Community mental health services for young adults challenged

Budget cuts make it increasingly difficult to aid those in early 20s

lbonner@newsobserver.com December 22, 2012 

  • Report lauds three-way contracts Local hospitals under contract to the state admit nearly as many psychiatric patients as the three state psychiatric hospitals combined, according to a new report by the N.C. Center for Public Policy Research. The center’s report focused on a practice beginning in 2008 that had the state and local mental health offices sign contracts with local hospitals to treat psychiatric patients. The “three-way contracts” as they are called, were meant to keep people who needed short-term admissions in hospitals close to their homes. The state started in 2008-2009 with contracts with 13 hospitals and 77 beds. Additional space has been purchased, and 122 local hospital beds are under three-way contracts. The average length of stay for patients admitted through a three-way contract is seven days, according to the report, and readmission rates are lower than for state hospitals. The center concluded that the three-way contracts are a qualified success. Staff writer Lynn Bonner

The mass shooting in Connecticut this month has brought increased attention to the lack of community mental health services available for young adults in North Carolina.

The shooter in the Connecticut massacre, 20-year-old Adam Lanza, was at an age where it’s hard to find community mental health treatment, said Vicki Smith, executive director of the Disability Rights North Carolina, an advocacy group.

“In North Carolina, he already would have fallen through a big crack in the services,” Smith said of Lanza. “A target for the coming year is to address the huge gap.”

But while the mass shooting has encouraged debate about the availability of mental health services nationwide, doctors worry about stigmatizing mentally ill people by tarring them as violent.

“I don’t want the stigma of mental illness to get attached to violence,” said Dr. Michael Lancaster, a child psychiatrist and director of mental health programs for Community Care of North Carolina, a network of locally controlled Medicaid managed-care organizations. “Few people with mental illness are capable of violence.”

The late teens and early 20s can be a time in a person’s life when mental health problems may first appear or intensify. Older teenagers have likely left school, have aged out of foster care, or are no longer young enough to live in residential institutions that treat children and adolescents.

“It’s catch-as-catch-can in terms of mental health services,” said Art Frankel, a professor of social work at UNC-Wilmington, who has studied the state’s mental health services. “They’re out of school, they’re out of foster care, they’re on their own.”

Older teenagers’ Medicaid eligibility has changed, so they may have to apply on their own for the government insurance program. And they are responsible for signing themselves up for treatment, something teens or young adults may be reluctant to do.

“There is sort of a transition challenge going from child services to adult services,” said Beth Melcher, chief deputy secretary for heath services at the state Department of Health and Human Services.

A federal law is supposed to ensure that low-income people younger than 21 receive necessary mental health treatment, but help can be hard to get, said Mark Brown, principal at Melange Health Solutions based in Charlotte.

“If a kid is aging out and requesting services, you have to make a compelling case for them,” Brown said. “It’s higher hurdles than if they were 15 years old.”

The Connecticut tragedy has united politicians of both parties behind the need for better mental health services.

Gov.-elect Pat McCrory, a Republican, said the shootings were a “wake-up call” to the state and nation.

“No doubt mental health is a major factor in these violent acts by primarily lone individuals who have some serious issues related to mental health,” he said. “Frankly, we have a broken mental health system in our nation and in our state. We’ve got to do some serious work to close those deficiencies.”

Feeling bruising cuts

Getting mental health treatment as a young adult isn’t easy in North Carolina, and the state is still recovering from a failed reform effort that had patients crowding hospitals and the state wasting money on low-level services for people who did not need treatment.

Patients, their families and advocates say they are getting worn down by constant changes, budget cuts and broken promises.

The state budget last year cut $20 million, or 8 percent, of the money used to purchase mental health treatment. Local mental health offices were to use reserve funds to make up for it.

After hearing from politicians for years that they wanted money from a sale of Dorothea Dix Hospital property to be put in a mental health trust fund, advocates were discouraged that the long-term lease with Raleigh provided no money for mental health.

Meanwhile, the state is in the middle of another sweeping transition, consolidating local mental health offices and converting regional offices into versions of managed care insurance companies.

The regional offices will receive limited money for mental health treatment and must provide therapies within those budgets. The aim is to put money toward the most effective services while controlling expenses in Medicaid, the government health insurance program.

Legislators and state administrators are optimistic about the reorganization, but people who watch and have to live with the change are not so sure they will lead to more effective treatment.

“I’m troubled by the system in the state, and it doesn’t look to me like it’s getting any better,” Frankel said. “It is not a happy scene for mental health in North Carolina. Everyone is talking about it.”

Hope in managed care

Patients and mental health providers are watching to see how mental health treatment fares under managed care.

Ann Oshel, director of Durham programs at the multi-county mental health office Alliance Behavioral Healthcare, said the moving to regional managed care offices will make it easier for administrators to attend to young adults mental health needs.

Durham is using a federal grant to provide mental health services to 16- to 21-year-olds in a way that takes into account their special circumstances and their frequent reluctance to seek treatment.

The effort involves schools, parents or guardians, police, probation officers, and a job counselor, in addition to mental health professionals, Oshel said. Over the life of the program they expect to enroll 800 people.

Oshel wants the Durham effort to be one other mental health offices in the state can copy, and she said that the change to managed care should make that easier because offices will have the chance to set up programs aimed at special populations.

“A lot happens between the ages of 16 and 21,” she said. “This is the best opportunity we have as a community to get them the help they need and get their lives on track.”

Rep. Nelson Dollar, a House budget writer, said legislators want to look at all areas where mental health treatment falls off.

“We are focused on analyzing where the gaps are in our mental health system and working on strategies to close those gaps in terms of services that are offered,” the Cary Republican said. But converting mental health offices to managed care organizations must be a top priority. “They’re going to be the framework around which we address areas that are gaps in coverage,” he said.

Staff writer Craig Jarvis contributed.

Bonner: 919-829-4821

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