Thursday, December 16, 2010

House Budget Update Dec 15

The North Carolina House got an early start on budget considerations this week.  The briefing started with an update on the state's General Fund, an overview of the 2010-11 budget spending and revenues, a briefing from Governor Perdue and a presentation from the Commerce Department.  I was only present for about half of the meeting because I needed to attend another committee meeting, but my notes from what I heard, including Governor Purdue's presentation are below.

General Fund Update
A look at the average make-up of the General Fund over the last 10 years:
  • Personal Income Tax 52.6%
  • Sales & Use Taxes 27.2%
  • Corporate Income 5.8% (volatile)
  • Franchise 3.2%
  • Insurance 2.6%
  • Other taxes 3.4% (e.g., tobacco, alcohol, estate, etc.)
  • Non-tax and transfers 5.3%
Collections through November are meeting the $7.5 billion target but it is a little early to estimate revenues - right now revenues may be a little more than estimated ($700 mil growth).

Recent good news/bad news:
  • Good: unemployment rate declining, consumer confidence increasing, existing home sales increasing, withholding and employment modest growth, total personal income up .8% (was down 2.8% this time last year), sales and use tax increasing (on par with collections level of FY 2005-06); economic conditions gradually, slowly improving
Governor Perdue's Remarks
The governor discussed the need to define the core missions of NC - investments in future; future workforce through strong education; services that make NC safe and healthy - boils down to jobs and stable economy. 

The governor asked the legislature to take 3 steps to transform how they do business as we focus on recrafting and redistributing services: 1) limit length of time they are in session - 90 days in a long session, 45 in a short session (suggestions taken from bills filed last year), costs $50K per day, $1 mil per month.  Will save money and work with efficiency.  2) Pass voter empowerment act that would create an independent bipartisan redistricting commission. 3) The legislature should become transparent and accountable.  Review public statutes that apply to the legislature and make consistent with laws related to other state agencies.

State Budget Overview and Preliminary Estimate of FY 2011-12 Budget Gap

  • We are facing the ARRA cliff
  • 15 states have new budget gaps since beginning of 2010-11
  • Looking back for NC: $4.6 bil gap in 09-10, $4.8 in 10-11
  • Preliminary availability for 2011-12 - $18.2 billion, adjusted for nonrecurring items $21 billion
  • Needs for growth in 2011-12 - state retirement system contribution, state health plan, school enrollment growth, $200 mil increase in Medicaid
  • General Fund Budget - dollars in HHS, JPS, Education = 2010-11 18.9 billion.  Medicaid (not HHS as a whole), Education and Justice & Public Safety = 76%
  • Public schools - given lots of flexibility in making cuts (recurring).  Opportunities for change - class sizes, optional spending (salary supplements and capital), review role and number of non-instructional staff; constrained by constitution and court cases on SBE.  $3 bil goes to classroom teachers, which directly relates to class size.  Have 90K public school teachers now.
  • Higher Ed - high growth in enrollment, cut $170 mil from UNC, allowed tuition increase, increased financial aid, funded community college growth, management flexibility cuts in community colleges, increased tuition (still one of lowest priced in country).  Opportunities for change: tuition, target specific programs for cuts, community colleges could move toward higher income programs like allied health,but must take into account accreditation standards and maintenance of effort requirements of federal funds.  For universities, over the past ten years, their budget has increased 48% and enrollment by 38%.
  • Medicaid - recent actions: assumed county share of costs, reduced selected provider rates, reformed and reduced costs in certain services, in particular Community Support and Personal Care Services.  Opportunities for change: optional services, new payment and performance strategies; constraints - legal entitlements, almost impossible to reduce eligibility, healthcare reform, counter-cyclical program.
  • Corrections - 7% of General Fund, 3.9% average annual growth, prison personnel 66% of budget.  Have closed 7 prisons, eliminated 1,033 positions.  Opportunities for change: reform sentencing policies and laws (misdemeanants and habitual felons), reform probation policies/procedures.  Constraints - shortage of prison beds, costs for use of local jail beds mounting ($40/day - over $1.8 mil/year).
  • Employee Compensation and Benefits - General Fund supported payroll exceeds $11 bil, education employment is 81% of that.  Opportunity for change: look at minimum benefit eligibility requirements, alternative benefit plan designs.
  • Owe 2.35 billion in unemployment debt to feds.

Monday, November 29, 2010

FCC reopens NPRM to refresh pending record on Closed Captioning

The FCC, via The Consumer Government Affairs Bureau, is seeking to refresh the record concerning standards for closed captioning that were stated in Notices of Proposed Rulemaking in 2005 and 2008. Due to advances in technology, the FCC hopes to gain a better understanding of the issues and how they relate to pending proceedings.  More than five years have passed since the Commission sought comment on several important matters relating to the quality and implementation of closed captioning of video programming, and a variety of changes in the closed captioning landscape warrant a refresh of the record created in response to that proceeding. For example, the benchmarks for 100% captioning of nonexempt new English and Spanish language programming have passed, the transition to digital television occurred on June 12, 2009, and advances in captioning technology and availability have occurred. The Bureau also believes that a refreshed record will help it to better understand the issues that were raised for comment in the 2008 Closed Captioning Declaratory Ruling, Order and NPRM. Because, in the 2008 Closed Captioning Declaratory Ruling, Order and NPRM, the Commission adopted requirements for video program distributors to make contact information available to consumers, and requirements concerning the process for filing and handling closed captioning complaints, the Commission does not seek to refresh the record with regard to those matters.

For more information about commenting, please refer to the Federal Register Notice here.  Comments were due on November 24, 2010 but Reply comments may be submitted on or before December 9, 2010.

Wednesday, November 24, 2010

Proposed State Budget Cuts

While we have a really long way to go in the budget process this year, the discussion of what to cut has begun.  Governor Perdue recently asked all state government departments to provide her with budget scenarios that include 5%, 10% and 15% cuts.  Budget documents are available on the TogetherNC website.  Below are some highlights.

Health and Human Services (HHS)

HHS proposed cuts of approximately $246 million, $402 million and $730 million from its $4.9 billion budget.  Please note that the proposed cuts I reviewed did not include any proposals to cut funding to the Division of Medical Assistance (DMA).  As DMA oversees all Medicaid funded services, this is a very big open question.

