Senate Budget Update

The full Senate Appropriations Committee met today to consider the budget. It is available online. The Senate will consider the budget bill on the floor tomorrow. I will provide a summary at the end of the week when it is final. Then, on to the House!

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.

And We're Off

The North Carolina General Assembly is back for the 2010 short session. I am going to try and communicate the happenings here on the blog as often as I can, but at least once a week. In just a few short days this week (the legislature convened on Wednesday, May 12), lots has been going on. See the DRNC legislative agenda on our website if you have not done so already.

Bills Filed Relevant to People with Disabilities and the Work of DRNC

• HB 1682/SB 1138: An Act to Prohibit the Use of Corporal Punishment for Students with Disabilities as Recommended by the Joint Legislative Education Oversight Committee. This bill seeks to amend the law to say that Corporal Punishment shall not be administered on students with disabilities. (DRNC Agenda bill).
• HB 1683/SB 1140: An Act to Delay the Sunset of an Act Pertaining to the Discipline and Homebound Instruction of Students with Disabilities as Recommended by the Joint Legislative Education Oversight Committee. This bill moves the sunset on this provision from March 1, 2011 to June 1, 2013. The provision was added to the statute on discipline and homebound instruction by 2008 legislation providing that a local educational agency shall be deemed to have a 'basis of knowledge' that a child is a child with a disability if, prior to the behavior that precipitated the disciplinary action, the behvior and performance of the child clearly and convincingly establishes the need for special education. NCGS 115C-107.7. (DRNC Agenda bill).
• HB 1674/ SB 1134: A Joint Resolution Authorizing the 2009 General Assembly to Consider a Bill to be Entitled an Act to Protect the Freedom to Choose Health Care and Health Insurance. This would allow the legislature to consider a bill with that title, presumably to direct the state away from provisions of the federal healthcare reform laws. There was also a bill filed seeking to amend the NC Constitution relating to health care services.
• HB 1698: An Act to Update and Clarify NC's General Statutes on Older Adults and Long-Term Services and Supports, as Recommended by the NC Study Commission on Aging. This bill would update language concerning older adults in the long-term care statutes.
• HB 1703: An Act to Direct the Division of Aging and Adult Services, Department of Health and Human Services, to Study the Issue of Criminal History Record Checks for Current and Prospective Owners, Operators and Volunteers of Adult Day Care Programs and Adult Day Health Services Programs, as recommended by the NC Study Commission on Aging.
• HB 1730: An Act to Authorize the NC Health Insurance Risk Pool to Contract with the US DHHS to Administer the Newly Created Federal High Risk Health Insurance Pool. This bill will allow the the NC Health Insurance Risk Pool, a nonprofit entity supported by state funds, to enter into contracts with the US DHHS to administer the federal high risk health insurance pool established under Health Care Reform.
• HB 1732: An Act to Direct DHSR, DHHS to Coordinate a Review of the Education and Training Requirements for Nurse Aides, as Recommended by the NC Study Commission on Aging.
• SB 1150: An Act to Appropriate Funds for the NC Special Olympics. This bill would appropriate $100,000 for the 2010-11 fiscal year.

Senate Budget Recommendations

Several Senate Appropriation sub-committees met on Friday to present budget recomendations. The Education sub-committee did not meet. The Health and Human Services (HHS) sub-committee met, and will meet again on Monday at 4. Highlights of differences from the Governor's budget are below:

Justice and Public Safety (JPS)

• Funding for the Samarkand Youth Development Facility was eliminated (The Governor's budget restored funding for Samarkand).
• Funding for wilderness camps was restored.

Health and Human Services (HHS)

The proposed Senate budget takes less reductions overall than the Governor's budget.

• It eliminates an additional 20 positions within the Division of Central Management.
• Eliminates 27 positions from the Division of Public Health.
• Eliminates state funding for vaccines (the Governor reduced funding).
• Reduced the appropriation to NC Health Choice for expanded enrollment.
• Eliminates 50 positions within the Office of Education Services (there are currently 79 vacant positions, and 20 of them are educator/aide positions), and an additional 12 administrative positions (which are specifically identified). However, the Senate's budget does not include the reduction of residential services to 4 nights. It also does not include the suspension of on-site summer programs.
• The Senate budget includes an expansion item in the budget for the Divisions of Services for the Blind and Services for the Deaf and Hard of Hearing: $75,000 for contracted electronic information services, which allow visually-impaired persons to access print media through telephone systems.

The Division of Medical Assistance (DMA) budget has several changes:

• Keeps the $41 million reduction in enhanced mental health services, which includes delaying implementation of peer support services until January 1, 2011, but also specifies changes to Community Support Team (CST) to include reducing the limit of hours per week from 18 to 5, and reducing the rate from $15.60 to $11.80 per unit.
• It does not include the reduction in the Governor's budget for durable medical equipment program improvements.
• It does not include the provision in the Governor's budget related to the addition of an indepenedent asesssment on high-cost services.
• It does not include the proposed changes to several optional services: podiatry services, speech therapy, physical therapy, occupational therapy and respiratory therapy, adult dental care and private duty nursing.
• It does still include the proposals related to Personal Care services: eliminating the program in the community, but applying for a 1915(c) Home and Community Based Services waiver for personal care services in Adult Care Homes.

The sub-committees and the full appropriations committee will be meeting early next week to vote on the budget, which will then proceed to the Senate floor.

April 21 Commission for MH/DD/SAS Advisory Committee

The Advisory Committee met on Wednesday for a discussion regarding the impact of CABHA (Critical Access Behavioral Health Agency) at the LME Level and to finalize the 2010 priority areas for the Advisory Committee on Access to Healthcare.

CABHA Discussion

Betty Taylor, Director of CenterPoint Human Services, presented on the impact of the CABHA model. She spoke about the difficulties of so much transition and uncertainty in a very short period of time. CenterPoint potentially could have 11 providers qualified to provide adult mental health services in a CABHA, 10 qualified to provide child/adolescent mental health, 3 qualified to provide adult substance abuse, and 4 qualified to provide child/adolescent substance abuse services (there is overlap in these numbers - a total of 14 providers are in the process). Her primary concern seemed to be care coordination for consumers during the transition.

Cham Trowell from East Carolina Behavioral Health also addressed the committee regarding CABHA. She discussed the CABHA certification process and the basics of the CABHA model. She discussed her hopes that CABHAs will enable the system to be based more on outcomes, and to offer information to consumers about outcomes.

Each speaker presented a Powerpoint. Contact me if you would like a copy.

2010 Priority Areas

The Committee discussed a ranked list of 8 topics: Housing, Community Support, Workforce Development Initiative, Veterans with MH/DD/SAS, Traumatic Brain Injury, Developmental Disabilities within Criminal Justice System, Designation of Facilities for the Custody and Treatment of Involuntary Clients, and Dental Care. There were also several other recommended topics: group homes, employment, status of recommendations from the IOM's substance abuse task force, homelessness, evidence based practices, and training for providers.

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.