Week of March 7 Budget Update

HHS Appropriations
Medicaid and Piedmont Behavioral Health
On Tuesday, Craigan Gray and Steve Owen finished up a presentation on Medicaid and Pam Shipman from PBH presented.  The Medicaid handout is online here.  The PBH presentation is online here.  The PBH presentation was not much different from other presentations they have done.  Some points that were made that I would like to note:

• The slide that states that the PBH model has management of all public resources, including Medicaid funds, state/federal funding and state institution funds, is misleading.  PBH only covers behavioral health.  Other Medicaid services (primary care, etc.) are covered under the Southern Piedmont Community Care Plan (the local CCNC affiliate).
• State funds account for 20% of the PBH budget.
• Although the slides related to comparative costs for certain types of services are not clear as to scale, they demonstrate no significant cost differential for ICF-MR, 1915(c) services (Innovations and CAP-MR/DD), and possibly outpatient and inpatient psychiatric care (without further explanation of their numbers it is impossible to know if the difference is statistically significant).

Division of Mental Health and the Division of State Operated Healthcare Facilities
On Wednesday, legislative staff  (NOT DHHS staff as was done for Medicaid) presented reduction options related to the Division of Mental Health and the Division of State Operated Healthcare Facilities.  Of particular note:

• It was stated that the cost of ICF-MRs is mostly medicaid, with only a small amount in the DMH and DMA budgets for state dollars, so there wouldn't be much savings to close the DD Centers.
• Total funds spent through the LMEs - $533 mil (state and federal) - $350 mil to community services ($350 mil) and $115 mil in administrative funding (22% of the money allocated to LMEs, $65 mil state and $50 mil federal).  Staff discussed the high percentage of administrative costs (according to the Mercer report the national average is 10-15%) and laid out options to consolidate and reduce the number of LMEs.  For community services funds, staff suggested standardizing the service package of benefits among LMEs, creating a standard benefits package among LMEs, and instituting a co-payment as reduction options.  There were alse questions about the LME fund balances.
• Staff put forth closing the Wrights School as an option.
• ADATCs – there is not really an option for this, but could see if there is a private market.
• Advocacy staff - $3.5 mil in salaries/fringe (both state and federal cost) – 40 positions to serve 15 facilities, 23 throughout communities.  In his response, Secretary Cansler pointed out that the advocacy staff is crucial to the facilities, and the amount saved in state dollars would be minimal.
• CRH Hospital Administrator Contract – could save $30K by hiring as an employee.  Cansler also responded to this point in his response.

Education Appropriation
K-12 Education Reduction Options - handout here.  Some options discussed include:

• Eliminating $9 mil in support for Child and Family Support Teams
• Children with Disabilities Reductions: 2 reductions are discussed: 1)  3.4, 4.2 and 5% reductions to the state allocation for children with disabilities ($23,964,707, $29,042,061, and $34,694707 reductions to $693,894,148).  Staff is further investigating this option regarding federal Maintenance of Effort requirements for IDEA funding.  These options were not in the Governor's budget.  2) The Governor's budget included a $7 mil reduction in anticipation of a reduced headcount.
• Reduce funding for the Residential Schools for the Deaf and Blind by 5 and 10% ($1.6 mil and $3.3 mil out of $32.6 mil budget).
• There are also proposals to reduce funding for teacher assistants, local school district central office administration, principal and assistant principals, instructional support (guidance counselors, social workers, etc.), eliminate funding for staff development, retirement incentives for LEAs and to eliminate the More at Four/DPI Office of School Readiness.

The Commission for MH/DD/SAS Advisory and Rules Committee meetings will be held January 27

The Commission for Mental Health, Developmental Disabilities and Substance Abuse Services (MH/DD/SAS) is a commission that reviews some of the MH/DD/SAS rules before they reach the Rules Review Commission, and also advises the DHHS Secretary on matters related to MH/DD/SAS. Their meetings are held at the Clarion Hotel State Capital, 320 Hillsborough Street, Raleigh, NC.



Agenda for the Commission for Mental Health, Developmental Disabilities and Substance Abuse Services Advisory Committee

Thursday, January 27, 2011, 9:30 am

9:30 – 9:55, Larry Pittman, Chairman, NC Commission for MH/DD/SAS, Advisory Committee

• Call to Order

• Moment of Reflection

• Ethics Statement

• Welcome and Introductions

• Approval of Minutes

• Subcommittee Guidance

10:00-11:30, Breakout Session for Subcommittees:

• CABHA

• Workforce Development Initiative

• Traumatic Brain Injury (TBI) – Veterans andMental Health, Developmental Disabilities and Substance Abuse Services

Agenda for the Commission for Mental Health, Developmental Disabilities and Substance Abuse Services Rules Committee Meeting
Thursday, January 27, 2011, 1:00 p.m.

