - DMH/DD/SAS Services for People with Developmental Disabilities The services for people with developmental disabilities include an array of habilitation and support services that are available to individuals who qualify for the level of services referred to as Intermediate Care Facilities – Mentally Retarded (referred to as ICF-MR) that are funded by Medicaid. Eligible individuals, who choose community services rather than in an ICF-MR facility, may receive services that are funded by the Community Alternative Program for Developmental Disabilities. This is most often referred to as the CAP-MR/DD waiver. The CAP-MR/DD waiver offers specific services that promote community living and thereby avoid institutionalization. Waiver services compliment and/or supplement services available through the State Medicaid Plan and other State, local and federal programs.36 North Carolina’s most recent Community Alternative Program for Developmental Disabilities waiver went into effect in September 2005. The specific services that an individual receives under the waiver are based on the person-centered planning process and the identification of the individual’s needs. Examples of the types of service that an individual might receive include Day Supports provided in a licensed day setting, Home and Community Supports provided in an individual’s home or in the community, Personal Care and Respite. Other services include tangible supports such Augmentative Communication Devices, Home Modifications and Vehicle Adaptations. Individuals who receive waiver funding and live in licensed residential settings such as a group home are supported under the service definition of Residential Supports to meet their habilitation needs in the residential setting. State funds are also used in these settings to address some support, supervision and care needs. Targeted Case Management is a required service for individuals participating in the waiver. These case managers provide a variety of functions to individuals on the waiver including facilitation of the person-centered planning process and identification of needed waiver services, locating and coordinating those services, as well as monitoring of services to assure services are delivered appropriately to insure the health and safety of the waiver recipient. For individuals who do not meet the ICF-MR level of care and/or are not CAP-MR/DD waiver recipients, there are a variety of State- funded services. These services are available to individuals who are ineligible for Medicaid and are not CAP recipients, or to individuals who receive Medicaid but are not CAP recipients. Some State-funded 36 For more about the CAP-MR/DD Waiver, see the Division’s Communication Bulletins: # 024: CAP/MRDD Waiver Team. # 042: Revised Implementation for New CAP-MR/DD Waiver. # 045: Approval of CAP-MR/DD Waiver. And Enhanced Services Implementation Update Memos: # 2: CAP-MR/DD Waiver. # 13: CAP-MR/DD. # 15: CAP-MR/DD and Targeted Case Management. State Plan 2006: Analysis of State Plans 2001-2005 48 North Carolina DHHS - DMH/DD/SAS services are available to individuals who are CAP recipients to pay for things the waiver does not cover, such as room and board in a group home. Services for Children and Adolescents with Mental Health or Substance Abuse Needs The new and revised services that were approved for both Medicaid covered services and for State funding include Community Support services that are often a consumer’s clinical home. Interventions that are delivered by Community Support providers include coordination of assessments, the involvement of the child and family team in developing the individual’s person-centered plan and the functions of linking the child and his/her family with other needed services or resources. In addition, Community Support providers can provide, for example, training for caregivers, preventive and therapeutic activities that will assist with skill building and development of skills that enable the child and family to have positive relationships with others. Examples of other more intensive services for children and adolescents that were made available in March 2006 are Intensive In-Home Services and Multisystemic Therapy (MST), Day Treatment and Substance Abuse Intensive Outpatient services. Several types of residential treatment continue to be available at varying levels of support and intensity. The delivery of services for individual children and adolescents is based on person-centered planning by a child and family team.37 The organizing principle for these services is for communities to have a “system of care.” The purpose of a system of care is to make comprehensive, flexible and effective support available for children, youth and families throughout the community and through this assistance make the community a better place to live. Services for Adults with Substance Abuse Service Needs The enhanced services implemented in March 2006 include a full continuum of substance abuse services based on the levels of care recognized by the American Society of Addiction Medicine. The service continuum includes Community Support, Mobile Crisis Management, Substance Abuse Intensive Outpatient Program, Substance Abuse Comprehensive Outpatient Program, Residential Treatment services and Detoxification services. Consumers are able to move from level of care to another base on their level of need and medical necessity. These services are designed to assist individuals with a primary substance abuse disorder to achieve positive life outcomes that support stable and ongoing recovery. 