Close to home: Local adult-care closing highlights the need to house the mentally ill

Canterbury Hills Adult Care Home sits high on hill in a residential area of Candler. Unmarked and invisible from the main road, this unassuming facility illustrates some of the underlying challenges in modern health care, especially for those with long-term mental illnesses who may have few other alternatives. (Photo by Ricky Emmons)

Viewed from outside on a typical visit, the brick building appears vacant, its curtains drawn and an empty basketball court where weeds sprout out of cracks in the playing surface. Inside, Canterbury’s long halls are dimly lit, the walls bare. The game room consists of a pool table, threadbare couches that face a mounted television, a craft table and empty vending machines shoved into a corner.

But the building is not what brought this place to the forefront in recent news. The fundamental issues relate to its patients, the 58 Buncombe County residents who have called Canterbury home and now face uncertain futures.

On July 1, the facility’s longtime owner, Wittner Wright, announced that he’s closing the place, citing general financial woes and other challenges. Canterbury is one of several adult-care homes that Wright and his company, Realty Residential, own in Buncombe County. Earlier this year, Buncombe officials levied fines against the company for such issues as housekeeping problems and failing to meet its residents’ health-care needs at Canterbury; and over the years, nearby homeowners have filed various complaints with local law enforcement.

But Wright says that a year of tumult in the adult-care system has left owners of such facilities — which house the elderly as well as those with mental illness, developmental disabilities and substance-abuse problems — with lean pockets and few choices.

“I’m proud of Canterbury Hills,” he insists. “It has a negative reputation because people just don’t understand it. Everyday we go to war, and we’re armed with a squirt gun. We’re getting pennies on the dollar to take care of these folks, our folks.”

A complex care system

The practice of housing the mentally ill within adult-care homes, in a system that may not benefit them best, results from several national and state health-care trends and pressures, say those who work within the care network.

Until fairly recently, the approach was profitable, says Cathie Beatty, social-work supervisor for the Buncombe County Department of Human and Health Services. “Over the past 20 years, there has been a rather lucrative business model for adult-care homes to take in persons [with a] primary mental illness diagnosis,” she says. Beatty also cites “the deinstitutionalization and narrowing of state hospitals,” which has moved residents out of public facilities and forced health-care officials to scramble to place them. “The adult-care industry was the default” choice, she says.

Tax breaks and incentives to owners encouraged them to take in non-elderly patients, but no longer, Beatty continues.

“The industry is undergoing a huge amount of change,” Beatty says. “One of those is in relation to a suit that was brought by the [federal] Department of Justice” a few years ago against North Carolina.

A 1999 U.S. Supreme Court decision in the case of Olmstead v. L.C. reasserted the federal guarantee that those with severe, persistent mental illness have full rights under the law, including being housed in the least restrictive environment possible — “a ruling that requires states to eliminate unnecessary segregation of persons with disabilities and to ensure that [they] receive services in the most integrated setting appropriate to their needs,” according to the DOJ.

Spurred by disability-rights groups, the DOJ investigated North Carolina’s practices and policies, concluding about two years ago that the state had mismanaged its placement of mentally ill adults: “Most people with mental illness receiving services in adult-care homes could be served in more integrated settings, but are relegated indefinitely and necessarily to adult-care homes because of systematic state actions and policies."

In the two years since that investigation, state officials have worked with the DOJ to create a new approach — an eight-year plan that includes helping transition residents out of adult-care homes.

According to those working in the system, however, the changes only brush the surface of what’s needed in North Carolina.

Buncombe County breakdown

Buncombe hosts 86 of the 1,200 adult-care facilities in the state. That’s the most, per capita, of any other county in North Carolina. Residents come from Buncombe as well as counties outside the region — mostly, from Mecklenburg and parts of eastern North Carolina, according to Beatty.

Nationwide, in the last decade or so, care has migrated away from public housing to the private sector — a move hinged on the premise that private facilities would bring resources and additional funding that had been lacking.

This hope was no more than a fantasy, says Buncombe County Sheriff Department Lt. Randy Sorrells. His department is often the first to respond to problems at the centers and in the neighborhoods where they’re located.

“There were these theories that companies would rush in to help out and take care of these people. There was money to be made,” says Sorrells. “Well, no private-sector big names rushed in,” he continues, noting that some residents “are trapped between jail and care homes.”

In his view, the long-term care system split in two — costly skilled nursing facilities and adult-care homes.

Wright acknowledges that the lower-cost, adult-care facilities often employ less educated, more transient staff than nursing homes, and, as he does, many owners run several establishments in any particular area. He says there’s less public income to help pay for the residents’ needs, and therefore, such homes contain more and more non-elderly residents whose primary diagnoses are a long-term mental illness.