Jerry Ratley, Chair, NC Commission for MH/DD/SAS, Rules Committee

• Call to Order

• Moment of Reflection

• Ethics Statement

• Welcome and Introductions

• Approval of Minutes


Stephanie Alexander, Chief, Mental Health Licensure Section, NC Division of Health Service Regulations

• Proposed Amendment of 10A NCAC 27G .0813 – Waiver of Licensure Rules

• Proposed Adoption of 10A NCAC 27G .0105 –General Definitions
Jerry Ratley, Betty Gardner, John Carbone

• Proposed Amendment of 10A NCAC 26D, NC Department of Correction Standards for Mental Health and Mental Retardation (DOC Response)

Public Comment


Adjournment

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.

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.

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.

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.

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.

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 http://www.ncleg.net/gascripts/DocumentSites/browseDocSite.asp?nID=20&sFolderName=\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 CLASS

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

MH/DD/SAS Rules Commission Meeting Thursday May 27

The Commission meets next Thursday from 8:30-4:15 at the Clarion Hotel State Capital in Raleigh. On the agenda:

• Division Director's Report, including 2 requests for waiver of a rule: 10A NCAC 27G .3806, Authorization: Facilities Providing SA Services to DWI Offenders, and 10A NCAC 27I .0606, Hearing Schedule and Composition of the Panel (for non-medicaid appeals)
• Rules Committee Report
• Advisory Committee Report
• Proposed Adoption of 10A NCAC 27E .0301-.0304, NCI QA Committee (this has already been published for public comment, and through the Rules committee)
• Proposed Amendment/Adoption of 10A Subchapter 26D, NC Department of Correction: Standards for Mental Health and Mental Retardation: Rules .0103 - .0906

Let me know if you would like the Commission materials emailed to you.

April 21 Commission for MH/DD/SAS Rules Committee

The Rules Committee met this week to discuss two groups of proposed rules: proposed new rules from the Division of MH/DD/SAS for the North Carolina Interventions (NCI) Quality Assurance (QA) Committee, and proposed amendments to rules regarding standards for mental health and mental retardation in the NC Department of Correction.

NCI QA Committee Proposed Rules

For those unfamiliar, NCI is a crisis intervention program (which includes restraint practices). It is one of several curricula in NC. The proposed rules for the QA Committee were published for public comment in the January 4, 2010 NC Register. The proposed rules describe the purpose of the committee: to establish policies and monitor the safety and effectiveness of the NCI training program; the duties of the committee; and the composition of the committee. The comments received during the comment period were presented to the Rules Committee on Wednesday.

DRNC provided the only comments to the proposed rules. We recommended 3 additional members: one licensed clinical social worker, psychologist, or physician with academic, clinical, or research experience relating to the effect of interventions on the three populations (persons with developmental disabilities, mental illness and addictive disorders). The proposed committee composition consists of 79% NCI Certified Instructor Trainers - we fear that with such an overwhelming percentage of members dedicated to the current program, there will not be any inclination to make changes to the program over time to maintain best practices.

The Division of MH/DD/SAS responded that the addition of such members is unnecessary because the most important function of the committee is to certify and recertify instructors. Additionally, the Division of MH/DD/SAS supports the use of licensed clinicians on its Curriculum Review Committee, which is an entity not set out in rule but exists by internal policy, to review and approve curricula related to restraint and seclusion. The Rules Committee recommended that a provision be added to the committee composition rule requiring that at least 2 instructors on the committee must be licensed clinicians. The Rules Committee also recommended that the policy regarding the Curriculum Review Committee be clear that there shall be members representing clinical and academic perspectives.

We also recommended that the duties section be amended to strengthen the role of the committee in improving the safety and effectiveness of the NCI training program. the Division of MH/DD/SAS accepted these recommendations.

The Rules Committee approved the Rules, as amended.

Proposed Amendment/Adoption of Department of Correction Rules: Standards for Mental Health and Mental Retardation

A subcommittee has been working on this set of rules for many years. The Committee spent a good deal of time reviewing the rules at this meeting but did not finish. Betty Gardner from the Division of Prisons presented the proposed rules. There were comments at the beginning about the use of the term "mental retardation" instead of "intellectual disability." There didn't appear to be a resolution on this issue but there was consensus that they needed to be consistent in whatever approach is taken.

There were comments about inconsistencies and lacking definitions throughout the discussion. Many revisions were requested so we will likely see a different version of the rules when they go to the full Commission for a vote before public comment.

