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JOINT LEGISLATIVE OVERSIGHT COMMITTEE
ON
MENTAL HEALTH, DEVELOPMENTAL DISABILITIES,
AND SUBSTANCE ABUSE SERVICES
REPORT TO THE 2008 REGULAR SESSION
OF THE
2007 GENERAL ASSEMBLY
A LIMITED NUMBER OF COPIES OF THIS REPORT ARE AVAILABLE
FOR DISTRIBUTION THROUGH THE LEGISLATIVE LIBRARY
ROOMS 2126, 2226
STATE LEGISLATIVE BUILDING
RALEIGH, NORTH CAROLINA 27611
TELEPHONE: ( 919) 733- 7778
OR
ROOM 500
LEGISLATIVE OFFICE BUILDING
RALEIGH, NORTH CAROLINA 27603- 5925
TELEPHONE: ( 919) 733- 9390
THE REPORT IS ALSO AVAILABLE ONLINE:
http:// www. ncleg. net/ LegLibrary/
2
TABLE OF CONTENTS
Page
Letter of Transmittal ................................................................................................................. 4
Committee Membership and Staff ......................................................................................... 5
Preface........................................................................................................................ ................ 7
Committee Proceedings ........................................................................................................... 8
Committee Findings and Recommendations........................................................................ 17
Introduction ................................................................................................................... 17
Finding and Recommendation One: Expenditure of Service Dollars ................... 20
Finding and Recommendation Two: State- Operated Services.............................. 23
Finding and Recommendation Three: Services in the Community ...................... 27
Appendix....................................................................................................................... ............ 31
3
JOINT LEGISLATIVEOVERSIGHT COMMITTEE ONMENTALHEALTH,
DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE SERVICES
State Legislative Building
Raleigh, North Carolina 27603
Senator Martin Nesbitt, Co- Chair Representative Verla Insko, Co- Chair
April 23, 2008
TO THE MEMBERS OF THE 2007 GENERAL ASSEMBLY ( 2008 Regular Session):
The Joint Legislative Oversight Committee on Mental Health, Developmental
Disabilities, and Substance Abuse Services submits for your consideration its
report pursuant to G. S. 120- 231.
Respectfully Submitted,
_______________________________
Sen. Martin Nesbitt, Co- Chair
_______________________________
Rep. Verla Insko, Co- Chair
4
JOINT LEGISLATIVE OVERSIGHT COMMITTEE
ON MENTAL HEALTH, DEVELOPMENTAL DISABILITIES,
AND SUBSTANCE ABUSE SERVICES
MEMBERSHIP LIST
2007- 2008
Senator Martin Nesbitt Co- Chair
300- B Legislative Office Building
Raleigh, NC 27603
O: 715- 3001 Email: Martinn@ ncleg. net
Representative Verla Insko Co- Chair
2121 Legislative Building
Raleigh, NC 27601
O: 733- 7208 Email: verlai@ ncleg. net
Senator Austin Allran
516 Legislative Office Building
Raleigh, NC 27603
O: 733- 5876 Email: Austina@ ncleg. net
Representative Martha Alexander
2208 Legislative Building
Raleigh, NC 27601
O: 733- 5807 Email: Marthaa@ ncleg. net
Senator Bob Atwater
312 Legislative Office Building
Raleigh, NC 27603
O: 715- 3036 Email: Boba@ ncleg. net
Representative Jeffrey Barnhart
608 Legislative Office Building
Raleigh, NC 27601
O: 715- 2009 Email: Jeffba@ ncleg. net
Senator Janet Cowell
1028 Legislative Building
Raleigh, NC 27601
O: 715- 6400 Email: Janetc@ ncleg. net
Representative Van Braxton: Advisory Member
403 Legislative Office Building
Raleigh, NC 27603
O: 715- 3017 Email: Vanb@ ncleg. net
Senator Charlie Dannelly
2010 Legislative Building
Raleigh, NC 27601
O: 733- 5955 Email: Charlied@ ncleg. net
Representative William Brisson: Advisory Member
1325 Legislative Building
Raleigh, NC 27601
O: 713- 5772 Email: Williambr@ ncleg. net
Senator James Forrester
1129 Legislative Building
Raleigh, NC 27601
O: 715- 3050 Email: Jamesf@ ncleg. net
Representative Beverly Earle
634 Legislative Office Building
Raleigh, NC 27603
O: 715- 2530 Email: Beverlye@ ncleg. net
Senator Vernon Malone
314 Legislative Office Building
Raleigh, NC 27603
O: 733- 5880 Email: Vernonm@ ncleg. net
Representative Bob England
2219 Legislative Building
Raleigh, NC 27601
O: 733- 5749 Email: Bobe@ ncleg. net
Senator William Purcell
625 Legislative Office Building
Raleigh, NC 27603
O: 733- 5953 Email: Williamp@ ncleg. net
Representative Jean Farmer- Butterfield
611 Legislative Office Building
Raleigh, NC 27603
O: 733- 5898 Email: Jeanf@ ncleg. net
Senator Larry Shaw Advisory Member
311 Legislative Office Building
Raleigh, NC 27603
O: 733- 9349 Email: Larrys@ ncleg. net
Representative Carolyn Justus
1023 Legislative Building
Raleigh, NC 27601
O: 713- 5956 Email: Carolynj@ ncleg. net
Representative Fred Steen
514 Legislative Office Building
Raleigh, NC 27603
O: 733- 5881 Email: Fredst@ ncleg. net
5
STAFF LIST
Rennie Hobby, Committee Assistant
O: 733- 5639
Email: mentalhealthca@ ncleg. net
Gann Watson, Bill Drafting
O: 733- 6660 Email: gannw@ ncleg. net
Shawn Parker, Research Division
O: 733- 2578 Email: shawnp@ ncleg. net
Andrea Poole, Fiscal Research
O: 733- 4910 Email: Andrear@ ncleg. net
Ben Popkin, Research Division
O: 733- 2578 Email: benp@ ncleg. net
Denise Harb, Fiscal Research
O: 733- 4910 Email: deniseha@ ncleg. net
Susan Barham, Research Division
O: 733- 2578 Email: Susanb@ ncleg. net
6
PREFACE
The Joint Legislative Oversight Committee on Mental Health, Developmental
Disabilities, and Substance Abuse Services ( LOC) is established in Article 27 of
Chapter 120 of the General Statutes. The LOC is charged with continually
examining system- wide issues that affect the development, financing,
administration, and delivery of mental health, developmental disabilities, and
substance abuse services, including issues related to governance, accountability
and service quality.
The Committee consists of sixteen members, eight appointed by the President Pro
Tempore of the Senate and eight appointed by the Speaker of the House of
Representatives. The members appointed by the President Pro Tempore must
include all of the following: at least two must be members of the Senate
Committee on Appropriations, the Chair of the Senate Appropriations Committee
on Human Resources and at least two must be of the minority party. The
members appointed by the Speaker of the House must include all of the following:
at least two members of the House Committee on Appropriations, the Co- Chairs
of the House of Representatives Appropriations Subcommittee on Health and
Human Services, and at least two members of the minority party. Advisory
members may also serve on the Committee. The Co- Chairs for 2007- 2008 are
Senator Martin Nesbitt and Representative Verla Insko.
7
COMMITTEE PROCEEDINGS
The Joint Legislative Oversight Committee on Mental Health, Developmental
Disabilities, and Substance Abuse Services met 10 times during the 2007- 2008
interim. Following is a summary of the Committee's proceedings. Detailed
minutes and information from each Committee meeting are available in the
Legislative Library.
September 25, 2007
The LOC convened its first meeting of the interim on Tuesday, September
25, 2007, at 10: 00 A. M. in Room 643 of the Legislative Office Building. Senator
Martin Nesbitt, Co- Chair, called the meeting to order and welcomed returning
members, new members, and guests.
Dempsey Benton, Secretary of the Department of Health and Human
Services ( DHHS), presented DHHS priorities for improving the mental health
system that included: implementation of the crisis services system, increasing
provider capacity, enhancing substance abuse treatment facilities, and providing
guidance and direction to the State hospitals.
Dr. Alice Lin, the Division of Mental Health, Developmental Disabilities,
and Substance Abuse Services ( DMH) consultant, presented her report on the
Implementation of Local Management Entities. Dr. Lin discussed immediate, short-term,
and mid- term recommendations.
Kory Goldsmith, Research Division, reviewed the process for the closure of
Dorothea Dix and John Umstead Hospitals. According to Session Law 2007- 323
Section 10.49.( t), the Secretary may close Dorothea Dix and John Umstead
Hospitals provided certain conditions are met.
Jim Osberg, Chief of State Operated Services, DMH, discussed the closure
plan for Dorothea Dix and John Umstead Hospitals pursuant to the opening of
Central Regional Hospital ( CRH) in Butner. Mr. Osberg provided a timeline for
the design, construction, and operation of CRH.
Several updates were presented by staff concerning legislative actions from
the 2007 Session. Andrea Poole, Fiscal Research Division, and Melanie Bush,
Fiscal Research Division, provided a review of budgetary actions. Kory
Goldsmith, Research Division, summarized substantive legislation enacted.
Shawn Parker, Research Division, gave an update on Local Management Entities
( LMEs) including historic and current LME configurations.
Trish Amend, NC Housing Finance Agency, and Julia Bick, DHHS,
discussed the Housing 400 Initiative. Ms. Amend announced that financing for
housing for persons with disabilities had been awarded for 425 units in 33
counties.
8
Jim Osberg, Chief of State Operated Services, DMH, provided an update to
the LOC on the hospital utilization pilot. Mr. Osberg discussed the distribution of
funding and the timeline for implementation of services to reduce utilization of
State psychiatric hospitals.
Phillip Hoffman, Chief of Resource and Regulatory Management, DMH,
reported on data collection of consumer income data. He also explained that
DMH established a workgroup to examine the collection of county funds
utilization data.
Bonnie Morrell, Team Leader for Best Practice, DMH, reported on crisis
services implementation. In SFY 2006- 2007, $ 7 million was expended for local
inpatient services, facility based crisis, detoxification, and mobile crisis resulting in
a decrease of admissions to the State psychiatric hospitals.
Flo Stein, Chief of Community Policy Management, DMH, discussed
performance indicators. Ms. Stein reported LMEs that provided continuity of
services saw significant improvement in mental health and substance abuse clients
in every measurable indicator.
October 31, 2007
The LOC convened its second meeting of the interim on Wednesday,
October 31, 2007, at 10: 00 A. M. in Room 643 of the Legislative Office Building.
Dr. Thomas McLellan, CEO of the Treatment Research Institute, discussed
the State s role in the improvement of effectiveness and accountability for the
treatment of addiction. Dr. McLellan explained the chronic care model in the
treatment of addiction. Goals to measure success included: retaining patients at
an appropriate level of care and monitoring, preparing patients to do well in the
next level of care, and evaluating effectiveness during treatment instead of post-discharge.
Dr. Mandy Chalk, Director, Center for Performance Based Policy,
Treatment Research Institute, provided information on funding treatment
networks and contracting for substance abuse treatment services.
Kim Johnson, Network for the Improvement of Addiction Treatment,
presented factors to consider regarding performance based contracting. Ms.
Johnson suggested key elements to consider: a good data collection system, clear
definitions for data elements, and agreed upon performance standards.
November 15, 2007
The LOC convened its third meeting of the interim on Thursday, November
15, 2007, at 10: 00 A. M. in Room 643 of the Legislative Office Building.
Andrea Poole, Fiscal Research Division, reviewed Section 10.49.( s1)-( s4) of
Session Law 2007- 323 regarding the hospital utilization pilot.
Laura White, Team Leader, State Psychiatric Hospitals, DMH, explained
the selection process for the LMEs participating in the hospital utilization pilot.
9
Don Herring, Director of Service Management, Western Highlands
Network, described plans for increasing crisis services and hospital diversion
systems to decrease State hospital utilization.
Betty Taylor, CEO, CenterPoint Human Services, reviewed existing crisis
services offered by CenterPoint and plans for expansion. Goals under the pilot
included: reserving bed days for patients requiring longer stays, increasing
enhanced psychiatric services, diverting clients from the legal system and the ER,
and increasing adult transitional housing.
Tom McDevittt, LME Director, Smoky Mountain Center, presented a
proposal to reduce hospital utilization by increasing local crisis services especially
inpatient psychiatric beds through public/ private partnerships with two hospitals
in the area.
Tom Galligan, Deputy Director for Budget and Finance, Division of Medical
Assistance ( DMA), gave an update on community supports financial status. Mr.
Galligan reported that approximately 45% of the 2007 budget for community
supports was spent during the first 4 months of the fiscal year.
Leza Wainwright, Deputy Director, DMH, and Tara Larson, Acting Deputy
Director for Clinical Affairs, DMA, gave an update on community support
services. Ms. Wainwright and Ms. Larson provided background and reviewed the
revised comprehensive plan that included clarification of service definitions,
suspending new provider endorsements until new rules and provider
qualifications are developed, monitoring and review of LMEs, and changing the
authorization process.
Ms. Wainwright then presented an update on single stream funding and
reviewed the criteria necessary for LMEs participation.
Next, Ms. Wainwright discussed the independent evaluation of LME
performance. Ms. Wainwright explained that the Department contracted with
Mercer Consulting for independent reviews to determine LME performance,
possible consolidation of functions, and requirements for LMEs to perform
utilization review.
Senator Nesbitt, Co- Chair, called on members of the audience for public
comment.
December 5, 2007
The LOC convened its fourth meeting of the interim on Wednesday,
December 5, 2007, at 10: 00 A. M. in Room 643 of the Legislative Office Building.
Grayce Crockett, Director, Mecklenburg Local Management Entity ( LME),
explained the Mecklenburg hospital utilization pilot to reduce bed days at
Broughton hospital.
Tom Galligan, Deputy Director for Budget and Finance, Division of Medical
Assistance ( DMA), gave an update on community supports services.
10
Andrea Poole, Fiscal Research Division, reviewed the 2007- 2008 FY LME
service dollars allocation.
Leza Wainwright, Deputy Director, DMH, discussed the current allocation
of community based services funds and explained the allocation of continuation
funds.
Kory Goldsmith, Research Division, reviewed an information packet
provided to committee members in response to questions from the previous
meeting. Mike Mosley, Director, DMH, and Leza Wainwright, Deputy Director,
DMH, presented the revised plan for the closure of Dorothea Dix and John
Umstead hospitals. Mr. Mosley reviewed the timeline for transition to the new
hospital. Mr. Mosely also announced the development of an additional 60 bed
unit on the Dorothea Dix campus.
Representative Insko, Co- Chair, called on members of the audience for
public comment.
January 23, 2008
The LOC convened its fifth meeting of the interim on Wednesday, January
23, 2008, at 10: 00 A. M. in Room 643 of the Legislative Office Building.
Shawn Parker, Research Division, and Andrea Poole, Fiscal Research,
reviewed an information packet provided to committee members in response to
questions from the previous meeting.
Dempsey Benton, Secretary of the Department of Health and Human
Services ( DHHS), presented an update on the State psychiatric hospitals and
community support services. Secretary Benton also discussed initiatives to
establish committees of external experts to help with mental health issues.
Andrea Poole, Fiscal Research Division, and Denise Harb, Fiscal Research,
reviewed a new report, the MH/ DD/ SA System Indicators report.
Shawn Parker, Research Division, provided background on the
development of local crisis services plans.
Anthony Ward, Provider Relations Manager, Guilford Center, described
the area s implementation of crisis services and discussed the successes and
challenges of the implementation.
Art Constantini, Director, Southeastern Center for MH/ DD/ SAS, reviewed
the crisis services in place at Southeastern Center. Mr. Constantini described the
plan as continuum consisting of prevention measures, crisis response services, and
post- crisis services.
Terry Hatcher, Director, Division of Property and Construction, DHHS,
gave an update on construction projects.
Andrea Poole, Fiscal Research Division, reviewed Session Law 2007- 323,
Section 10.51( b) that directs DHHS to develop a revised service dollar allocation
methodology to equalize funding to LMEs across the State.
11
Leza Wainwright, Deputy Director, discussed the revised service dollars
allocation and explained a combination of two formulas was used to develop the
methodology.
February 27, 2008
The LOC convened its sixth meeting of the interim on Wednesday, January
23, 2008, at 10: 00 A. M. in Room 643 of the Legislative Office Building.
Andrea Poole, Fiscal Research Division, reviewed an information packet
provided in response to questions from the previous meeting. Next, Ms. Poole
explained the monthly MH/ DD/ SA system indicators report and gave an update
on construction projects.
Dan Coughlin, Area Director/ CEO, Pam Shipman, Deputy Area Director,
and Dr. Craig Hummel, Medical Director of Piedmont Behavioral Healthcare
( PBH) discussed PBH s use of a 1915( b)/ 1915( c) combination Medicaid waiver.
The waiver allowed PBH to restrict the freedom of choice of providers and to
determine the size and scope of the provider network.
Gann Watson, Bill Drafting Division, explained the process for appealing a
decision made by a State agency.
Emery Milliken, General Counsel, DHHS, provided information regarding
the Medicaid appeals process, both formal and informal appeals.
Tara Larson, Deputy Director for Clinical Affairs, DMA, addressed the
status of applications for additional Medicaid waivers. Ms. Larson highlighted
options available through the waiver process with CMS. Leza Wainwright,
Deputy Director, DMH, explained that DMH was working with LMEs to examine
different waivers.
Flo Stein, Chief of Community Policy Management, DMH, presented an
update on regionally funded and locally hosted substance abuse programs.
Leza Wainwright, Deputy Director, DMH, explained a technical
amendment to the Community Alternatives Program ( CAP) MR/ DD waiver that
allows family members or guardians to act as providers and provide personal care
services to adult children.
Representative Insko, Co- Chair, called on members of the audience for
public comment.
February 28, 2008
The LOC convened its seventh meeting of the interim on Thursday,
February 28, 2008, at 9: 00 A. M. in Room 643 of the Legislative Office Building.
As a follow- up on the appeals process, Representative Insko, Co- Chair,
welcomed Judge Julian Mann, Director and Chief Administrative Law Judge of
the Office of Administrative Hearings ( OAH). Administrative Law Judge Don
Overby, and Chief Clerk, Kim Housing were also in attendance. Judge Mann
provided an overview of the OAH and addressed questions regarding the impact
12
of the community support appeals cases on the OAH. Judge Mann suggested that
for cases that are pro se, the State file instead of the petitioner and that pre trial
motions that interfere with getting to the merit of the case be eliminated.
Representative Insko asked Vicky Smith, Executive Director of Disabilities
Rights of North Carolina, to respond to comments. Ms. Smith suggested that a
clearly articulated, easily understood bill of rights for people with disabilities
receiving services was needed whether the services were federally funded or State
funded.
Next, Phillip Hoffman, Chief of Resources/ Regulatory Management, DMH,
gave an update on data collection and county funds utilization. He explained that
DMH s reporting requirements were modified to include information on family
size. Currently, the amount of county funds budgeted and received through the
LMEs is reported but not how the funds are utilized.
