The editorial board and some news reporters met with Wake County manager David Cooke and several other folks this week to get an update on upcoming changes that are transforming the behavioral health system. The other participants were Denise Foreman, assistant Wake County manager; Brian Sheitman, medical director at WakeBrook and a UNC psychiatrist; Jack Naftel, vice chair of the UNC Department of Psychiatry; Anita Watkins, strategic relations at Rex; Rob Robinson, COO of Alliance Behavioral Healthcare, and Alan Wolf, media relations at Rex/UNC.
I heartily thank Alan, a former N&Oer, for his synopsis here of the situation:
Because of Medicaid restrictions, Wake County was forced to divest itself from the business of providing mental health care and services as of July 1. That responsibility now falls to Alliance Behavioral Healthcare, one of nine Managed Care Organizations, or MCOs, across the state. Alliance is working with various provider partners, including UNC Health Care.
In 2012, UNC Health Care began the Wake County Behavioral Health Partnership, in collaboration with Wake County Government and Alliance. The goal was to help create a smooth transition of behavioral health services from Wake County to the local MCO (Alliance).
As part of UNC Health Care’s mission to serve all of North Carolina and last year’s settlement agreement with WakeMed, UNC Health Care agreed to assume management and operations of the WakeBrook campus. WakeBrook is a behavioral health campus owned by Wake County on Sunnybrook Road in Raleigh. The goal is to enhance and expand the services and care available to behavioral health patients and to ease the strain those patients put on hospital emergency departments.
UNC Health Care began running WakeBrook in February, with a phased-in approach, hoping to create an innovative model of comprehensive mental health that will allow patients to be matched with the level of care they require. As patients’ needs change, they can shift between different levels of care in one location.
The financial model is also a collaborative approach. Wake County will continue paying the same amount for the care and services at WakeBrook as it has in the past (the budgets for Fiscal Year 2014 and 2015 each include up to about $10 million). UNC Health Care agreed to invest $40 million to improve mental health care in Wake County. Some of that money is being invested to improve the WakeBrook campus, including adding 28 inpatient beds, and some will pay for care, treatment and services.
What’s happening at WakeBrook?
Since February, UNC Health Care has taken various steps to improve the care and aervices available at WakeBrook. They include:
• Taking over management of crisis and assessment and operation of 16 residential crisis beds and services.
• Assuming oversight of a 16-bed Addiction Treatment Center for substance abuse and detoxification and rehabilitation.
• Improving existing space at WakeBrook to add 16 inpatient psychiatric beds that will be available to patients in July. (This was a Certificate of Need that was approved by the state in February. It involved converting 16 existing but unused beds to inpatient beds for acute levels of care.)
• Filing for state approval (a second Certificate of Need) to add another 12 inpatient psychiatric beds. Plans are for those additional beds to be operational in mid-2015.
• Adding clinical staff at WakeBrook, including psychiatrists (and medical coverage, including lab and X-ray) 24/7 to substantially reduce the need for patients to go to local emergency departments.
• Forming an Assertive Community Treatment Team, or ACTT, to improve the outpatient care available and provide a more proactive approach to treating behavioral health patients.
• Opening an outpatient clinic at 3010 Falstaff Drive, Raleigh. The UNC STEP Community Clinic will improve the treatment and management of more than 500 seriously and persistently mentally ill patients in Wake County.
• Coordinating with local Emergency Departments and advance paramedics to coordinate patient care and reduce the number of mental health patients in the emergency department,
What are the services available at WakeBrook?
• Crisis and Assessment Service: immediate attention for patients suffering from mental illness, developmental disability or substance abuse disorder.
• Facility Based Crisis: a 24-residential facility with 16 beds.
• Addiction Treatment Center: detox and rehab for substance abuse in a 16-bed, 24-hour residential treatment program.
• Acute Inpatient Psychiatric Unit: a 16-bed facility opening in July to provide short-term psychiatric inpatient care. (This will expand to 28 beds in 2015
with the addition of 12 more beds.)
What follows are my notes from the meeting. They are NOT verbatim.
County manager DAVID COOKE: One way to describe what’s going on is we had to become part of a managed care organization. Up until last year, Wake County was in the mental health business. We were all in the mental health business. Over the last two years, we had to do two things: One, we had to align with another managed care organization. Wake County merged with Durham in the creation of Alliance Behavioral Health. The merger with Cumberland will be effective July 8. It’s on our board agenda for July 1, the final step. Durham has already approved it. Cumberland approved it. Wake commissioners are the last body to approve it.
All of the money for mental health, the Medicaid dollars, state dollar or local dollar will flow through that organization. They’ll be handling $400 million worth of federal, state and local dollars to provide mental health, developmental disabilities, substance abuse care. Now all the money including our county and state monety that used to come to Wake, and the Medicaid money, all flow through Alliance.