One thing I did want to note specifically, in the Scope section, there was a question about whether there is oversight of the Chief of Mental Health Services. This led to a conversation about prison accreditation. 10 prisons are currently accredited in addition to the Central Office. They are also discussing JCAHO accreditation for the 2 new inpatient facilities.

Public Comments

An attorney from NC Prisoner Legal Services spoke during the public comment period and stated that NCPLS would be sending a letter to the Rules Committee regarding the rules relating to seclusion and restraint.

Martha Brock spoke during the public comment period and stated that she would be sending a letter to the Rules Committee regarding her concerns about the forced medication of inmates.

Governor's Budget Recommendations April 20, 2010

Governor Perdue released her recommended adjustments to the state budget today. The full document is available online. The budget cuts approximately $1 billion from the overall state budget. Just a reminder, this is just the beginning of the budget process - the budget has to go through the Senate and the House, and back to the Governor before all is said and done.



Of particular note for people with disabilities:

• In the Division of Medical Assistance recommendations, there are several proposed changes to the Medicaid program that are predicted to save money by reducing or eliminating services:

Implement independent assessments on high-cost services to ensure proper utilization. Targeted rate reductions and "other measures" may be implemented to achieve necessary savings.

Various changes to optional services to improve utilization management, including reducing the maximum number of visits for adult speech therapy, physical therapy, occupational therapy and respiratory therapy.

Elimination of in-home Personal Care Services for adults and the creation of a new program for adults with the most intense needs.

Changes to private duty nursing (PDN) services, including transitioning adult PDN recipients to a new Community Alternatives Program (CAP) technology waiver. PDN services will continue to be available for children but it is recommended that independent assessments be conducted for children that receive the service.

Changes to mental health services, including modifying Community Support Team services and delaying the implementation of Peer Support from July 1, 2010 to January 1, 2011.

Limit adult dental coverage to emergency care only.

Reduce the number of outpatient mental health service visits for children before approval from 26 to 16.

• There are proposed expansions in the Division of Medical Assistance budget: One regarding adult care homes: "Funds are recommended to develop and implement a 1915(c) Medicaid Assisted Living waiver for individuals that reside in adult care homes that meet skilled nursing level of care and currently receive State County Special Assistance (SCSA). The waiver will allow fora targeted reimbursement based on acuity levels for the personal care services provided in adult care homes." ($9 million appropriation)
• There is also a proposal to allocate $8.5 million to expand NC Health Choice enrollment.
• In the Division of Mental Health, there is estimated savings from the conversion of the Whitaker School to a PRTF ($1.9 million). There are also proposals to provide funding to develop local in-patient bed capacity ($12 million for an additional 50 beds), improve the quality of care in residential facilities through training of staff ($534,795), and to restore $40 million to state funded mh/dd/sa services.
• In the Division of Health Service Regulation, there are several proposals to replace state appropriations with federal receipts (from civil monetary penalties assessed against nursing homes and Medicaid receipts to support licensure and certification activities), to establish fees (for adult care home medication aide and administrator testing), and to make the jails and sections receipt supported ($420/facility and $17.50/bed).
• In the Division of Vocational Rehabilitation, there is a proposal to reduce the Basic Support Case Services program by $2 million on a non-recurring basis; and to reduce the Independent Living program budget and staff by $1.3 million (eliminates 8 recreational therapist positions).
• In the Division of Social Service recommendations, the Governor is proposing a change in the percentage the state pays for Adult Care Home Specialists who monitor and inspect adult care homes. Federal funds pay for 50% - currently the other 50% is split with 40% paid by the state and 10% by the counties; this proposes that the state pay 25% and the counties 25%. An elimination of funding for the school-based Child and Family Teams pilot ($420,804) is also proposed (supported 12 team facilitators) - also eliminated from the Division of Mental Health budget.


• In the Division of Public Health budget recommendations, an additional $3 million is recommended for the AIDS Drug Assistance Program to allow eligible individuals on the waiting list to be enrolled.


• In the Office of Education Services in DHHS, it is proposed to suspend on-site summer school programs ($280,000) and to permanently reduce residential services from 5 to 4 nights at the residential schools ($619,558).


• A $100,000 appropriation to the Special Olympics is proposed.


• In the public schools, state funding to local education agencies (LEAs) is being reduced by $135 million and the amount appropriated for central office administration in LEAs is being reduced by 5%, $5.4 million.


• Funding for Child and Family Support Teams through public education is being reduced by $2.5 million. $9.1 million will remain to support the initiative.


• In the community colleges, $19.8 million will be restored to fund prisoner re-entry education (limited to basic skills and continuing education courses that ensure adequate literacy and job skills to pursue a productive life but curriculum courses and instruction at federal and local facilities will not be offered).