Flo Stein, Chief of Community Policy Management, DMH, gave a
presentation on crisis services for the developmentally disabled. Ms. Stein
described barriers to receiving service and explained the importance of a
functional assessment, training, and technical assistance. She explained several
proven models in detail. Ms. Stein stated that DMH recommended that the
Systematic Therapeutic Assessment Respite and Treatment ( START) Program be
implemented on a regional basis.
Next, Carol Donin, Developmental Center Team Leader, DMH, addressed
downsizing at the developmental centers. Ms. Donin reported that most
consumers moved to community residential settings such as Intermediate Care
Facilities ( ICF/ MR) group homes and live- in group homes supported by the
Community Alternatives Program ( CAP) MR/ DD waiver. Ms. Donin also
mentioned the ICF- MR bed transfer initiative.
Tara Larson, Acting Deputy Director of Clinical Affairs, DMA, addressed
cost- sharing under CAP. She explained that the Department looking at families
currently on the CAP/ MR and CAP/ C waiver programs and developing a
process by which families would pay for part of their care.
Rose Burnette, Tiered Waiver Project Manager, DMH, gave an update on
the CAP- MR/ DD waiver development. She explained that DHHS requested an
extension from CMS to develop the four tiered waivers and projected
implementation for the tiered waivers between January and June 2009.
Andrea Poole, Fiscal Research, reviewed a draft of recommendation options
with committee members.
March 26, 2008
The LOC convened its eighth meeting of the interim on Wednesday, March
26, 2008, at 9: 00 A. M. in Room 643 of the Legislative Office Building.
13
Shawn Parker, Research Division, reviewed an information packet
provided to committee members in response to questions from the previous
meeting.
Denise Harb and Andrea Poole, Fiscal Research Division, reviewed the
monthly MH/ DD/ SA system indicators report.
Roman Rojano, Area Director, Wake County Human Services presented
short and long term initiatives that addressed the closure of Dorothea Dix
hospital.
Sharen Prevatte, Area Director, Southeastern Regional MH/ DD/ SA
Services, discussed the status of the LME. Ms. Prevatte explained that
Southeastern Regional utilized a combination of inpatient services at area
hospitals, a mobile crisis team, a local crisis stabilization facility, and psychiatrists.
Andrea Poole, Fiscal Research Division, and Shawn Parker, Research
Division, presented draft findings and recommendations to the LOC.
Trish Amend, NC Housing Finance Agency, and Julia Bick, DHHS,
discussed the Housing 400 Initiative. Ms. Amend announced that over 1,300 units
had been funded, 681 units completed, and 604 of those units were occupied.
Bonnie Morrell, Team Leader for Best Practice, DMH, gave a presentation
on transitional residential treatment options for housing individuals with mental
illness in the community.
Tara Larson, Acting Deputy Director for Clinical Affairs, DMA, explained
issues surrounding the suspension of Medicaid eligibility for individuals in State
institutions.
Denise Harb, Fiscal Research Division, and Gann Watson, Bill Drafting
Division, continued the presentation of draft findings and recommendations to the
committee members and incorporated proposals from members of the committee.
Dempsey Benton, Secretary of the Department of Health and Human
Services, presented a report on the Department s recommendations.
April 17, 2008
The LOC convened its ninth meeting of the interim on Wednesday, April
17, 2008, at 9: 00 A. M. in Room 544 of the Legislative Office Building.
Mike Watson, CEO, Sandhills Center for MH/ DD/ SAS, discussed single
stream initiatives and hospital transition teams at Sandhills.
Roy Wilson, CEO, East Carolina Behavioral Health ( ECBH), gave an
overview of services at ECBH and explained that quality services are based on
consumers needs.
Tara Larson, Acting Deputy Director for Clinical Affairs, DMA, presented
background on the Workforce Development Initiative. Ms. Larson then
introduced John Morris, Annapolis Coalition on the Behavioral Health Workforce,
and Dr. Amy Hewitt, University of Minnesota, Institute on Community
Integrations.
14
Mr. Morris discussed goals and strategies for strengthening and supporting
the workforce in the areas of behavioral health, developmental disabilities, and
aging.
Dr. Hewitt, provided an overview of the direct support workforce in North
Carolina and identified strategies to build systems that maximize support and
development of direct support workers.
Leza Wainwright, Co- Director, Division of MH/ DD/ SAS, presented the
findings and recommendations from the Independent Evaluation of the Performance of
Local Management Entities report by Mercer.
Dempsey Benton, Secretary, Department of Health and Human Services
( DHHS), announced priorities for DHHS including funding for additional staff at
the State psychiatric hospitals, establishment of a statewide network of mobile
crisis teams, procurement of additional community inpatient beds, and the
voluntary development of regional LMEs.
Representative Insko, Co- Chair, called on members of the audience for
public comment.
After lunch the LOC reconvened in Room 643 of the Legislative Office
Building and Representative Insko, continued the public comment period.
Steve Hairston, Chief of Operations Support, DMH, reported on the
Workforce Development Initiative.
Dr. Marvin Swartz, Chair, Commission for MH/ DD/ SAS presented an
overview and the recommendations for the MH/ DD/ SAS Workforce Plan.
Pam Silberman, President/ CEO, North Carolina Institute of Medicine,
discussed the Substance Abuse Task Force draft findings and recommendations.
Andrea Poole, Fiscal Research, reviewed changes to the LOC draft report
and incorporated proposals from members of the committee.
Gann Watson, Bill Drafting Division, explained the bill draft containing the
LOC recommendations.
April 23, 2008
The LOC convened its tenth meeting of the interim on Wednesday, April 23, 2008,
at 10: 00 A. M. in Room 643 of the Legislative Office Building.
Representative Insko, Co- Chair, called on members of the audience for
public comment.
Denise Harb and Andrea Poole, Fiscal Research Division, reviewed the
monthly MH/ DD/ SA system indicators report.
Tara Larson, Acting Deputy Director for Clinical Affairs, Division of
Medical Assistance ( DMA), presented DMA's plans to renew the contract with
ValueOptions for utilization review services and answered questions from the
LOC regarding the contract.
Andrea Poole, Fiscal Research Division, reviewed changes to the draft
report and Gann Watson, Bill Drafting Division, explained changes to the bill draft
15
containing the LOC recommendations. After discussion, the LOC approved the
bill with some modifications and moved to include it in the LOC report.
Representative Insko, Co- Chair, offered a joint resolution to authorize the
Legislative Research Commission to study the involuntary commitment statutes in
Chapter 122C of the General Statutes. The LOC approved the joint resolution and
voted to include it in the LOC Report.
Senator Nesbitt, Co- Chair, made the motion that the report be approved as
amended and instructed staff to make technical and conforming changes as
necessary. The motion was approved by the LOC.
16
COMMITTEE FINDINGS AND RECOMMENDATIONS
INTRODUCTION
The LOC and more recently the Department of Health and Human Services and
the press has identified problems concerning the administration of mental
health, developmental disabilities, and substance abuse services at the State and
local levels. Some of these problems and issues can be addressed in the 2008
Regular Session of the 2007 General Assembly. Others will require more review
and scrutiny, and thus more time to identify and implement significant, long- term
changes in the system at all levels of administration.
As a backdrop for the recommendations and legislative proposals contained in
this report, it is important to understand the historical context and the
fundamental policy behind MH/ DD/ SA System Reform enacted by the 2001
General Assembly in House Bill 381 and amendments enacted since that time.
During the mid to late- 1990' s, North Carolina's public system for delivering
services to those with mental illness, developmental disabilities, and substance
abuse addictions faced significant challenges. Several local agencies were in
imminent danger of financial collapse and the State- run psychiatric hospitals were
threatened with the loss of federal funding due to inadequate staffing and record-keeping
violations. During this same period, the United States Supreme Court
held that States have an obligation to provide community- based treatment for
persons with mental disabilities when: ( i) State medical professionals determine
community placement is appropriate; ( ii) placement would be less restrictive and
is not opposed by the patient; and ( iii) community placement can be reasonably
accommodated, given resources available to the State and the needs of others with
mental disabilities. 1 In response to these challenges, the General Assembly
commissioned a series of studies and created the Legislative Oversight Committee
on Mental Health, Developmental Disabilities, and Substance Abuse Services
( LOC) to make recommendations as to what should be done.
Policy enacted in Session Law 2001- 4872 set the framework for system reform.
Specifically, it made significant changes addressing issues of State and local
1 Olmstead v. L. C., 527 U. S. 581 ( 1999); Title II of the Americans with Disabilities Act.
2 HB 381 - An Act to Phase in the Implementation of Mental Health System Reform at the State and Local
Level ( S. L. 2001- 437).
17
governance and increased accountability. The act emphasized consumer- driven
community- based services. It required that State and local governments provide
certain core services to all individuals and required the development of enhanced
services that targeted persons with the most severe disabilities. In addition, the
act shifted the role of local public mental health agencies from being direct service
providers to managing and coordinating services delivered by private providers. 3
Policy of the State
" The policy of the State is to assist individuals with needs for mental health,
developmental disabilities, and substance abuse services in ways consistent with the
dignity, rights, and responsibilities of all North Carolina citizens. Within available
resources it is the obligation of State and local government to provide mental health,
developmental disabilities, and substance abuse services through a delivery system
designed to meet the needs of clients in the least restrictive, therapeutically most
appropriate setting available and to maximize their quality of life
.. State and local
governments shall develop and maintain a unified system of services centered in area
authorities or county programs. The public service system will strive to provide a
continuum of services for clients while considering the availability of services in the
private sector
". 4
Administration of the System
" The Secretary shall administer and enforce the provisions of this Chapter and the
rules of the Commission and shall operate State facilities. An area director or program
director shall ( i) manage the public mental health, developmental disabilities, and
substance abuse services system for the area authority or county program according to the
local business plan, and ( ii) enforce applicable State laws, rules of the Commission, and
rules of the Secretary. The Secretary in cooperation with area and county program
directors and State facility directors shall provide for the coordination of public services
between area authorities, county programs, and State facilities
". 5
" Local management entities are responsible for the management and oversight of
the public system of Mental Health, Developmental Disabilities, and Substance Abuse
Services at the community level. An LME shall plan, develop, implement, and monitor
services within a specified geographic area to ensure expected outcomes for consumers
within available resources." 6
3 N. C. Legislative Services Office, Research Division. System Reform for Mental Health, Developmental Disabilities,
and Substance Abuse Services. 1 INFO BRIEF, no. 2 ( Oct. 10, 2006).
4 N. C. G. S. § 122C- 2
5 N. C. G. S. § 122C- 111
6 N. C. G. S. § 122C- 115.4
18
Systemwide Accountability
" Every county, through an area authority or county program, shall provide for the
development, review, and approval of an LME business plan for the management and
delivery of mental health, developmental disabilities, and substance abuse services." 7
If an LME is not providing minimally adequate services the law authorizes the
Secretary of DHHS to take certain actions after notice and time for correction by the LME.
Those actions include suspension of funding, appointing a caretaker administrator or
caretaker board of directors, and termination of an area director of program director when
the Secretary appoints a caretaker administrator. 8
Upon a determination by the Secretary that an area authority or county program is
in imminent danger of failing financially and of failing to provide direct services to clients,
the Secretary may assume control of the financial affairs of the area authority or county
program and appoint an administrator to exercise the power assumed9.
In light of the issues that have emerged regarding the implementation and
administration of MH/ DD/ SA system reform, the LOC respectfully reports the
following findings and recommendations for consideration by the 2007 General
Assembly, Regular Session, 2008. The legislative proposal can be found in the
Appendix to this report.
7 N. C. G. S § 122C- 115.2
8 N. C. G. S. § 122C- 124.1.
9 N. C. G. S. § 122C- 125
19
FINDING ONE: EXPENDITURE OF SERVICE DOLLARS
State funds appropriated for services are not being fully expended for the
intended purpose, especially in the areas of crisis services and substance abuse
services. For example, in FY 2006- 07, $ 47.7 million in State service dollars was
unexpended. Of that, the 2007 General Assembly realigned $ 26.4 million for FY
2007- 08 and the remaining funds were earmarked for LME systems administration
for FY 2007- 08. In FY 2007- 08, it appears that service dollars will again be under-expended
particularly State funding for crisis services and substance abuse
services.
Since FY 2003- 04, the State has served fewer clients each year through the State
IPRS system, the claims processing system for State- paid clients. The State served
half as many clients in FY 2006- 07 as it did in FY 2003- 0410. The decline in clients
served is particularly high for individuals with mental health and substance abuse
services needs, as is shown in the chart below. While there was a corresponding
increase in the number of persons with mental health needs served through
Medicaid, more research is needed to determine if those services are reaching the
same population that State- paid services are designed to help.
DD
MH
SA
-
20,000
40,000
60,000
80,000
100,000
120,000
2003- 04 2004- 05 2005- 06 2006- 07
Clients Served Through IPRS by Disability
( FY2003- 04 to FY2006- 07)
Additionally, there have anecdotal reports that providers are increasingly
unwilling to provide services to State- paid clients and prefer to provide services to
Medicaid- paid clients. A preliminarily review of available data suggests that this
may be the case.
There are conflicting explanations available for the under- expenditure of funds,
the decrease in services to State- paid individuals, and the lack of service providers
available to treat State- paid clients. However, despite hearing from and meeting
10 Measuring Trends in Public MHDDSA Payments and Persons Served, Medicaid and IPRS Aggregate
Utilization Data by LME as presented at FARO in November, 2007:
http:// www. ncdhhs. gov/ mhddsas/ statspublications/ reports/ index. htm.
20
with LMEs, providers, and DHHS, the LOC has not been able to determine a full
explanation of the problem.
Given the increased needs for these services seen in the community, the jails, State
hospitals, and emergency rooms, it is vital that these funds are spent appropriately
and that within those available resources, services be made available to
individuals who do not qualify for Medicaid.
RECOMMENDATION ONE:
1. Adjust the timing and method by which each non- single- stream LME's
services dollar allocations are distributed, in order to mitigate cash- flow
problems that many LMEs experience at the beginning of the fiscal year.
Specifically, distribute no less than one- twelfth of each non- single-stream
LME's allocation to the respective LME at the beginning of the
fiscal year, and subtract this amount from the LME s total
reimbursements for the fiscal year.
2. Appropriate $ 6 million for DHHS to establish additional regionally-purchased
and locally- hosted substance abuse programs.
3. Encourage the conversion of the remaining non- single- stream LMEs to
single- stream funding as soon as possible.
Appropriate to DHHS $ 675,000 for technical assistance to those LMEs
not currently meeting the standards necessary for single- stream
funding.
Direct DHHS to develop standards for the removal of single- stream
designation for those LMEs that do not continue to meet the single-stream
standards once designated.
4. Direct DHHS to simplify the current State Integrated Payment and
Reporting System ( IPRS) to encourage more providers to serve State-paid
clients.
5. Direct DHHS to create a reporting system for both single- stream
funding and non- unit- cost- reimbursement funding that is readily
comprehensible and integrates with payment systems.
6. Direct DHHS, in consultation with LMEs and providers, to determine
why there have been over- and under- expenditures of State service
dollars by LMEs and to take the actions necessary to address the
21
problem. Also direct DHHS to report to the General Assembly no later
than January 1, 2009 on the actions taken.
7. Appropriate $ 1 million to the General Assembly to be used to retain the
services of an independent consultant to perform a services gap analysis
of the Mental Health, Developmental Disabilities, and Substance Abuse
Services System. The RFP should require the Independent Consultant
to report its findings and recommendations by May 1, 2009.
Also, recommend that the Joint Legislative Program Evaluation
Oversight Committee include in the work plan for the Program
Evaluation Division a thorough performance evaluation of the State's
mental health agencies in the Department of Health and Human
Services ( the Division of Mental Health, Developmental Disabilities, and
Substance Abuse Services and the Division of Medical Assistance) to be
completed by May 1, 2009.
22
FINDING TWO: STATE- OPERATED SERVICES
The State psychiatric hospitals are admitting more clients than in prior years
approximately 2,600 more admissions in FY 2006- 07 than in FY 2002- 03.
In January 2007, due to increased admissions to the hospitals acute units
( particularly the adult acute units), the Department of Health and Human Services
put a delayed admissions policy into effect: when a State psychiatric hospitals'
acute units reach 110% capacity, no admissions are accepted until those units are
once again below 110% capacity.
Three hospitals ( Dix, Umstead, and Broughton) have been on delayed status11.
The chart below shows the percent of days that each of those three hospitals have
been on delayed status in the portion of FY 2006- 07 that the policy was in effect
and in FY 2007- 08 as of February 2008. Broughton and Dix each have been at or
above 110% capacity and thus on delayed status more than half the time.
Additionally, during SFY 2007- 08, due in part to the absence of qualified
permanent staff, State psychiatric hospitals were in jeopardy of losing their
certification by the federal Centers for Medicaid and Medicare Services ( CMS),
and Broughton hospital did lose certification.
A hospital without CMS certification cannot bill Medicaid or Medicare for
services, increasing the portion of the cost of hospital services that must be paid
for by the State. Moreover, a non- certified hospital diminishes public confidence
in our mental health system. The services and administrative practices at the State
psychiatric hospitals need to be improved, to meet federal and State standards and
to restore the public confidence. State institutions need the ability to hire and
retain high- quality staff.
11As of February 2008, Cherry Hospital has not been on delayed status the hospital has been over capacity,
but has been able to divert referrals rather than delay admissions.
Broughton Dix Umstead
January 2007 -
June 2007
65% 49% 22%
July 2007 -
February 2008
71% 59% 31%
Percent ofDays onDelayed Status
23
It is the policy of the State that the State hospitals be used only as a last resort: to
be used for those individuals whose level of acuity prevents them from being
served adequately by community service providers and for those individuals who
local hospitals are unable to admit12. In the short- term, the increased demand for
State hospital admissions needs be met to ensure the availability of that level of
care when it is needed. However, this short- term increase in availability should
not undermine the system's commitment to the previously stated policy. In the
long- term, the demand needs to be reduced by providing alternative services in
the community for individuals in crisis who can be adequately served in the
community and by providing stabilizing services and supports to prevent crises
from occurring.
In addition to issues relating to the State Hospitals, the Committee heard a report
on downsizing at the State s Developmental Centers and found that the Centers
have been unable to reduce the number of patients served. The General
Assembly, in SL 2007- 323, directed the State s Developmental Centers ( the
Caswell, Murdoch and Riddle centers) to reduce their number of residential
patients and directed DHHS s budget to be reduced accordingly as the Centers
censuses decreased. However, DHHS has informed the LOC that the Centers are
not downsizing as expected, primarily because the patients living there are unable
to be adequately and appropriately served in the community and due to increased
demand from population increases. In order for the Centers to downsize
effectively, consumers need supports for living, working, and participating in all
aspects of community needs to be available. In addition to the direct supports,
there also need to be affordable options for the actual residence.
