The state needs to answer basic questions about money and responsibility before it can build an effective mental-health system, according to a report out today.
After many rounds of mental-health revisions, including the reform of 2001, the state should make clear which patients should get public care, who should be paid for it, who should be responsible, and who should provide the treatment, said Mebane Rash, editor of North Carolina Insight, a journal published by the N.C. Center for Public Policy Research in Raleigh.
"Those four things have to be in place for the state to have a model mental-health system," Rash said.
Caring for people with mental illness has evolved with changes in federal laws, court decisions and medical advances, but questions about quality, cost and responsibility have persisted over the centuries, according to the Raleigh think tank's study of the history of mental-health reform.
The structure that was supposed to support the latest changes remains unsettled.
In 2001, the state started a mental health reform effort with the goal of treating more patients near their homes and fewer in psychiatric hospitals. Though the state eliminated hundreds of hospital beds, the number of patients admitted for short-term stays increased. The short-term wards got so full that the state decided to cap admissions.
Local mental-health offices, which must follow state guidelines but are not run by the state, stopped providing most services. Private companies stepped in to provide care. But people with severe mental illnesses still have trouble getting treatment.
The public policy report highlights the shortage of trained workers available in communities.
Rash said she saw some promise for attention to work-force issues in Gov. Beverly Perdue's budget proposal, which would add $325,000 to train hospital workers and expand a psychiatric nurse scholarship program.
The tug-of-war over who is in charge of mental health has gone on for years, with state administrators arguing for more control over local offices. "We still don't agree on what the system ought to look like," said Rep. Verla Insko, a Chapel Hill Democrat who helps run a legislative oversight committee on mental health.
Insko said the Insight report was right about the questions that need solutions, but the legislature and state administrators haven't come together on the issues. "I don't think things will change until we change the way we do things," she said.
Patients were hurt by disconnections between local care and state hospitals. Often, there was no follow-up treatment planned for patients when they were discharged. Patient deaths and abuse have kept the hospitals in trouble with the federal government.
Part of the problem with crowding in state hospitals was that local hospitals stopped admitting mentally ill patients. The state is seeking to rebuild the stock of local beds by signing contracts with hospitals to keep space reserved for mentally ill patients. In her budget, Perdue proposes shutting down 50 state hospital beds while adding $12 million to pay local hospitals to reserve 111 additional beds for mentally ill patients.
The center will look at the effectiveness of that strategy in its second report on mental health, which will be published later this year.
"On the one hand, we know that regional hospitals sometimes don't provide the kind of care that works best for people who need around-the-clock supervision," Rash said. "On the other hand, we absolutely need local, inpatient beds for clients that can be served in a week or less."
The center's second report will explore local mental-health operations, and discuss the pros and cons of privatization.
The third report will include a survey of mental-health systems in other states, interviews with policymakers and suggestions for future action.