NC mental health and substance abuse services failing, consultant tells state lawmakers

by Jordan Green

A consultant hired by the Department of Health and Human Services painted a distressing picture of North Carolina’s system of support for citizens struggling with mental illness and substance abuse problems in a report presented to state legislators on Jan. 10.

The state suffers significant gaps in its care for the mentally ill and the addicted, including a dearth of crisis intervention and community detoxification services, with the result that consumers land in emergency rooms, jails and state psychiatric hospitals far more often than they should. That was the message Christina Thompson of Heart of the Matter, a consulting group with offices in Michigan and Florida, gave members of a joint legislative oversight committee with responsibility for the state’s mental health, developmental disabilities and substance abuse services.

Thompson’s report, presented as a long-range plan for North Carolina, presents a troubling paradox: although the state ranks last in the nation for per capita spending on mental health it comes in first for admission rates to state psychiatric hospitals – at about double the national average.

“One of the things that we want to put right in front of you is that mental health and substance abuse services are under-funded,” Thompson said, adding that “North Carolina over-utilizes state institutions.”

Without directly challenging the state’s recently implemented plan to privatize mental health services, the long-range plan takes an understated swipe at that trend in governing.

“The system is growing haphazardly in a free market kind of way,” the plan states. “This will ultimately result in failed provider systems and providers who refuse to treat the indigent population…. Division monitoring and technical assistance requires additional work which cannot be effectively pursued with current levels of staff.”

The state’s over-reliance on institutionalization is matched by a poorly functioning patchwork of efforts to screen persons with mental illness and provide community-based support, Thompson told the legislators.

“You have a lot of people who are being seen, but they’re not coming back through the door,” she said. “You are basically serving more people, but you’re not providing an adequate dose of care. When you don’t provide an adequate dose of care, bad things happen. Your rate of institutionalization goes up. If you want people to stay out of emergency rooms and stay out of prison, then you need to increase your dose of care, which is the most expensive part of this. You need to do more screening in the emergency room.”

The long-range plan characterizes community detoxification accommodations as “negligible.”

“Substance abuse services are bad across the nation,” Thompson said. “They’re particularly bad in North Carolina.”

The full cost of funding services to provide consistent and effective care to North Carolinians who struggle with mental illness, developmental disabilities and substance abuse problems would be $2.7 billion, the long-term plan states.

Top officials at the state’s Division of Mental Health, Developmental Disabilities and Substance Abuse Services said they largely concurred with Thompson’s assessment. Legislators acknowledged that services for the mentally ill and those with substance abuse problems fall below adequate levels for some and are not delivered at all for others, but they balked at the price tag presented by Thompson and quibbled with her assessment of the severity of the state’s challenges.

“When we all saw that two and half billion figure we stuck our heads back in the sand because we didn’t want to hear it, but we need to hear it,” Nesbitt said. He added: “When it comes to that two and a half billion dollars, all other states aren’t measured against that utopian measure. It’s our job not to solve all problems with mental health, but to make some incremental improvements.”

At one point Thompson chided legislators for the state’s slow progress in investing in community detoxification centers and other community-based programs and continuing to rely on emergency rooms and jails to deliver services.

“My opinion is this is not a learning curve because you’ve been at this since 2002,” she said. “You ought to get it by now.”

As the committee heard, jail is not the ideal setting for treating mental health illnesses.

“We also hear from sheriffs that they get a lot of people with mental health problems because there’s nowhere else for them to go,” testified Eddie Caldwell, general counsel for the NC Sheriff’s Association. “Jail is not the best place to provide the help they need; the best place is on the outside.”

Caldwell said access to mental health services for pre-trial detainees across the state remains inconsistent, with some county jails providing no services at all.

Sen. Martin Nesbitt, a Democrat from Asheville who co-chairs the committee with Rep. Verla Insko, said legislators have received reports of local detention facilities facing difficulties.

“They’re saying their jails are full, and they’re not getting any help,” he said. “We hear from a number of court officials that there’s nothing to help pre-trial detainees. We heard yesterday that some jails won’t even fill a prescription.”

Nesbitt said he believes the long-range plan overstates some of the state’s problems. The legislature allocated funding for emergency mental health crisis intervention in the last session, he said, adding that the money may not have been applied yet and the improved services would not be reflected in the report.