“It’s a complex issue,” Sorrells says. “Quite the quagmire.”

The much-hoped-for and anticipated resources never coalesced, he says, and 12 years out from privatization, problems with the system are mounting.

The lack of checks and balances on the private sector allowed problems to fester, Sorrells speculates. Indeed, the 1996 Health Insurance Portability and Accountability Act (HIPAA) allows adult-care facilities to function with little public scrutiny, and problems connected to adult-care homes strain local resources, he continues. Homes located in residential areas draw neighborhood attention, he says, and homeowners have reported a variety of problems to which his office responds, such as break-ins, drug activity and loitering.

“We’re responding to these concerns,” he says. “It’s a tremendous drain on the system.”

In an April 2012 Buncombe County Board of Commissioners meeting, Community Care of Western North Carolina reported that more than $3 million in Medicaid expenses were paid to just three facilities in 2011 — one of them Canterbury. That’s 30 percent of the county’s total Medicaid expenditures.

But Wright says the DOJ case — combined with dwindling resources overall — has caused funds formerly available to owners to be constricted.

“Basically, since Jan. 1, people who operate homes like we do have struggled to get two-thirds of their previous revenue,” he says. Some “operators [are] just walking in and closing the door and telling all the staff to go home, and [they tell] the state Division of Social Services to come get the residents. It’s happening everywhere.”

Through good billing practices and saving where possible, Wright juggled to keep Canterbury, his largest facility, afloat, he says. But now, he says he must close it in the hope of saving his other centers.

But where will those residents go?

Some have already found new situations, says Beth Boone, a Buncombe County adult-care home specialist who manages complaints, citations and violations for several local facilities. “Canterbury has been looking for places,” Boone says. “Wright has some friends who own other facilities — that could be an option. If they can’t find a place, they’ll call us in, but we’re not miracle workers. I don’t know where some of these people are going to go,” she adds.

Wright hopes to move some residents back to their home counties, he says, and he’s optimistic that all get to stay within in the state, Boone says.

So far, Wright reports that he has found homes for most Canterbur residents. As for the center’s 30 or so employees, his other Buncombe adult-care homes are fully staffed, though he plans to retain key administrators.

The big picture

Meanwhile, state officials continue to work long-term on moving mentally ill residents from adult care and into alternative living situations.

As part of the DOJ settlement, North Carolina was divided into regions; in each one, contracting organizations were enlisted in a process known as the Transitions to Community Living Initiative. The state DSS serves as a partner in this statewide, eight-year plan, but in Western North Carolina, the Asheville-based Western Highlands Network has been implementing it. (In April, however, Western Highlands announced a merger with Waynesville-based Smoky Mountain Center, which will likely absorb the project.)

“Several funding streams are being implemented to cover the cost of moving these individuals,” Beatty says. “We expect the cost of community living to be roughly equivalent to what Medicaid and special assistance is paying these larger facilities now.”

Rents in the Asheville area often exceed what Medicaid can cover, however, so extra assistance will continue for all those who move out of the facilities, Beatty reports. County officials also hope to tap into available incentives for landlords who agree to house individuals transitioning to community living.

Canterbury Administrator Jimmie Singleton suggests that costs for the county could increase once individuals have transitioned. “I don’t see them being able to function and take their medications,” he says. “We would probably see some success, but I would expect more break-ins, drugs on the street, suicides, fires, hospitalizations — that kind of thing.”

“Any individual who has those types of vulnerabilities would be assessed for what kind of services would assist them,” says Karol Gebbia, community living program lead care coordinator for Western Highlands. Current funding streams to assist those with severe problems would remain, no matter what living arrangements they chose, she continues. Gebbia also says that those who seek community living have access to up to $2,000 in transitional funds.

“There will be services now that will be available to wrap around and support these individuals, [and] that could make a difference,” she notes. “And really, that’s what it’s all about.”

By May, Western Highlands had reached out to 34 local adult-care residents who are candidates for placement.  Gebbia remarks, “We’ve received really great reception from these individuals,” Gebbia says. “They are excited to hear about their options and know that we intend to do right by them, supplying them with opportunities.”

Ultimately, the state initiative seeks to move 3,000 individuals from the adult-care system into community housing by July 2020.

“When you get to the base of it all, it’s about these individuals choosing to try and live independently,” Gebbia adds. “We are to make every possible effort in order for them to be successful. It’s not a perfect process for everyone, but they have the right to try.”

— Maayan Schechter and Ricky Emmons are UNCA graduates. Jackie Starkey is an Xpress editorial intern and senior at UNCA. All three contributed to this story, which is based on work they did for a public-affairs class at UNCA earlier this year.