2016
January 1 2016 to March 31, 2016
Children and adolescents with complex mental health needs receive medically necessary community-based services and supports.
Summary of Progress:
Disability Rights continues to work on Target 6 to ensure that children with complex needs in North Carolina get the health care they need when they need it – the right care to the right child at the right time and in the right setting. This is the mandate under Medicaid/EPSDT (Early and Periodic Screening, Diagnosis and Treatment). This is the legal tool we plan to use to keep pushing this issue to the forefront of our state officials, DHHS, providers, LME/MCOs by pursuing numerous innovative advocacy legal efforts/initiatives.
Disability Rights NC provided training about the EPSDT mandate at the NC Council on Community Program annual conference in December, at NC Tide training in Wilmington in April and anticipates partnering with AHEC to provide further training to providers. Making EPDST operational is a goal that is directly tied to the four demands - ((1) every child that needs case management or intensive care coordination services receives it; (2) children and adolescents across North Carolina have access to clinicians who have the expertise to address all of their needs (developmental disabilities; mental health and pharmacological); (3) families have someone who is available to resolve disputes that may arise; and (4) NC START is operational for all children in North Carolina).
Disability Rights NC continues to meet monthly and collaboratively with DHHS, LME-MCOs and community providers about the four demands. This past quarter, we were able to initiate progress on the expert demand. A Lean event was held to organize dual diagnosed experts and determine how they can be a meaningful resource for this population. This piece of the demand is still in its infancy stages. Additionally, our consulting expert attended the March 18, 2016 meeting to share that a lot of work is being done, but it is not enough that has made much change in our client’s lives. He encouraged them to operationalize the four demands in a way that will make a difference in the lives of our clients. He emphasized that making NC START available to children in all catchment areas and ensuring that children have access to someone who is bird-dogging the case will go a long way. NC START teams are operational only in Alliance’s catchment area and have made a big impact in the lives of our clients who are receiving the service. Although we have not been able to confirm, DHHS Department leaders shared that allocations letter were distributed three LME-MCOs. Letters were sent to the individual LME/MCOs encouraging them to add additional funding to make the services available statewide.
Disability Rights NC partnered with NHELP and Legal Services on Piedmont to provide comments on North Carolina EPSDT Policy Instructions. The North Carolina EPSDT Policy Instructions provide direction to North Carolina vendors and contractors taking responsibilities under North Carolina’s Medicaid program on how to implement the federal EPSDT mandate. This has been a very helpful advocacy tool as well. We reviewed the proposed policy and made suggestions for how the North Carolina EPSDT Policy Instructions can continue to reflect the excellent content of the current policy. While the proposed updates eliminated redundancy that appeared in the current policy, it excluded many of the helpful examples and some of the proposed modifications introduced confusion. We requested that the current language remain to reduce the confusion.
Governor McCrory released his budget on April 11, 2016. He is nibbling around many of our issues. His funding budget includes the following:
1.Invests $30 million to implement the recommendations of the Governor’s Task Force on Mental Health and Substance Use, including transitional housing, case management, mental health first aid training, child crisis centers.
2. Invests $2.5 million to expand Medicaid services for people with developmental disabilities. This investment supports an additional 250 Medicaid Innovations Waiver slots providing the needed services to help individuals with developmental disabilities live successful lives in the community.
3.Includes a line item for children who have autism and receive Medicaid to have access to ABA therapy.
We are also being told that a letter went out to the LME/MCOs on Monday, April 18, 2016 from DHHS requiring EPSDT compliance and outlining the process for approval/billing of autism relates services.
We will continue to demand that this population receive what they need, timely and in the right setting.
Examples of Individual Closed Cases Only:
MH: InOctober 2015, MH’s mom called to share that her son had only been authorized to receive respite services and that the service had been discontinued without notice. She shared that MH had been hospitalized four times in the past and that he had had three suicide attempts. She shared that because of his complex needs, he needed the respite services restored.
Disability Rights NC contacted the legal team at Cardinal Innovations and shared a summary of what had happened. The legal team conducted an investigation and had Dr. Ronata Hall complete a comprehensive assessment. MH’s respite services were restored and the following recommendations were made to assist with meeting MH’s ongoing treatment needs: 1. Obtain a psychiatric evaluation; 2. Obtain an OT evaluation for sensory issues; 3. Obtain a behavioral consultation; 4. Obtain parent skill training; 5. Obtain a pharmacological assessment; 6. Make a referral to Autism Society; 7. Make a referral to sleep study; 8. Obtain a trauma screening; 9. Re-instate respite, 10. Request skill building and additional B3 services; 11. Assign care coordination to the case; and 12. Schedule a family team meeting. All of the recommendations have been implemented. The case is closed.
AF: We opened AF’s case in November 2014 when his grandmother called to share that he was at Caldwell Memorial Hospital in the emergency room and had been there for over two weeks without any treatment. She shared that his crisis team at Smoky was struggling to identify appropriate discharge services/treatment for him. She was also concerned that AF had been given high doses of Thorazine and Depakote to contain his behaviors.