$135 million in proposed cuts to the Divisions of MH/DD/SAS and State Operated Healthcare Facilities which includes:
  • $20+ million/$24+ million/$41+ million reductions to services provided statewide through contracts with LMEs, including reductions in LME Cross Area Service Program (CASP) funds.  The reduction was calculated on a pro rata basis excluding crisis services funding.
  • $1.7 million reduction to LMEs for system management.
  • $20 million/$26 million reduction to LME Systems Management - counties would pay a portion of the non-federal share in varying amounts depending on the size of the LME, with the percentage decreasing as LMEs become larger ending at 15%.  The purpose is to incentivize counties and LMEs to achieve economies of scale and participate in the 1915(b)/(c) managed care waivers.  The state does not pay separate LME Systems Management fees to LMEs participating in the waiver because administrative costs are paid as a percentage of the service funds.
  • $523,638 reduction to LMEs to fund School Based Child and Family Teams.  This proposal does not eliminate the Child and Family Teams altogether, but eliminates additional funding to 12 LMEs to place school nurses and social workers in low-wealth schools. (DSS has a companion proposal to eliminate the LME funding).
$9 million in proposed cuts to the Division of Aging and Adult Services which includes:
  • A reduction of $2 million to eliminate the the State Adult Protective Services (APS) Fund, which pays for APS social workers in 52 county departments of social services to carry out their duties, including evaluating reports of alleged abuse, neglect and exploitation of adults with disabilities.
  • $875,000 reduction to eliminate the State Adult Care Home Specialist Fund which funds the state share (25%) for these specialists who help assure that adult care homes meet state licensing standards and provide care to meet the residents' needs.   
  • $500,000/$2.4 million reduction to non-Medicaid community based services, including in-home personal care, in-home respite care, home delivered meals, and medical transportation.
$7.6 million in proposed cuts to the Division of Central Management and Support

$67 million in proposed cuts to the Division of Child Development which includes:
  • $9.4 million/18.8 million/28.2 million reduction to Smart Start.
  • $1.3 million reduction to More at Four.
$846,322 and $1.8 million in proposed cuts to the Division of Health Service Regulation which includes:
  • Eliminating 21 vacant positions ($846,322).
$31 million in proposed cuts to the Division of Public Health which includes:
  • $9 million/11 million/1.2 million reduction to School Health Services to eliminate School Nurse positions.
$11 million in proposed cuts to the Division of Social Services

$8 million in proposed cuts to the Division of Rehabilitation Services which includes:
  • $2 million reduction to funding for basic support case services that assist individuals in obtaining and retaining employment.
  • $284,502 reduction to eliminate the remaining recreational therapist positions within Independent Living Services.
  • $1.7/3.9 million million reduction to aid and public assistance through Independent Living Services , which prevents institutionalization and assists with deinstitutionalization.
$2.5 million in proposed cuts to the Division of Services for the Blind, Deaf, and Hard of Hearing which includes:
  • $1.3 million/419,456/838,911 reductions to case service funds in the Medical Eye Care Program.
Department of Public Instruction (DPI)

DPI proposed cuts of 5% and 10%, amounting to $396 million and $793 million in reductions, which include:
  • The elimination of 69,524.5 classroom teachers ($239 million/292 million proposed reductions).
  • $24 million/29 million reduction to Children with Special Needs (a 3.4%/4.2% reduction) - there is no detail, so we don't know if this is a per pupil reduction or reduction of particular programs.  There have been reductions in the past two years that were due to a declining number of children with special needs.
  • $202 million/394 million reduction for Teacher Assistants (a 38% and 75% proposed reduction!).
  • $4 million reduction to More at Four.
  • 5 and 10% reductions to the Residential Schools ($1.6 million/3.3 million).
Department of Juvenile Justice and Delinquency Prevention (DJJDP)

DJJDP proposed cuts of $2.4 million which include:
  • $1.3 million reduction in Clinical Services, including eliminating up to 3 Psychological Program Managers, a 10% and 15% reduction in psychological services contracts, and the closing of Camp Woodson.
  • $265,447 reduction in Community Services, including elimination of funding to Project Challenge and the Juvenile Assessment Center, and reduction of the Community Services motor fleet/travel budget.
  • $419,502 reduction for Education Services which will eliminate 6 educator positions.
  • $265,428 reduction in Juvenile Court Services.
  • $137,989 in Youth Development
Department of Corrections (DOC)

DOC proposed cuts of $19 million and $28 million which include:
  • $2 million/2.1 million reductions to the Administrative Division, including the elimination of funding for Harriett's House, Our Children's Place, Summit House and Women at Risk.
  • $4.4 million/5.2 million reductions to the Division of Alcoholism and Chemical Dependency Programs, which will eliminate Evergreen Substance Abuse Treatment Services and Mary Frances Substance Abuse Treatment Services.
  • $600,943/776,258 reduction to the Division of Community Corrections.
  • $12 million/20 million reductions to the Division of Prisons, including closing Haywood Correctional.
Again, this is just the beginning and we have a very long road to go with the budget, but this gives an indication of where the departments think the cuts should be made.

Monday, November 22, 2010

NC Commission for MH/DD/SAS Meeting on Thursday, November 18, 2010

The NC Commission for MH/DD/SAS met on Thursday, November 18, 2010.  The agenda for the meeting is posted on the Commission website here.

Luckey Welsh, Director of the NC Division of State Operated Healthcare Facilities (DSOHF) addressed the Commission:

• Funds have been allocated for education and training in facilities – doing an assessment throughout the facilities asking what needs are beyond what is already being done. Started doing specialized training for managers and supervisors.

• Residential Schools Transfer – 156 teachers, 8 schools. Need to make sure teachers have their licenses, evaluations. Kathy Roades from OES will work for DSOHF to oversee education in the state facilities (psych hospitals and DD Centers).

• Walter B Jones undergoing Joint Commission survey soon.

• Blackley moving into new building in January – a lot of difficulty getting completed.

• DD Centers – TRAC program at Murdoch has 6 beds. Waiting list 6-12.

• O’Berry converting from ICF-MR to SNF. 3d cottage renovation on hold.

• Long Leaf converted a nursing unit into “Main Street" - a grant funded project that provides the residents with a main street type environment.

• Whitaker did outstanding on Joint Commission survey and received accreditation.

• New Cherry schedule to open January 2013.

• Broughton groundbreaking still scheduled for Spring.

• JIRDC incident: in a particular cottage, there was an individual who was being investigated, thought incidents were accidents until someone came forward and said they weren’t accidents. Several people in the cottage knew what was going on. In last quarter, only 4 instances of physical abuse. Each dealt with swiftly with the zero tolerance policy.

• Insko visit to Dix – No safeguards, administration not informed, policies not followed. She was not removed from the hospital. She met with everyone she wanted to. The next day, 4 representatives, including Insko, toured the facility. Secretary met with the representatives then as well.

• Delays of Care – Mr. Welsh believes do not have enough beds. State closed 450 beds, community closed 200 beds. Demands increasing. Laura White spoke about the delays as well. With Dix closure, charged with maintaining capacity and to not increase delays. (Handout with average patients on delay) Not tracking number of people presenting to ERs. Hospitals are on delay almost every day, but not every unit – i.e., a geriatric might be admitted right away, so we don’t know # of people who present and are admitted right away. Average wait is 51 hours. Commission member Don Trorbrough spoke about how patients should be treated during their wait. Chaining someone to the bed is not the way a person should be treated. Magistrate education program started in Catawba to educate on options short of IVC to state hospitals. Also working with Mobile Crisis Teams to try and avoid in-patient at state hospital if appropriate. ERs feel hamstrung by EMTALA. They are collecting data from local ERs on who these folks are. 50-58% coming into ER have no connection to mental health system. City police approach differently than sheriffs. In some areas, MCTs are working with local law enforcement for back-up when they have safety concerns. Victoria Wit in Sandhills has an ER training on array of services, etc. LME should be contacted after 24 hours, and DMH should be called after 48 hours in ER (this started in past two months). Pitt has a 10 bed MR/MI diversion unit. DMH is checking up on treatment providers who are supposed to be first responders to ensure they are available 24/7.

