Issue Brief: Transforming North Carolina's Mental Health and Substance Use Systems

Strengthening North Carolina's Public Mental Health and Substance Use Prevention, Treatment, and Recovery Services and Supports

North Carolina's public mental health and substance use disorder service system has undergone tremendous and nearly continuous change over the past 15 years. No single agency is in charge of the public system today. The Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, the Division of Medical Assistance, and the North Carolina General Assembly wield the most influence over the public system through service contracts and funding. The North Carolina Department of Health and Human Services has identified a number of concerns/gaps in the current service delivery system including: emergency department overutilization, lack of available inpatient beds, mismatch between available services and individual needs, lack of prevention services, fragmentation, underfunding, and a heavy focus on individuals in crisis.

One challenge that continues to plague the public mental health system for adults is the heavy reliance on the highest level of care, inpatient services. There is a need to balance the system with more prevention and other community-based services that can decrease the need for higher levels of care. System balance cannot happen without additional resources in the short-term, because funding cannot be removed from inpatient services if a comprehensive system of lower intensity services is not in place to keep people out of higher level services. Stability of existing funding as well as additional resources are required to correct imbalances in the current public mental health and substance use services system. Recommendation 2.1: Support and Expand Availability of a Full Array of Mental Health and Substance Abuse Services through LME/MCOs. In addition to needing adequate funding, mental health and substance use funds should be spent on services that have been shown to produce positive outcomes or on actual improved outcomes for individuals with mental health and substance use disorders. Recommendation 2.6: Increase Utilization of Evidence-Based Mental Health and Substance Use Services and Tie Payment to Positive Health Outcomes.

Successful treatment and recovery cannot happen if people do not access services. However, most North Carolinians do not understand who provides which services, whether services are covered, or how to access services. Case management services, which provide a bridge to navigate the multiple systems, can improve quality and decrease expenses. Recommendation 2.2: Create Medicaid Case Management/Recovery Navigation Options. Currently, state funding for mental health and substance abuse treatment services is inadequate to meet the mental health and substance use treatment and recovery needs of the uninsured and underinsured. This leaves many of our most vulnerable residents without the services they need to be healthy, safe, productive members of our communities. Recommendation 2.5: Expand Access to Mental Health and Substance Abuse Services.

One of the barriers to improving the delivery of mental health and substance use services is the underutilization of data. Cross-agency data sharing is critical to understanding the complex needs of the individuals and families served by these systems and to assess the effectiveness of services provided. To do this well, the state needs to establish metrics and common data points that are tracked across systems in order to assess patient mental health and substance use treatment outcomes. Recommendation 2.3: Require North Carolina Agencies to Share Data Cross-Agency. In order to fully understand the gaps and needs in North Carolina's mental health and substance use systems, LME/MCOs should collect and analyze data by age, race/ethnicity, diagnosis, and other factors. Recommendation 2.4: Assess and Address Disparities in the LME/MCO System.

Few Understand the Complex Mental Health System

Many people try to access services, but have difficulties navigating the systems, finding a provider who will treat them, or getting a diagnosis and treatment plan. For any system to work, the intended beneficiaries must understand it, however, North Carolina's complex mental health system is not well understood. For these and other reasons, more than half of North Carolinians with mental health and substance use disorders do not receive treatment. Ongoing education of consumers, providers, and other stakeholders is needed to improve understanding and access. Recommendation 3.1: Educate Communities on Available Mental Health and Substance Use Services

Recommendation 3.2: Develop a Common Access Point for the Mental Health and Substance Use Prevention, Treatment, and Recovery System

Recommendation 3.3: Increase Number of North Carolinians Trained in Mental Health First Aid

Recommendation 3.4: Involve Consumers and Local Communities in the LME/MCO Service Gaps Improvement Process

Meeting the Mental Health and Substance Use Needs of Consumers and Communities

North Carolina has developed a range of services to meet the needs of individuals experiencing mental health and substance use crisis. In many communities, services are available, but there are not strong collaborative relationships between the key stakeholders in the crisis response system. For crisis services to work best, law enforcement, emergency medical services, crisis response providers, local hospitals, and other providers must work together. Recommendation 3.5: Support and Encourage Crisis Response Stakeholders to Collaborate and Recommendation 3.6 Develop New Payment Models to Support Community Paramedicine Programs with Mental Health and Substance Use Crisis Response

A robust, diverse work force is necessary to meet the mental health and substance use needs of North Carolinians. There is a need for an infrastructure to support and improve the consistency and quality of mental health and substance abuse services statewide, to retain qualified staff, and to sustain evidence-informed practices. Recommendation 3.7: Strengthen Training and Work Force Development. Recommendation 3.8: Develop More Robust Transition to Practice System for Mental health and Substance Use Professionals.

