Grading the States 2006: North Carolina - Narrative

North Carolina is performing massive surgery on its mental health system, and the situation is critical at this time. Post-operative care will make the difference for people living with serious mental illnesses in the state.

The surgery was necessary. In 2000, the state auditor issued a report describing a system in collapse - characterized by fragmentation, lack of funding, lack of access to care, no crisis services, poor accountability, and hospitals that were failing patients. The state legislature enacted a reform plan, including voting $50 million to fund the bills. But then the national economy soured. The state chopped its budget. And the investment was withdrawn.

Meanwhile, the state has tried to move forward, essentially performing a multi-organ operation, involving state hospitals and community services, reorganization of service areas, and privatization of many aspects of care. Too much happens at once, with not enough funds and not enough support personnel. Then the bleeding starts. 

Every mental health system requires carefully balanced levels of care. That includes state hospitals for longer-term inpatient care, but its primary components are crisis centers and short-term acute inpatient and intermediate care facilities in communities, as well as outpatient community services like Assertive Community Treatment (ACT), supported housing, and independent living options.

If a state starts closing or reducing hospitals without community services in place, it soon gets in trouble. If services are not available, the entire system backs up. Long waiting lists reduce access. People languish in hospital beds at one level because they can't be placed elsewhere - or discharged, if outpatient services aren't available. Overcrowding and shortages arise.

The problem is one of capacity. In human terms, a person who experiences a psychotic episode ends up discharged prematurely from the hospital before medications have had time to work. If a follow-up appointment is scheduled, no one investigates if the person never appears. According to advocates, in some areas, if a person misses three appointments at a local mental health office, they are dropped. If they turn up later, they have to go through the admission process all over again.

Dorothea Dix Hospital in Raleigh, the main state hospital, and John Umstead Hospital in Butner, North Carolina, will be closed, to be replaced by a single new hospital in Butner. Unfortunately, advocates report that the net result will be approximately 200 fewer beds, and that community services "absolutely are not in place to deal with it."

In December 2005, a Winston-Salem Journal series, "Breakdown: A Crisis in Mental Health Care" examined what went wrong. The co-chair of the legislativeoversight committee answered, succinctly: "The missing factor is money." That should not have come as news to anyone. The agency's five-year plan in 2001 clearly noted: "The massive disconnect between the resources needed for supports and services and resources available to provide supports and services is the most important factor in North Carolina." 

Coming on top of difficulties involved in the transformation, the U.S. Department of Justice (DOJ) cited the four state hospitals in 2004 for a litany of violations:

• inadequate mental health treatment
• inappropriate use of restraint and seclusion
• inadequate nursing and medical care
• failure to ensure reasonable safety of patients
• unsafe physical plant conditions
• inadequate discharge planning

"A major cause of many of the unlawful conditions we identified stems from a fragmented, decentralized mental health system with unclear, unspecified standards of care, and an insufficient number of adequately trained professional and direct care staff to meet the needs of patients," observed DOJ. The hospitals were cited for "inadequate assessments and treatment planning, inadequate care for patients with specialized needs,inadequate psychosocial rehabilitation services, and inadequate psychopharmacological practices."

DOJ's observations also exposed the chasm between the hospitals and community services. In one case, a hospital patient was discharged simply to "self," and another to a homeless shelter.

Still, there are positive features:

• DOJ has acknowledged that NC has been "collaborative" in working to address violations at the hospitals. At Dix Hospital, DOJ found an "exemplary Clinical Research Unit and good behavioral programming on the specialty deaf service."
• Planning for the transformation is open and transparent. The state appears open to feedback and willing to learn from experience.
• Medicaid in NC has not taxed service recipients with high co-pays, medication restrictions, or other barriers to care.
• The state is exploring possibilities for using Medicaid funds to support evidence-based practices (EBPs) such as ACT.
• Development of alcohol-dedicated units will help to reduce bed demand at the state hospitals.
• Jail diversion exists in many areas of the state in pre- and post-booking services.

At this stage, one highly symbolic as well as practical step might be for the legislature to dedicate all revenue from the sale or redevelopment of state hospital land or facilities to the mental health system. A hospital closure should be seen not as a cost-cutting measure, but as a transfer and reinvestment of resources. Those resources can serve as a "trust" for people with serious mental illnesses.

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