Future treatment for as many as 3,000 Wake County people with mental illness – from child sexual-abuse victims to former Dorothea Dix hospital patients – remains in limbo as the county works to complete a partnership with UNC Health Care and the Alliance managed care organization.
Under mental health reform, Wake County will no longer offer care through its own staff or choose professionals for treatment paid for by the federal Medicaid program. UNC is preparing to take over management of several operations at Wakebrook, a new mental health facility near WakeMed, and has committed to spending $30 million on the Wake system. Alliance Behavioral Health, based in Durham, will eventually coordinate care for people in Wake, Durham, Cumberland and Johnston counties.
But the involved parties are struggling to pin down and evaluate all the services Wake provides. Then they must find companies or nonprofits to look after mental-health needs of victims of child sexual abuse, people on hard-to-manage medications, jail inmates and ex-inmates, people with HIV and others. About 200 county employees are still in the dark about whether to seek jobs with UNC or another program, take severance packages, or take Wake jobs outside their areas of training.
“You’re going to have close to three thousand mental health consumers who at this point have no idea where they are going to be able to receive services once Wake County ceases providing care,” said Ellen Betts Clemmer, a retired Wake County licensed clinical social worker whose father, Dr. Wilmer Betts, helped open Wake County’s first mental health clinic in 1963.
The transition to having care provided through the Alliance MCO is supposed to take place by July 1. However, Wake officials say the process will be occur in phases and that the county could be granted extra time if needed.
The county, spending $22 million a year on mental health, had “imbedded” care for those groups into widespread operations and clinics. Now each part of the care that Wake County had offered through its Human Services Department must be examined as part of the ongoing “divestiture.” That means some other private or nonprofit entity will likely take over the work through a contract with Alliance.
But defining the heart of each service, and how best to replace it, is proving taxing for a 40-member mental health review team in which Wake leaders are joined weekly by advocates for people with mental illness, UNC, Alliance and other area hospitals.
“We think will actually provide a better level of service than what we are currently providing to our citizens,” county manager David Cooke said Friday. “We believe the services will be more efficiently and more effectively provided.
“Our goal is make sure that no one falls through the cracks.”
The Dix dilemma
An example of the way the county system has worked is the forensics program, which offers coordination between specially trained staff at the Wake County Sheriff’s Department and the mental health system. People with mental illness are monitored and receive care both as inmates and after release. That function will continue, but it’s not clear who will do the work, said Denise Foreman, assistant to the county manager.
“The question is, how do we maintain a service that has been important to us?” Foreman said. “How do we get that same level of service through a private provider?”
The team is coming up with detailed requests for proposals and descriptions for a range of services so that, for example, homeless people will continue to be treated at agencies logically located for their care, Foreman said.
Wake County resident Ann Akland, a longtime advocate for people with mental illness, notes that Wake has an unusually large number of clients, partly because of the closing of Dorothea Dix state hospital. “When Dix was in the phase-out status, they released 500 people in Wake County,” Akland said. “They have very serious problems. They also have some physical issues, so the total health of the person is more complex than someone who is only suffering from depression.”
The former Dix patients and many others have been treated as outpatients by Wake County, in many cases by the same professionals for years. People involved in the transition to managed care say they are putting a premium on making sure that fragile clients aren’t harmed by sudden changes. But Clemmer, the licensed clinical social worker who spent 25 years with Wake, says the situation is troublesome for staff and patients alike.
“You have a very experienced seasoned staff who still don’t know what’s going to happen to their jobs or whether they are going to be able to continue to work with these patients they’ve had therapeutic relationships with for years and years,” Clemmer said. “They are not all Dix patients. It’s a conglomerate of all of kinds of patients, mostly Medicaid and indigent patients. To try to absorb 3,000 Wake County residents who need those services right now, I don’t see how they are going to be able to do that.”
A ‘delicate’ transition
Jack Naftel, vice chair of clinical affairs for UNC, calls the transition a “delicate operation” that’s causing worries about people being lost in the shuffle of care.
Cooke, the county manager, credits UNC with working to pick up difficult parts of the system such as assessing patients in crisis and treating inpatient substance-abuse clients. In addition, UNC will be moving to electronic medical records, a national trend.
“Our philosophy is that these systems are functional now,” Naftel said. “We are going to go in, shadow the operations, see how Wake County is doing what it does now. When we go into Wakebrook, we are going to really make sure that Wake County has been billing Medicaid for all the services they could have billed for. We are going to try to beef up some of the services there.”
Cooke says Wake County has committed to spending the same amount of money on mental health services. Any additional money would have to be considered in the context of overall county needs, he said. “If we decide we want to keep doing a service, the question is, who is going to do it?” he said. “It could be another provider; it could be UNC if they so choose. We don’t have a preconceived solution.”