State plan ... : blueprint for change.

              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
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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
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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.”
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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.
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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
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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
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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 .
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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.
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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
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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.
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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)
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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)
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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)
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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.
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· 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.
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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.
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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.”
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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
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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,
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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.
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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.
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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
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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.
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· 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.
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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%
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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/.
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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
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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
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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
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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.
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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.
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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.”
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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.”
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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.”
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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.
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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.”
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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.
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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
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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.”
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§ 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
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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.
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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.
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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.”
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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.
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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.
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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.
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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.
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State Pla