North Carolina statutes on involuntary commitments of individuals to psychiatric
facilities provide for transportation to the physician or eligible psychologist for the
examination required by law. G. S. 122C- 261, et seq. Questions have arisen
regarding supervision of the individual during this time. Interpretations of
current law, G. S. 122C- 263( a), permit law enforcement officers who transport the
individual to the appropriate facility to discontinue supervision of the individual
once the officers have delivered the individual to the facility so long as there is
adequate supervision at the facility. This situation raises issues of detention of an
individual by the facility when the individual has neither been arrested nor
committed to a State hospital by court order. Also involved is the question of
using limited law enforcement resources to continue supervision of the individual
pending the required examination.
12 North Carolina Department of Health and Human Services, State Plan 2001: Blueprint for Change,
( November 31, 2001).
24
RECOMMENDATION TWO:
1. Due to the high use of adult admissions unit beds, appropriate
$ 5,274,000 on a one- time basis and authorize the temporary opening of
the Central Regional Hospital Wake Unit on the Dorothea Dix Campus.
2. Require that all deaths occurring in State institutions be reported to the
State Medical Examiner to determine if further investigation into the
cause of death and circumstances surrounding the death is necessary
and appropriate the necessary funds of $ 155,226 to DHHS for an
additional Public Health Nurse Consultant and other associated costs
with the increased investigatory requirements.
Direct the Commission for Mental Health, Developmental Disabilities, and
Substance Abuse Services to study the current death reporting requirements
established under G. S. § 122C- 26( 5)( c) and assess the need for any additional
reporting requirements or modifications to existing rules or procedures.
3. Appropriate $ 30 million to expand the Hospital Utilization Pilot
statewide, in a manner that maintains local control of funds and of bed
utilization, with a goal of reducing the use of State psychiatric hospital
beds for those individuals staying 2 weeks or less.
4. Appropriate $ 1,134,168 to implement the Transitional Residential
Treatment Program in each of the 3 psychiatric hospital catchment
areas.
Also, direct DHHS, in consultation with LMEs and providers, to
develop and implement a plan for discharge planning at the local level
for all disability groups to ensure that those individuals willing and able
to transition to the community can successfully make that transition.
Also direct DHHS to report to the General Assembly no later than
January 1, 2009 on the actions taken.
5. Continue funding for the Housing 400 Initiative by appropriating $ 10
million to the Housing Trust Fund and $ 2.5 million to DHHS for
recurring operating support for approximately 500 units. By providing
stabilizing services and supports to prevent crises from occurring,
appropriate housing will reduce the need for State Psychiatric hospitals
in the long- term.
6. Provide for automatic re- enrollment in Medicaid for those individuals
whose eligibility had been cancelled while in the hospital so that upon
25
their release they will have access through Medicaid to care and
medications.
7. Direct DHHS, within current available resources, to implement the
tiered CAP- MR/ DD waiver program as directed in SL 2007- 323, Section
10.49( dd). The Department shall implement the program with four tiers:
( i) up to $ 10,000; ( ii) between $ 10,001 and $ 25,000; ( iii) between $ 25,001
and $ 75,000; and ( iv) greater than $ 75,000.
8. Direct the Institute of Medicine ( IOM) to study and report on the best
practices in transition for persons with developmental disabilities from
one life setting to another, including barriers to transition and best
practices in successful transitions. The Institute of Medicine should
conduct this study using funds appropriated for IOM studies in the 2007
Session, and the study should encompass at least the following topics:
( i) the transition for adolescents leaving high school, including
adolescents in foster care and those in other settings; ( ii) the transition
for persons with developmental disabilities who live with aging parents;
and ( iii) the transition from the developmental centers to other settings.
9. Direct DHHS to review State- County Special Assistance rates to
establish an appropriate rate for special care units for persons with a
mental health disability, including individuals with a Traumatic Brain
Injury ( TBI) and to review the rules pertaining to special care units for
persons with a mental health disability to determine if additional
standards are necessary.
10. Authorize a study of the pertinent commitment statutes, particularly
G. S. 122C- 263( a), to determine if an individual lawfully ordered to
undergo an examination by a physician or eligible psychologist is being
appropriately supervised during the period of the individual's
examination.
11. Support DHHS's recommendation for additional funds for hiring and
retention of proper staffing in the State Hospitals.
26
FINDING THREE: SERVICES IN THE COMMUNITY
In March 2006, DHHS enacted new federally- approved service definitions for a
variety of mental health services, including Community Support Services ( CS). CS
was designed to replace two former services ( Community- Based Services and
Case Management), and the State expected CS to cost approximately the same as
what it replaced. However, in FY 2006- 07, the service s State and Federal Medicaid
cost was about $ 500 million higher than expected.
In the 2007 regular session, the General Assembly enacted Session Law 2007- 323,
of which Section 10.49( ee) implemented a number of changes to slow CS
spending. DHHS also has taken steps to control the program s growth and
expenses. But CS costs remain higher than anticipated in FY 2007- 08, and
spending is likely to exceed budget if it continues at the current rate.
The LOC believes that the overspending in the CS program has been caused by
multiple factors, which are outlined below. It is the LOC s belief that not only have
these factors caused the current problems with Community Support, but they
leave the system vulnerable to similar problems in other MHDDSA areas.
The CS Reimbursement Rate Encourages Low- Qualified Providers
The State- and federally- approved CS definition allows for CS to be provided by
paraprofessionals, associate professionals and qualified professionals all of
whom are reimbursed at the same rate. This blended rate has resulted in a rapid
increase in the number of CS providers and in the service s costs, without
administrative control over the necessity for the service, the type of service, and
the qualifications of the service provider.
Service Providers Have a Conflict of Interest In Performing Assessments
Before receiving services or treatment, clients are evaluated and assessed to
determine their diagnosis and treatment needs. However, these assessments are
often conducted by a provider who also offers the services or treatments to which
the client is referred. This creates a potential conflict of interest on the part of the
provider and can lead to non- objective client assessments.
DHHS Has Undercut the LMEs Ability to Perform Statutory Core Functions
LMEs core functions, as defined by General Statute 122C- 115, include utilization
management, utilization review, and determination of the appropriate level and
intensity of services to ensure that services are needed and appropriately
provided. However, the DHHS has transferred this function from LMEs to an
27
outside vendor for Medicaid- funded services. The outside vendor's performance
of utilization review has been ineffective and inconsistent in its application, due in
part to the absence of uniform review standards.
One function that has remained with the LMEs is provider endorsement. In order
to provide Medicaid services, providers must first be endorsed by an LME as
being qualified to provide the service. However, LMEs are not State agencies and
have not been given sufficient authority to implement, monitor, and effectively
enforce provider endorsement requirements in order to hold providers
accountable. As a result, some endorsed providers are performing below
standards required by State law and federal law.
Poor provider performance has given rise to concerns about the level, volume, and
quality of services by providers, particularly with respect to community support
services. In response to these concerns, LMEs have begun to deny, suspend, or
refuse to renew provider endorsements; this has caused a spike in the number of
provider appeals.
The Appeals Process Should be Streamlined to Address a Substantial Backlog
in Appeals Pending, and Should Be Simplified to Address Issues of Fairness
The appeals process for Medicaid applicants and recipients needs to be
streamlined, simplified, and balanced. Federal law requires a " fair hearing" when
Medicaid services are reduced or denied and also requires resolution of the case
within 90 days. Recent actions taken by the DHHS to reduce or eliminate services
has caused a substantial increase in the volume of appeals, which in turn has
caused a very large backlog of appeals pending. The result has created an increase
in State Medicaid expenditures, case resolution far in excess of the time allowed
under federal law, and a lawsuit recently filed raising due process issues. Last
session the General Assembly provided for simplified appeals of Department of
Revenue decisions by taxpayers, G. S. 105- 241.15, and authorized the Chief
Administrative Law Judge ( OAH) to limit and simplify the procedures that apply
to a contested tax case involving a taxpayer who is not represented by an attorney.
G. S. 150B- 31.1. A similar expedited process could be replicated for Medicaid
contested cases. Changes to the appeals process to ensure that the interests of
Medicaid clients are adequately represented may require additional funding to
reduce the number of clients that appear pro se due to their financial situation.
The Ability to Control the Provider Network Can Contribute to LME Success
Piedmont Behavioral Health the LME whose catchment area includes Davidson,
Rowan, Cabarrus, Stanly and Union Counties has a 1915 ( b)/( c) combination
Medicaid waiver that gives it flexibility in managing care. Among other features
28
the waiver allows Piedmont Behavioral Health ( PBH) to control the size of its
provider network. The LOC believes that this control has aided PBH s success.
RECOMMENDATION THREE:
1. Require that DHHS develop and implement a tiered rate structure for
community support services to replace the current blended rate.
Under the new tiered structure, services that are necessary but do not
require the skill, education, or knowledge of a qualified professional
should not be paid at the same rate as services provided by qualified
skilled professionals. Require DHHS to report to the LOC prior to
implementing the new rate structure.
2. Require DHHS to develop and implement a service authorization
process that separates the assessment function from the service delivery
function. In doing so, the Department should consider as an option LME
assessment centers whose duties would include care coordination.
Require DHHS to report to the LOC prior to implementing the new
service authorization process.
3. Direct DHHS to conduct a thorough study of the service authorization,
utilization management, and utilization review processes and to
develop a plan to return the service authorization, utilization review,
and utilization management functions to LMEs for all clients.
Direct DHHS to comply with the requirements of S. L. 2007- 323, Section
10.49( ee). Prohibit DHHS from contracting with an outside vendor for
service authorization, utilization review, or utilization management
functions, or otherwise obligating the State for these functions beyond
June 30, 2009. Direct DHHS to require LMEs to include in their service
authorization, utilization management, and utilization review a review
of assessments as well as person centered plans, and random or
triggered audits of services and assessments.
Also, require that the licensed professional who signs a medical order
for services must indicate whether the licensed professional has ( i) had
contact with the consumer, and ( ii) reviewed the consumer's assessment.
4. Direct DHHS to adopt guidelines for LME periodic review and re-endorsement
of providers to ensure that only qualified providers are
endorsed and that LMEs hold those providers accountable for the
Medicaid and State- funded services they provide. Additionally, amend
29
state law to allow providers to appeal LME decisions on provider
endorsements to the Office of Administrative Hearings.
5. Authorize the Office of Administrative Hearings ( OAH) to develop a
simplified procedure to streamline the process for hearing appeals of
Medicaid recipients, applicants, and providers ( including an automatic
appeal for recipients and applicants). In developing the process the
OAH should consult with DHHS to ensure that the streamlined and
simplified process complies with federal " fair hearing" requirements.
The process should be as simple and straightforward as possible,
especially for appellants appearing without an attorney, without
compromising the purpose of the Administrative Procedure Act, G. S.
150B- 2, et seq., and allowing for a complete record of the hearing to be
maintained by the presiding administrative law judge.
Also, require DHHS, in its written notice of the reduction, termination,
or denial of services, to provide information clearly explaining the
opportunities for appeal and the reasons for the decision.
6. Direct DHHS to study Medicaid waivers, including 1915( b) and ( c)
waivers, for all LMEs or some other mechanism to allow LMEs to the
ability to provide case management, assessment, or other management
functions and to limit provider networks. Recognizing that waivers may
not be appropriate for all LMEs, direct the Department to study what
would be needed to increase LMEs flexibility for innovation.
7. Direct DHHS to develop a plan for General Assembly review that
would merge, consolidate, or provide for regional arrangements or
consortia with respect to LME structure. The Secretary should consult
with LMEs in the development of the plan and should submit the plan
to the General Assembly for review. Further, require that the Secretary
take no action to merge, consolidate, or provide for regional
arrangements or consortia with respect to LME structure before January
1, 2010.
8. Support the recommendation of the MH/ DD/ SAS Workforce Plan to
appropriate the necessary funds to DHHS to establish a Workforce
Development Specialist position within the Division of MH/ DD/ SAS.
This specialist should have expertise in assessing workforce issues and
will serve as the project manager for implementing the Division's
workforce development initiatives, particularly the recommendations
identified in the MH/ DD/ SAS Workforce Plan.
30
APPENDIX
Copies of the proposed legislation begin on the following page.
31
GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2007
H/ S D
BILL DRAFT 2007- LNz- 309A* [ v. 10] ( 4/ 2)
( THIS IS A DRAFT AND IS NOT READY FOR INTRODUCTION)
4/ 30/ 2008 1: 18: 42 PM
Short Title: Recommendations of MH/ DD/ SA Oversight Comm. ( Public)
Sponsors:
Referred to:
1 A BILL TO BE ENTITLED
2 AN ACT TO ENACT VARIOUS LAWS TO IMPROVE THE MENTAL HEALTH,
3 DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE SERVICES
4 SYSTEM, AS RECOMMENDED BY THE JOINT LEGISLATIVE OVERSIGHT
5 COMMITTEE ON MENTAL HEALTH, DEVELOPMENTAL DISABILITIES,
6 AND SUBSTANCE ABUSE SERVICES.
7 The General Assembly of North Carolina enacts:
8 SECTION 1.1. Expenditure of Service Dollars. - For the purpose of
9 mitigating cash- flow problems that many non- single- stream LMEs experience at the
10 beginning of each fiscal year, the Department of Health and Human Services, Division
11 of Mental Health, Developmental Disabilities, and Substance Abuse Services, shall
12 adjust the timing and method by which allocations of service dollars are distributed to
13 each non- single- stream LME. To this end, the allocations shall be adjusted such that at
14 the beginning of the fiscal year, the Department shall distribute not less than one- twelfth
15 of the LME's continuation allocation and subtract the amount of the adjusted
16 distribution from the LME's total reimbursements for the fiscal year.
17 SECTION 1.2. There is appropriated from the General Fund to the
18 Department of Health and Human Services, Division of Mental Health, Developmental
19 Disabilities, and Substance Abuse Services, the sum of six million dollars ($ 6,000,000)
20 for the 2008- 2009 fiscal year. These funds shall be used to support LMEs in
21 establishing additional regionally- purchased and locally- hosted substance abuse
22 programs. Funds appropriated shall be for the purpose of developing and enhancing the
23 American Society of Addiction Medicine ( ASAM) continuum of care at the community
24 level. The Department of Health and Human Services shall work with LMEs in
25 establishing these programs.
26 SECTION 1.3.( a) There is appropriated from the General Fund to the
27 Department of Health and Human Services, Division of Mental Health, Developmental
32
General Assembly Of North Carolina Session 2007
1 Disabilities, and Substance Abuse Services, the sum of six hundred seventy- five
2 thousand dollars ($ 675,000) for the 2008- 2009 fiscal year. These funds shall be used to
3 contract with an outside vendor for technical assistance to LMEs that are not meeting
4 the standards necessary for single- stream funding.
5 SECTION 1.3.( b) The Department shall encourage the conversion of the
6 remaining non- single- stream LMEs to single- stream funding as soon as possible. The
7 Department shall also develop standards for the removal of single- stream designation
8 for those LMEs that do not continue to comply with the applicable requirements for
9 single- stream funding.
10 SECTION 1.4. The Department of Health and Human Services shall
11 simplify the current State Integrated Payment and Reporting System ( IPRS) to
12 encourage more providers to serve State- paid clients.
13 SECTION 1.5. The Department of Health and Human Services shall create a
14 reporting system for both single- stream funding and non- unit- cost reimbursement
15 funding that is readily comprehensible and integrates with payment systems.
16 SECTION 1.6. The Department of Health and Human Services shall
17 determine why there have been under- and over- expenditure of State service dollars by
18 LMEs and shall take the action necessary to address the problem. In making its
19 determination the Department shall consult with LMEs and providers. Not later than
20 January 1, 2009, the Department shall report to the House of Representatives
21 Appropriations Subcommittee on Health and Human Services, the Senate
22 Appropriations Committee on Health and Human Services, the Fiscal Research Division
23 and the Joint Legislative Oversight Committee on Mental Health, Developmental
24 Disabilities, and Substance Abuse Services on actions taken to address problem of LME
25 under- and over- expenditure of service dollars.
26 SECTION 1.7.( a) There is appropriated from the General Fund to the
27 General Assembly the sum of one million dollars ($ 1,000,000) for the 2008- 2009 fiscal
28 year. These funds shall be used to retain the services of an independent consultant to
29 perform a services gap analysis of the Mental Health, Developmental Disabilities, and
30 Substance Abuse Services System. In developing the RFP the Fiscal Research Division
31 shall require the Independent Consultant to report on or before May 1, 2009 its findings
32 and recommendations to the House of Representatives Appropriations Subcommittee on
33 Health and Human Services, the Senate Appropriations Committee on Health and
34 Human Services, the Joint Legislative Oversight Committee on Mental Health,
35 Developmental Disabilities, and Substance Abuse Services, and the Fiscal Research
36 Division.
37 SECTION 1.7.( b) In developing its work plan, the Joint Legislative Program
38 Evaluation Oversight Committee may include a thorough performance evaluation of the
39 State's mental health agencies in the Department of Health and Human Services,
40 Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
41 and the Division of Medical Assistance. The performance evaluation shall be
42 completed not later than May 1, 2009.
43
33
General Assembly Of North Carolina Session 2007
1 SECTION 2.1.( a). State- Operated Services. – In order to temporarily
2 address high admissions to adult acute unit beds in the State psychiatric hospitals, the
3 Secretary of the Department of Health and Human Services may open and operate on a
4 temporary basis the Central Regional Hospital Wake Unit on the Dorothea Dix Campus
5 and may maintain the Wake Unit on the Dix Campus until beds become available in the
6 system.
7 SECTION 2.1.( b). G. S. 122C- 181( a)( 1) reads as rewritten:
8 " § 122C- 181. Secretary's jurisdiction over State facilities.
9 ( a) Except as provided in subsection ( b) of this section, the Secretary shall
10 operate the following facilities:
11 ( 1) Psychiatric Hospitals:
12 a. Cherry Hospital.
13 a1. ( Contingent effective date, see Editor's note) Central
14 Regional Hospital.
15 b. ( Contingent repeal date, see Editor's note) Dorothea Dix
16 Hospital.
17 c. ( Contingent repeal date, see Editor's note) John Umstead
18 Hospital.
19 d. Broughton Hospital.
20 e. The Central Regional Hospital Wake Unit on the Dorothea Dix
21 Campus."
22 This subsection expires upon the earlier of July 1, 2009 or the availability of
23 beds at Central Regional Hospital.
24 SECTION 2.1.( c) There is appropriated from the General Fund to the
25 Department of Health and Human Services the sum of five million two hundred
26 seventy- four thousand dollars ($ 5,274,000) for the 2008- 2009 fiscal year. These one-27
time funds shall be used to support the temporary opening and operation of the Central
28 Regional Hospital Wake Unit on the Dorothea Dix Campus.
29 SECTION 2.2.( a) G. S. 130A- 383( a) reads as rewritten:
30 " § 130A- 383. Medical examiner jurisdiction.