37 See Enhanced Services Implementation Update Memo # 3: Crosswalk from Old Services to New and Children’s Services Issues; Enhanced Services Implementation Update Memo # 5: Developmental Therapy; and Enhanced Services Implementation Update Memo # 11: Children’s Residential Treatment Facility Services/EPSDT. State Plan 2006: Analysis of State Plans 2001-2005 49 North Carolina DHHS - DMH/DD/SAS Services for Adults with Serious Mental Illness As is the case for children and adolescents, the Community Support service is the clinical home for many adults. Other adults may receive more intensive community services such as Assertive Community Treatment Team (ACTT) that comprehensively addresses the needs of adults who have had multiple hospitalizations or other serious functional difficulties related to living successfully in the community. Other adults with mental illness who are on the path to rehabilitation and recovery may need services such as Supported Employment, Psychosocial Rehabilitation Day Services, and/or affordable housing with appropriate levels of support from mental health service providers or other community agencies.38 Emergency Services During State fiscal year 2007, the Division will assist local management entities with the development of a model for a continuum for crisis services for both urban and rural areas with the assistance of a consultant. The model will include: · 24/7/365 crisis access to services (telephone, walk- in, mobile response, crisis outreach). · Regional crisis facilities (respite, observation and stabilization units). · Inpatient facilities (with options for voluntary admission to a psychiatric hospital). · Transportation. The development of the continuum will be based upon the findings and recommendations from the Division after conducting an assessment of crisis services and needs throughout the State.39 Prevention, education and consultation House Bill 381 refers to consultation, prevention and education as core services that shall be made available by State and local governments to individuals with mental health, developmental disabilities and substance abuse needs within available resources. The mission of the Division states it will provide the necessary prevention, intervention, treatment, services and supports that individuals need to live successfully in communities of their choice. Prevention programs are reaching a new level of sophistication that includes evidence-based practices, outcome evaluations and cost/benefit considerations. In recent years, developing and delivering prevention services and programs has become a specialty in its own right. 38 See the Division’s Communication Bulletin #007 “Best Practice-Adult Mental Health.” 39 See the Division’s Communication Bulletin #035 entitled “Policy Guidance (Provision of Local Crisis Services), Communication Bulletin #048 “Service Transition Guidance: How to Use Existing Definitions in Transition-Mobile Crisis Management” and Co mmunication Bulletin #061 “Partners for Planning Regional Crisis Services.” State Plan 2006: Analysis of State Plans 2001-2005 50 North Carolina DHHS - DMH/DD/SAS Prevention implies taking advance measures against something possible or probable. Within the Division, prevention may be designed to inform and teach individuals, various groups or the population at large about the insights and skills related to healt hy living. Prevention may also support policies that prevent undesired consequences, such as death or injury due to driving while intoxicated. Local business plans must address how prevention will be provided in the catchment area. Education is defined as a practice of developing mentally, morally or aesthetically, especially by instruction or to provide with information. Within the Division, education is designed to inform and teach various groups including persons being served, families, schools, bus inesses, churches, industries, civic and other community groups about the nature of mental illness, developmental disabilities and substance abuse and the services and supports in the state and community. Local business plans must outline how education will be provided. Consultation is defined as professional advice or services. Within the Division, these services are provided to other agencies, groups, or organizations and to individual practitioners to promote planning and development of services. Training and technical assistance may be offered directly, or by a contracted consultant, regarding the development of practices, tools, and resources. Local management entities may provide consultation to their providers in an effort to maintain continuity. Local business plans must outline how they will provide this service to the community. Past methods of prevention within the Division and its contract providers have mainly focused on substance abuse prevention, working with the federal Center for Substance Abuse Prevention (CSAP) and other nationally known prevention agencies. New prevention and intervention methods are crossing disability categories. The Division is currently developing and creating a comprehensive prevention plan that will be culturally competent, utilize evidence-based techniques and involve best practice. This plan will guide the Division, local management entities, providers, consumers, advocates and other stakeholders to engage in prevention and early intervention practices throughout the State. State Operated Facilities The Department of Health and Human Services has committed to the construction of a new regional psychiatric hospital in Butner, North Carolina. The 432 bed facility will serve persons who need inpatient psychiatric services in both the north and south central regions of the state. Dorothea Dix Hospital in Raleigh and John Umstead Hospital in Butner continue to provide services until remaining patients and admissions can be accommodated in the new facility. Construction is expected to be completed by late summer of 2007. The General Assembly has also approved construction of new facilities to replace Cherry and Broughton Hospitals within the next eight years. State Plan 2006: Analysis of State Plans 2001-2005 51 North Carolina DHHS - DMH/DD/SAS Between State fiscal year 2002 and State fiscal year 2005 the psychiatric hospitals engaged in efforts to downsize. Target reductions were met for skilled nursing and adult long-term units. The number of gero-psychiatric beds was also reduced, although current census