• Laura White spoke about cost reduction matters at Dix – in the process of transferring current patients to Cherry and CRH, to be done by end of December. Forensic Minimum, child outpatient and outpatient clinical research program will remain on Dix campus. They started with patients in long-term unit – 11 CRH, 24 Cherry – all transferred by earlier this week. Transfers to Cherry over 6 weeks, in very deliberate manner. Transferring people with significant behavioral needs to CRH now. Sandhills and Wake admissions will stop to Dix on Dec 3 at 8 pm, rolls over to CRH. Folks on Dix admission unit will be discharged over the next two weeks. Anyone remaining on Dec 20 will be transferred to CRH. 99% of staff (all but 3) have been offered positions at CRH. There were a few supervisory positions where individuals weren’t offered the same job. Established a priority in hiring at all facilities. Cherry is hiring the most so far, don’t know total number, in 30 range. Our system will be stronger with highly qualified Dix staff in other hospitals.

Steve Jordan, Director of NC Division of MH/DD/SAS:

• CABHA – biggest driving issue for them right now. Transferring 19,000 people from non-CABHA to CABHA agencies. 8/31 deadline to have application processed to continue services after 12/31. 300 applications came in the last two days. Processed all but 20 of those. In September issued benchmarks for transition for those who did not qualify or did not apply. By 10/15, those agencies had to submit a transition plan to local LMEs. LMEs review for appropriateness, 77% deemed appropriate. Of those denied, some providers just moved everyone over to outpatient therapy. Over the whole process 900 applications processed for over 600 agencies (3 chances to get attestation letter through desk review). 20 agencies still under consideration.

o There was a question from a member from Cumberland County - only 1 CABHA showing approved in Cumberland County.  Jordan said 96 now approved statewide – 4 now approved in Cumberland County (can be satellite offices of CABHA HQ’d elsewhere). Cumberland is well positioned because just went through the major transition with all of their level iii and iv group homes.
• 1915 (b)/(c) waivers – Mecklenburg has a 1 year extension. Looking to see if any other programs interested in going forward sooner. Need to establish momentum and move these forward. Using Mercer as external review to set tasks and timeline for Western Highlands.

• Budget - At DMH, each 5% cut = 25 mil in state services. 15% cut = $75 mil less in state services. Even if optional mental cut, DMH still responsible for serving all those cut from Medicaid. Starting to look at total system redesign, talking to other states. There are workgroups being held to determine what the core services need to be statewide. Any money that comes out of facilities will disappear, it won’t go to the community. Commitment to keep community crisis on the table. We must see collaboration to get through this.

• Corne gave a speech about Olmstead and ADA pushing people into least restrictive environment. Push to put person into their own home and that is not sustainable (his opinion). The system doesn’t have control over because federal government pushing this. There will likely be a lot of lawsuits. Steve responded that from the federal level, not having enough money to do it is not the answer.

Waiver Requests:

• 10A NCAC 27E .0107 Training on Alts to Restrictive Interventions – Rule addresses staff competencies for alternatives. They are asking that licensed professionals attest to their competency and not have to go through the training. The reasoning is that licensed individuals have to adhere to requirements of their licensure boards.  A thorough discussion ensued among the members of the Commission.  Members made different points and had differing views of the matter: some said that licensed professionals are not taught in a graduate program how to physically manage behavior; there is nothing in the attestation to say that the person’s training addresses restrictive interventions, anything to ensure that the professional is doing this by free choice – need to include documentation. John Owen moved to not approve waiver – motion failed. 2d motion – waiver approved. Copy of license, training certificates will be requested as attachments to the attestation.

• Lynn Jones, oversees DWI services for state – they authorize private providers to provide DWI services – want more time to review applications. Now only 20 business days, asking for 60 business days (got a waiver in May); it’s on the draft rules list but hasn’t gone to public comment yet, so asking for an extension of May waiver. # of applicants increasing – a lot of CABHA applicants and those not approved by CABHAs. Waiver granted.

Rules Committee:

• No October meeting. Prison rules sent over to DOC for review, done pursuant to G.S. 148-19. They got a response just this morning.

• 4 rules up for repeal – 27G .2200 withdrawn because of transitioning concerns for these facilities.

Advisory Committee

• Report on meeting held in October – CABHA, workforce development, veterans services with focus on TBI.

Rules to be Repealed, Amanda Reeder:

• 10A NCAC 27B .0600 Early Childhood Intervention Services for Children with or at risk of developmental delays, developmental disabilities or Atypical Development and their Families – passed in 1979. Rulemaking authority transferred to Div of Public Health, which has already issued rules related to these services. This repeal shouldn’t affect any services. Motion to repeal passed.

• 10A NCAC 27G .2400 Developmental Day Services for Children With or At Risk for Developmental Delays, developmental disabilities or Atypical Development and their Families. S.L. in 2009 amended authority – rules given to child care commission. They published rules effective July 1, 2010. Child Care Commission coordinated with DPI and DMH to draft. Motion to repeal passed.

• 10A NCAC 27G .2500 Childhood Intervention Services for Children with or at risk of developmental delays, developmental disabilities or Atypical Development and their Families. Motion to Repeal Passed.
Marcus Lodge, AG’s Office re Governor’s EO 70 re Rules Modification and Improvement

• Office of State Budget and Management already reviewing current rules and should be inviting public comment soon – the web portal has been established. OSBM will review comments as they come in and then send out to the agencies. Agencies will do a report each year.

• For new rules, OSBM will look at new rules as well to make sure cost benefit analysis done correctly, timely, etc. (all before publication).

Tracy Hayes, DMA AG, CABHA Rules Authority

• State Plan defines optional services, all CABHA services are optional.

• S.L. to implement state plan amendments give authority to issue temporary rules

• Reviewing comments now and will submit rules to RRC

Rule Update, Denise Baker:
• Provider endorsement rules pending for quite some time – initially the Secretary had rulemaking authority, then went to the Commission. Rules have undergone a number of changes. It is now pending (suspended) further revisions to the policy. Policy is in the final version so rulemaking should resume soon.

• DOC rules – DOC gave comments today. Next step should be January Rule Committee meeting to consider DOC comments.

• NCI QA rule – objected to by RRC.

• Several rules in fiscal note process

• Rule related to electronic supervision – waiting for new Medical director to draft.

• TBI rules – pending development by content experts – maybe some language will be generated by the advisory subcommittee.

• Smoking rule expired because it has been more than a year. The pilot study is nearing end – data collected and now analyzing. Commission will need to decide if they want to resume work on the rule.

Thursday, November 18, 2010

North Carolina Senate Leadership

The Senate Republican Caucus has nominated Sen. Phil Berger as its candidate for Senate President Pro Tem, and has chosen Sen. Harry Brown as Majority Leader.

Wednesday, November 17, 2010

Disability Rights NC Opposes Proposed Community College Change to Admissions

Back in September, the State Board of Community Colleges published proposed changes to the rule related to admissions. The proposed language would allow community colleges to adopt policies refusing admission "if it is necessary to protect the health or safety of the applicant or other individuals."  The proposed language does not detail how such a determination will be made, nor does it mandate notice and appeal of the decision by the applicant.  In response, Disability Rights NC, along with the ACLU of North Carolina, the Arc of North Carolina, the Autism Society of North Carolina, and the National MS Society in NC, filed written comments and commented in person at a public hearing to voice our opposition to the proposed rule amendment.