31 ( a) Upon the death of any person resulting from violence, poisoning, accident,
32 suicide or homicide; occurring suddenly when the deceased had been in apparent good
33 health or when unattended by a physician; occurring in a jail, prison, correctional
34 institution institution, State facilities operated in accordance with Part 5 of Article 4 of
35 Chapter 122C of the General Statutes; or in police custody; occurring pursuant to
36 Article 19 of Chapter 15 of the General Statutes; or occurring under any suspicious,
37 unusual or unnatural circumstance, the medical examiner of the county in which the
38 body of the deceased is found shall be notified by a physician in attendance, hospital
39 employee, law- enforcement officer, funeral home employee, emergency medical
40 technician, relative or by any other person having suspicion of such a death. No person
41 shall disturb the body at the scene of such a death until authorized by the medical
42 examiner unless in the unavailability of the medical examiner it is determined by the
43 appropriate law enforcement agency that the presence of the body at the scene would
44 risk the integrity of the body or provide a hazard to the safety of others. For the limited
34
General Assembly Of North Carolina Session 2007
purposes of this Part, 1 expression of opinion that death has occurred may be made by a
2 nurse, an emergency medical technician or any other competent person in the absence of
3 a physician."
4 SECTION 2.2.( b) G. S. 122C- 31 is amended by adding the following new
5 subsection to read:
6 " § 122C- 31. Report required upon death of client.
7 "…
8 "( g) In addition to the reporting requirements specified in subsections ( a) through
9 ( e) of this section, and pursuant to G. S. 130A- 383, every State facility shall report the
10 death of any client of the facility, regardless of the manner of death, to the medical
11 examiner of the county in which the body of the deceased is found."
12 SECTION 2.2.( c) There is appropriated from the General Fund to the
13 Department of Health and Human Services, the sum of one hundred fifty- five thousand
14 two hundred twenty- six dollars ($ 155,226) for the 2008- 2009 fiscal year. These funds
15 shall be used for one additional public health nurse consultant position and other costs
16 associated with the increased investigatory requirements of this section.
17 SECTION 2.2.( d) The Commission for Mental Health, Developmental
18 Disabilities, and Substance Abuse Services shall study the current death reporting
19 requirements under G. S. 122C- 26( 5)( c) and assess the need for any additional reporting
20 requirements or modifications to existing rules or procedures. The Commission shall
21 report its findings to the Joint Legislative Oversight Committee on Mental Health,
22 Developmental Disabilities, and Substance Abuse Services not later than November 1,
23 2008.
24 SECTION 2.3. There is appropriated from the General Fund to the
25 Department of Health and Human Services, Division of Mental Health, Developmental
26 Disabilities, and Substance Abuse Services, the sum of thirty million dollars
27 ($ 30,000,000) for the 2008- 2009 fiscal year. These funds shall be used to expand the
28 Hospital Utilization Pilot Program statewide in a manner that maintains local control of
29 funds and bed allocations, with a goal of reducing the use of State psychiatric hospital
30 beds for those individuals staying two weeks or less.
31 SECTION 2.4.( a) There is appropriated from the General Fund to the
32 Department of Health and Human Services, Division of Mental Health, Developmental
33 Disabilities, and Substance Abuse Services, the sum of one million one hundred thirty-34
four thousand one hundred sixty- eight dollars ($ 1,134,168) for the 2008- 2009 fiscal
35 year to implement three pilot programs of the Transitional Residential Treatment
36 Program. One pilot program shall be located in each of the State's three State
37 psychiatric hospital catchment areas.
38 SECTION 2.4.( b) The Department of Health and Human Services, Division
39 of Mental Health, Developmental Disabilities, and Substance Abuse Services, shall
40 develop and implement a plan for discharge planning at the local level for all disability
41 groups. The Department shall implement its plan as soon as possible.
42 SECTION 2.5.( a) There is appropriated from the General Fund to the
43 Housing Trust Fund the sum of ten million dollars ($ 10,000,000) for the 2008- 2009
35
General Assembly Of North Carolina Session 2007
fiscal year 1 for the Housing 400 Initiative in order to reduce the need for State
2 psychiatric hospitals in the long- term.
3 SECTION 2.5.( b) There is appropriated from the General Fund to the
4 Department of Health and Human Services, Division of Mental Health, Developmental
5 Disabilities, and Substance Abuse Services, the sum of two million five hundred
6 thousand dollars ($ 2,500,000) for the 2008- 2009 fiscal year to continue operating
7 support for an estimated 500 units of the Housing 400 Initiative in order to reduce the
8 need for State psychiatric hospitals in the long- term. It is the intent of the General
9 Assembly that these funds shall be appropriated on a recurring basis.
10 SECTION 2.6. Not later than October 1, 2008, the Department of Health
11 and Human Services, Division of Medical Assistance, shall provide for automatic re-12
enrollment of Medicaid recipients whose Medicaid eligibility had been cancelled
13 because of admission to the hospital. The purpose of automatic re- enrollment is to
14 ensure that upon release from the hospital the eligible Medicaid recipient will have
15 uninterrupted access to care and medications under the Medicaid program.
16 SECTION 2.7. The Department of Health and Human Services, Division of
17 Mental Health, Developmental Disabilities, and Substance Abuse Services, shall, within
18 available resources, implement the tiered CAP- MR/ DD waiver program in accordance
19 with Section 10.49( dd) of S. L. 2007- 323. The Department shall implement the program
20 with four tiers: ( i) up to $ 10,000; ( ii) between $ 10,001 and $ 25,000; ( iii) between
21 $ 25,001 and 75,000; and ( iv) greater than $ 75,000.
22 SECTION 2.8. The North Carolina Institute of Medicine shall study and
23 report on the transition for persons with developmental disabilities from one life setting
24 to another, including barriers to transition and best practices in successful transitions.
25 The IOM should conduct this study using funds appropriated for IOM studies in the
26 2007 Session. The study should encompass at least the following topics: ( i) the
27 transition for adolescents leaving high school, including adolescents in foster care and
28 those in other settings; ( ii) the transition for persons with developmental disabilities who
29 live with aging parents; and ( iii) the transition from the developmental centers to other
30 settings.
31 SECTION 2.9. The Department of Health and Human Services shall review
32 State- County Special Assistance rates to establish an appropriate rate for special care
33 units for persons with a mental health disability, including individuals with Traumatic
34 Brain Injury ( TBI), and shall review current rules pertaining to special care units for
35 persons with a mental health disability to determine if additional standards are
36 necessary. Effective July 1, 2008, care provided to individuals with Traumatic Brain
37 Injury shall be paid at the special care unit rate paid for care of persons with a mental
38 health disability. The Department shall report its findings and recommendations to the
39 House of Representatives Appropriations Subcommittee on Health and Human
40 Services, the Senate Appropriations Committee on Health and Human Services, the
41 Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities,
42 and Substance Abuse Services, and the Fiscal Research Division not later than January
43 1, 2009.
36
General Assembly Of North Carolina Session 2007
1 SECTION 3.1 Community Services. - In order to ensure accountability
2 for services provided and funds expended for community services, the Department of
3 Health and Human Services, Division of Mental Health, Developmental Disabilities,
4 and Substance Abuse Services, shall develop a tiered rate structure to replace the
5 blended rate currently used for community support services. Under the new tiered
6 structure, services that are necessary but do not require the skill, education, or
7 knowledge of a qualified professional should not be paid at the same rate as services
8 provided by qualified skilled professionals. The Department shall report on the
9 development of the structure to the Joint Legislative Oversight Committee ( LOC) on
10 Mental Health, Developmental Disabilities, and Substance Abuse Services not later than
11 October 1, 2008. The Department shall not implement the tiered rate structure until
12 after it has consulted with the LOC.
13 SECTION 3.2. The Department of Health and Human Services, Division of
14 Mental Health, Developmental Disabilities, and Substance Abuse Services, shall
15 develop a service authorization process that separates the assessment function from the
16 service delivery function at the LME level. In developing the process the Department
17 shall consider as an option separate LME assessment centers, the duties of which would
18 include care coordination. The Department shall report on the development of the
19 service authorization process to the Joint Legislative Oversight Committee ( LOC) on
20 Mental Health, Developmental Disabilities, and Substance Abuse Services not later than
21 October 1, 2008. The Department shall not implement the service authorization process
22 until after it has consulted with the LOC.
23 SECTION 3.3.( a). The Department of Health and Human Services shall
24 conduct a thorough study of the service authorization, utilization review, and utilization
25 management processes and shall develop a plan to return the service authorization,
26 utilization review and utilization management functions to LMEs for all clients. Not
27 later than February 1, 2009, the Department shall report its findings and
28 recommendations to the House of Representatives Appropriations Subcommittee on
29 Health and Human Services, the Senate Appropriations Committee on Health and
30 Human Services, the Joint Legislative Oversight Committee on Mental Health,
31 Developmental Disabilities, and Substance Abuse Services, and the fiscal research
32 division. The Department shall comply with the requirements of S. L. 2007- 323, Section
33 10.49( ee). The Department shall not contract with an outside vendor for service
34 authorization, utilization review, or utilization management functions, or otherwise
35 obligate the State for these functions beyond June 30, 2009. The Department shall
36 require LMEs to include in their service authorization, utilization management, and
37 utilization review a review of assessments as well as person centered plans, and random
38 or triggered audits of services and assessments.
39 SECTION 3.3.( b). The Department shall require that the licensed
40 professional that signs a medical order for behavioral health services must indicate on
41 the order whether the licensed professional has ( i) had direct contact with the consumer,
42 and ( ii) has reviewed the consumer's assessment. This requirement shall take effect no
43 later than October 1, 2008.
44 SECTION 3.4.( a) G. S. 122C- 151.4reads as rewritten:
37
General Assembly Of North Carolina Session 2007
1 " § 122C- 151.4. Appeal to State MH/ DD/ SA Appeals Panel.
2 ( a) Definitions. – The following definitions apply in this section:
3 ( 1) " Appeals Panel" means the State MH/ DD/ SA Appeals Panel
4 established under this section.
5 ( 1a) " Client" means an individual who is admitted to or receiving public
6 services from an area facility. " Client" includes the client's personal
7 representative or designee.
8 ( 1b) " Contract" means a contract with an area authority or county program
9 to provide services, other than personal services, to clients and other
10 recipients of services.
11 ( 2) " Contractor" means a person who has a contract or who had a contract
12 during the current fiscal year. year, or whose application for
13 endorsement has been denied by an area authority or county program.
14 ( 3) " Former contractor" means a person who had a contract during the
15 previous fiscal year.
16 ( b) Appeals Panel. – The State MH/ DD/ SA Appeals Panel is established. The
17 Panel shall consist of three members appointed by the Secretary. The Secretary shall
18 determine the qualifications of the Panel members. Panel members serve at the pleasure
19 of the Secretary.
20 ( c) Who Can Appeal. – The following persons may appeal to the State
21 MH/ DD/ SA Appeals Panel after having exhausted the appeals process at the appropriate
22 area authority or county program:
23 ( 1) A contractor or a former contractor who claims that an area authority
24 or county program is not acting or has not acted within applicable
25 State law or rules in denying the contractor's application for
26 endorsement or in imposing a particular requirement on the contractor
27 on fulfillment of the contract;
28 ( 2) A contractor or a former contractor who claims that a requirement of
29 the contract substantially compromises the ability of the contractor to
30 fulfill the contract;
31 ( 3) A contractor or former contractor who claims that an area authority or
32 county program has acted arbitrarily and capriciously in reducing
33 funding for the type of services provided or formerly provided by the
34 contractor or former contractor;
35 ( 4) A client or a person who was a client in the previous fiscal year, who
36 claims that an area authority or county program has acted arbitrarily
37 and capriciously in reducing funding for the type of services provided
38 or formerly provided to the client directly by the area authority or
39 county program; and
40 ( 5) A person who claims that an area authority or county program did not
41 comply with a State law or a rule adopted by the Secretary or the
42 Commission in developing the plans and budgets of the area authority
43 or county program and that the failure to comply has adversely
38
General Assembly Of North Carolina Session 2007
1 affected the ability of the person to participate in the development of
2 the plans and budgets.
3 ( d) Hearing. – All members of the State MH/ DD/ SA Appeals Panel shall hear an
4 appeal to the Panel. An appeal shall be filed with the Panel within the time required by
5 the Secretary and shall be heard by the Panel within the time required by the Secretary.
6 A hearing shall be conducted at the place determined in accordance with the rules
7 adopted by the Secretary. A hearing before the Panel shall be informal; no sworn
8 testimony shall be taken and the rules of evidence do not apply. The person who appeals
9 to the Panel has the burden of proof. The Panel shall not stay a decision of an area
10 authority during an appeal to the Panel.
11 ( e) Decision. – The State MH/ DD/ SA Appeals Panel shall make a written
12 decision on each appeal to the Panel within the time set by the Secretary. A decision
13 may direct a contractor, an area authority, or a county program to take an action or to
14 refrain from taking an action, but it shall not require a party to the appeal to pay any
15 amount except payment due under the contract. In making a decision, the Panel shall
16 determine the course of action that best protects or benefits the clients of the area
17 authority or county program. If a party to an appeal fails to comply with a decision of
18 the Panel and the Secretary determines that the failure deprives clients of the area
19 authority or county program of a type of needed service, the Secretary may use funds
20 previously allocated to the area authority or county program to provide the service.
21 ( f) Chapter 150B Appeal. – A person who is dissatisfied with a decision of the
22 Panel may commence a contested case under Article 3 of Chapter 150B of the General
23 Statutes. Notwithstanding G. S. 150B- 2( 1a), an area authority or county program is
24 considered an agency for purposes of the limited appeal authorized by this section. If
25 the need to first appeal to the State MH/ DD/ SA Appeals Panel is waived by the
26 Secretary, a contractor may appeal directly to the Office of Administrative Hearings
27 after having exhausted the appeals process at the appropriate area authority or county
28 program. The Secretary shall make a final decision in the contested case."
29 SECTION 3.4.( c) The Department of Health and Human Services shall
30 adopt guidelines for LME periodic review and re- endorsement of providers to ensure
31 that only qualified providers are endorsed and that LMEs hold those providers
32 accountable for the Medicaid and State- funded services they provide.
33 SECTION 3.5.( a) Effective October 1, 2008, the Title of G. S. 108A- 79
34 reads as rewritten:
35 " § 108A- 79. Appeals. Appeals of county level decisions."
36 SECTION 3.5.( b). Effective October 1, 2008, Article 4 of Chapter 108A of
37 the General Statutes is amended by adding the following new section to read:
38 " § 108A- 79.1. Appeals by Medicaid applicants and recipients.
39 ( a) An action by the Department to deny, terminate, suspend, or reduce Medicaid
40 eligibility, or to deny, terminate, suspend, or reduce Medicaid services is a " contested
41 case" subject to the provisions of Chapter 150B of the General Statutes, except as
42 provided by this section. At the time of providing the notice required under subsection
43 ( b) of this section, the Department shall file a petition with the Office of Administrative
44 Hearings to determine the Medicaid applicant's or recipient's rights duties or privileges.
39
General Assembly Of North Carolina Session 2007
1 ( b) In addition to the notice requirements of G. S. 150B- 23, the Department shall
2 provide within 30 days of its decision written notice to the aggrieved applicant or
3 recipient, or the applicant's or recipient's legal guardian, which notice shall include:
4 ( 1) An explanation of the Department's decision.
5 ( 2) A clear and concise statement of what service is being reduced,
6 terminated, or denied and the basis upon which the decision was made.
7 ( 3) A statement that the Department has filed a petition for administrative
8 review of its decision in the Office of Administrative Hearings, and
9 that the applicant or recipient has 30 days from the date of the
10 Department's decision to decide whether or not to proceed with the
11 hearing.
12 ( 4) A clear explanation of how the hearing will proceed, what is required
13 of the applicant in order to proceed or to decline to proceed, and that
14 the applicant or recipient may be represented by an attorney or other
15 person at the hearing. The notice shall further state that representation
16 by an attorney may be available from Disability Rights of NC legal
17 services, and attorneys working with mediation centers throughout the
18 State.
19 ( 5) A statement that the recipient will continue to receive Medicaid
20 services at the level provided on the day immediately preceding the
21 Department's decision pending a final decision.
22 ( 6) The telephone number of a contact person at the Department to
23 respond in a timely fashion to applicant or recipient questions.
24 ( 7) A brochure supplied by the North Carolina Protection and Advocacy
25 System that explains the rights of applicants and recipients under the
26 State Medical Assistance Program, including the rights to appeal
27 decisions of the Department."
28 SECTION 3.6. The Department of Health and Human Services, Division of
29 Mental Health, Developmental Disabilities, and Substance Abuse Services, shall study
30 Medicaid waivers, including 1915( b) and ( c) waivers, for all LMEs. In cases where
31 Medicaid waivers are not appropriate for an LME, the Department shall identify and
32 recommend strategies to increase LME flexibility to provide case management,
33 assessment, limit provider networks, or other innovative approach for managing care.
34 Not later than March 1, 2009, the Department shall report its findings and
35 recommendations to the House of Representatives Appropriations Subcommittee on
36 Health and Human Services, the Senate Appropriations Committee on Health and
37 Human Services, the Joint Legislative Oversight Committee on Mental Health,
38 Developmental Disabilities, and Substance Abuse Services, and the fiscal research
39 division.
40 SECTION 3.7.( a) The Secretary of the Department of Health and Human
41 Services shall develop a detailed plan for General Assembly review on its
42 recommendation to merge, consolidate or establish regional arrangements or consortia
43 of LMEs. In developing the plan the Secretary shall consult with LMEs to obtain input
44 on the feasibility and effectiveness of potential mergers, and the time frame needed to
40
General Assembly Of North Carolina Session 2007
fully implement the mergers, 1 regional arrangements, or consortia at the local level. The
2 Secretary shall provide the plan to the House of Representatives Appropriations
3 Subcommittee on Health and Human Services, the Senate Appropriations Committee on
4 Health and Human Services, the Joint Legislative Oversight Committee on Mental
5 Health, Developmental Disabilities, and Substance Abuse Services, and the Fiscal
6 Research Division not later than March 1, 2009.
7 SECTION 3.7.( b) The Secretary of the Department of Health and Human
8 Services shall not take any action prior to January 1, 2010 that would result in the
9 merger or consolidation of LMEs operating on January 1, 2008 or that would establish
10 consortia or regional arrangements for the same purpose, except that LMEs that do not
11 meet the catchment area requirements of G. S. 122C- 115 as of January 1, 2008, may
12 initiate, continue, or implement the LMEs' merger or consolidation plans to overcome
13 noncompliance with G. S. 122C- 115.