• There is money being allocated on a non-recurring basis to the State Board of Elections to provide matching funds for the Help America Vote Act (HAVA) grant application. This will allow for the maintenance and licensing of voting equipment.
• In the Department of Justice budget, there is a proposal to eliminate the NC Legal Education Assistance Fund program (NC LEAF), which provides loan repayment assistance to legal services attorneys as well as public defenders and district attorneys.
• In the Department of Juvenile Justice and Delinquency Prevention, there is one expansion item: to restore funding for the Samarkand Youth Development Center. It is recommended that the Woodson Wilderness Camp and the Macon County Multi-Purpose Home be eliminated, that the Eckerd Wilderness Camp program be reduced by 155 beds, and that the direct appropriation to the Juvenile Assessment Center be eliminated.
• In the Department of Corrections budget proposals, the Governor has proposed the establishment of operating reserves for the Central Prison Hospital and Mental Health Facility and the NC Correctional Institute for Women Mental Health Facility (both are scheduled for completion in August 2011).

Stay tuned for updates and more details as we move forward!

April 13 Joint HHS Appropriations Meeting

Legislators are back in Raleigh in advance of the 2010 short session to begin discussions on the budget. Because of the state of the economy, NC is again facing a budget shortfall. So far, there is no talk of a balanced approach to close this gap and still maintain public structures. So we are looking at cuts, cuts, and more cuts.

Today, DHHS presented options for 3%, 5% and 7% cuts from the agency's budget. Secretary Cansler made it clear that these are options to make the cuts - not recommendations. However you put it, these cuts will be disasterous for people with disabilities.

There are 53 options on the list - I won't list them all here. Email me if you would like the whole list. Of particular note:
• Change State Participation in State Adult Care Home Specialist Fund: Reduces state portion of funding for staff at county DSS to monitor Adult Care Homes to assure that state licensure standards are being met and to investigate complaints about inadequate care.
• Reduced funding to counties for foster care/adoption, child protective services,and Adult Care Home Case Management Services.

• Elimination of Medicaid Services for Adults:
o Dental
o Optical Supplies
o Chiropractic
o Optical
o - Podiatry (except services relative to diabetes complications and certain vascular diseases)
o DD Case Management for Adults (except for CAP-MR/DD case management)
o Private Duty Nursing
o HIV Case Management
o Personal Care Services
o Case Management FSO - proposal to eliminate services provided by social workers under this programs which is 100% FEDERALLY funded

• Shift portion of LME systems management cost to counties, depending on the size of the LME (to incentivize counties and LMEs to achieve economies of scale and to "become prepared" to participate in 1915 Medicaid waivers)
• Close Wright School (effective Jan. 1 , 2011)
• Eliminate the Jails and Detention section from the Division of Health Services Regulation
• Consolidate responsibility for licensing facilities under G.S. 122C (consolidate endorsement and licensure efforts of DMH, DHSR and LMEs)
• Eliminate 8 recreational therapist positions in the Independent Living program in the Division of VR
• Reduce aid and public assistance within the Indpendent Living program:VR has instituted a priority of services plan.

The majority of the cuts proposed are to Medicaid-funded services, which are predominantly federally funded with a state match. These reductions to the Medicaid program would result in a loss of $450 million in federal funds coming in to North Carolina.

This is just the beginning . . . so stay tuned.

March 31 Meeting of the Joint Select Committee on Emergency Preparedness and Disaster Management Recovery

Because people with disabilities are a particularly vulnerable population during times of emergency and natural disasters, we at DRNC have been following and participating in NC's efforts to prepare for such events. While the effort for government entities to prepare is moving forward, we are hoping to put together a resource guide for people with disabilities themselves sometime this year.

Presentation from the Division of Emergency Management

There was a lot of information presented yesterday about the great work that is being done at the state level to assist local entities with their emergency prepredness. The Division of Emergency Management received an award at the National Hurrican conference this week for its North Carolina Coastal Region Evacuation and Sheltering Standard Operating Guide The Division of Emergency Management has, or is close to finishing, templates for county-level recovery plans, licensed care facility disaster plans and a country best practice evacuation and sheltering plan.

Additionally, the special needs registry was deployed to all counties last month. Precautions have been taken to protect the privacy of individuals who choose to participate - each county is firewalled from other counties, and no individually identifying information can be viewed at the state level. To learn more about the special needs registry, contact your county emergency management office.

Presentation from MDC Inc.

There was also a presentation from MDC Inc. about emergency preparedness for socially vulnerable communities. MDC has produced a number of reports on promising practices for emergency management, including with regard to individuals with mobility challenges and with special medical needs.