exceeds the target capacity. Due to increased admissions and census, no adult admission units have been downsized. Downsizing the hospitals continues to be a goal and the Division is developing a new plan to address further downsizing of the admissions units. The Division is transforming the alcohol and drug abuse treatment centers (ADATCs) to increase acute capacity in order to serve individuals with substance abuse disorders who are involuntarily committed. This increased capacity will divert involuntary substance abuse commitments from the state psychiatric hospitals and provide immediate access for individuals needing inpatient substance abuse treatment interventions. Strategic planning is ongoing with the ADATCs to operationalize their new mission to provide medically monitored detoxification, crisis stabilization and short-term treatment to prepare adults with substance abuse problems for ongoing community-based recovery services. The ADATCs are in the process of implementing a redesigned evidence based treatment model for individuals who require inpatient treatment in order to initiate recovery before returning to ongoing treatment in the community. The Division continues its efforts to downsize the developmental centers by working closely with consumers who are interested in receiving community services, their guardians, local management entities and providers. Specialized programs have been established at the developmental centers to provide time-limited active treatment for individuals meeting specific admission criteria and who have been unsuccessful in the community. The specialized services at the developmental centers have either not been available in the individuals’ home communities or have not been sufficient to meet intensive, complex needs. The goal of the specialized programs is to provide individualized, multi-disciplinary services, while working in partnership with local management entities to prepare individuals for successful transition back to their communities. Practice Improvement Collaborative While a first foundation of services has been approved by the federal Centers for Medicare and Medicaid Services and was implemented in March 2006, the ongoing North Carolina Practice Improvement Collaborative (PIC) continues to monitor research and development of promising best practices for possible adoption by North Carolina. The mission for the Practice Improvement Collaborative is to ensure that each time any North Carolinian comes into contact with the mental health, developmental disabilities and substance abuse services system he or she will receive excellent care that is consistent with the scientific understanding of what works. State Plan 2006: Analysis of State Plans 2001-2005 52 North Carolina DHHS - DMH/DD/SAS Comprised of representatives specializing in all three disabilities, the Practice Improvement Collaborative meets quarterly to review and discuss relevant programs. Annually, the group presents a report of prioritized program recommendations to the Division Director at a public forum. This forum, defined as the North Carolina Practice Improvement Congress, will feature brief educational descriptions of the practices being recommended by the Practice Improvement Collaborative in its report. Workforce Development Early in the process of system reform, the Division recognized that development of the workforce would be a significant and complex issue to ensure the success of transformation. This issue involves professional standards, the requirements of service definitions, determination and measurement of competencies, availability of curricula and educational opportunities, and the development and implementation of strategies to build a statewide workforce. The Division recognizes that workforce development for the system is part of a much greater situation for the entire State. The Division is participating in the Department’s initiative to address workforce issues in all of human services.40 In 2001, the Division identified some specific strategies, such as the establishment of regional training facilities that were later eliminated due to the lack of sufficient Division infrastructure to operate. The 2001 tasks that focused on the reasonable compensation of the workforce have also been deleted because these are beyond the scope of the Department. While the State establishes rates paid for services and requires certain types and levels of training as a compliance measure, market forces actually control the rates paid by private providers to staff. During 2002-2003, initial training was begun along with technical assistance to local management entities in collaboration with the North Carolina Council for Community Programs. Workshops were held on person-centered planning and the new service definitions. In depth training has evolved and is ongoing. The North Carolina Commission for Mental Health, Developmental Disabilities and Substance Abuse Services in conjunction with the Division has undertaken workforce development as a priority initiative for State fiscal year 2007. 40 See Communication Bulletin # 22: Workforce Development Plan (Final); Communication Bulletin # 33: Clinical Skills Series (Faculty Application); Enhanced Services Implementation Update Memo # 1: CMS approval of Medicaid State Plan Amendment (SPA) to implement the Enhanced Benefit Services proposed under the Rehabilitation Option. (Training); and Enhanced Services Implementation Update Memo # 10: Courses which Satisfy the Training Requirements for Service Definitions; and Communication Bulletin # 51: (DRAFT) Cultural and Linguistic Competency Action Plan. State Plan 2006: Analysis of State Plans 2001-2005 53 North Carolina DHHS – DMH/DD/SAS Appendices A. Applicable provisions from legislation. B. Glossary. C. Index to State Plans 2001 through 2005 by topic. D. Detailed tasks and status of tasks from prior State Plans. State Plan 2006: Analysis of State Plans 2001-2005 54 North Carolina DHHS – DMH/DD/SAS State Pla |
OCLC number | 50701360 |