We have grave concerns that the proposed language runs afoul of the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act (Section 504). Additionally, we object to the lack of procedural protections provided.  Our full comments are available on our website here

New information available online for the 2010 ADA Standards for Accessible Design

The Department of Justice has assembled an official online version of the 2010 ADA Standards for Accessible Design (2010 Standards) to bring together the information in one easy-to-access location. You will remember that the Department of Justice recently revised the Title II and III regulations (published in the September 15, 2010 Federal Register).
Remember that if the start date for construction is on or after March 15, 2012, all newly constructed or altered State and local government facilities must comply with the 2010 Standards.

Before that date, the 1991 Standards (without the elevator exemption), the UFAS, or the 2010 Standards may be used for such projects when the start of construction commences on or after September 15, 2010.

For more information about the New ADA Title II and III Regulations and these ADA Design Standards, the archived version of the Access Board and DOJ joint Webinar held on September 2, 2010 has finally been posted at:

Sunday, November 14, 2010

Notes from the MH/DD/SAS Legislative Oversight Committee Last Week

The Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities and Substance Abuse Services met last Tuesday, November 9th.  Co-chair Representative Insko presided over the committee meeting.  Her senate co-chair, Senator Nesbitt, was absent.  All of the handouts from the meeting are available on the committee website here.   Highlights from the meeting are below.

Secretary’s Comments

Secretary Cansler gave an update on the budget and the closure of Dix (very similar to those made to the Governmental Operations subcommittee - see previous post here). He discussed the Dix closure plan (available here) which was provided to all of the members the week before. He also talked about expanding the 1915 (b)/(c)waivers and measures the department will be seeking in the coming session. Mecklenburg LME will be delaying their implementation of the 1915(b)/(c) waiver by a year. Smokey LME is interested in pursuing the (b)/(c) waiver as well. He also noted that counties are still interested in joining PBH but the concerns about non-contiguous counties joining as one LME remain.

Expenditures and Utilization Tracking Update

The handout is on the website here.  Of particular note, Intensive In-Home for children is up, Day Treatment for children is down, Multisystemic Therapy is up, Community Support Team is down 28%, Assertive Community Treatment Team is up, Psychosocial Rehabilitation is up (200 more adults per month),  I/DD Targeted Case Management is down (CAP and non-waiver).

LME Presentation on TASC (Treatment Alternatives for Safer Communities)

There is a handout on website here.  East Carolina Behavioral Health presented.  The program operates under a Memorandum of Agreement between DHHS, the Department of Corrections and the Administrative Office of the Courts regarding the offender management model to ensure all agencies are connected.

Three-Way Contracts Update

The handout is on the website here.  Of particular note: The three-way contract beds are paid at a bundled rate of $750/day, which compares to about $1100-1200/day in state hospitals.  The hospitals with these contracts have  priority in transferring patients to state hospitals.  The total funding for these contracts is now a little over $29 million.  This is helping to stop the trend of closing community inpatient beds.  The LME Contract Responsibilities include authorization of admissions, collecting patient data, facilitate discharge planning, and paying hospitals.  Last year 100% of the funding allocated was used – 26,829 bed days purchased, 98 beds across the state. 

There are 20 contracts with 1 pending currently, added Pitt Memorial, Western Highlands did not renew 1 contract because of low utilization.  They needed to put additional money into existing contracts this year because of utilization, projecting 38,829 bed days, projected beds at 75% utilization=142.  The handout shows allocation by hospital and region. 

State hospital stays of 7 days or less have decreased to 27% of total (in part because of reduction in admissions).
At the start, 22 LMEs had these contracts without the state contract and funding.  There is a need to shore up these relationships as well. There is still $13-14 million in LME funded contracts, Mecklenburg being a good example (they use county funds).
ICF-MR Cost Analysis and Comparison with CAP-MR/DD Services

The handout is on the website here.  DMH/DD/SAS Director Steve Jordan presented a comparison of NC's ICF-MR services which include the state developmental centers (3), community ICF-MRs (327) and CAP-MR/DD services offered statewide.  Of particular note:
  • Must be 18 years or older to be admitted to developmental center except for time-limited programs for children
  • Average of 1517 people served in state DD Centers last year
  • In NC, 30% of recipients live in ICF-MRs, 15% nationally
  • 70% in waiver in NC, 85% nationally
  • The handout details the total expenditures in state, community ICF-MRs and waiver services and cost per recipient (includes soc security, etc.) – the level of acuity in state facilities varies – generally those recipients are older, profound, feeding tubes, partial or total assistance with dressing, and nonverbal.
  • Tennessee is going to close a large DD Center – moving people into community ICF-MRs
Update on CAP-MR/DD Tiered Waivers and Waitlist

The handout is on the website here.  Rose Burnette provided a general update on the status of the CAP-MR/DD waivers.  The Comprehensive Waiver is now serving 9798 and the supports waiver is serving 853 recipients.  Last year NC spent $493 mil in waiver services and $112 mil in other Medicaid services for Comprehensive Waiver recipients; and about $2.5 mil in waiver services and about $2.5 mil in other Medicaid services for supports waiver recipients.
With regard to the support waiver, they are doing trainings on the supports waiver this month.  They are estimating serving 126 participants on self- direction – these costs are outside of the waiver costs and are not in individual budget, (case management outside of waiver as well because it is Medicaid funded and not a waiver service) average cost $4000 per participant.

They are planning major revisions to the comprehensive waiver. They want to create a new Community Intensive Waiver – for those with the highest behavioral and medical supports needs. There will not be banding within a waiver – need to have a very specific plan for determining need and level of care within a band. They will have stakeholder workgroup meetings and then larger public forums to seek input.  The plan is to submit the new waivers in March or April to get approved in time for implementation (expire 11-1-11).

Waiting List Update: 8191 people are potentially eligible for CAP-MR/DD: 4,481 people waiting for residential (independent, group home); 4800 not receiving any service; 1785 waiting for support to work; people in Adult Care Homes may be on this list.  In the short term they continue to use a spreadsheet.  They are evaluating the feasibility of a web-based solution, and are meeting next month with LME IT staff to talk about possibilities. 

Res Supports Level V Update: expected staffing is 1:1 24 hours per day, plus specific experience and supervision;  PAG reviewed twice, last time in October; will be posted for 45 day public comment, review and revise as needed, hoping to implement early next year.

Friday, November 12, 2010

Find out who is representing you!

       Due to the results of last week’s election, North Carolina’s General Assembly has changed. It is important to remain aware of who your representatives are so, your voice can be heard. You can find out who will be representing you  by using the following link,

Friday, November 5, 2010

Changes at the Legislature Next Year, But For Now We Keep On Rolling

Unless you are really good at staying away from all media (in which case you probably won't be reading this), you know that we are going to see a change in leadership at the North Carolina General Assembly next year.  The Republican party will now hold a majority in the House and the Senate (the Democrats have long held a majority in both chambers).  For people with disabilities, I believe change is opportunity.  The leadership that has eviscerated mental health services and kept the system for people with developmental disabilities in constant flux no longer holds power.  We have a real opportunity to put forth cost effective solutions that will lead to better lives for all people with disabilities in North Carolina.