Better Coordination Needed Between Mental Health and Primary Health Care

Mental health and physical health are not separate, but they are often treated as such within the medical community. Integrated care has gained prominence across the country and in North Carolina as a health care delivery model that addresses both individuals' physical and mental health needs. Integrated care is one way to provide the prevention, early detection, brief intervention, and, when needed, timely referral to mental health and substance use treatment services that are needed to reduce cost and improve outcomes. However transforming practices from traditional medical/mental health and substance use practices into integrated care practices often requires substantial technical assistance. Recommendation 3.9: Support Practice and System Transformation towards Integrated Care

Technology Can Improve Access to Mental Health and Substance Use Services

There is a shortage of mental health and substance use professionals in many parts of North Carolina, which restricts consumer access to services in those areas. One way to mitigate the shortage of mental health and substance use professionals in rural areas is to provide services for individuals with mental health and substance use disorders remotely using technology. Recommendation 3.10: Update DMA's Telepsych Policy. Recommendation 3.11: Maintain Adequate Funding for the NC STeP Program. Recommendation 3.12: Standardize Credentialing Across Systems.

Mental Health and Substance Use during Adolescence

Mental health and substance use disorders are the most significant threat to the lifelong health and well-being of youth. Approximately one in five adolescents has a diagnosable mental health or substance use disorder, that, if left untreated, will likely persist into adulthood and contribute to poor lifelong education, employment, and health outcomes. Youth with mental health and substance use disorders are often involved in more than one special service system, including mental health, special education, child welfare, juvenile justice, and health care. Prevention and early intervention are particularly important among adolescents, as are follow-up care and recovery supports after treatment. Ensuring a full continuum of care for adolescents can result in substantially shorter and less disabling experiences with mental health and substance use disorders and create a more positive health trajectory into adulthood.

Many youth with mental health and substance use disorders have experienced trauma, including child maltreatment and family dysfunction. Unaddressed trauma increases an individual's risk of developing mental health and substance use disorders, as well as heart disease, obesity, lung disease, diabetes, and other conditions in adulthood. Identifying and addressing trauma can help improve outcomes for children and youth, including minimizing the likelihood of developing mental health and substance use disorders. Recommendation 4.5: Support the Implementation of Trauma-Informed Child and Family Serving Systems across North Carolina Counties

There is a need for better coordination and cross-system collaboration at the local systems level to ensure that information, policies, procedures, and funding are better coordinated to meet the needs of youth and families. At the state and community level, North Carolina uses the System of Care (SOC) framework to bring together child-serving systems in the interest of individual children and families to provide care to children with mental health needs. SOC is supported at the local level by Community Collaboratives, which serve as a forum at the local county/regional level for child-serving systems to design protocols and coordinate policy to improve service coordination for special populations, including multi-agency involved children with behavioral health needs. LME/MCOs, as the mental health and substance use service provider for more than half of all children, are well-positioned to lead local cross-systems collaboration efforts. Recommendation 4.1: LME/MCOs Should Act as Lead Player in Cross-System Collaboration. Recommendation 4.2: Support and Further Develop Local System of Care Community Collaboratives.

The majority of mental health and substance use disorders among adolescents go unrecognized or untreated. If they access services, youth with mental health and substance use disorders are most likely to do so through schools and health care settings. School personnel, in particular, are in a key position to identify youth with mental health and substance use problems, and may determine whether an adolescent is identified as needing mental health and substance use services or is identified as having behavioral problems that should be handled through discipline and juvenile justice involvement. Raising awareness of youth mental health and substance use and teaching skills to handle various behaviors can increase school personnel's ability to identify and respond in constructive ways. Recommendation 4.3: Educate School Personnel on the Behavioral Health Needs of Adolescents. School districts across the state have increased access to needed services for students with mental health and substance use need through partnering with local LME/MCO and provider communities to bring services into schools. Recommendation 4.4: Encourage Partnerships between Schools and LME/MCOs

