US DOJ seal large

After a year of negotiating with the U.S. Department of Justice, state officials agreed to a plan to move people with mental health problems closer to their communities.

By Taylor Sisk

The North Carolina Department of Health and Human Services has reached a much-awaited agreement with the U.S. Department of Justice to provide more services to those with serious mental illness within their own communities.

NC Secretary of Health and Human Services Al Delia Photo by Rose Hoban
NC Secretary of Health and Human Services Al Delia. Photo by Rose Hoban

Thursday’s agreement follows a plan announced last month by Secretary of Health and Human Services Al Delia to develop more community-based housing for those who have been placed in adult care homes. Many of those residents might prefer to explore living options that allow more interaction with family, friends and everyday life, but until now, have had little opportunity.

“We think this is an important step towards resolving important problems in the state’s mental health system,” said Corye Dunn, director of public policy for Disability Rights North Carolina. “This is all new, we’re reviewing the specific aspects of it, but we’re very pleased the settlement was reached.”

The plan calls for the state to provide housing slots for at least 3,000 individuals by 2020, with the first 100 to 300 to be available by July 1 of next year. It also calls for an investment in job training, employment assistance and 24-hour crisis care.

“This will allow us to isolate some of the issues and address them more directly,” Dunn said. “Now we have a timeline; we know when services have to start being provided.”

The estimated cost of the plan is $287 million over eight years.

‘Appropriate and effective’

In November 2010, Disability Rights North Carolina filed a complaint with the U.S. DOJ alleging the state was warehousing people with mental health problems in adult care homes.

Federal officials eventually agreed.

US DOJ seal

After an eight-month investigation, the US DOJ reported to state Attorney General Roy Cooper last summer that North Carolina was in violation of the 1990 Americans with Disablities Act, as well as a subsequent Supreme Court decision stating that people with disabilities should be integrated into the community.

The DOJ said the state must take action to better care for individuals who could be served through community-based services. Instead many have ended up in adult care homes because, according to the report, “existing housing programs are woefully inadequate.”

State officials have been negotiating with attorneys from DOJ since last summer.

Community-based services include case management, peer support, employment services and Assertive Community Treatment, a form of care that brings therapy and crisis care to people while they’re still in their homes.

The investigation also found that rather than adequately providing these services, North Carolina subsidized the cost of stays in adult care homes that in most cases provided few activities designed for those with mental illness.

Adult care home activities observed during the course of  the investigation were “largely infantile and consist of activities such as bingo, arts and crafts, puzzles, movie-watching, and board games.”

The report concluded that the adult homes presented “significant barriers” to community integration for those with serious mental illness, and that residents most would welcome the move to community-based settings.

State mental health officials had acknowledged that community-based housing is an “appropriate and effective” environment for persons with serious mental illness, and that adult care homes are not.

The same conclusion had already been reached by four separate state blue-ribbon panels over the course of the past decade.

Close to an agreement

In July of this year, Delia announced that although the state and the DOJ had failed to reach an agreement, the state was moving forward with an eight-year plan to provide more integrated services. An attorney for the DHHS told legislators during a meeting earlier this month that state officials found the idea of outside enforcement to be “repugnant.”

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. Earlier this summer, Milliken told lawmakers the idea of federal oversight was “repugnant” to state officials. Photo by Rose Hoban

But state law forbids the General Assembly from obligating future legislators to make expenditures on any given program. Advocates worried that without oversight, money could dry up as political winds changed. Federal officials maintained that in order for the state to avoid a costly lawsuit, it must agree to a legally binding agreement regarding oversight of the plan.

In the end, the two sides met halfway.

Thursday’s agreement stipulates that an independent reviewer – Marylou Sudders, former commissioner of the Massachusetts Department of Mental Health – will have “full authority to independently assess, review, and report annually on the State’s implementation of and compliance with the provisions of this Agreement.”

Jim Jarrard, acting director of the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services, said that the reviewer would report to both the Department of Justice and the state.

This person will also be considered as a consultant to us,” Jarrard said.

“We’ve all been in this fog,” said Laurie Coker, director of the N.C. Consumer Advocacy, Networking, and Support Organization, which advocates for people  with mental illness, developmental disabilities and addiction. “We’ve known what the right thing has been for years and years, and to finally hear it announced was pretty exciting.”

“I’m also, quite frankly, glad that there will be official oversight from outside of the state, because you just need an independent perspective on what’s happening to be sure that things get done right sometimes,” Coker added, “and I think this might be one of those times.”

“We’ve been very close for a very long time,” Dunn said of the agreement. “We’ve crossed the threshold.”

Rose Hoban contributed reporting to this story.

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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...

4 replies on “State Reaches Agreement with Feds on Community-based Care”

  1. Perhaps it’s finally time for some cautious optimism. When NC mental health reform started a decade ago, the service of community support was created with persons with severe mental illness in mind. In its original iteration, it included case management, skill building, and evidence-based practices including family psychoeducation and illness management and recovery. But the service really never was used to support persons with severe mental illness — it became the go-to service for everyone else in the mental health system, particularly children. Given the content of the DOJ settlement, It’s pretty ironic that the state eliminated community support entirely, and last spring, did away with mental health case management. We should be clear on what a huge transition this will be for persons who have been institutionalized for years, and give them the support they will need to be successful in community living. Let’s hope we can get it right this time.

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