But, for now, we keep on rolling with the current members and committees until the new regime is sworn in.  So, as an FYI, here is the agenda for next week's MH/DD/SAS Legislative Oversight Committee meeting.  Remember, audio is available through the legislature's website,
Joint Legislative Oversight Committee on

Mental Health, Developmental Disabilities, & Substance Abuse Services


November 9, 2010 10:00 A.M.; Room 643, Legislative Office Building

Representative Verla Insko, Co-Chair, Presiding


Welcome and Opening Remarks Senator Martin Nesbitt, Co-Chair

Representative Verla Insko, Co-Chair


Secretary's Remarks

 Dorothea Dix Closure Lanier Cansler, Secretary

Department of Health and Human Services


Expenditures; Utilization Tracking Update Dr. Craigan Gray, Director

Division of Medical Assistance, DHHS


LME Presentation/TASC Mr. Mike Kupecki, Assistant Area Director

East Carolina Behavioral Health

Michael Gray the Vice President of Region 3 TASC, Partnership for Drug Free NC and

Vice President of National TASC

Karen V. Chapple, Executive Vice President of Coastal Horizons Center and Immediate Past President of National TASC.


Three-Way Contracts Update Mr. Mike Watson, Deputy Secretary for Health Services, DHHS




ICF-MR Cost Analysis and Comparison w/ CAP/MRDD Services Steve Jordan, Director,

Division of Mental Health, Developmental Disabilities, & Substance Abuse Services, DHHS


Overview of the DD Waiting List Rose Burnette, DD Project Manager

Division of Mental Health, Developmental Disabilities, & Substance Abuse Services, DHHS


Update on CAP-MR/DD Tiered Waivers Rose Burnette, DD Project Manager,

Division of Mental Health, Developmental Disabilities, & Substance Abuse Services, DHHS

2:45-3:00 Public Comments

3:00 Closing Comments; Adjournment

Tuesday, November 2, 2010

North Carolina Legislative Briefings Coming to a Location Near You!

GET READY FOR 2011 at a Legislative Briefing by local legislators and staff from the NC Budget & Tax Center, NC Justice Center and United Way of North Carolina. Hot topics on the agenda include:

• The impact of the Great Recession on nonprofits and working families
• The state of North Carolina’s budget and projections for recovery
• Updates on key state programs including our education system and health and human services programs that support low and moderate-income families such as child care subsidies and health insurance.

Using your voice to make a difference in the issues you care most about.

Legislative Briefings will take place in:

Asheville, Chapel Hill, Charlotte, Fayetteville, Greensboro, Hickory, Raleigh, and Wilmington

Events begin November 15 and run through December 1

Raleigh event in January 2011

Visit for a complete list of events and to RSVP.

Monday, November 1, 2010


Don't forget to VOTE tomorrow, Tuesday November, 2, 2010 for the mid-term elections. It's important that the voice of everyone in North Carolina is heard.   

 If you experience any difficulties while voting please call Disability Rights North Carolina at (919) 856-2195.


Election Protection at 1-866-OUR-VOTE (687-8683)

Thursday, October 28, 2010

National Disability Rights Network Endorses Senate Seclusion and Restraint Bill

Disability Rights North Carolina has been working to support federal legislation that would establish new guidelines for the use of seclusion and restraint in public schools.  If you are unfamiliar with our work in this area, please refer to our website.  A House version of the bill was filed earlier in the session.  Shortly before the break, the Senate filed its own version, S. 3895.  There were two big differences in the Senate bill: 1) It has a Republican co-sponsor, our own Senator Richard Burr; and 2) It allows seclusion and restraint that complies with the standards set out in the bill to be included in a child's IEP when there is a documented history showing a series of behaviors in the past 2 years that has created an imminent danger of serious bodily injury in school and a comprehensive, data-driven functional behavioral assessment has been conducted, and a behavioral intervention plan implemented, by a qualified team of proffesionals.  Depending on the outcome of the election, the first change may allow this bill to pass and become law this year.  The second change has been very controversial in the advocate community.  Many groups feel that the inclusion in the IEP will increase the use of seclusion and restraint and serve as an impediment to enforcing a child's rights when the use is inappropriate.

Our national organization, National Disability Rights Network (NDRN), has adopted the following recommendation with regard to teh pending Senate bill, which we at Disability Rights NC endorse:

This legislation responds to a critical need identified by the P&As and NDRN for strong, consistent national standards regarding the use of restraint and seclusion. While NDRN recognizes that there are reservations about allowing restraint and seclusion in an Individualized Education Program (IEP), we believe that the criteria contained in this legislation for when these interventions can be utilized or written into an IEP are sufficient to ensure this occurs only in very limited circumstances. On balance, the benefits of establishing national standards, together with creating a threshold for their enforcement, outweigh the ever present risks that restraint and seclusion will be misapplied. Therefore, we support this legislation and believe it should be passed.

Please let me know if you

Wednesday, October 27, 2010

Opportunities to contribute to the future of cloud computing and to share your IDEA story

       The Federal Communications Commission (FCC), the Coleman Institute for Cognitive Disabilities, and Raising the Floor challenged the public to submit short multimedia presentations on how cloud computing will create new opportunities for people with disabilities.  The Federal Communication's Commission will post the most innovative designs on its Accessibility and Innovation Initiative website, and they will be considered for the Chairman’s Awards for Advancement in Accessibility. The Coleman Institute for Cognitive Disabilities will award $1,000 to the presentation that best describes how cloud computing will improve communication for people with cognitive disabilities. Raising the Floor will award $1,000 for the best presentation that focuses on the needs of people in developing countries.

       Submissions for the challenge will be accepted between October 22, 2010 and May 1, 2011. The winner or “popular choice” will be determined by the public on May 2-3, 2011. Individuals can vote by visiting

You can find out more about the Chairman’s Accessibility and Innovation Initiative by visiting,

Share your IDEA story

       To celebrate the 35th anniversary of IDEA the Office of Special Education and Rehabilitation Services (OSERS) is asking anyone, individual with a disability, parent, student, teacher, principal, researcher, teacher trainer, or advocate, who has been positively affected by IDEA to share his or her story. Individuals are encouraged to share art work, photography, and poetry to describe their experiences. Personal stories and other documents are due before November 8th and should be submitted to

Monday, October 25, 2010

10/19/2010 Alternatives to Housing Task Force

This is the legislature-mandated task force formed by NC DHHS Secretary Cansler.  The task force is charged with looking at measures that will reduce the numbers of individuals with mental illness hospitalized.  Last time we reviewed the legislation and past studies. They have gathered data since last time but there are still a lot of holes. Below is a summary of the date presented at the meeting.  Unfortunately, I missed the afternoon, which focused on housing model presentations.
Who are we serving and what are their living arrangements?