Disability Rights NC contacted the hospital liaison at Smoky and requested that he assist grandmother with discharge planning and help the treatment team develop more meaningful options to correct or ameliorate AF's condition. AF was eventually transferred to Strategic Behavioral Health in Leland. Disability Rights NC requested that an IDD and MI care coordinators be staffed with his case to address not just his mental health needs, but instead address his IDD/MI needs, concurrently. This request was granted. Disability Rights NC attended several child and family team meetings via conference call and discussed step-down options for AF. We worked to make sure that AF received the right care at the right time in the right setting. Disability Rights NC Education Team was instrumental in helping AF access services in the school setting as well. This helped to alleviate many of the issues as many of AF’s behaviors manifested in the school setting. Austin is doing well.
AM-C: AM was identified through our monitoring efforts at Central Regional Hospital. AM was receiving treatment at CRH, but was unable to access services to transition back to the community due to her immigration status. Disability Rights NC staff worked very closely with the treatment team at CRH and the legal team at Alliance to secure the medically necessary services for her. AM transitioned back to the community in early March and is doing well.
Example of Advocacy on Behalf of a Group:
- Continued monthly meetings with DHHS/LME-MCOs regarding children and adolescents who have complex needs. See details in above summary.
- Comments on revisions for NC Medicaid’s EPSDT Update. See details in above summary.
Coalition Activities (if part of the work plan):
- Monthly LME-MCOs/DHHS workgroup meetings to enforce recommendations from our consulting expert.
- Monthly case review meetings with LME/MCOs to discuss specifics of cases and gather trends and promote resolution.
- Lean Event. See details above in summary.
Helping people with disabilities transition out of institutions into the least restrictive community setting.
Summary of Progress:
Disability Rights NC continues to work with individual clients to help them access the services promised by the state in their settlement with the U.S. Department of Justice. Additionally, we are researching the issue of institutional bias that pervades the North Carolina behavioral health services system, including the failure of discharge planning as individuals return to the community, lack of case management, barriers to discharge, etc. We are working across teams to identify specific issues and clients while we research how to respond to the systemic issue of institutional bias.
Examples of Individual Closed Cases Only:
Wereceived a call from special counsel at CRH about a fifteen-year-old at the hospital who was sexually abused by her step-father at the age of 11 and in danger of being discharged back to that same environment. She was unable to access mental health services due to her immigration status. We were able to help prevent discharge back to the unsafe home environment and were able to confirm with her clinical team that an out of home placement was needed. Disability Rights NC agreed to assist with helping this individual access the medically necessary service needed to complete her discharge from CRH.
Investigate and report on the safety of people with mental illness admitted to our jails.
Summary of Progress:
Staff continued to reach out to suicide prevention efforts in NC and the nation to gather the most relevant documents and resources for the report.
Autopsies revealed two additional deaths caused by jail personnel’s mishandling of behavioral issues.
One person died in a restraint chair after 9 continuous hours of restraint. The policy required release after two hours. (Carteret County)
Another died after a week of “bizarre” behavior. When he was finally taken to the hospital he was found to have lithium toxicity, elevated renal function studies and elevated potassium, LDH and CK. He was pronounced dead at 2:00 am the next morning. The family has legal representation. (Craven County Jail)
Ensure appropriate treatment for people with mental illness in North Carolina prisons.
Summary of Progress:
Disability Rights NC staff continue to monitor conditions in the prison to forcefully advocate for reforms; we continue to work in two coalitions pressuring administrators to quicken the pace of implementation on promised reforms; engage in issue outreach and correspond with inmates who have MH treatment needs.
Most significantly this quarter was the commitment of Commissioner Guice to end juvenile segregation, including an order to his executive staff to develop written policies in short order.
Example of Advocacy on Behalf of a Group:
During a meeting with Commissioner Guice and his executive staff on March 17, 2016, Disability Rights NC understands the Department will take the following actions [note that Commissioner Guice returned the first draft of new policies to the Director of Prisons because they were not as far-reaching as he thinks is needed]:
1. Director Solomon and his staff will develop policies governing the confinement of youth, ages 16 and 17 years old, in Adult Corrections within 2 weeks (March 31, 2016);
a. Under the policy to be developed, no youth will be assigned to a control status (ICON,MCON, HCON);
b. The policy will define disciplinary sentences for this population that are shorter than the punishments used for the adult population;
c. The policy will include a specific out-of-cell hour requirement when youth are removed from the general population;
2. At least three additional programming/clinical staff will be added to D-Unit, youth population;
3. Maintaining family connection will be facilitated by weekly calls to home/family by the youth;
4. Mr. William [Billy] Lassiter and his staff [JJ staff] will assist with targeted staff training on adolescent development.
Outreach:
Staff participated in a panel the UNC School of Law regarding prison segregation in NC on February 27, 2016. The conference was called Cruel and Unusual: How the United states Punishes Persons with Mental Illness, the 2016 Conference on Race, Class, Gender and Ethnicity (CRCGE).
Coalition Activities (if part of the work plan):
See above for meetings the Prison MH Coalition and the law-based Coalition had with DPS.
Public Policy Activities (if part of the work plan):
The Prison MH Coalition sent a letter in March, 2016, to the Governor, Secretary and Commissioner Guice urging additional funds be sought during the short session for prison MH services.
Promote the self- determination of people with mental illness
Summary of Progress:
Activities this quarter focused on the Rethinking Guardianship work group, which has developed smaller committees, one of which is devoted to statutory and regulatory changes. That smaller group has begun to explore possible changes to NC’s guardianship statute, Section 35A, as well as other changes in guidance to Clerks, guardians (public, contract, and family), guardians’ ad litem, and others that would further our vision of utilizing alternatives to guardianship more readily and making guardianships less restrictive.
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