14 SECTION 4. Effective date. - This act becomes effective July 1, 2008.
41
GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2007
H D
BILL DRAFT 2007- LNz- 313 [ v. 4] ( 4/ 16)
( THIS IS A DRAFT AND IS NOT READY FOR INTRODUCTION)
4/ 24/ 2008 11: 33: 16 AM
Sponsors:
Referred to:
1 A JOINT RESOLUTION TO AUTHORIZE THE LEGISLATIVE RESEARCH
2 COMMISSION TO STUDY CERTAIN MENTAL HEALTH COMMITMENT
3 STATUTES, AS RECOMMENDED BY THE JOINT LEGISLATIVE
4 OVERSIGHT COMMITTEE ON MENTAL HEALTH, DEVELOPMENTAL
5 DISABILITIES, AND SUBSTANCE ABUSE SERVICES.
6 Be it resolved by the House of Representatives, the Senate concurring:
7 SECTION 1.( a) The Legislative Research Commission may study the
8 involuntary commitment statutes in Chapter 122C of the General Statutes, in particular
9 G. S. 122C- 263( a), to determine if an individual lawfully ordered to undergo an
10 examination by a physician or eligible psychologist is being appropriately supervised to
11 protect the health and safety of the individual and others during the period of the
12 individual's examination.
13 SECTION 1.( b) The Legislative Research Commission may make an
14 interim report to the 2008 General Assembly, and shall make its final report to the 2009
15 General Assembly.
16 SECTION 2. The Legislative Services Officer shall allocate funds
17 appropriated to the General Assembly for the expenditures of the Legislative Services
18 Commission in conducting this study.
19 SECTION 3. This resolution is effective upon ratification.
42
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| Title | Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services : report to the... regular session of the... General Assembly. |
| Other Title | Report to the... regular session of the... General Assembly; Report to the... General Assembly; Interim report to the General Assembly of North Carolina... regular session |
| Date | 2008-04-23 |
| Description | April 23, 2008 |
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| Full Text | JOINT LEGISLATIVE OVERSIGHT COMMITTEE ON MENTAL HEALTH, DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE SERVICES REPORT TO THE 2008 REGULAR SESSION OF THE 2007 GENERAL ASSEMBLY A LIMITED NUMBER OF COPIES OF THIS REPORT ARE AVAILABLE FOR DISTRIBUTION THROUGH THE LEGISLATIVE LIBRARY ROOMS 2126, 2226 STATE LEGISLATIVE BUILDING RALEIGH, NORTH CAROLINA 27611 TELEPHONE: ( 919) 733- 7778 OR ROOM 500 LEGISLATIVE OFFICE BUILDING RALEIGH, NORTH CAROLINA 27603- 5925 TELEPHONE: ( 919) 733- 9390 THE REPORT IS ALSO AVAILABLE ONLINE: http:// www. ncleg. net/ LegLibrary/ 2 TABLE OF CONTENTS Page Letter of Transmittal ................................................................................................................. 4 Committee Membership and Staff ......................................................................................... 5 Preface........................................................................................................................ ................ 7 Committee Proceedings ........................................................................................................... 8 Committee Findings and Recommendations........................................................................ 17 Introduction ................................................................................................................... 17 Finding and Recommendation One: Expenditure of Service Dollars ................... 20 Finding and Recommendation Two: State- Operated Services.............................. 23 Finding and Recommendation Three: Services in the Community ...................... 27 Appendix....................................................................................................................... ............ 31 3 JOINT LEGISLATIVEOVERSIGHT COMMITTEE ONMENTALHEALTH, DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE SERVICES State Legislative Building Raleigh, North Carolina 27603 Senator Martin Nesbitt, Co- Chair Representative Verla Insko, Co- Chair April 23, 2008 TO THE MEMBERS OF THE 2007 GENERAL ASSEMBLY ( 2008 Regular Session): The Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services submits for your consideration its report pursuant to G. S. 120- 231. Respectfully Submitted, _______________________________ Sen. Martin Nesbitt, Co- Chair _______________________________ Rep. Verla Insko, Co- Chair 4 JOINT LEGISLATIVE OVERSIGHT COMMITTEE ON MENTAL HEALTH, DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE SERVICES MEMBERSHIP LIST 2007- 2008 Senator Martin Nesbitt Co- Chair 300- B Legislative Office Building Raleigh, NC 27603 O: 715- 3001 Email: Martinn@ ncleg. net Representative Verla Insko Co- Chair 2121 Legislative Building Raleigh, NC 27601 O: 733- 7208 Email: verlai@ ncleg. net Senator Austin Allran 516 Legislative Office Building Raleigh, NC 27603 O: 733- 5876 Email: Austina@ ncleg. net Representative Martha Alexander 2208 Legislative Building Raleigh, NC 27601 O: 733- 5807 Email: Marthaa@ ncleg. net Senator Bob Atwater 312 Legislative Office Building Raleigh, NC 27603 O: 715- 3036 Email: Boba@ ncleg. net Representative Jeffrey Barnhart 608 Legislative Office Building Raleigh, NC 27601 O: 715- 2009 Email: Jeffba@ ncleg. net Senator Janet Cowell 1028 Legislative Building Raleigh, NC 27601 O: 715- 6400 Email: Janetc@ ncleg. net Representative Van Braxton: Advisory Member 403 Legislative Office Building Raleigh, NC 27603 O: 715- 3017 Email: Vanb@ ncleg. net Senator Charlie Dannelly 2010 Legislative Building Raleigh, NC 27601 O: 733- 5955 Email: Charlied@ ncleg. net Representative William Brisson: Advisory Member 1325 Legislative Building Raleigh, NC 27601 O: 713- 5772 Email: Williambr@ ncleg. net Senator James Forrester 1129 Legislative Building Raleigh, NC 27601 O: 715- 3050 Email: Jamesf@ ncleg. net Representative Beverly Earle 634 Legislative Office Building Raleigh, NC 27603 O: 715- 2530 Email: Beverlye@ ncleg. net Senator Vernon Malone 314 Legislative Office Building Raleigh, NC 27603 O: 733- 5880 Email: Vernonm@ ncleg. net Representative Bob England 2219 Legislative Building Raleigh, NC 27601 O: 733- 5749 Email: Bobe@ ncleg. net Senator William Purcell 625 Legislative Office Building Raleigh, NC 27603 O: 733- 5953 Email: Williamp@ ncleg. net Representative Jean Farmer- Butterfield 611 Legislative Office Building Raleigh, NC 27603 O: 733- 5898 Email: Jeanf@ ncleg. net Senator Larry Shaw Advisory Member 311 Legislative Office Building Raleigh, NC 27603 O: 733- 9349 Email: Larrys@ ncleg. net Representative Carolyn Justus 1023 Legislative Building Raleigh, NC 27601 O: 713- 5956 Email: Carolynj@ ncleg. net Representative Fred Steen 514 Legislative Office Building Raleigh, NC 27603 O: 733- 5881 Email: Fredst@ ncleg. net 5 STAFF LIST Rennie Hobby, Committee Assistant O: 733- 5639 Email: mentalhealthca@ ncleg. net Gann Watson, Bill Drafting O: 733- 6660 Email: gannw@ ncleg. net Shawn Parker, Research Division O: 733- 2578 Email: shawnp@ ncleg. net Andrea Poole, Fiscal Research O: 733- 4910 Email: Andrear@ ncleg. net Ben Popkin, Research Division O: 733- 2578 Email: benp@ ncleg. net Denise Harb, Fiscal Research O: 733- 4910 Email: deniseha@ ncleg. net Susan Barham, Research Division O: 733- 2578 Email: Susanb@ ncleg. net 6 PREFACE The Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services ( LOC) is established in Article 27 of Chapter 120 of the General Statutes. The LOC is charged with continually examining system- wide issues that affect the development, financing, administration, and delivery of mental health, developmental disabilities, and substance abuse services, including issues related to governance, accountability and service quality. The Committee consists of sixteen members, eight appointed by the President Pro Tempore of the Senate and eight appointed by the Speaker of the House of Representatives. The members appointed by the President Pro Tempore must include all of the following: at least two must be members of the Senate Committee on Appropriations, the Chair of the Senate Appropriations Committee on Human Resources and at least two must be of the minority party. The members appointed by the Speaker of the House must include all of the following: at least two members of the House Committee on Appropriations, the Co- Chairs of the House of Representatives Appropriations Subcommittee on Health and Human Services, and at least two members of the minority party. Advisory members may also serve on the Committee. The Co- Chairs for 2007- 2008 are Senator Martin Nesbitt and Representative Verla Insko. 7 COMMITTEE PROCEEDINGS The Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services met 10 times during the 2007- 2008 interim. Following is a summary of the Committee's proceedings. Detailed minutes and information from each Committee meeting are available in the Legislative Library. September 25, 2007 The LOC convened its first meeting of the interim on Tuesday, September 25, 2007, at 10: 00 A. M. in Room 643 of the Legislative Office Building. Senator Martin Nesbitt, Co- Chair, called the meeting to order and welcomed returning members, new members, and guests. Dempsey Benton, Secretary of the Department of Health and Human Services ( DHHS), presented DHHS priorities for improving the mental health system that included: implementation of the crisis services system, increasing provider capacity, enhancing substance abuse treatment facilities, and providing guidance and direction to the State hospitals. Dr. Alice Lin, the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services ( DMH) consultant, presented her report on the Implementation of Local Management Entities. Dr. Lin discussed immediate, short-term, and mid- term recommendations. Kory Goldsmith, Research Division, reviewed the process for the closure of Dorothea Dix and John Umstead Hospitals. According to Session Law 2007- 323 Section 10.49.( t), the Secretary may close Dorothea Dix and John Umstead Hospitals provided certain conditions are met. Jim Osberg, Chief of State Operated Services, DMH, discussed the closure plan for Dorothea Dix and John Umstead Hospitals pursuant to the opening of Central Regional Hospital ( CRH) in Butner. Mr. Osberg provided a timeline for the design, construction, and operation of CRH. Several updates were presented by staff concerning legislative actions from the 2007 Session. Andrea Poole, Fiscal Research Division, and Melanie Bush, Fiscal Research Division, provided a review of budgetary actions. Kory Goldsmith, Research Division, summarized substantive legislation enacted. Shawn Parker, Research Division, gave an update on Local Management Entities ( LMEs) including historic and current LME configurations. Trish Amend, NC Housing Finance Agency, and Julia Bick, DHHS, discussed the Housing 400 Initiative. Ms. Amend announced that financing for housing for persons with disabilities had been awarded for 425 units in 33 counties. 8 Jim Osberg, Chief of State Operated Services, DMH, provided an update to the LOC on the hospital utilization pilot. Mr. Osberg discussed the distribution of funding and the timeline for implementation of services to reduce utilization of State psychiatric hospitals. Phillip Hoffman, Chief of Resource and Regulatory Management, DMH, reported on data collection of consumer income data. He also explained that DMH established a workgroup to examine the collection of county funds utilization data. Bonnie Morrell, Team Leader for Best Practice, DMH, reported on crisis services implementation. In SFY 2006- 2007, $ 7 million was expended for local inpatient services, facility based crisis, detoxification, and mobile crisis resulting in a decrease of admissions to the State psychiatric hospitals. Flo Stein, Chief of Community Policy Management, DMH, discussed performance indicators. Ms. Stein reported LMEs that provided continuity of services saw significant improvement in mental health and substance abuse clients in every measurable indicator. October 31, 2007 The LOC convened its second meeting of the interim on Wednesday, October 31, 2007, at 10: 00 A. M. in Room 643 of the Legislative Office Building. Dr. Thomas McLellan, CEO of the Treatment Research Institute, discussed the State s role in the improvement of effectiveness and accountability for the treatment of addiction. Dr. McLellan explained the chronic care model in the treatment of addiction. Goals to measure success included: retaining patients at an appropriate level of care and monitoring, preparing patients to do well in the next level of care, and evaluating effectiveness during treatment instead of post-discharge. Dr. Mandy Chalk, Director, Center for Performance Based Policy, Treatment Research Institute, provided information on funding treatment networks and contracting for substance abuse treatment services. Kim Johnson, Network for the Improvement of Addiction Treatment, presented factors to consider regarding performance based contracting. Ms. Johnson suggested key elements to consider: a good data collection system, clear definitions for data elements, and agreed upon performance standards. November 15, 2007 The LOC convened its third meeting of the interim on Thursday, November 15, 2007, at 10: 00 A. M. in Room 643 of the Legislative Office Building. Andrea Poole, Fiscal Research Division, reviewed Section 10.49.( s1)-( s4) of Session Law 2007- 323 regarding the hospital utilization pilot. Laura White, Team Leader, State Psychiatric Hospitals, DMH, explained the selection process for the LMEs participating in the hospital utilization pilot. 9 Don Herring, Director of Service Management, Western Highlands Network, described plans for increasing crisis services and hospital diversion systems to decrease State hospital utilization. Betty Taylor, CEO, CenterPoint Human Services, reviewed existing crisis services offered by CenterPoint and plans for expansion. Goals under the pilot included: reserving bed days for patients requiring longer stays, increasing enhanced psychiatric services, diverting clients from the legal system and the ER, and increasing adult transitional housing. Tom McDevittt, LME Director, Smoky Mountain Center, presented a proposal to reduce hospital utilization by increasing local crisis services especially inpatient psychiatric beds through public/ private partnerships with two hospitals in the area. Tom Galligan, Deputy Director for Budget and Finance, Division of Medical Assistance ( DMA), gave an update on community supports financial status. Mr. Galligan reported that approximately 45% of the 2007 budget for community supports was spent during the first 4 months of the fiscal year. Leza Wainwright, Deputy Director, DMH, and Tara Larson, Acting Deputy Director for Clinical Affairs, DMA, gave an update on community support services. Ms. Wainwright and Ms. Larson provided background and reviewed the revised comprehensive plan that included clarification of service definitions, suspending new provider endorsements until new rules and provider qualifications are developed, monitoring and review of LMEs, and changing the authorization process. Ms. Wainwright then presented an update on single stream funding and reviewed the criteria necessary for LMEs participation. Next, Ms. Wainwright discussed the independent evaluation of LME performance. Ms. Wainwright explained that the Department contracted with Mercer Consulting for independent reviews to determine LME performance, possible consolidation of functions, and requirements for LMEs to perform utilization review. Senator Nesbitt, Co- Chair, called on members of the audience for public comment. December 5, 2007 The LOC convened its fourth meeting of the interim on Wednesday, December 5, 2007, at 10: 00 A. M. in Room 643 of the Legislative Office Building. Grayce Crockett, Director, Mecklenburg Local Management Entity ( LME), explained the Mecklenburg hospital utilization pilot to reduce bed days at Broughton hospital. Tom Galligan, Deputy Director for Budget and Finance, Division of Medical Assistance ( DMA), gave an update on community supports services. 10 Andrea Poole, Fiscal Research Division, reviewed the 2007- 2008 FY LME service dollars allocation. Leza Wainwright, Deputy Director, DMH, discussed the current allocation of community based services funds and explained the allocation of continuation funds. Kory Goldsmith, Research Division, reviewed an information packet provided to committee members in response to questions from the previous meeting. Mike Mosley, Director, DMH, and Leza Wainwright, Deputy Director, DMH, presented the revised plan for the closure of Dorothea Dix and John Umstead hospitals. Mr. Mosley reviewed the timeline for transition to the new hospital. Mr. Mosely also announced the development of an additional 60 bed unit on the Dorothea Dix campus. Representative Insko, Co- Chair, called on members of the audience for public comment. January 23, 2008 The LOC convened its fifth meeting of the interim on Wednesday, January 23, 2008, at 10: 00 A. M. in Room 643 of the Legislative Office Building. Shawn Parker, Research Division, and Andrea Poole, Fiscal Research, reviewed an information packet provided to committee members in response to questions from the previous meeting. Dempsey Benton, Secretary of the Department of Health and Human Services ( DHHS), presented an update on the State psychiatric hospitals and community support services. Secretary Benton also discussed initiatives to establish committees of external experts to help with mental health issues. Andrea Poole, Fiscal Research Division, and Denise Harb, Fiscal Research, reviewed a new report, the MH/ DD/ SA System Indicators report. Shawn Parker, Research Division, provided background on the development of local crisis services plans. Anthony Ward, Provider Relations Manager, Guilford Center, described the area s implementation of crisis services and discussed the successes and challenges of the implementation. Art Constantini, Director, Southeastern Center for MH/ DD/ SAS, reviewed the crisis services in place at Southeastern Center. Mr. Constantini described the plan as continuum consisting of prevention measures, crisis response services, and post- crisis services. Terry Hatcher, Director, Division of Property and Construction, DHHS, gave an update on construction projects. Andrea Poole, Fiscal Research Division, reviewed Session Law 2007- 323, Section 10.51( b) that directs DHHS to develop a revised service dollar allocation methodology to equalize funding to LMEs across the State. 11 Leza Wainwright, Deputy Director, discussed the revised service dollars allocation and explained a combination of two formulas was used to develop the methodology. February 27, 2008 The LOC convened its sixth meeting of the interim on Wednesday, January 23, 2008, at 10: 00 A. M. in Room 643 of the Legislative Office Building. Andrea Poole, Fiscal Research Division, reviewed an information packet provided in response to questions from the previous meeting. Next, Ms. Poole explained the monthly MH/ DD/ SA system indicators report and gave an update on construction projects. Dan Coughlin, Area Director/ CEO, Pam Shipman, Deputy Area Director, and Dr. Craig Hummel, Medical Director of Piedmont Behavioral Healthcare ( PBH) discussed PBH s use of a 1915( b)/ 1915( c) combination Medicaid waiver. The waiver allowed PBH to restrict the freedom of choice of providers and to determine the size and scope of the provider network. Gann Watson, Bill Drafting Division, explained the process for appealing a decision made by a State agency. Emery Milliken, General Counsel, DHHS, provided information regarding the Medicaid appeals process, both formal and informal appeals. Tara Larson, Deputy Director for Clinical Affairs, DMA, addressed the status of applications for additional Medicaid waivers. Ms. Larson highlighted options available through the waiver process with CMS. Leza Wainwright, Deputy Director, DMH, explained that DMH was working with LMEs to examine different waivers. Flo Stein, Chief of Community Policy Management, DMH, presented an update on regionally funded and locally hosted substance abuse programs. Leza Wainwright, Deputy Director, DMH, explained a technical amendment to the Community Alternatives Program ( CAP) MR/ DD waiver that allows family members or guardians to act as providers and provide personal care services to adult children. Representative Insko, Co- Chair, called on members of the audience for public comment. February 28, 2008 The LOC convened its seventh meeting of the interim on Thursday, February 28, 2008, at 9: 00 A. M. in Room 643 of the Legislative Office Building. As a follow- up on the appeals process, Representative Insko, Co- Chair, welcomed Judge Julian Mann, Director and Chief Administrative Law Judge of the Office of Administrative Hearings ( OAH). Administrative Law Judge Don Overby, and Chief Clerk, Kim Housing were also in attendance. Judge Mann provided an overview of the OAH and addressed questions regarding the impact 12 of the community support appeals cases on the OAH. Judge Mann suggested that for cases that are pro se, the State file instead of the petitioner and that pre trial motions that interfere with getting to the merit of the case be eliminated. Representative Insko asked Vicky Smith, Executive Director of Disabilities Rights of North Carolina, to respond to comments. Ms. Smith suggested that a clearly articulated, easily understood bill of rights for people with disabilities receiving services was needed whether the services were federally funded or State funded. Next, Phillip Hoffman, Chief of Resources/ Regulatory Management, DMH, gave an update on data collection and county funds utilization. He explained that DMH s reporting requirements were modified to include information on family size. Currently, the amount of county funds budgeted and received through the LMEs is reported but not how the funds are utilized. Flo Stein, Chief of Community Policy Management, DMH, gave a presentation on crisis services for the developmentally disabled. Ms. Stein described barriers to receiving service and explained the importance of a functional assessment, training, and technical assistance. She explained several proven models in detail. Ms. Stein stated that DMH recommended that the Systematic Therapeutic Assessment Respite and Treatment ( START) Program be implemented on a regional basis. Next, Carol Donin, Developmental Center Team Leader, DMH, addressed downsizing at the developmental centers. Ms. Donin reported that most consumers moved to community residential settings such as Intermediate Care Facilities ( ICF/ MR) group homes and live- in group homes supported by the Community Alternatives Program ( CAP) MR/ DD waiver. Ms. Donin also mentioned the ICF- MR bed transfer initiative. Tara Larson, Acting Deputy Director of Clinical Affairs, DMA, addressed cost- sharing under CAP. She explained that the Department looking at families currently on the CAP/ MR and CAP/ C waiver programs and developing a process by which families would pay for part of their care. Rose Burnette, Tiered Waiver Project Manager, DMH, gave an update on the CAP- MR/ DD waiver development. She explained that DHHS requested an extension from CMS to develop the four tiered waivers and projected implementation for the tiered waivers between January and June 2009. Andrea Poole, Fiscal Research, reviewed a draft of recommendation options with committee members. March 26, 2008 The LOC convened its eighth meeting of the interim on Wednesday, March 26, 2008, at 9: 00 A. M. in Room 643 of the Legislative Office Building. 