All LME data is held in the Client Data Warehouse. 87% of clients served by LMEs are in a private residence (children and adults combined); 85% of adults are in a private residence, 5% homeless

• Those not in private residence – looked at NC TOPPS (MH/SA only): at most recent update, close to 20% not in a private residence once they enter treatment. 43% in private residence, 36% residential program, institution or other type of program; 21% in temporary housing or homeless.

o The task force is focusing is on that 21%

• For those in a residential program, over half receiving treatment (but nowhere near all)

• Co-occurring MH/SA has greater needs – housing status quite different from MH and SA alone

• Those not in housing have higher number of crises, ER trips, nights in hospital, jail and arrests.
o Questions about whether any indicators in data about services and outcomes? NC TOPPS doesn’t track services but could match claims data

o They were going to seek data from the chronic homeless population counts
o Wake county estimates high end users 1-5% of SPMI (Wake has 10% of state population)

Data from State Operated Services – HEARTS, Healthcare Enterprise Accounts Receivable Tracking System – tracks Medicaid and IPRS patients

o Different definitions used in HEARTS – if sleeping on a couch, considered private residence (LME considers temporary residence)

o Their data is adults and kids, chart is 91% of all discharges

 5% to homeless shelter (would be higher if just looked at adults) – 8% cite homeless as a prior – state operated services is supposed to oversee discharges to homeless shelters – Wake Med rep says numbers much higher (1,000 he estimates)

 Really low numbers across the board in community placements

 A lot of MR/MI coming into hospitals

 Their data indicates 56% to private residence but many task force members questioned that statistic, one reason being that many of those folks bounce out of there in a short period of time

 Wake estimates 15% entering state hospistals are homeless

 Identified issue - LMEs still not following up quickly enough

 Shelters see people coming out with too few meds, can’t get into psychiatrist quickly enough – state operated services says they give people 1 week of meds

 $20K in New Freedom funding to implement Olmstead

 Don’t have recidivism numbers

 The task force should start with group discharged to homeless shelters

Effective Use of State Hospitals from Community Systems Progress Report April – June 2010

o In that quarter only 34% with stays of 7 days or less, Wake Med says more people waiting in ERs – but clients are higher acuity

o Much improved since 2006

o Only 53% of consumers discharged from state psych hosp were seen within 7 days following discharge; we don’t know what service was billed within 7 days

o 7% readmission within 30 days; 18% readmission within 180 days

o There is a meeting next week (now this week) between LMEs and hospitals

• Must be coordination regardless of state hospital or private hospital

• Durham Center pilot project started in July – tracking 50 repeat consumers who touch multiple systems in community; serve 500+ through care coordination; have a whatever it takes fund focused on recovery; biggest challenge was getting providers to buy into it – bringing it to LMEs attention and tell them what the wraparound services are that the person needs; quarterly quality of life services; housing is the key factor for these individuals; doing one year of rental assistance

Crisis Services

o Walk-In Psych Centers – 66 centers served 110,296 Jan-June 2010: 3.7% referred from state facility, ER, community hospital psych bed; 1.1% referred to state facility, etc.

o Community Hospitals 887 persons served over 15 mos ending Sept 2010 (this is just the 3 way contracts and previously existing psych units)

o Can get more data for beds in 3 way contracts

DOC Data, John Carbone

o Started by distinguishing them from jail system

o DOC has an M grade system for prisoners (M1-M5)

o Depending on source, data is all over the place – different diagnoses, different definitions

o LME-prison liaisons? Not statewide. Dr. Carbone said that would be wonderful. This needs to be formalized. Laura Yates oversees everything in community, including housing, not a designated housing specialist

o They have a study draft looking at Dix patients and those in corrections to identify cross-over – should be finished by the end of this year.

o Placement in the community is becoming harder because of funding.

o Prisons give inmates 30 days of medication upon release. Virginia mails meds to inmate’s residence or where they are going to receive treatment.

LME Housing Needs Assessment

o Average number of additional units needed = 415 housing units per LME (23 LMEs) – includes mh/dd/sa

o LMEs identified needs – services and supports, housing top barriers

Those who are homeless are neediest – a group to target; less data on where people end up after discharge but can target those knowingly being discharged to homeless shelters

May recommend looking at matched data looking at individuals across the systems
Unfortunately, a constant theme is money.  Any change to funding is seen as an expansion, even if the change will result in cost savings overall across systems.

White House Call re Georgia Olmstead Settlement, a Template to be used across the Nation

There was a White House Conference Call on Friday, October 22 regarding the Georgia Olmstead settlement signed last week.  It is being hailed as the most comprehensive Olmstead settlement to date.  Kareem Dale, Associate Director, White House Office of Public Engagement & Special Assistant to the President for Disability Policy, began the call with an overview of the administration's position on community living.  President Obama launched the Year of Community Living more than a year ago.  HHS, HUD and the DOJ have come together on improving Community Living, including the new housing vouchers and other initiatives.

Tom Perez and Sam Bagenstos from the DOJ then spoke about the case - The case has been going on for a long time so this was a landmark week for the department and people with disabilities.  This is a textbook example of partnership at its best - between government agencies, and between agencies and advocacy organizations.  He thanked all of the people involved, including HHS (funding) and HUD (housing).  Tom says to implement the Olmstead mandate, states must answer 2 questions: 1) who in institutions doesn't need to be there; and 2) for those remaining in institutions how can we ensure the conditions are safe and constitutional.  This is the framework for all of their Olmstead work.  In this case, they were able to reach this agreement.

For full details, please refer to the OCR site.  Some highlights: GA will stop admitting people with DD to state institutions by July 1, 2011.  They will transfer all people with DD out of state facilities by July 1, 2015.  They will provide support coordination services to ensure access to necessary community supports (medical, transportation, nutrition, etc.).  They will provide supports to 9,000 people with MI to be served in community. They will establish 24 hour crisis centers and crisis teams to respond to individuals anywhere in community.  They will create 1,150 waiver slots by July 2015.  750 of those are to help transition people from the hospital to the community, and 400 to prevent people returning to institutions.  The amount of supports in the mental health setting is noteworthy - ACT, CST, intensive case management, crisis centers, and community based crisis beds.  The DOJ has earned from movements of past decades - Need to give attention to wide ranging community supports that must be in place.  This can be a template for work they will do across the nation.

During the Q&A, they were asked, does it cost alot of money?  This agreement not only fulfills legal and moral obligations, but is also in economic self-interest.  In GA, estimate for state DD hospitals $147,000 compared to $47,000 in their home.

Where do we go from here?  Tom said this is a critical milestone because it is the most comprehensive settlement to date.  It will be their template.  They are involved across the country.  There are 2 sections involved - special litigation and disability rights sections.  They have been involved in the DAI case in NY, Haddad case in FL, in CA advocating that you can't use budget crisis as an excuse to shirk Olmstead responsibilities, statements of interest across the country, and just completed trial in Arkansas.  They are also establishing a body of case law to ensure P&A's, and others, have standing to file on behalf of people with disabilities.  They need both aggressive leadership and also private attorneys to ensure we have the capacity to assist people.  Want to share this settlement with other states.  They need continuing assistance to let them know about complaints. 