In addition to more prevention and treatment options for youth, changes to Medicaid policy are needed to best serve youth with serious emotional disturbance. Recommendation 4.6: Submit Medicaid Waiver to Best Serve Youth with Serious Emotional Disturbance

Mental Health and Substance Use among Older Adults

Older adult mental health and substance use disorders are not currently at the forefront of public health issues, but the rapidly increasing size of the older adult population indicates the need to address mental health and substance use issues preemptively. Older adults (65 and older) are a particularly complicated population regarding mental health and substance use prevention, treatment, and recovery. Depression, anxiety, alcohol, and psychoactive medication misuse are the most common types of mental health and substance use disorders among older adults. While there are effective prevention, treatment, and recovery services and supports for older adults, older adults are significantly less likely to be diagnosed and referred to treatment than younger adults. Older adults face additional challenges as well: difficulties understanding available Medicare coverage and what providers can bill for which services, too few providers contracting with traditional Medicare or Medicare Advantage/Replacement plans, and the prevalence of co-morbid conditions. Further complicating these challenges, there is no state agency tasked with ensuring this population's mental health and substance use prevention, treatment, and recovery needs are met. Rec 5.1: Establish Statewide Coordinated Leadership to Oversee Older Adult Health. In North Carolina, Geriatric Adult Mental Health Specialty Teams (GASTs) are funded by the state to provide training and consultation to people working in community organizations that provide services and support to older adults with mental health and substance use needs. Historically, GAST focused primarily on adult care homes, family care homes, and nursing home settings. However, GAST teams could also be used to train other community organizations that work with older adults. Recommendation 5.3: Use GAST Teams to Train Communities on Issues of Older Adult Mental Health.

Most older adults are eligible to enroll in Medicare when they turn 65. Unlike Medicaid, the state does not have any control over the rules and regulations of Medicare. Individuals enrolled in Medicare can select traditional Medicare or choose from a number of Medicare Advantage Plans. The Seniors Health Insurance Information Program (SHIIP), part of the North Carolina Department of Insurance's Consumer Services Group, provides assistance to Medicare beneficiaries in understanding their choices of insurance products and services available, a service referred to as navigation insurance assistance. Without navigation insurance assistance, many seniors stay in ill-fitting plans, overpay for their benefits, and do not receive the coverage they need. Recommendation 5.2: Increase Support for SHIIP Program.

Older adults are less likely to seek specialty care to address mental health and substance use disorders because they may already have a long term relationship with their primary care doctors, fear perceived stigma, face transportation challenges, and/or be able to find providers with experience treating older adults who accept Medicare. Additionally, mental health and substance use concerns are often under-identified by health professionals and older adults themselves. For these reasons, integrated care is particularly well-suited to older adults. Recommendation 5.4: Improve Capacity of Primary Care Practices to Screen, Treat, and Refer Older Adults to Treatment for Behavioral Health Needs. Furthermore, older adults with mental health and substance use disorders often have additional, co-occurring chronic health conditions. Care management, which involves assessing a patient's needs, developing a care plan, and ensuring care is provided, can help individuals with co-occurring conditions manage their health conditions and reduce overall costs. As of January 1, 2015, Medicare reimburses for non-face-to-face chronic care management (CCM) services furnished to Medicare fee-for-service beneficiaries with multiple chronic conditions. Although the CCM code exists, few practitioners are providing care coordination services under this code. Recommendation 5.5: Increase Care Management Services for Older Adults.

Many private practice behavioral health providers do not accept Medicare payment. Barriers include the privatization of Medicare through Medicare Advantage plans, anxiety regarding audits, and confusion regarding the new and evolving Merit-based Incentive Payment Systems (MIPS) and Alternative Payment Models. In addition to shortages of enrolled providers, Medicare-enrolled mental health and substance use treatment providers are underutilizing both available codes and helpful Medicare outpatient services. The barriers for mental health professionals accepting Medicare patients could be ameliorated with education on how to best file claims, reduce audit anxiety, and bill under health and behavior services codes (which can be used by a wider variety of providers), underutilized codes, and availability of outpatient services for Medicare beneficiaries. Recommendation 5.6: Increase Number of Eligible Behavioral Health Care Providers Billing Medicare

These recommendations, if implemented, would build upon current infrastructure to create an accessible, community-based, flexible system of mental health and substance use treatment services that produces positive outcomes for North Carolinians though a full range of services, provided in a timely manner, at the most appropriate level of care.