Nowhere to turn

Mental-health care in North Carolina has been towed into the garage for a major overhaul. At the moment, there are parts spread all over the workbench, grease spots and wrenches on the floor, and a cluster of experts poking around under the hood, shaking their heads. Some maintain that this baby will run better than ever once it’s back on the road. In the meantime, however, it looks as though some heavy-duty shock absorbers might come in handy.

Reform efforts mandated by the General Assembly ramped up a year ago when the former management structure was dissolved. In Buncombe, Henderson, Madison, Mitchell, Polk, Rutherford, Transylvania and Yancey counties, several separate agencies — Blue Ridge Mental Health, Rutherford-Polk Area Mental Health/Developmental Disabilities/Substance Abuse Services and Trend Community Mental Health Services — were replaced by a new “local management entity” called the Western Highlands Network. Under the new plan, LMEs don’t provide services directly; instead, they oversee local care providers and steer people to services provided by private for-profit or nonprofit agencies.

Last year, Blue Ridge and its associated corporations divested themselves of facilities even as a host of private providers was springing up. In September, Buncombe County Manager (and Western Highlands board member) Wanda Greene told the Board of Commissioners that Western Highlands was ahead of the curve compared to other areas in the state. (See “Commissioners Continue Curtailed Meeting Schedule,” Sept. 15, 2004 Xpress). But Greene also cautioned, “Crisis stabilization is a major issue.” Five months later, it appears that crisis mental-health care in North Carolina may be the major issue.

A widening gap

The lack of crisis care for juveniles is a particular concern, and Dan Zorn is one of many who are convinced that mental-health reform is a head-on collision waiting to happen. “There are not sufficient facilities for crisis care,” he warns, echoing the concerns of mental-health professionals across Western North Carolina.

Crisis care is the immediate stabilization treatment required when a person “decompensates” — the technical term for what’s more commonly known as a nervous breakdown.

“When kids decompensate,” Zorn explains, “they may run away, cut on themselves, threaten parents and siblings severely, threaten suicide, brandish weapons, overdose on medications — you name it. He or she really wants to be heard and really wants to be understood and will go to remarkable extremes to ask people to pay attention.”

As the founder and CEO of Families Together, an in-home treatment program for kids, Zorn knows whereof he speaks. The former COO of Eliada Homes — a Buncombe County-based nonprofit that provides services for abused, dependent and neglected children — Zorn also served on the Western Highlands Network board until last year. “I don’t believe Copestone can handle the load, [although] they’ve been a pretty good partner of ours lately in serving these kids.” Copestone Psychiatric Center is a department within Mission Hospitals.

And Diane Bauknight, chair of WNC Families CAN (an advocacy group for children’s mental-health care), notes, “The need for a crisis facility has been … urgent and unmet … in Western North Carolina since Charter Hospital closed in early 2000.” As the parent of a child who is a client in the system, Bauknight has an insider’s perspective on the problem.

In a wide-ranging Dec. 9 interview, Zorn discussed mental-health-care options for local children. “We still very much need a children’s unit in this area for crisis stabilization. For long-term care, Mission might play that role. But we need short-term, intense, locked services for our kids. Because what’s happening is they go to Copestone, there’s no place for them, and they end up — directly or indirectly — placed in Broughton. They languish there. The community’s not ready to have them back, and we create monsters.”

Broughton State Hospital in Morganton, the largest of the four state-operated psychiatric hospitals, serves the 37 westernmost counties in North Carolina. And Zorn’s reference to it touches on another matter that’s already sending shudders through the entire mental-health system. In 2008, the state is slated to downsize Broughton from 550 beds to 250 — part of a statewide cutback that will slash the number of beds in state mental hospitals by half.

23/7: The magic, missing hour

Care providers are already beginning to plan for the anticipated deluge of children and adults. At the Buncombe County Board of Commissioners’ Dec. 7 meeting, Western Highlands CEO Larry Thompson reported on plans for a 16-bed, 23-hour facility to be built on Biltmore Avenue near Matthews Ford. (See “Commissioners Authorize $35 Million in Bonds,” Dec. 15, 2004 Xpress.)

“General hospitals that have psychiatric care are willing to pick up some services,” Thompson told the commissioners, noting that these facilities are not equipped to handle crisis care.

A study of the now defunct Charter Asheville Behavioral Health System that Thompson cited in December found that 90 percent of such events are resolved within 23 hours. Medicaid funds each type of care differently, and both the facility designation and the 16-bed size are based on Medicaid stipulations.