Sam Bagenstos, a DOJ attorney, wrote the book on disability rights.  Sam talked about what this is all about - the fundamental value that people with disabilities can live their life like everyone else does. They can choose where to live, when to eat, where to go for work, etc.  This is what they are trying to enforce across disabilities.  This also applies to people with physical disabilities in nursing homes - that's what they are working on with Alabama and Florida.  There is a new paradigm in enforcement - they made a commitment in the way they enforce Olmstead.  It was about institutions, very process-focused.  The new pieces added: focused intensively on services in community (!) including housing, employment, crisis, etc.; focusing on people at risk of institutionalization, not just those in institutions; close collaboration with people in disability rights community and people in local community.  They are looking for relief that looks like the Georgia. 

During the Q&A, they addressed the state perception that deinstitutionalization would be costly.  A NJ case claimed they didn't have the funding.  The record showed that they would save a substantial amount of money.  Litigation becomes necessary to get inertia.  They want to use this settlement with the assistance of HHS, etc. to show it is in the state's self-interest. In addition to DD stats, they want to give a reminder that states get the medicaid match for adults with MI served in the community (but not in institutions).  The need to draw down federal dollars is in the state's self-interest. 

It seems that a budget crisis may be an opportunity to seek more community living arrangements for people with disabilities.

Friday, October 22, 2010

Election Protection for November Elections

       It is possible that on Election Day (Tuesday, November 2, 2010) some Americans with disabilities will be at risk for disenfranchisement because of poorly trained poll workers, inaccessible voting sites, and malfunctioning or inaccessible voting machines. AAPD joined the Election Protection coalition, as a way to ensure that voting sites are accessible to people with disabilities. The goal of the Election Protection coalition is to make sure the rights of all registered voters are protected. The coalition has a hotline with hundreds of lawyers ready to answer questions and give resources. Building field programs have also been established in 20 states.  
            Disability Rights North Carolina is a point of reference about voting issues affecting people with disabilities for the Election Protection coalition in North Carolina. Disability Rights North Carolina staff’s efforts to lessen disenfranchisement began before Election Day and will continue until November 2nd.  We have been providing voter rights information on our regular monitoring visits to Adult Care Homes in North Carolina. We engaged in education and information sharing with disability advocacy groups across North Carolina. DRNC staff is also providing information to State and Local Boards of Elections to educate volunteer poll workers on issues related to voters with disabilities. We have even used the media to highlight the importance of voting and voter’s rights. Our Public Service Announcements aired on over 250 North Carolina radio stations and we have promoted of voters rights for people with disabilities via public access television. Our staff is also performing accessibility surveys of OneStop and Election Day voting sites.

You can learn more about the Election Protection coalition and their efforts on Election day by visiting the following website,

If you trouble voting call 1-866-OUR-VOTE (866.687.8683) or report your problems at

Tuesday, October 19, 2010

Secretary Cansler Gives Official Notice of Dix Closing to Legislature Today

The Education and Health & Human Services Subcommittee of the Joint Legislative Commission on Governmental Operations ("Gov Opps") met today.  The first agenda item was HHS notice to the legislature of the closure of Dix hospital.  Secretary Cansler gave the committee background information about the budgetary reasons for the closure of the hospital.  Specifically, with no money designated for the continued operation of Dix, DHHS has been forced to pull money designated for community services. Additionally, they have been about $30 mil over budget in the facilities budget. Even though additional beds are opening at Cherry and Broughton, the closure will still result in a net savings of $17 mil.  The plan for closure and official letters will be sent to legislators in next few weeks. The closure also has to go to the Council of State.

There were no questions or comments from the committee members.  When the Committee voted to accept the report and submit it to the full committee, Senators Stevens and Blue voted No.
The Secretary then went on to discuss the HHS budget status.  Of particular note:

• Total HHS budget is 23% state dollars, 77% federal dollars (most need state match or MOE)

• Can’t reduce staffing because we are at the bare minimum in facilities staffing now.  They are implementing technology to better manage facility budgets.

• Outside of state facilities, only 4% of the budget is staffing.  If include facility staffing, still only 7% goes to personnel.

• 86% of budget goes to provision of services.

• 60% of appropriations go to Medicaid. 54% is mandatory services. 17% of optional services goes to children. 29% is adult services (17% of overall budget).

• MH/DD/SAS is 10.76% of the total DHHS budget

• Enrollment growth rate about 4.25%, less than 6% projected (under-budget by about $140 mil, which will offset overspending last year)

• 2014 500-700K in increased Medicaid enrollment

• We will have over one million applicants in 2014 – need to update technology

• There are 14 outstanding State Plan Amendments.

Opportunity for young musicians with disabilities (under 25)!

          The VSA International Young Soloists Program has made it application for the International Young Soloists Award available. The award is given to four musicians, two from the United States and two international applicants. Each recipient will earn $ 5,000 and a performance in Washington D.C. VSA affiliates in the United States implement their own International Young Soloist Award and entry materials should be sent to the corresponding address for each state. International applicants must submit their recording, application, and biographical information to :

VSA International Young Soloists Award
818 Connecticut Avenue, NW
Suite 600
Washington, D.C. 20006

To learn more about VSA International Young Soloists Program and the International Young Soloists Award, you can visit the following website,

Friday, October 15, 2010

October 1 NC Register

The October 1 Register is available here.  Of particular note are the following:

The 2011 Low-Income Housing Tax Credit Qualified Allocation Plan for the state of North Carolina is published at pages 756-802.  The low-income housing tax credits are allocated in compliance with the plan.

The North Carolina Psychology Board published a proposal to amend the rule 21 NCAC 54 .2001 to require supervisors to obtain three hours of training in licensing act and rules concerning supervision. The proposal is based upon the following reason: The Board believes that this change is important because of the abundance of supervision rules infractions in recent years. Often, psychologists have appeared not to comply with supervision requirements because of ignorance of the law. The Board intends to reduce this problem by instituting the supervision training requirement.  The proposed effective date is February 1, 2011.  There will be a public hearing on December 2 and written comments are also due the same day.

Major events of the week 10/3-/10/9

             Before Congress took a break for the election it made several decisions on the budget, tax cuts, healthcare, and housing. Congress will reconvene November 15.
            Members of Congress passed a Continuing Resolution Act regarding the budget. This will keep the federal government operating at the current level until December 3. Because of the deadline, Congress will need to address the budget during a lame duck session after the election.*  Upon their return, Congress will also decide whether or not to extend some or all of the tax cuts set in place during the Bush Administration.
           On September 29, the House of Representatives passed H.R. 3421, “Medical Debt Relief Act” and H.R. 758, “Pediatric Research Consortia Establishment Act”. The Medical Debt Relief Act excludes from consumer credit reports medical debt seen as delinquent, charged off, or debt in collection that has been paid in full or settled.  This can be a problem for individuals who have serious medical conditions and disabilities, and affect insured and uninsured consumers.  The Pediatric Research Consortia Establishment Act will grant funding to establish up to 20 national pediatric research consortia to conduct clinical, behavioral, social, and translational research. Funds will also cover trainings and demonstrations of advanced diagnostic and treatment methods relating to pediatrics.   The bills now go to the Senate.
          The Senate also passed the S. 1481, the Frank Melville Supportive Housing Investment Act, which creates new standards for leases to tenants with disabilities. It requires HUD to provide housing assistance through local authorities and allows HUD to take administrative control if housing authorities fail to meet the established guidelines. It also directs the HUD secretary to provide technical support to ensure public housing agencies to administer housing voucher program for people with disabilities. 
*When Congress reconvenes in an even-numbered year following the November general elections to consider various items of business. Some lawmakers who return for this session will not be in the next Congress. Hence, they are informally called "lame duck" Members participating in a "lame duck" session.