He also cast doubt on the long-term plan’s conclusions about the scope of needs in the state’s mental health, developmental disability, and substance abuse populations. Thompson acknowledged that her assessment of service levels was made without complete data because counties are not required to report services paid for with their own funds.

“When you see how bad it looks, it may not be that bad,” Nesbitt said. “A lot of local dollars are spent, particularly in Mecklenburg County.”

Leza Wainwright, deputy director of the mental health division, said that without the legislature creating a new law requiring full reporting counties are unlikely to treat it as a priority. She added that county funding only accounts for about 6 percent of the state’s overall expenditures on mental health, developmental disabilities and substance abuse services so she does not believe the lack of complete data undermines the long-range plan’s credibility.

An exception is the state’s handful of densely populated urban counties, Wainwright added. Mecklenburg County matches the state’s funding about one to one. Funding commitments by other urban counties fall in the range of 10 to 20 percent.

In one area, Thompson’s report gave the state a passing grade. In contrast to mental health and substance abuse services, in which the long-range plan found services were respectively among the lowest in the nation and practically nonexistent, the percentage of people treated for developmental disabilities was deemed above average. That finding raised protests among parents, consumers and service providers, many of whom attended the committee meeting to express their objections to a recent rule change announced by the division.

“The statement that developmental disabilities is adequately funded gave some of us who work in developmental disabilities a stab in the chest,” said Julie Ewing, executive director of Ralph Scott Life Services in Burlington. “It’s very difficult to serve more people because people are aging. People with developmental disabilities are living longer, thank God, because we love them… but our capacity is diminishing.”

Michael Moseley, director of the mental health division, echoed Wainwright’s support for the long-range plan.

“A lot of what’s in this report validates what we already knew,” he said. “Most importantly it proposes to us a mode moving forward to have a more rational way of projecting what we need. In the past it’s been quite subjective.”

Local developments

In Guilford County, developments in service delivery both hew to and pull away from the assessment provided by Thompson. The Guilford Center, the county agency responsible for delivering mental health, developmental disabilities and substance abuse services, privatized all services except psychiatric care and crisis intervention on Dec. 29. Deputy Director Ida Glasgow said on Jan. 9 that 650 consumers formerly served directly by the county agency have been placed with outside service providers, and 35 others have refused services.

The privatization resulted in the agency laying off 105 employees. Exit interviews indicate that 81 of them had found other employment, returned to school or retired. The rest had not yet found employment or their status was unknown.

Breaking from the state’s pattern of neglecting community detoxification services, the Guilford County Commission voted in November to fund a $2.7 million substance abuse center on Wendover Avenue. The county has had no treatment program in place since the nonprofit Alcohol & Drug Services suspended operations at the same location. Mental Health Services Coordinator Tana Wirz said Alcohol & Drug Services is currently operating a halfway house there, but has agreed to vacate the premises to allow the Guilford Center to contract another substance abuse provider.

“It’s big, important work, and we want to do it well,” Wirz said.

Division revisits controversial rule change

Many of the spectators in the gallery attended the meeting specifically to confront the division on an unpopular rule change announced in October that promised to prevent parents who are the legal guardians of severely disabled adult children from acting as their paid caregivers, and to prevent parents from working in that capacity for more than 40 hours a week. Under pressure from parents and advocates the division had already agreed to postpone implementation of the rule change from Feb. 1 to April 1. Mental Health Programmer Vivian Leon disclosed to YES! Weekly on Jan. 3 that the division decided to reconsider the rule change.

A week later at the legislative oversight committee meeting, the division announced that implementation of the rule change would be indefinitely postponed.

“We put in writing that the new date is April first,” Wainwright told YES! Weekly on Jan. 10. “If we haven’t gotten it right by April first, then we’ll extend the implementation date still further.”

She added: “We still are concerned, but we’re looking for other ways of addressing the conflict of interest [between legal guardianship and paid care-giving]. One possibility might be that perhaps someone else besides the legal guardian and paid caregiver could sign the person-centered plan. We’re also looking at ways to make the forty-hour cap more flexible. People should not on average be working more than forty hours, because people need rest.”