North Carolina state officials have a plan for moving people with mental illnesses from adult care homes into housing that’s more integrated into the community – almost.

By Rose Hoban

After 13 months of negotiation with federal officials over resolving North Carolina’s longstanding practice of housing mentally ill people in old folks’ homes, the state has a plan of action to move mentally ill residents into the community.

President George HW Bush signed the Americans with Disabilities Act into law on July 26, 1990
President George H W Bush signed the Americans with Disabilities Act into law on July 26, 1990

State officials say they’re ready to take first steps at implementation.

The plan answers complaints made to the US Department of Justice two years ago by Disability Rights North Carolina that alleged the state was in violation of the Americans with Disabilities Act by housing people with mental illnesses in facilities, originally meant to house the frail elderly. The US DOJ investigated the complaint, and last summer agreed North Carolina was breaking the law, and also was in violation of a Supreme Court ruling that calls for housing to integrate people with disabilities into the community.

State and federal officials have been in negotiations since last summer, hoping to avoid a lawsuit. But a lawsuit may come anyway, because North Carolina will not agree to any plan that has an enforcement mechanism, said Disability Rights head, Vicki Smith.

“The DOJ desperately wanted to settle in North Carolina, they conceded quite a bit,” Smith said. “But without enforcement, there’s no way to make sure that services are in place for people with mental illness once and for all.”

“We think DOJ will sue,” Smith concluded.

“We’re still in negotiations with DOJ,” said DHHS spokeswoman Crissy Pearson. “The only hiccup seems to be on enforcement. The Department of Justice has indicated they would like to see a consent decree, we are more comfortable with a private settlement agreement.”

A signed consent decree between North Carolina and the DOJ would give a court the power to enforce any plan in the future.

“It’s flied with the court, and that’s important, because each party promises to undertake certain duties or certain actions,” explained John Rittelmeyer, the director of litigation for Disability Rights. “And, if the party fails to do whatever they promise, they are subject to court order… in other words, a court can tell them to do something.”

Rittelmeyer also believes the lack of a consent agreement means the DOJ is quite likely to sue the state.

“The DOJ places all of their settlement agreements online, and all of them have enforcement mechanisms as a keystone of the agreement,” he said. “And all of these negotiations become precedent. Not having one in North Carolina would be a bad precedent for them.”

Creating housing for 3,000

In this year’s state budget, the General Assembly provided for $10.7 million for the Department to begin creating housing for 3,000 of the estimated 6,000 people with mental health problems who live in adult care homes.

This year’s target is to create a hundred units of housing.

“We have promised a hundred, we believe we’ll be able to create more like 300,” Pearson said. “Part of it is putting together processes and getting things started for this change… making sure that this system gets in place so that it will work.”

DHHS General Counsel Emery Milliken and Secretary Al Delia listen to comments by lawmakers at Tuesday's Oversight Committee meeting
DHHS General Counsel Emery Milliken and Secretary Al Delia at a meeting in May where they told lawmakers in May that it was in North Carolina’s best interest to settle the adult care home case with the US DOJ.
DHHS General Counsel Emery Milliken and Secretary Al Delia at a meeting in May where they told lawmakers in May that it was in North Carolina’s best interest to settle the adult care home case with the US DOJ.

Pearson also confirmed that the state is prepared to spend a total of nearly $70 million dollars over eight years to create community-based housing for those people with mental health problems who want to move into the community.

This year’s state budget also calls for the creation of a blue ribbon commission to guide the transition.

State Secretary of Health and Human Services Al Delia made the plan public in an interview with Associated Press published early Thursday morning. No official announcement has come from the Department of Health and Human Services or from the Governor’s office.

Details are still unclear.

“It’s a high level sketch of what we have in the works,” Pearson said, noting that Delia was out of state Thursday and unavailable for further comment.

The General Assembly budget also provided for $39.7 million to go to adult care homes this year. The industry stands to lose at least ten percent of their residents over the eight year period.

“The Baby Boomers are aging and the aging population in North Caroline is expected to grow quite a bit in the next few years,” said Janet Schazenbach, head of the state’s long term care association, that represents adult care homes. “If there’s an opportunity to do a systemtatic change rather than an overnight change, I think… our industry can adjust and maybe attract a different group.”

Schazenbach and Disability Rights’ Vicki Smith have frequently been on opposite sides of the adult care home issue, but on Thursday both agreed that it was time for North Carolina to move forward with providing appropriate housing for people with mental illness.

“Over the long term, there is not enough currently housing for the 3,000 people who are being targeted right now,” Schazenbach said. “We support the development of that and there will be need for wraparound services also. You can’t just move them out into the community, they will have to have other services.”

Still many outstanding questions

Resolution of the adult care home issue is further complicated because a number of the facilities are currently also under investigation by the federal Centers for Medicare and Medicaid Services for having too many people with mental health disabilities living in them.

CMS has been warning North Carolina about the situation since 2005.

Under the Medicaid Act, written in 1965, a facility with too many mentally ill people in it can be prohibited from receiving Medicaid payments for care. According to federal officials, as many as 1200 people live several dozen adult care homes that could meet this criteria, and the facilities have been improperly billing Medicaid for years.

If that’s found to be the case, those adult care homes would be in jeopardy of losing Medicaid funding for all their residents.

“These two issues are intertwined because they both result from the same policy decision, and that is that the preferred placement for people with mental illness in adult care homes,” said Disability Rights’ Rittelmeyer. “They’re there not as a transitional placement, but as a permanent placement. And what this results in is large adult care homes that specialize in inappropriately housing people with mental illness.”

State and federal officials are currently assessing that situation.

Finally, some advocates harkened back to North Carolina’s recent history of providing services to the mentally ill and then pulling back, such as in the case of the Thomas S. lawsuit, decided in 1988.

In that case, a judge ruled North Carolina was deficient in providing services and housing for people with developmental disabilities in state psychiatric hospitals, and ordered the state to discharge them and provide services in the community. The case was finally closed in 1997.

“The Thomas S. lawsuit was dismissed after people were placed in the community appropriately,” said Fred Waddle, chief compliance and policy officer for Easter Seals/ UCP.  “And then when it was dismissed, the DHHS stopped funding those placements. Then people had to move back out of the community settings, some to adult care homes, some to nursing homes, some back to state institutions.”

Despite the complications, advocates said they were cautiously pleased. But many circled back to the lack of teeth in the deal.

“There needs to be enforcement,” said state representative Verla Insko (D-Chapel Hill), who chaired the legislative oversight committee on mental health reform for close to a decade. “The whole adult care home issue is really complicated and about half of the House will be brand new next year and won’t know anything about these issues.”

“I doubt that this would get carried out over a period of 8 or 10 years, the way we’re going now, cutting back, cutting services,” Insko said. “There’s a question about whether the members of the General Assembly will be willing to fund it in the long term.”

Front page image courtesy Casey Geib, Flickr Creative Commons

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...

3 replies on “NC Proposes Plan to Move Mentally Ill from Adult Care Homes”

  1. The problem I have with the above article is they have combined the mentally ill, substance abuse and the developementally disabled into 1 catagory and 1 budget, The DD population had the largest budget because the would permanently be in need of assistance. Well they are now sharing their funding with other disabilities and cutting services for people who are developementally disabled. I say helping 1 population should not destroy another . I can tell you as the parent of 2 developementally disabled adults I will find it very difficult to keep them home with me. They both need these services to remain at home.
    I am in the process of finding out how much more it will cost the state if I am forced to seek placement. I am sure it will be atleast triple the cost of services to keep them home. Please know this is not what I want but, I am only 1 person and I can only do so much in a day

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