You can learn more about Capital Insider by visiting the following link,

Wednesday, October 13, 2010

October 13 NC Legislative Oversight Committee on Mental Health, Developmental Disabilities and Substance Abuse Services

Below are some highlights from the meeting today of the Legislative Oversight Committee for MH/DD/SAS. The handouts are on the LOC website at\LOC Minutes and Handouts\Minutes and Handouts 2010\October 13, 2010 (Note that they did not get to the CAP-MR/DD Update).

Rep. Insko chaired the meeting, Sen Nesbitt absent

Secretary Cansler not there so he did not make remarks

Dr Gray Expenditures & Utilization (Handout)

• Child Day treatment down, stricter policy criteria and increased staffing reqs

• Moving in more clinically oriented direction

• CST: 25-40% denial rate by VO per month per clinical criteria

• Mobile Crisis – is it really diverting people from ER? They will f/u with data

• CAP Waiver recipients have increased by 7%, non-waiver TCM recipients have decreased by 5% - providers now billing by weekly rate, hopefully will give more flexibility

• Braxton: how do we decide who gets care – from dollar standpoint or needs standpoint? Insko: how do we know we are doing more appropriate services? (My note: you need to assess need, design services to meet needs and plan within budget) Watson: can put max amount on services for adults and adjust rates

• Cost of CST should drop below the cost of ACT

• In context of ACA need to think about moving toward case rate rather than fee for service – case rate allows for more flexibility, and also looks at outcomes

SIS Pilot Project – Rose Burnette (Handout)

• FT staff person at DDTI working on pilot project

• 20 SIS assessors have been trained

• As of Oct 11, 895 assessments have been completed but have not met the numbers in the legislation

• An additional 175 children have been assessed by the tool is not normed for children – data is being included in the norming process

• All participants are volunteers

• Data so far indicates NC recipients have higher support needs as compared to other states

• Insko: 1 LME did a study on patient need and the amount of $ for their services – that study did not show a correlation

• Waiver TA to require SIS but would still do SIS and SNAP?

• Medicaid funding for assessment, negotiating fee for licensing and assessment tool

• Legislation says to assign people to waivers based on SIS assessment but LMEs don’t assign people to waivers, the state does

Independent Assessment – Beth Melcher (Handout)

• FY10 had over 40K new service recipients (Medicaid and iprs)

• Placed assessment within CABHA core services so no infrastructure for IA outside of CABHAs

• Proposed how to implement the legislation in a way that would not interfere with care – at point of service order, review of providers

• Draft plan focuses on duration or frequency for ACTT, CST, PSR, IIH, day treatment, inpatient or crisis (i.e., ACTT for greater than 18 months) – submitted to PAG, will be posted for 45 day comment period

Dix Update – Luckey Welsh (handout)

• To CRH: 60 dult admission, 11 adult long term; 54 forensic med/max and pretrial beds

• To Cherry: 30 long term

• Side note: Secretary plans to give official notice of hospital closure at Gov Ops committee meeting next week

• Reviewed budget shortfall info from last time – about $29 mil

• Insko: Dix appropriations a topic of much discussion during the budget process, in order to fund would have had to take money from other essential services

• Timeline for patient transfers – have moved patients in adult long term to CRH; Oct/Nov move patients in adult long term to Cherry, move clinical research unit (recent development), stop admission to inpatient pretrial eval (but continue outpatient evals – most are already outpatient); Dec move forensic max, stop admissions to DDH, move pretrial eval, move patients in forensic med, move remaining patients in adult admission – working with all hosps, DRNC on moves

• Goal to have completed by December 23

• Cost to operate remaining units on Dix – Child Outpatient and Forensic Min - $9 mil

• Additional 19 adult admission beds at Broughton $2.9 mil

• Division estimates $16.9 mil savings by closing Dix beds

• Investigating employee transportation from Raleigh to CRH

• Insko: HHS budget chairs met with Cansler yesterday and he said that they are maintaining enough at the hospital to bring back up if GA says they want to remain open; discussed how NC overutilizes inpatient beds in large institutions

• Watson – moving toward plan to have 3 regions with 3 hospitals

• Barnhart: Another $3-4 bil shortfall this year; Effects Wake county more than other places; losing jobs everywhere – employees may have to commute but most jobs preserved; have to make hard decisions the next few years; not losing beds

• Braxton: need to consider increasing population (my note: not taking into account current overutilization); Luckey: new Cherry and Broughton have additional capacity

• Had been a plan to open forensic beds at Broughton and that hasn’t happened.

Health Reform – Pam Silberman, IOM (Handout)

• Good Overview for DRNC folks

• Pam highlighted:

o special outreach requirements to people with mental health or addictive disorders

o prevention and wellness – funds for a prevention and public health fund – mh, behavioral health and substance abuse disorder included priority areas

o Efforts to expand health professional workforce, including specifically mh and addiction licensed health professionals

o Expand National Health Service Corps

o Quality Improvement; comparative effectiveness research

o New models of care to improve quality and efficiency, i.e., reverse co-location (primary care provider in community mental health agencies), Medicaid emergency psychiatric coverage in IMDs

o Expansion of community health centers (NC has applied for funding to expand community health centers)


o Options to expand HCBS to achieve an enhanced match rate – Community First Choice Option and state balancing initiative

• Impact on People with MH/DD/SAS Conditions

o Expanded insurance coverage

o Essential benefits plans should include preventative services related to MH/SA

o Many people now receiving state funded services through LME will now have Medicaid or private insurance coverage – LMEs still have role in authorizing services to people who lack insurance coverage, authorizing wrap-around services and in UM

o There will still be a role in state financing for gaps

o Question: what is the role of the LME in the new system?

o No mention of the revised 1915(i) waiver option

• Youth Villages Transitional Living Program, Youth Villages & Guilford Center (Handout)

o Program targets kids coming out of foster care with behavioral health issues

o In NC average daily census 55 kids/day; target number about 400 kids/year

o 10 locations across NC

o Doing clinical trials in TN to compare outcomes; now can compare to national outcomes

Public Comment Portion

• Union member discussed OAH decisions overturning employee terminations, Dix closure, disproportionate effect on black workers

• Louise Jordan spoke in favor of keeping Dix open, no part of discussion is person-centered, only budget centered

• Beverly Moriarty, Dix nurse – declining admissions because all hospitals on delay; reform didn’t happen, we don’t have community services, patients not being treated, building new hospitals in wrong places and staffing shortage

• Current temp psychiatrist at Dix – Dix long term care has better outcomes than other hospitals

Effectiveness of Single Stream Funding, Steve Jordan (Handout)

• Report submitted to GA August 31, 2010

• Put monitoring in place to ensure some maintenance of effort for individual disability services

• Allows LMEs to use funds for projects to fill gaps

• Looking at expenditure comparisons, LMEs spending closer to allocation, increased SA spending significantly

• Majors programming – managing access for juvenile justice – 15 year old JJ initiative to screen, identify and provide treatment for young people with SA issues
Next Meeting November 9th