13 Shawn Parker, Research Division, reviewed an information packet provided to committee members in response to questions from the previous meeting. Denise Harb and Andrea Poole, Fiscal Research Division, reviewed the monthly MH/ DD/ SA system indicators report. Roman Rojano, Area Director, Wake County Human Services presented short and long term initiatives that addressed the closure of Dorothea Dix hospital. Sharen Prevatte, Area Director, Southeastern Regional MH/ DD/ SA Services, discussed the status of the LME. Ms. Prevatte explained that Southeastern Regional utilized a combination of inpatient services at area hospitals, a mobile crisis team, a local crisis stabilization facility, and psychiatrists. Andrea Poole, Fiscal Research Division, and Shawn Parker, Research Division, presented draft findings and recommendations to the LOC. Trish Amend, NC Housing Finance Agency, and Julia Bick, DHHS, discussed the Housing 400 Initiative. Ms. Amend announced that over 1,300 units had been funded, 681 units completed, and 604 of those units were occupied. Bonnie Morrell, Team Leader for Best Practice, DMH, gave a presentation on transitional residential treatment options for housing individuals with mental illness in the community. Tara Larson, Acting Deputy Director for Clinical Affairs, DMA, explained issues surrounding the suspension of Medicaid eligibility for individuals in State institutions. Denise Harb, Fiscal Research Division, and Gann Watson, Bill Drafting Division, continued the presentation of draft findings and recommendations to the committee members and incorporated proposals from members of the committee. Dempsey Benton, Secretary of the Department of Health and Human Services, presented a report on the Department s recommendations. April 17, 2008 The LOC convened its ninth meeting of the interim on Wednesday, April 17, 2008, at 9: 00 A. M. in Room 544 of the Legislative Office Building. Mike Watson, CEO, Sandhills Center for MH/ DD/ SAS, discussed single stream initiatives and hospital transition teams at Sandhills. Roy Wilson, CEO, East Carolina Behavioral Health ( ECBH), gave an overview of services at ECBH and explained that quality services are based on consumers needs. Tara Larson, Acting Deputy Director for Clinical Affairs, DMA, presented background on the Workforce Development Initiative. Ms. Larson then introduced John Morris, Annapolis Coalition on the Behavioral Health Workforce, and Dr. Amy Hewitt, University of Minnesota, Institute on Community Integrations. 14 Mr. Morris discussed goals and strategies for strengthening and supporting the workforce in the areas of behavioral health, developmental disabilities, and aging. Dr. Hewitt, provided an overview of the direct support workforce in North Carolina and identified strategies to build systems that maximize support and development of direct support workers. Leza Wainwright, Co- Director, Division of MH/ DD/ SAS, presented the findings and recommendations from the Independent Evaluation of the Performance of Local Management Entities report by Mercer. Dempsey Benton, Secretary, Department of Health and Human Services ( DHHS), announced priorities for DHHS including funding for additional staff at the State psychiatric hospitals, establishment of a statewide network of mobile crisis teams, procurement of additional community inpatient beds, and the voluntary development of regional LMEs. Representative Insko, Co- Chair, called on members of the audience for public comment. After lunch the LOC reconvened in Room 643 of the Legislative Office Building and Representative Insko, continued the public comment period. Steve Hairston, Chief of Operations Support, DMH, reported on the Workforce Development Initiative. Dr. Marvin Swartz, Chair, Commission for MH/ DD/ SAS presented an overview and the recommendations for the MH/ DD/ SAS Workforce Plan. Pam Silberman, President/ CEO, North Carolina Institute of Medicine, discussed the Substance Abuse Task Force draft findings and recommendations. Andrea Poole, Fiscal Research, reviewed changes to the LOC draft report and incorporated proposals from members of the committee. Gann Watson, Bill Drafting Division, explained the bill draft containing the LOC recommendations. April 23, 2008 The LOC convened its tenth meeting of the interim on Wednesday, April 23, 2008, at 10: 00 A. M. in Room 643 of the Legislative Office Building. Representative Insko, Co- Chair, called on members of the audience for public comment. Denise Harb and Andrea Poole, Fiscal Research Division, reviewed the monthly MH/ DD/ SA system indicators report. Tara Larson, Acting Deputy Director for Clinical Affairs, Division of Medical Assistance ( DMA), presented DMA's plans to renew the contract with ValueOptions for utilization review services and answered questions from the LOC regarding the contract. Andrea Poole, Fiscal Research Division, reviewed changes to the draft report and Gann Watson, Bill Drafting Division, explained changes to the bill draft 15 containing the LOC recommendations. After discussion, the LOC approved the bill with some modifications and moved to include it in the LOC report. Representative Insko, Co- Chair, offered a joint resolution to authorize the Legislative Research Commission to study the involuntary commitment statutes in Chapter 122C of the General Statutes. The LOC approved the joint resolution and voted to include it in the LOC Report. Senator Nesbitt, Co- Chair, made the motion that the report be approved as amended and instructed staff to make technical and conforming changes as necessary. The motion was approved by the LOC. 16 COMMITTEE FINDINGS AND RECOMMENDATIONS INTRODUCTION The LOC and more recently the Department of Health and Human Services and the press has identified problems concerning the administration of mental health, developmental disabilities, and substance abuse services at the State and local levels. Some of these problems and issues can be addressed in the 2008 Regular Session of the 2007 General Assembly. Others will require more review and scrutiny, and thus more time to identify and implement significant, long- term changes in the system at all levels of administration. As a backdrop for the recommendations and legislative proposals contained in this report, it is important to understand the historical context and the fundamental policy behind MH/ DD/ SA System Reform enacted by the 2001 General Assembly in House Bill 381 and amendments enacted since that time. During the mid to late- 1990' s, North Carolina's public system for delivering services to those with mental illness, developmental disabilities, and substance abuse addictions faced significant challenges. Several local agencies were in imminent danger of financial collapse and the State- run psychiatric hospitals were threatened with the loss of federal funding due to inadequate staffing and record-keeping violations. During this same period, the United States Supreme Court held that States have an obligation to provide community- based treatment for persons with mental disabilities when: ( i) State medical professionals determine community placement is appropriate; ( ii) placement would be less restrictive and is not opposed by the patient; and ( iii) community placement can be reasonably accommodated, given resources available to the State and the needs of others with mental disabilities. 1 In response to these challenges, the General Assembly commissioned a series of studies and created the Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services ( LOC) to make recommendations as to what should be done. Policy enacted in Session Law 2001- 4872 set the framework for system reform. Specifically, it made significant changes addressing issues of State and local 1 Olmstead v. L. C., 527 U. S. 581 ( 1999); Title II of the Americans with Disabilities Act. 2 HB 381 - An Act to Phase in the Implementation of Mental Health System Reform at the State and Local Level ( S. L. 2001- 437). 17 governance and increased accountability. The act emphasized consumer- driven community- based services. It required that State and local governments provide certain core services to all individuals and required the development of enhanced services that targeted persons with the most severe disabilities. In addition, the act shifted the role of local public mental health agencies from being direct service providers to managing and coordinating services delivered by private providers. 3 Policy of the State " The policy of the State is to assist individuals with needs for mental health, developmental disabilities, and substance abuse services in ways consistent with the dignity, rights, and responsibilities of all North Carolina citizens. Within available resources it is the obligation of State and local government to provide mental health, developmental disabilities, and substance abuse services through a delivery system designed to meet the needs of clients in the least restrictive, therapeutically most appropriate setting available and to maximize their quality of life .. State and local governments shall develop and maintain a unified system of services centered in area authorities or county programs. The public service system will strive to provide a continuum of services for clients while considering the availability of services in the private sector ". 4 Administration of the System " The Secretary shall administer and enforce the provisions of this Chapter and the rules of the Commission and shall operate State facilities. An area director or program director shall ( i) manage the public mental health, developmental disabilities, and substance abuse services system for the area authority or county program according to the local business plan, and ( ii) enforce applicable State laws, rules of the Commission, and rules of the Secretary. The Secretary in cooperation with area and county program directors and State facility directors shall provide for the coordination of public services between area authorities, county programs, and State facilities ". 5 " Local management entities are responsible for the management and oversight of the public system of Mental Health, Developmental Disabilities, and Substance Abuse Services at the community level. An LME shall plan, develop, implement, and monitor services within a specified geographic area to ensure expected outcomes for consumers within available resources." 6 3 N. C. Legislative Services Office, Research Division. System Reform for Mental Health, Developmental Disabilities, and Substance Abuse Services. 1 INFO BRIEF, no. 2 ( Oct. 10, 2006). 4 N. C. G. S. § 122C- 2 5 N. C. G. S. § 122C- 111 6 N. C. G. S. § 122C- 115.4 18 Systemwide Accountability " Every county, through an area authority or county program, shall provide for the development, review, and approval of an LME business plan for the management and delivery of mental health, developmental disabilities, and substance abuse services." 7 If an LME is not providing minimally adequate services the law authorizes the Secretary of DHHS to take certain actions after notice and time for correction by the LME. Those actions include suspension of funding, appointing a caretaker administrator or caretaker board of directors, and termination of an area director of program director when the Secretary appoints a caretaker administrator. 8 Upon a determination by the Secretary that an area authority or county program is in imminent danger of failing financially and of failing to provide direct services to clients, the Secretary may assume control of the financial affairs of the area authority or county program and appoint an administrator to exercise the power assumed9. In light of the issues that have emerged regarding the implementation and administration of MH/ DD/ SA system reform, the LOC respectfully reports the following findings and recommendations for consideration by the 2007 General Assembly, Regular Session, 2008. The legislative proposal can be found in the Appendix to this report. 7 N. C. G. S § 122C- 115.2 8 N. C. G. S. § 122C- 124.1. 9 N. C. G. S. § 122C- 125 19 FINDING ONE: EXPENDITURE OF SERVICE DOLLARS State funds appropriated for services are not being fully expended for the intended purpose, especially in the areas of crisis services and substance abuse services. For example, in FY 2006- 07, $ 47.7 million in State service dollars was unexpended. Of that, the 2007 General Assembly realigned $ 26.4 million for FY 2007- 08 and the remaining funds were earmarked for LME systems administration for FY 2007- 08. In FY 2007- 08, it appears that service dollars will again be under-expended particularly State funding for crisis services and substance abuse services. Since FY 2003- 04, the State has served fewer clients each year through the State IPRS system, the claims processing system for State- paid clients. The State served half as many clients in FY 2006- 07 as it did in FY 2003- 0410. The decline in clients served is particularly high for individuals with mental health and substance abuse services needs, as is shown in the chart below. While there was a corresponding increase in the number of persons with mental health needs served through Medicaid, more research is needed to determine if those services are reaching the same population that State- paid services are designed to help. DD MH SA - 20,000 40,000 60,000 80,000 100,000 120,000 2003- 04 2004- 05 2005- 06 2006- 07 Clients Served Through IPRS by Disability ( FY2003- 04 to FY2006- 07) Additionally, there have anecdotal reports that providers are increasingly unwilling to provide services to State- paid clients and prefer to provide services to Medicaid- paid clients. A preliminarily review of available data suggests that this may be the case. There are conflicting explanations available for the under- expenditure of funds, the decrease in services to State- paid individuals, and the lack of service providers available to treat State- paid clients. However, despite hearing from and meeting 10 Measuring Trends in Public MHDDSA Payments and Persons Served, Medicaid and IPRS Aggregate Utilization Data by LME as presented at FARO in November, 2007: http:// www. ncdhhs. gov/ mhddsas/ statspublications/ reports/ index. htm. 20 with LMEs, providers, and DHHS, the LOC has not been able to determine a full explanation of the problem. Given the increased needs for these services seen in the community, the jails, State hospitals, and emergency rooms, it is vital that these funds are spent appropriately and that within those available resources, services be made available to individuals who do not qualify for Medicaid. RECOMMENDATION ONE: 1. Adjust the timing and method by which each non- single- stream LME's services dollar allocations are distributed, in order to mitigate cash- flow problems that many LMEs experience at the beginning of the fiscal year. Specifically, distribute no less than one- twelfth of each non- single-stream LME's allocation to the respective LME at the beginning of the fiscal year, and subtract this amount from the LME s total reimbursements for the fiscal year. 2. Appropriate $ 6 million for DHHS to establish additional regionally-purchased and locally- hosted substance abuse programs. 3. Encourage the conversion of the remaining non- single- stream LMEs to single- stream funding as soon as possible. Appropriate to DHHS $ 675,000 for technical assistance to those LMEs not currently meeting the standards necessary for single- stream funding. Direct DHHS to develop standards for the removal of single- stream designation for those LMEs that do not continue to meet the single-stream standards once designated. 4. Direct DHHS to simplify the current State Integrated Payment and Reporting System ( IPRS) to encourage more providers to serve State-paid clients. 5. Direct DHHS to create a reporting system for both single- stream funding and non- unit- cost- reimbursement funding that is readily comprehensible and integrates with payment systems. 6. Direct DHHS, in consultation with LMEs and providers, to determine why there have been over- and under- expenditures of State service dollars by LMEs and to take the actions necessary to address the 21 problem. Also direct DHHS to report to the General Assembly no later than January 1, 2009 on the actions taken. 7. Appropriate $ 1 million to the General Assembly to be used to retain the services of an independent consultant to perform a services gap analysis of the Mental Health, Developmental Disabilities, and Substance Abuse Services System. The RFP should require the Independent Consultant to report its findings and recommendations by May 1, 2009. Also, recommend that the Joint Legislative Program Evaluation Oversight Committee include in the work plan for the Program Evaluation Division a thorough performance evaluation of the State's mental health agencies in the Department of Health and Human Services ( the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services and the Division of Medical Assistance) to be completed by May 1, 2009. 22 FINDING TWO: STATE- OPERATED SERVICES The State psychiatric hospitals are admitting more clients than in prior years approximately 2,600 more admissions in FY 2006- 07 than in FY 2002- 03. In January 2007, due to increased admissions to the hospitals acute units ( particularly the adult acute units), the Department of Health and Human Services put a delayed admissions policy into effect: when a State psychiatric hospitals' acute units reach 110% capacity, no admissions are accepted until those units are once again below 110% capacity. Three hospitals ( Dix, Umstead, and Broughton) have been on delayed status11. The chart below shows the percent of days that each of those three hospitals have been on delayed status in the portion of FY 2006- 07 that the policy was in effect and in FY 2007- 08 as of February 2008. Broughton and Dix each have been at or above 110% capacity and thus on delayed status more than half the time. Additionally, during SFY 2007- 08, due in part to the absence of qualified permanent staff, State psychiatric hospitals were in jeopardy of losing their certification by the federal Centers for Medicaid and Medicare Services ( CMS), and Broughton hospital did lose certification. A hospital without CMS certification cannot bill Medicaid or Medicare for services, increasing the portion of the cost of hospital services that must be paid for by the State. Moreover, a non- certified hospital diminishes public confidence in our mental health system. The services and administrative practices at the State psychiatric hospitals need to be improved, to meet federal and State standards and to restore the public confidence. State institutions need the ability to hire and retain high- quality staff. 11As of February 2008, Cherry Hospital has not been on delayed status the hospital has been over capacity, but has been able to divert referrals rather than delay admissions. Broughton Dix Umstead January 2007 - June 2007 65% 49% 22% July 2007 - February 2008 71% 59% 31% Percent ofDays onDelayed Status 23 It is the policy of the State that the State hospitals be used only as a last resort: to be used for those individuals whose level of acuity prevents them from being served adequately by community service providers and for those individuals who local hospitals are unable to admit12. In the short- term, the increased demand for State hospital admissions needs be met to ensure the availability of that level of care when it is needed. However, this short- term increase in availability should not undermine the system's commitment to the previously stated policy. In the long- term, the demand needs to be reduced by providing alternative services in the community for individuals in crisis who can be adequately served in the community and by providing stabilizing services and supports to prevent crises from occurring. In addition to issues relating to the State Hospitals, the Committee heard a report on downsizing at the State s Developmental Centers and found that the Centers have been unable to reduce the number of patients served. The General Assembly, in SL 2007- 323, directed the State s Developmental Centers ( the Caswell, Murdoch and Riddle centers) to reduce their number of residential patients and directed DHHS s budget to be reduced accordingly as the Centers censuses decreased. However, DHHS has informed the LOC that the Centers are not downsizing as expected, primarily because the patients living there are unable to be adequately and appropriately served in the community and due to increased demand from population increases. In order for the Centers to downsize effectively, consumers need supports for living, working, and participating in all aspects of community needs to be available. In addition to the direct supports, there also need to be affordable options for the actual residence. North Carolina statutes on involuntary commitments of individuals to psychiatric facilities provide for transportation to the physician or eligible psychologist for the examination required by law. G. S. 122C- 261, et seq. Questions have arisen regarding supervision of the individual during this time. Interpretations of current law, G. S. 122C- 263( a), permit law enforcement officers who transport the individual to the appropriate facility to discontinue supervision of the individual once the officers have delivered the individual to the facility so long as there is adequate supervision at the facility. This situation raises issues of detention of an individual by the facility when the individual has neither been arrested nor committed to a State hospital by court order. Also involved is the question of using limited law enforcement resources to continue supervision of the individual pending the required examination. 