08/19/07 — Wrestling with mental health reform: A whole new world

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Wrestling with mental health reform: A whole new world

By Matthew Whittle
Published in News on August 19, 2007 10:09 AM

Some people say North Carolina's mental health system is broken and that the old methods worked better.

Others say the reforms set in motion in 2001 just need more time to work -- that after all, it wasn't until July 1, 2006, that the local mental health centers finished the process of diverting all of their services out to private providers.

But most agree that, for better or worse, the mental health system has been radically changed in recent years -- beginning on the local level where people receive services.

"We are now more of a management agency," Eastpointe Director Ken Jones said.

Prior to reform, mental health services were provided by county centers, which served as one-stop shops for almost all of people's mental health needs, providing out-patient care, such as psychiatric services and case management.

Today, they no longer provide those services. Instead, Eastpointe is the local management entity (LME) for Wayne, Lenoir, Duplin and Sampson counties, serving more than 9,000 people -- nearly 3,500 in Wayne alone.

"Our job has changed. It's totally different. We are no longer a direct provider," Jones said. "We are contracting out everything. We are a manager of services. Our job is to provide a network of providers and monitor those providers."

The move toward mental health reform began on the federal level in the late 1990s and has continued across the nation.

In North Carolina, the reforms began in earnest in 2001 with the state General Assembly giving Department of Health and Human Services Secretary Carmen Hooker Odom the authority to plan the system overhaul.

In preparation for the reforms, studies found that North Carolina had too many public mental health centers and too many people using the state's psychiatric hospitals.

To fix those problems, Odom ordered the state psychiatric hospitals to begin to shrink and the consolidation of the state's nearly 40 mental health centers, so that each of those left would end up covering at least 200,000 people. Today, Eastpointe covers a population base of about 290,000.

Then, in July 2006, she ordered the LMEs to divest themselves of all their services and contract those out to approved private providers.

Today, Eastpointe has endorsed more than 200 providers -- for mental illness, substance abuse and developmental disabilities services -- across the four counties. Some of those offer more than one service and operate across the whole region, while others stay in their base communities.

"It's a pretty big network," Jones said. "There's a wide range of providers out there."

But for many people, especially those without insurance or on Medicaid, Eastpointe is still the gateway.

When a person needs help, the road to getting it begins with a visit, or more often, a phone call to Eastpointe. From there, a team of clinical technicians identifies that client's needs and then schedules an appointment with the appropriate provider.

Eastpointe also works with state institutions such as Cherry Hospital to create aftercare plans for patients re-entering the community.

The agency's final role is one of customer service, handling complaints and grievances from both clients and providers.

Still, Eastpointe Clinical Director Dr. Jonathan Barnes admitted that there are some people who don't receive the services they need, whether it is because they are unfamiliar with how to access the new system or because they are unable to get the right help once in it.

"There is a population that's not getting served," Barnes said. "They are falling through the cracks, and they're showing up in the emergency room and in the jails."

He also cited the growing number of people being committed to state psychiatric institutions for short-term, in-patient care. Across the state, he noted that there's been an 83 percent increase in psychiatric hospital admissions since the mental health centers were closed.

"We have seen our admission numbers increase," said Jack St. Clair, director of Cherry Hospital. "We have experienced a significant increase in the number of people referred here for services, and that has really put a large burden on our ability to provide good patient care."

It's a phenomenon that's exactly the opposite of what was supposed to happen. And despite plans to increase the size of Cherry and consolidate Dorthea Dix and John Umstead hospitals, it's a problem that will only grow worse as the number of public facility psychiatric beds declines to 1,153 across the state over the next few years.

The results of that squeeze are already being seen at Cherry, where, St. Clair said, there have been days when their 90-bed adult acute care unit has had more than 120 patients.

Because of those high numbers, the average stay has become eight days, and a mandatory cap has been placed on all transfers once the hospitals hit their bed limit -- a move that is placing a strain on regular emergency departments.

"It (mental health reform) forces us to do our best to stabilize the patient and get them back in the community as quickly as possible," he said. "For most patients (eight days) is a sufficient amount of time if they can get hooked up with a service provider in the community."

But within 30 days, there is a 9 percent re-admission rate.

"We think that's too high," St. Clair said. "And it happens either because (the patients) don't follow up, they have a hard time accessing appointments, they stop taking their medications or for a whole host of other reasons."

But the bottom line, Eastpointe officials said, is that few people were prepared for the consequences of the reform process

"We just didn't have in place the infrastructure so that we could just close down our centers and the private providers pick it up," Barnes said. "When divestiture occurred, there was an expectation that there would be community providers to pick up the patients and there wasn't enough.

"But we are doing the best we can and if we find a client has fallen between the cracks, we do everything we can to make sure that client gets services."