We were also a provider of service. We had to get out of being a mental health provider of service business by June 30. What we’ve had to do is a divesting of services. Some we talked UNC into doing. The rest of the services were competitively procured. We solicited proposals, working with Alliance, and we’ve gone through the entire provision of service and found other providers to do it.
We don’t take this lightly. You’re a client of mental health services of Wake County and you’ve been going to the same person for 10, 15 years. Saying to that client, “You no longer come to Wake County. Now you go to Monarch, which is a provider,” or “You’re going to UNC.” When you think about the transition for clients, it’s a very difficult transition, and it’s all occurring right now. Clients are having to transition from being served by Wake for years and years to another provider. We tried to put a lot of care into that transition. For people who are vulnerable, that has to go smoothly.
Q: What happened to the Wake County mental health employees?
BRIAN SHEITMAN, medical director at WakeBrook and a UNC psychiatrist: Many were offered positions. Very few have accepted positions with UNC. One of the people in crisis and assessment services has remained.
COOKE: The other piece of that, the exciting one, is the partnership with UNC. This really started about two years ago when UNC and Wake County a study and worked with the state to look at behavioral health services and identify gaps that would need to be filled. The study’s under way coincidentally at the same time this issue between WakeMed and Rex. There was this situation with WakeMed wanting to buy Rex. Part of the settlement agreement of WakeMed stopping pursuit of Rex was that UNC agreed to spend $30 million to build 28 inpatient beds, which comes from that study. The commitment to do 28 beds inpatient and an additional $10 million on outpatient services, Wake County was a huge winner in that settlement agreement. We’ve been working in partnership with UNC, and UNC has been running WakeBrook since February. They have been running WakeBrook, the crisis center at WakeBrook and the substance abuse detox facility since February.
Some of the inpatient beds will become live next month. The way they’re going to provide services at WakeBrook has been in transition, but UNC has been running it since February.
SHEITMAN: It was a unique opportunity to get the thing somewhat right. The WakeBrook campus, most places are open Monday through Friday 8 to 5, then if you’re in a mental health crisis, you go to the Emergency Department. We have 400 to 450 people a month (coming to WakeBrook), which is great. Except it wasn’t complete. What wasn’t finished was there’s not much medical coverage there. If you had a medical problem, too, you were sent to the hospital across the street, which in this case would be WakeMed.
One of the future plans is to open medical clinic at WakeBrook. People with serious mental illness die a lot sooner. We want to set up a clinic there and really expand the medical coverage, complete what was already started. We also want to work with WakeMed and Wake County emergency medical services. When people call 911, they don’t say, “I’m hearing voices” or “I want to kill myself.”
In the real world, a person will come into the ED, say “I’m suicidal,” sometimes they’re drinking or using drugs. Within 12 hours they’re no longer suicidal but need substance abuse treatment. WakeBrook has a substance abuse treatment facility, 16 beds. If you come in and it’s clear what your problem is, we can specialize. It’s like a stepdown unit for an acute unit. If you have a medical problem and get admitted to a medical hospital, you might have to go to intensive care for a day or two, then you get stepped down to a four-bed. WakeBrook has those kinds of pieces in place. This has potential to model what goes on in the medical world. You read about state hospitals not having enough beds. On the acute units, there’s no need for people to stay that long. We could demonstrate over time how to do that (create a step down situation), which would lead to better care and less money because people don’t need the acute beds.
If you look at Wake County, data from the database, and compare it to Orange, the same number of people are on Clozapine when Wake is so much bigger. Clozapine is complicated. You have to draw blood, and a lot of people don’t want to do it because it’s a hassle. At the state hospital, we had people who people thought were impossible to treat. A lot got better, and not giving people the opportunity is terrible. I had one patient who for 15 years heard voices all the time. I work with her a year before she agreed to do it. The voices are gone. She goes out with family. We have to make sure we give people a chance.
Another thing I’d like to do is look at the jails. It’s a tragedy we have so many young, psychotic people in jails. We need to go out and get them to WakeBrook and give them treatment. It’s better care.
Q: How many of the 450 visits a month are repeat patients?
SHEITMAN: It depends on the severity of the patients. One-third of those who come in are triaged out. They come in and say, “I’m not doing that well. Can I talk to someone?” We get them an appointment and there’s no need to keep them. Another third come in with a bigger problem and may stay 6 or 8 or 10 hours. We hook them up with an appointment, and then they’ll go out. And there’s a third who end up getting hospitalized. It’s the people who are the most complicated who wait the longest to come in. It’s not an insurance issue but a complexity issue.