12 North Carolina Department of Health and Human Services, State Plan 2001: Blueprint for Change, ( November 31, 2001). 24 RECOMMENDATION TWO: 1. Due to the high use of adult admissions unit beds, appropriate $ 5,274,000 on a one- time basis and authorize the temporary opening of the Central Regional Hospital Wake Unit on the Dorothea Dix Campus. 2. Require that all deaths occurring in State institutions be reported to the State Medical Examiner to determine if further investigation into the cause of death and circumstances surrounding the death is necessary and appropriate the necessary funds of $ 155,226 to DHHS for an additional Public Health Nurse Consultant and other associated costs with the increased investigatory requirements. Direct the Commission for Mental Health, Developmental Disabilities, and Substance Abuse Services to study the current death reporting requirements established under G. S. § 122C- 26( 5)( c) and assess the need for any additional reporting requirements or modifications to existing rules or procedures. 3. Appropriate $ 30 million to expand the Hospital Utilization Pilot statewide, in a manner that maintains local control of funds and of bed utilization, with a goal of reducing the use of State psychiatric hospital beds for those individuals staying 2 weeks or less. 4. Appropriate $ 1,134,168 to implement the Transitional Residential Treatment Program in each of the 3 psychiatric hospital catchment areas. Also, direct DHHS, in consultation with LMEs and providers, to develop and implement a plan for discharge planning at the local level for all disability groups to ensure that those individuals willing and able to transition to the community can successfully make that transition. Also direct DHHS to report to the General Assembly no later than January 1, 2009 on the actions taken. 5. Continue funding for the Housing 400 Initiative by appropriating $ 10 million to the Housing Trust Fund and $ 2.5 million to DHHS for recurring operating support for approximately 500 units. By providing stabilizing services and supports to prevent crises from occurring, appropriate housing will reduce the need for State Psychiatric hospitals in the long- term. 6. Provide for automatic re- enrollment in Medicaid for those individuals whose eligibility had been cancelled while in the hospital so that upon 25 their release they will have access through Medicaid to care and medications. 7. Direct DHHS, within current available resources, to implement the tiered CAP- MR/ DD waiver program as directed in SL 2007- 323, Section 10.49( dd). The Department shall implement the program with four tiers: ( i) up to $ 10,000; ( ii) between $ 10,001 and $ 25,000; ( iii) between $ 25,001 and $ 75,000; and ( iv) greater than $ 75,000. 8. Direct the Institute of Medicine ( IOM) to study and report on the best practices in transition for persons with developmental disabilities from one life setting to another, including barriers to transition and best practices in successful transitions. The Institute of Medicine should conduct this study using funds appropriated for IOM studies in the 2007 Session, and the study should encompass at least the following topics: ( i) the transition for adolescents leaving high school, including adolescents in foster care and those in other settings; ( ii) the transition for persons with developmental disabilities who live with aging parents; and ( iii) the transition from the developmental centers to other settings. 9. Direct DHHS to review State- County Special Assistance rates to establish an appropriate rate for special care units for persons with a mental health disability, including individuals with a Traumatic Brain Injury ( TBI) and to review the rules pertaining to special care units for persons with a mental health disability to determine if additional standards are necessary. 10. Authorize a study of the pertinent commitment statutes, particularly G. S. 122C- 263( a), to determine if an individual lawfully ordered to undergo an examination by a physician or eligible psychologist is being appropriately supervised during the period of the individual's examination. 11. Support DHHS's recommendation for additional funds for hiring and retention of proper staffing in the State Hospitals. 26 FINDING THREE: SERVICES IN THE COMMUNITY In March 2006, DHHS enacted new federally- approved service definitions for a variety of mental health services, including Community Support Services ( CS). CS was designed to replace two former services ( Community- Based Services and Case Management), and the State expected CS to cost approximately the same as what it replaced. However, in FY 2006- 07, the service s State and Federal Medicaid cost was about $ 500 million higher than expected. In the 2007 regular session, the General Assembly enacted Session Law 2007- 323, of which Section 10.49( ee) implemented a number of changes to slow CS spending. DHHS also has taken steps to control the program s growth and expenses. But CS costs remain higher than anticipated in FY 2007- 08, and spending is likely to exceed budget if it continues at the current rate. The LOC believes that the overspending in the CS program has been caused by multiple factors, which are outlined below. It is the LOC s belief that not only have these factors caused the current problems with Community Support, but they leave the system vulnerable to similar problems in other MHDDSA areas. The CS Reimbursement Rate Encourages Low- Qualified Providers The State- and federally- approved CS definition allows for CS to be provided by paraprofessionals, associate professionals and qualified professionals all of whom are reimbursed at the same rate. This blended rate has resulted in a rapid increase in the number of CS providers and in the service s costs, without administrative control over the necessity for the service, the type of service, and the qualifications of the service provider. Service Providers Have a Conflict of Interest In Performing Assessments Before receiving services or treatment, clients are evaluated and assessed to determine their diagnosis and treatment needs. However, these assessments are often conducted by a provider who also offers the services or treatments to which the client is referred. This creates a potential conflict of interest on the part of the provider and can lead to non- objective client assessments. DHHS Has Undercut the LMEs Ability to Perform Statutory Core Functions LMEs core functions, as defined by General Statute 122C- 115, include utilization management, utilization review, and determination of the appropriate level and intensity of services to ensure that services are needed and appropriately provided. However, the DHHS has transferred this function from LMEs to an 27 outside vendor for Medicaid- funded services. The outside vendor's performance of utilization review has been ineffective and inconsistent in its application, due in part to the absence of uniform review standards. One function that has remained with the LMEs is provider endorsement. In order to provide Medicaid services, providers must first be endorsed by an LME as being qualified to provide the service. However, LMEs are not State agencies and have not been given sufficient authority to implement, monitor, and effectively enforce provider endorsement requirements in order to hold providers accountable. As a result, some endorsed providers are performing below standards required by State law and federal law. Poor provider performance has given rise to concerns about the level, volume, and quality of services by providers, particularly with respect to community support services. In response to these concerns, LMEs have begun to deny, suspend, or refuse to renew provider endorsements; this has caused a spike in the number of provider appeals. The Appeals Process Should be Streamlined to Address a Substantial Backlog in Appeals Pending, and Should Be Simplified to Address Issues of Fairness The appeals process for Medicaid applicants and recipients needs to be streamlined, simplified, and balanced. Federal law requires a " fair hearing" when Medicaid services are reduced or denied and also requires resolution of the case within 90 days. Recent actions taken by the DHHS to reduce or eliminate services has caused a substantial increase in the volume of appeals, which in turn has caused a very large backlog of appeals pending. The result has created an increase in State Medicaid expenditures, case resolution far in excess of the time allowed under federal law, and a lawsuit recently filed raising due process issues. Last session the General Assembly provided for simplified appeals of Department of Revenue decisions by taxpayers, G. S. 105- 241.15, and authorized the Chief Administrative Law Judge ( OAH) to limit and simplify the procedures that apply to a contested tax case involving a taxpayer who is not represented by an attorney. G. S. 150B- 31.1. A similar expedited process could be replicated for Medicaid contested cases. Changes to the appeals process to ensure that the interests of Medicaid clients are adequately represented may require additional funding to reduce the number of clients that appear pro se due to their financial situation. The Ability to Control the Provider Network Can Contribute to LME Success Piedmont Behavioral Health the LME whose catchment area includes Davidson, Rowan, Cabarrus, Stanly and Union Counties has a 1915 ( b)/( c) combination Medicaid waiver that gives it flexibility in managing care. Among other features 28 the waiver allows Piedmont Behavioral Health ( PBH) to control the size of its provider network. The LOC believes that this control has aided PBH s success. RECOMMENDATION THREE: 1. Require that DHHS develop and implement a tiered rate structure for community support services to replace the current blended rate. Under the new tiered structure, services that are necessary but do not require the skill, education, or knowledge of a qualified professional should not be paid at the same rate as services provided by qualified skilled professionals. Require DHHS to report to the LOC prior to implementing the new rate structure. 2. Require DHHS to develop and implement a service authorization process that separates the assessment function from the service delivery function. In doing so, the Department should consider as an option LME assessment centers whose duties would include care coordination. Require DHHS to report to the LOC prior to implementing the new service authorization process. 3. Direct DHHS to conduct a thorough study of the service authorization, utilization management, and utilization review processes and to develop a plan to return the service authorization, utilization review, and utilization management functions to LMEs for all clients. Direct DHHS to comply with the requirements of S. L. 2007- 323, Section 10.49( ee). Prohibit DHHS from contracting with an outside vendor for service authorization, utilization review, or utilization management functions, or otherwise obligating the State for these functions beyond June 30, 2009. Direct DHHS to require LMEs to include in their service authorization, utilization management, and utilization review a review of assessments as well as person centered plans, and random or triggered audits of services and assessments. Also, require that the licensed professional who signs a medical order for services must indicate whether the licensed professional has ( i) had contact with the consumer, and ( ii) reviewed the consumer's assessment. 4. Direct DHHS to adopt guidelines for LME periodic review and re-endorsement of providers to ensure that only qualified providers are endorsed and that LMEs hold those providers accountable for the Medicaid and State- funded services they provide. Additionally, amend 29 state law to allow providers to appeal LME decisions on provider endorsements to the Office of Administrative Hearings. 5. Authorize the Office of Administrative Hearings ( OAH) to develop a simplified procedure to streamline the process for hearing appeals of Medicaid recipients, applicants, and providers ( including an automatic appeal for recipients and applicants). In developing the process the OAH should consult with DHHS to ensure that the streamlined and simplified process complies with federal " fair hearing" requirements. The process should be as simple and straightforward as possible, especially for appellants appearing without an attorney, without compromising the purpose of the Administrative Procedure Act, G. S. 150B- 2, et seq., and allowing for a complete record of the hearing to be maintained by the presiding administrative law judge. Also, require DHHS, in its written notice of the reduction, termination, or denial of services, to provide information clearly explaining the opportunities for appeal and the reasons for the decision. 6. Direct DHHS to study Medicaid waivers, including 1915( b) and ( c) waivers, for all LMEs or some other mechanism to allow LMEs to the ability to provide case management, assessment, or other management functions and to limit provider networks. Recognizing that waivers may not be appropriate for all LMEs, direct the Department to study what would be needed to increase LMEs flexibility for innovation. 7. Direct DHHS to develop a plan for General Assembly review that would merge, consolidate, or provide for regional arrangements or consortia with respect to LME structure. The Secretary should consult with LMEs in the development of the plan and should submit the plan to the General Assembly for review. Further, require that the Secretary take no action to merge, consolidate, or provide for regional arrangements or consortia with respect to LME structure before January 1, 2010. 8. Support the recommendation of the MH/ DD/ SAS Workforce Plan to appropriate the necessary funds to DHHS to establish a Workforce Development Specialist position within the Division of MH/ DD/ SAS. This specialist should have expertise in assessing workforce issues and will serve as the project manager for implementing the Division's workforce development initiatives, particularly the recommendations identified in the MH/ DD/ SAS Workforce Plan. 30 APPENDIX Copies of the proposed legislation begin on the following page. 31 GENERAL ASSEMBLY OF NORTH CAROLINA SESSION 2007 H/ S D BILL DRAFT 2007- LNz- 309A* [ v. 10] ( 4/ 2) ( THIS IS A DRAFT AND IS NOT READY FOR INTRODUCTION) 4/ 30/ 2008 1: 18: 42 PM Short Title: Recommendations of MH/ DD/ SA Oversight Comm. ( Public) Sponsors: Referred to: 1 A BILL TO BE ENTITLED 2 AN ACT TO ENACT VARIOUS LAWS TO IMPROVE THE MENTAL HEALTH, 3 DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE SERVICES 4 SYSTEM, AS RECOMMENDED BY THE JOINT LEGISLATIVE OVERSIGHT 5 COMMITTEE ON MENTAL HEALTH, DEVELOPMENTAL DISABILITIES, 6 AND SUBSTANCE ABUSE SERVICES. 7 The General Assembly of North Carolina enacts: 8 SECTION 1.1. Expenditure of Service Dollars. - For the purpose of 9 mitigating cash- flow problems that many non- single- stream LMEs experience at the 10 beginning of each fiscal year, the Department of Health and Human Services, Division 11 of Mental Health, Developmental Disabilities, and Substance Abuse Services, shall 12 adjust the timing and method by which allocations of service dollars are distributed to 13 each non- single- stream LME. To this end, the allocations shall be adjusted such that at 14 the beginning of the fiscal year, the Department shall distribute not less than one- twelfth 15 of the LME's continuation allocation and subtract the amount of the adjusted 16 distribution from the LME's total reimbursements for the fiscal year. 17 SECTION 1.2. There is appropriated from the General Fund to the 18 Department of Health and Human Services, Division of Mental Health, Developmental 19 Disabilities, and Substance Abuse Services, the sum of six million dollars ($ 6,000,000) 20 for the 2008- 2009 fiscal year. These funds shall be used to support LMEs in 21 establishing additional regionally- purchased and locally- hosted substance abuse 22 programs. Funds appropriated shall be for the purpose of developing and enhancing the 23 American Society of Addiction Medicine ( ASAM) continuum of care at the community 24 level. The Department of Health and Human Services shall work with LMEs in 25 establishing these programs. 26 SECTION 1.3.( a) There is appropriated from the General Fund to the 27 Department of Health and Human Services, Division of Mental Health, Developmental 32 General Assembly Of North Carolina Session 2007 1 Disabilities, and Substance Abuse Services, the sum of six hundred seventy- five 2 thousand dollars ($ 675,000) for the 2008- 2009 fiscal year. These funds shall be used to 3 contract with an outside vendor for technical assistance to LMEs that are not meeting 4 the standards necessary for single- stream funding. 5 SECTION 1.3.( b) The Department shall encourage the conversion of the 6 remaining non- single- stream LMEs to single- stream funding as soon as possible. The 7 Department shall also develop standards for the removal of single- stream designation 8 for those LMEs that do not continue to comply with the applicable requirements for 9 single- stream funding. 10 SECTION 1.4. The Department of Health and Human Services shall 11 simplify the current State Integrated Payment and Reporting System ( IPRS) to 12 encourage more providers to serve State- paid clients. 13 SECTION 1.5. The Department of Health and Human Services shall create a 14 reporting system for both single- stream funding and non- unit- cost reimbursement 15 funding that is readily comprehensible and integrates with payment systems. 16 SECTION 1.6. The Department of Health and Human Services shall 17 determine why there have been under- and over- expenditure of State service dollars by 18 LMEs and shall take the action necessary to address the problem. In making its 19 determination the Department shall consult with LMEs and providers. Not later than 20 January 1, 2009, the Department shall report to the House of Representatives 21 Appropriations Subcommittee on Health and Human Services, the Senate 22 Appropriations Committee on Health and Human Services, the Fiscal Research Division 23 and the Joint Legislative Oversight Committee on Mental Health, Developmental 24 Disabilities, and Substance Abuse Services on actions taken to address problem of LME 25 under- and over- expenditure of service dollars. 26 SECTION 1.7.( a) There is appropriated from the General Fund to the 27 General Assembly the sum of one million dollars ($ 1,000,000) for the 2008- 2009 fiscal 28 year. These funds shall be used to retain the services of an independent consultant to 29 perform a services gap analysis of the Mental Health, Developmental Disabilities, and 30 Substance Abuse Services System. In developing the RFP the Fiscal Research Division 31 shall require the Independent Consultant to report on or before May 1, 2009 its findings 32 and recommendations to the House of Representatives Appropriations Subcommittee on 33 Health and Human Services, the Senate Appropriations Committee on Health and 34 Human Services, the Joint Legislative Oversight Committee on Mental Health, 35 Developmental Disabilities, and Substance Abuse Services, and the Fiscal Research 36 Division. 37 SECTION 1.7.( b) In developing its work plan, the Joint Legislative Program 38 Evaluation Oversight Committee may include a thorough performance evaluation of the 39 State's mental health agencies in the Department of Health and Human Services, 40 Division of Mental Health, Developmental Disabilities, and Substance Abuse Services 41 and the Division of Medical Assistance. The performance evaluation shall be 42 completed not later than May 1, 2009. 43 33 General Assembly Of North Carolina Session 2007 1 SECTION 2.1.( a). State- Operated Services. – In order to temporarily 2 address high admissions to adult acute unit beds in the State psychiatric hospitals, the 3 Secretary of the Department of Health and Human Services may open and operate on a 4 temporary basis the Central Regional Hospital Wake Unit on the Dorothea Dix Campus 5 and may maintain the Wake Unit on the Dix Campus until beds become available in the 6 system. 7 SECTION 2.1.( b). G. S. 122C- 181( a)( 1) reads as rewritten: 8 " § 122C- 181. Secretary's jurisdiction over State facilities. 9 ( a) Except as provided in subsection ( b) of this section, the Secretary shall 10 operate the following facilities: 11 ( 1) Psychiatric Hospitals: 12 a. Cherry Hospital. 13 a1. ( Contingent effective date, see Editor's note) Central 14 Regional Hospital. 15 b. ( Contingent repeal date, see Editor's note) Dorothea Dix 16 Hospital. 17 c. ( Contingent repeal date, see Editor's note) John Umstead 18 Hospital. 19 d. Broughton Hospital. 20 e. The Central Regional Hospital Wake Unit on the Dorothea Dix 21 Campus." 22 This subsection expires upon the earlier of July 1, 2009 or the availability of 23 beds at Central Regional Hospital. 24 SECTION 2.1.( c) There is appropriated from the General Fund to the 25 Department of Health and Human Services the sum of five million two hundred 26 seventy- four thousand dollars ($ 5,274,000) for the 2008- 2009 fiscal year. These one-27 time funds shall be used to support the temporary opening and operation of the Central 28 Regional Hospital Wake Unit on the Dorothea Dix Campus. 29 SECTION 2.2.( a) G. S. 130A- 383( a) reads as rewritten: 30 " § 130A- 383. Medical examiner jurisdiction. 31 ( a) Upon the death of any person resulting from violence, poisoning, accident, 32 suicide or homicide; occurring suddenly when the deceased had been in apparent good 33 health or when unattended by a physician; occurring in a jail, prison, correctional 34 institution institution, State facilities operated in accordance with Part 5 of Article 4 of 35 Chapter 122C of the General Statutes; or in police custody; occurring pursuant to 36 Article 19 of Chapter 15 of the General Statutes; or occurring under any suspicious, 37 unusual or unnatural circumstance, the medical examiner of the county in which the 38 body of the deceased is found shall be notified by a physician in attendance, hospital 39 employee, law- enforcement officer, funeral home employee, emergency medical 40 technician, relative or by any other person having suspicion of such a death. No person 41 shall disturb the body at the scene of such a death until authorized by the medical 42 examiner unless in the unavailability of the medical examiner it is determined by the 43 appropriate law enforcement agency that the presence of the body at the scene would 44 risk the integrity of the body or provide a hazard to the safety of others. For the limited 34 General Assembly Of North Carolina Session 2007 purposes of this Part, 1 expression of opinion that death has occurred may be made by a 2 nurse, an emergency medical technician or any other competent person in the absence of 3 a physician." 