At that time, Thompson said he hoped to have approval from county and city planners by late January. Progress on the new facility has been slower than expected, however. The architect is still working to satisfy county concerns about access to the proposed parking deck, reports Beverly Atkins, clerk to the Western Highlands board. And once that’s resolved, both the city and the state will also have to sign off on the plans. “Then we’ll need federal approval for the beds,” concluded Atkins.

But although the new facility (which is slated to open in 2006) would provide substantial help with adult cases in Buncombe, it would not offer juvenile care. Western Highlands processes about 60 juvenile crisis cases per month, reports Access Director Charlie Schoenheit. In addition, an unknown number of cases are handled by private providers.

In neighboring counties served by Western Highlands, there are still no plans for crisis beds of any kind.

“The 16-bed facility would be available to all eight counties,” Schoenheit told Xpress. “It’s not economically feasible to create more than one unit with that high level of care.” At present, he added, “the treatment options are limited — it’s either hospital or home and not much in between.” Western Highland’s goal, Schoenheit explained, is to fill that middle ground. “The 16-bed unit is at the high end of that spectrum. We’re looking at developing some adult-care homes where we could put people for a couple of days to stabilize before they go home.”

Group home or stay home?

The shortage of local treatment facilities for children, whether short- or long-term, claimed the spotlight last September when Shirley Arciszewski, a 12-year-old Buncombe County girl, died in a group home in Charlotte after a worker pulled her to the floor and lay on top of her (according to state records). A report in The Charlotte Observer said the worker had not been properly trained and had been fired by another group home.

Arciszewski had been placed in the group home in Charlotte after she attacked her foster mother here and there was no residential facility in Buncombe County that could take her. According to a Jan. 25 story in the Observer, “Mecklenburg and Cumberland continue to play host to out-of-county children, in large part because entrepreneurs have opened many more homes than the counties need to serve their own children. These private, mostly for-profit group homes seek to fill beds by e-mailing and telephoning mental-health agencies around the state, alerting them to empty beds and agreeing to take residents on short notice.”

The Observer story also notes, “Since 2000, the number of group homes in North Carolina has grown from more than 300 to more than 1,000.” And though the boom (which followed an increase in payment rates for group-home care) isn’t directly related to mental-health-care reform, such facilities may loom even larger in the constellation of care options as state beds are eliminated.

Zorn, meanwhile, emphasizes what he calls “a significant need for specialized beds. Specifically therapeutic foster [care] beds … where the environment that the kid’s going to experience when they enter that home is more like a family versus a group home versus a floor with a bunch of other kids that are decompensated.”

But Zorn also believes that the kind of in-home intervention his company provides can reduce the reliance on live-in facilities for long-term treatment of most of the kinds of problems children face. Of his own work, Zorn has written: “Families Together uses a team approach to support families, reduce stress and meet comprehensive mental-health needs of at-risk children. … By working on-site at homes, schools and communities, we keep the child in environments that feel familiar and safe.” His company, Zorn explained, operates a 24-hour emergency-intervention team that’s always ready to step in.

Zorn’s mobile crisis team is a unique, grant-funded pilot program, notes Schoenheit. “If it works, we plan to replicate the model elsewhere in the system,” he explains. For now, however, these services are available only to clients of Zorn’s company.

The rapid growth of Families Together (which opened for business in January 2004) provides further evidence of the pent-up need for children’s services. “We hoped to have a dozen employees by the end of the second year,” said Zorn. “We have 43 now on the payroll.”

One pricey bed at a time

In late December, Eliada Homes submitted a crisis-stabilization proposal to Western Highlands. In its proposal, the nonprofit noted that it has frequent, intermittent vacancies. Accordingly, the proposal calls for designating a bed for crisis care whenever one is available. To satisfy Medicare payment criteria, however, that bed would have to be formally redesignated, and Eliada would need a full-time intake staffer to evaluate potential clients.

The proposal asks for $42,000 per year to cover the crisis coordinator’s salary and benefits. It also stipulates that clients be eligible for Medicaid, Health Choice or N.C. Comprehensive Treatment Services Program funding, and that Western Highlands commit to paying $78.46 per day to cover Eliada’s expenses over and above the $218.69 per diem paid for room, board and treatment. All told, the costs would run to $172,200 per year — for a single bed that wouldn’t even be available all the time.

According to Schoenheit, the Eliada proposal is “very much on the table” and will probably be presented to the Western Highlands board at its Feb. 25 formal meeting.

To advocates like Bauknight, crisis care is already too little, too late. Meanwhile, the delivery vehicle is in the shop and work is under way. And it appears that the revamped model will be practically brand new — sticker shock and all.