The wait now is almost two weeks for a bed (in general). Someone’s in prison, who got out of prison and is psychotic, and no one will take them.
JACK NAFTEL, vice chair of the UNC Department of Psychiatry: That’s the kind of patient we’re going to try to treat in WakeBrook. The other services I should bring up UNC is offering. We’ve got an assertive community treatment team we started in March. We picked up 22 patients on that team. That’s a team that goes out and treats people in their homes, makes sure they’re doing OK, to keep them out of higher levels of care. We’ve agreed to take the 500 chronic and fragile patients Wake County was seeing, patients with severe illnesses, taking two medicines, getting shots. We moved our research center in with that clinic, so we’ll be doing population-based research there.
COOKE: This mental health issue permeates all these institutions. Part of the money the county spends is care of people in the jails. If there’s a better way to do it, not only can a person get better care but we can save money in other institutions. The money we’d spend on jail or over here on mental health, we have to connect those two things, the effect and the outcome. It’s exciting to have UNC at the table because they bring that expertise and the School of Psychiatry. From an institutional standpoint, we hope to see benefits in a lot of institutional areas.
First-responders are part of this system. A lot of times paramedics will go out there and sometimes know the people. With these protocols they can decide they don’t need to go to the ER, let’s take them to WakeBrook. What the system is trying to do is figure out the best place to send someone after a 911 call.
Wake County has been spending more money over the years on mental health. The building of WakeBrook, we’re currently spending about $25 million a year. That all flows through alliance. We added $800,000 to the budget this year.
And UNC is spending more money. There is more money going into this system.
ROB ROBINSON, COO of Alliance Behavioral Healthcare: The state is spending less money, both on Medicaid funding and indigent funding. With the ACA, if North Carolina takes that on, the number of people on Medicaid will increase, and more money will flow to us for services.
Q: What happened to the Wake County mental health employees?
COOKE: They had the opportunity to apply for jobs with companies assuming provision of service, ask to get another job in Wake County or they can retire or take severance.
On the fragile 500, Denise convenes a group every two weeks or once a month, it used to meet weekly, and it includes all the hospitals, NAMI Wake County, advocacy groups. When we talked about divesting adult mental health services, Jerry Akland (of NAMI) put a halt to that. He said we ought to be able to categorize the patient, the people who are really fragile we need to take extra care of. UNC agreed to do that. They’ve stepped to say we’ll take the most fragile of that 500. Let’s define who that is.
Q: There has been so much mental health “reform.” People talk about needing more state hospital beds. How do you know this will be the right way?
SHEITMAN: Nobody explained to me how many beds do we really need if we do everything right. There’s a fantasy that no one needs a long-time bed. I don’t think it’s true, but it’s not clear how many we need. We need to figure out the optimum number of beds. If we had better outpatient services maybe people wouldn’t be in crisis so often. We could follow people. What’s the right mix to provide access and quality? People should have access to appropriate services, and the services should be a reasonable quality.
Some people medical science doesn’t know what to do with that. It’s like that in every specialty. Behavioral health has patients we don’t know how to treat yet. I don’t think we’re ever going to eliminate that. And there’s a big overlay of social problems. If people don’t have a place to live, food, money, a place to take a shower, they’re going to have problems. That’s just the human condition.
ROBINSON: We haven’t had stability in our public mental health system since 2002. We just got started in the managed care environment, and the governor has proposed another plan. The budget cuts have also not been helpful. Wake County for me is definitely going in the right direction. In We’re in the midst of redesigning the system, led by Wake County, UNC. We have new providers in the area with good reputations. We need to get through the transitions, see where we stand. We have the makings of a good foundation. We need stability and not using behavioral health services for every budget cut.
SHEITMAN: The real problem is we don’t have an IT system to monitor outcome measures. Data goes into a black hole for a few years, someone finds a problem. How would we claim victory? No one ever knows. Where’s the data analysis? We’re fundamentally always going to be this problem.
COOKE: But part of the expectation of this managed care organization is to provide those measurements, to be able to say whether the money is being spent in the right way to provide those services.
The idea of mental health reform in my mind was somebody decided all these citizens didn’t have to be institutionalized and could be taken care of in the community. The state downsizes state beds and assumed community services would take it up from there. When we were just starting to build WakeBrook five years ago, we were working with UNC, we did full due diligence on what it would take to operate WakeBrook. We weren’t going to have to build inpatient beds in communities. That was the state’s responsibility. We were going to do lower level. But UNC looks at the data and says we’re afraid those things are going to turn into inpatient beds. So what are we doing right now? Building 28 inpatient beds at WakeBrook. It was predicted. It was predicted after the assumption that it wasn’t going to go in that direction.