4 SECTION 2.2.( b) G. S. 122C- 31 is amended by adding the following new 5 subsection to read: 6 " § 122C- 31. Report required upon death of client. 7 "… 8 "( g) In addition to the reporting requirements specified in subsections ( a) through 9 ( e) of this section, and pursuant to G. S. 130A- 383, every State facility shall report the 10 death of any client of the facility, regardless of the manner of death, to the medical 11 examiner of the county in which the body of the deceased is found." 12 SECTION 2.2.( c) There is appropriated from the General Fund to the 13 Department of Health and Human Services, the sum of one hundred fifty- five thousand 14 two hundred twenty- six dollars ($ 155,226) for the 2008- 2009 fiscal year. These funds 15 shall be used for one additional public health nurse consultant position and other costs 16 associated with the increased investigatory requirements of this section. 17 SECTION 2.2.( d) The Commission for Mental Health, Developmental 18 Disabilities, and Substance Abuse Services shall study the current death reporting 19 requirements under G. S. 122C- 26( 5)( c) and assess the need for any additional reporting 20 requirements or modifications to existing rules or procedures. The Commission shall 21 report its findings to the Joint Legislative Oversight Committee on Mental Health, 22 Developmental Disabilities, and Substance Abuse Services not later than November 1, 23 2008. 24 SECTION 2.3. There is appropriated from the General Fund to the 25 Department of Health and Human Services, Division of Mental Health, Developmental 26 Disabilities, and Substance Abuse Services, the sum of thirty million dollars 27 ($ 30,000,000) for the 2008- 2009 fiscal year. These funds shall be used to expand the 28 Hospital Utilization Pilot Program statewide in a manner that maintains local control of 29 funds and bed allocations, with a goal of reducing the use of State psychiatric hospital 30 beds for those individuals staying two weeks or less. 31 SECTION 2.4.( a) There is appropriated from the General Fund to the 32 Department of Health and Human Services, Division of Mental Health, Developmental 33 Disabilities, and Substance Abuse Services, the sum of one million one hundred thirty-34 four thousand one hundred sixty- eight dollars ($ 1,134,168) for the 2008- 2009 fiscal 35 year to implement three pilot programs of the Transitional Residential Treatment 36 Program. One pilot program shall be located in each of the State's three State 37 psychiatric hospital catchment areas. 38 SECTION 2.4.( b) The Department of Health and Human Services, Division 39 of Mental Health, Developmental Disabilities, and Substance Abuse Services, shall 40 develop and implement a plan for discharge planning at the local level for all disability 41 groups. The Department shall implement its plan as soon as possible. 42 SECTION 2.5.( a) There is appropriated from the General Fund to the 43 Housing Trust Fund the sum of ten million dollars ($ 10,000,000) for the 2008- 2009 35 General Assembly Of North Carolina Session 2007 fiscal year 1 for the Housing 400 Initiative in order to reduce the need for State 2 psychiatric hospitals in the long- term. 3 SECTION 2.5.( b) There is appropriated from the General Fund to the 4 Department of Health and Human Services, Division of Mental Health, Developmental 5 Disabilities, and Substance Abuse Services, the sum of two million five hundred 6 thousand dollars ($ 2,500,000) for the 2008- 2009 fiscal year to continue operating 7 support for an estimated 500 units of the Housing 400 Initiative in order to reduce the 8 need for State psychiatric hospitals in the long- term. It is the intent of the General 9 Assembly that these funds shall be appropriated on a recurring basis. 10 SECTION 2.6. Not later than October 1, 2008, the Department of Health 11 and Human Services, Division of Medical Assistance, shall provide for automatic re-12 enrollment of Medicaid recipients whose Medicaid eligibility had been cancelled 13 because of admission to the hospital. The purpose of automatic re- enrollment is to 14 ensure that upon release from the hospital the eligible Medicaid recipient will have 15 uninterrupted access to care and medications under the Medicaid program. 16 SECTION 2.7. The Department of Health and Human Services, Division of 17 Mental Health, Developmental Disabilities, and Substance Abuse Services, shall, within 18 available resources, implement the tiered CAP- MR/ DD waiver program in accordance 19 with Section 10.49( dd) of S. L. 2007- 323. The Department shall implement the program 20 with four tiers: ( i) up to $ 10,000; ( ii) between $ 10,001 and $ 25,000; ( iii) between 21 $ 25,001 and 75,000; and ( iv) greater than $ 75,000. 22 SECTION 2.8. The North Carolina Institute of Medicine shall study and 23 report on the transition for persons with developmental disabilities from one life setting 24 to another, including barriers to transition and best practices in successful transitions. 25 The IOM should conduct this study using funds appropriated for IOM studies in the 26 2007 Session. The study should encompass at least the following topics: ( i) the 27 transition for adolescents leaving high school, including adolescents in foster care and 28 those in other settings; ( ii) the transition for persons with developmental disabilities who 29 live with aging parents; and ( iii) the transition from the developmental centers to other 30 settings. 31 SECTION 2.9. The Department of Health and Human Services shall review 32 State- County Special Assistance rates to establish an appropriate rate for special care 33 units for persons with a mental health disability, including individuals with Traumatic 34 Brain Injury ( TBI), and shall review current rules pertaining to special care units for 35 persons with a mental health disability to determine if additional standards are 36 necessary. Effective July 1, 2008, care provided to individuals with Traumatic Brain 37 Injury shall be paid at the special care unit rate paid for care of persons with a mental 38 health disability. The Department shall report its findings and recommendations to the 39 House of Representatives Appropriations Subcommittee on Health and Human 40 Services, the Senate Appropriations Committee on Health and Human Services, the 41 Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, 42 and Substance Abuse Services, and the Fiscal Research Division not later than January 43 1, 2009. 36 General Assembly Of North Carolina Session 2007 1 SECTION 3.1 Community Services. - In order to ensure accountability 2 for services provided and funds expended for community services, the Department of 3 Health and Human Services, Division of Mental Health, Developmental Disabilities, 4 and Substance Abuse Services, shall develop a tiered rate structure to replace the 5 blended rate currently used for community support services. Under the new tiered 6 structure, services that are necessary but do not require the skill, education, or 7 knowledge of a qualified professional should not be paid at the same rate as services 8 provided by qualified skilled professionals. The Department shall report on the 9 development of the structure to the Joint Legislative Oversight Committee ( LOC) on 10 Mental Health, Developmental Disabilities, and Substance Abuse Services not later than 11 October 1, 2008. The Department shall not implement the tiered rate structure until 12 after it has consulted with the LOC. 13 SECTION 3.2. The Department of Health and Human Services, Division of 14 Mental Health, Developmental Disabilities, and Substance Abuse Services, shall 15 develop a service authorization process that separates the assessment function from the 16 service delivery function at the LME level. In developing the process the Department 17 shall consider as an option separate LME assessment centers, the duties of which would 18 include care coordination. The Department shall report on the development of the 19 service authorization process to the Joint Legislative Oversight Committee ( LOC) on 20 Mental Health, Developmental Disabilities, and Substance Abuse Services not later than 21 October 1, 2008. The Department shall not implement the service authorization process 22 until after it has consulted with the LOC. 23 SECTION 3.3.( a). The Department of Health and Human Services shall 24 conduct a thorough study of the service authorization, utilization review, and utilization 25 management processes and shall develop a plan to return the service authorization, 26 utilization review and utilization management functions to LMEs for all clients. Not 27 later than February 1, 2009, the Department shall report its findings and 28 recommendations to the House of Representatives Appropriations Subcommittee on 29 Health and Human Services, the Senate Appropriations Committee on Health and 30 Human Services, the Joint Legislative Oversight Committee on Mental Health, 31 Developmental Disabilities, and Substance Abuse Services, and the fiscal research 32 division. The Department shall comply with the requirements of S. L. 2007- 323, Section 33 10.49( ee). The Department shall not contract with an outside vendor for service 34 authorization, utilization review, or utilization management functions, or otherwise 35 obligate the State for these functions beyond June 30, 2009. The Department shall 36 require LMEs to include in their service authorization, utilization management, and 37 utilization review a review of assessments as well as person centered plans, and random 38 or triggered audits of services and assessments. 39 SECTION 3.3.( b). The Department shall require that the licensed 40 professional that signs a medical order for behavioral health services must indicate on 41 the order whether the licensed professional has ( i) had direct contact with the consumer, 42 and ( ii) has reviewed the consumer's assessment. This requirement shall take effect no 43 later than October 1, 2008. 44 SECTION 3.4.( a) G. S. 122C- 151.4reads as rewritten: 37 General Assembly Of North Carolina Session 2007 1 " § 122C- 151.4. Appeal to State MH/ DD/ SA Appeals Panel. 2 ( a) Definitions. – The following definitions apply in this section: 3 ( 1) " Appeals Panel" means the State MH/ DD/ SA Appeals Panel 4 established under this section. 5 ( 1a) " Client" means an individual who is admitted to or receiving public 6 services from an area facility. " Client" includes the client's personal 7 representative or designee. 8 ( 1b) " Contract" means a contract with an area authority or county program 9 to provide services, other than personal services, to clients and other 10 recipients of services. 11 ( 2) " Contractor" means a person who has a contract or who had a contract 12 during the current fiscal year. year, or whose application for 13 endorsement has been denied by an area authority or county program. 14 ( 3) " Former contractor" means a person who had a contract during the 15 previous fiscal year. 16 ( b) Appeals Panel. – The State MH/ DD/ SA Appeals Panel is established. The 17 Panel shall consist of three members appointed by the Secretary. The Secretary shall 18 determine the qualifications of the Panel members. Panel members serve at the pleasure 19 of the Secretary. 20 ( c) Who Can Appeal. – The following persons may appeal to the State 21 MH/ DD/ SA Appeals Panel after having exhausted the appeals process at the appropriate 22 area authority or county program: 23 ( 1) A contractor or a former contractor who claims that an area authority 24 or county program is not acting or has not acted within applicable 25 State law or rules in denying the contractor's application for 26 endorsement or in imposing a particular requirement on the contractor 27 on fulfillment of the contract; 28 ( 2) A contractor or a former contractor who claims that a requirement of 29 the contract substantially compromises the ability of the contractor to 30 fulfill the contract; 31 ( 3) A contractor or former contractor who claims that an area authority or 32 county program has acted arbitrarily and capriciously in reducing 33 funding for the type of services provided or formerly provided by the 34 contractor or former contractor; 35 ( 4) A client or a person who was a client in the previous fiscal year, who 36 claims that an area authority or county program has acted arbitrarily 37 and capriciously in reducing funding for the type of services provided 38 or formerly provided to the client directly by the area authority or 39 county program; and 40 ( 5) A person who claims that an area authority or county program did not 41 comply with a State law or a rule adopted by the Secretary or the 42 Commission in developing the plans and budgets of the area authority 43 or county program and that the failure to comply has adversely 38 General Assembly Of North Carolina Session 2007 1 affected the ability of the person to participate in the development of 2 the plans and budgets. 3 ( d) Hearing. – All members of the State MH/ DD/ SA Appeals Panel shall hear an 4 appeal to the Panel. An appeal shall be filed with the Panel within the time required by 5 the Secretary and shall be heard by the Panel within the time required by the Secretary. 6 A hearing shall be conducted at the place determined in accordance with the rules 7 adopted by the Secretary. A hearing before the Panel shall be informal; no sworn 8 testimony shall be taken and the rules of evidence do not apply. The person who appeals 9 to the Panel has the burden of proof. The Panel shall not stay a decision of an area 10 authority during an appeal to the Panel. 11 ( e) Decision. – The State MH/ DD/ SA Appeals Panel shall make a written 12 decision on each appeal to the Panel within the time set by the Secretary. A decision 13 may direct a contractor, an area authority, or a county program to take an action or to 14 refrain from taking an action, but it shall not require a party to the appeal to pay any 15 amount except payment due under the contract. In making a decision, the Panel shall 16 determine the course of action that best protects or benefits the clients of the area 17 authority or county program. If a party to an appeal fails to comply with a decision of 18 the Panel and the Secretary determines that the failure deprives clients of the area 19 authority or county program of a type of needed service, the Secretary may use funds 20 previously allocated to the area authority or county program to provide the service. 21 ( f) Chapter 150B Appeal. – A person who is dissatisfied with a decision of the 22 Panel may commence a contested case under Article 3 of Chapter 150B of the General 23 Statutes. Notwithstanding G. S. 150B- 2( 1a), an area authority or county program is 24 considered an agency for purposes of the limited appeal authorized by this section. If 25 the need to first appeal to the State MH/ DD/ SA Appeals Panel is waived by the 26 Secretary, a contractor may appeal directly to the Office of Administrative Hearings 27 after having exhausted the appeals process at the appropriate area authority or county 28 program. The Secretary shall make a final decision in the contested case." 29 SECTION 3.4.( c) The Department of Health and Human Services shall 30 adopt guidelines for LME periodic review and re- endorsement of providers to ensure 31 that only qualified providers are endorsed and that LMEs hold those providers 32 accountable for the Medicaid and State- funded services they provide. 33 SECTION 3.5.( a) Effective October 1, 2008, the Title of G. S. 108A- 79 34 reads as rewritten: 35 " § 108A- 79. Appeals. Appeals of county level decisions." 36 SECTION 3.5.( b). Effective October 1, 2008, Article 4 of Chapter 108A of 37 the General Statutes is amended by adding the following new section to read: 38 " § 108A- 79.1. Appeals by Medicaid applicants and recipients. 39 ( a) An action by the Department to deny, terminate, suspend, or reduce Medicaid 40 eligibility, or to deny, terminate, suspend, or reduce Medicaid services is a " contested 41 case" subject to the provisions of Chapter 150B of the General Statutes, except as 42 provided by this section. At the time of providing the notice required under subsection 43 ( b) of this section, the Department shall file a petition with the Office of Administrative 44 Hearings to determine the Medicaid applicant's or recipient's rights duties or privileges. 39 General Assembly Of North Carolina Session 2007 1 ( b) In addition to the notice requirements of G. S. 150B- 23, the Department shall 2 provide within 30 days of its decision written notice to the aggrieved applicant or 3 recipient, or the applicant's or recipient's legal guardian, which notice shall include: 4 ( 1) An explanation of the Department's decision. 5 ( 2) A clear and concise statement of what service is being reduced, 6 terminated, or denied and the basis upon which the decision was made. 7 ( 3) A statement that the Department has filed a petition for administrative 8 review of its decision in the Office of Administrative Hearings, and 9 that the applicant or recipient has 30 days from the date of the 10 Department's decision to decide whether or not to proceed with the 11 hearing. 12 ( 4) A clear explanation of how the hearing will proceed, what is required 13 of the applicant in order to proceed or to decline to proceed, and that 14 the applicant or recipient may be represented by an attorney or other 15 person at the hearing. The notice shall further state that representation 16 by an attorney may be available from Disability Rights of NC legal 17 services, and attorneys working with mediation centers throughout the 18 State. 19 ( 5) A statement that the recipient will continue to receive Medicaid 20 services at the level provided on the day immediately preceding the 21 Department's decision pending a final decision. 22 ( 6) The telephone number of a contact person at the Department to 23 respond in a timely fashion to applicant or recipient questions. 24 ( 7) A brochure supplied by the North Carolina Protection and Advocacy 25 System that explains the rights of applicants and recipients under the 26 State Medical Assistance Program, including the rights to appeal 27 decisions of the Department." 28 SECTION 3.6. The Department of Health and Human Services, Division of 29 Mental Health, Developmental Disabilities, and Substance Abuse Services, shall study 30 Medicaid waivers, including 1915( b) and ( c) waivers, for all LMEs. In cases where 31 Medicaid waivers are not appropriate for an LME, the Department shall identify and 32 recommend strategies to increase LME flexibility to provide case management, 33 assessment, limit provider networks, or other innovative approach for managing care. 34 Not later than March 1, 2009, the Department shall report its findings and 35 recommendations to the House of Representatives Appropriations Subcommittee on 36 Health and Human Services, the Senate Appropriations Committee on Health and 37 Human Services, the Joint Legislative Oversight Committee on Mental Health, 38 Developmental Disabilities, and Substance Abuse Services, and the fiscal research 39 division. 40 SECTION 3.7.( a) The Secretary of the Department of Health and Human 41 Services shall develop a detailed plan for General Assembly review on its 42 recommendation to merge, consolidate or establish regional arrangements or consortia 43 of LMEs. In developing the plan the Secretary shall consult with LMEs to obtain input 44 on the feasibility and effectiveness of potential mergers, and the time frame needed to 40 General Assembly Of North Carolina Session 2007 fully implement the mergers, 1 regional arrangements, or consortia at the local level. The 2 Secretary shall provide the plan to the House of Representatives Appropriations 3 Subcommittee on Health and Human Services, the Senate Appropriations Committee on 4 Health and Human Services, the Joint Legislative Oversight Committee on Mental 5 Health, Developmental Disabilities, and Substance Abuse Services, and the Fiscal 6 Research Division not later than March 1, 2009. 7 SECTION 3.7.( b) The Secretary of the Department of Health and Human 8 Services shall not take any action prior to January 1, 2010 that would result in the 9 merger or consolidation of LMEs operating on January 1, 2008 or that would establish 10 consortia or regional arrangements for the same purpose, except that LMEs that do not 11 meet the catchment area requirements of G. S. 122C- 115 as of January 1, 2008, may 12 initiate, continue, or implement the LMEs' merger or consolidation plans to overcome 13 noncompliance with G. S. 122C- 115. 14 SECTION 4. Effective date. - This act becomes effective July 1, 2008. 41 GENERAL ASSEMBLY OF NORTH CAROLINA SESSION 2007 H D BILL DRAFT 2007- LNz- 313 [ v. 4] ( 4/ 16) ( THIS IS A DRAFT AND IS NOT READY FOR INTRODUCTION) 4/ 24/ 2008 11: 33: 16 AM Sponsors: Referred to: 1 A JOINT RESOLUTION TO AUTHORIZE THE LEGISLATIVE RESEARCH 2 COMMISSION TO STUDY CERTAIN MENTAL HEALTH COMMITMENT 3 STATUTES, AS RECOMMENDED BY THE JOINT LEGISLATIVE 4 OVERSIGHT COMMITTEE ON MENTAL HEALTH, DEVELOPMENTAL 5 DISABILITIES, AND SUBSTANCE ABUSE SERVICES. 6 Be it resolved by the House of Representatives, the Senate concurring: 7 SECTION 1.( a) The Legislative Research Commission may study the 8 involuntary commitment statutes in Chapter 122C of the General Statutes, in particular 9 G. S. 122C- 263( a), to determine if an individual lawfully ordered to undergo an 10 examination by a physician or eligible psychologist is being appropriately supervised to 11 protect the health and safety of the individual and others during the period of the 12 individual's examination. 13 SECTION 1.( b) The Legislative Research Commission may make an 14 interim report to the 2008 General Assembly, and shall make its final report to the 2009 15 General Assembly. 16 SECTION 2. The Legislative Services Officer shall allocate funds 17 appropriated to the General Assembly for the expenditures of the Legislative Services 18 Commission in conducting this study. 19 SECTION 3. This resolution is effective upon ratification. 42 |
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