NAVIGATING the MAZE an Assessment of Mental Health Resources for Children and Adolescents in Charlotte-Mecklenburg

NAVIGATING THE MAZE An Assessment of Mental Health Resources For Children and Adolescents In Charlotte-Mecklenburg

Prepared by Jonathan Scott, consultant Published November 2017 This project is generously funded by:

In an endeavor to impact improvements to the local systems of mental health services and support for adolescents and children, Children’s Medical Fund, Foundation For The Carolinas, and Mitch- ell’s Fund commissioned a study of the issues and opportunities. The three foundations hired an independent consultant to lead the project and produce this report. The project is a response to growing concern among early educators, physicians, service providers, parents and other community members about the state of mental healthcare for Charlotte- Mecklenburg children ages 0 to 18. The objective of this needs assessment is to shine a light on the situation in hopes of serving as a catalyst for change. This project is an early outcome of the Charlotte-Mecklenburg Opportunity Task Force report—leadingonopportunity.org—which highlights research on early brain development and how it lays the foundation for emotional, physical, intellectual and social development. Among the task force’s key recommendations are to “deepen our understanding of the childhood mental health system and develop tangible strategies to address identified needs and gaps.” (Strategy R) Therefore, this report includes a description of the ecosystem of services, providers and funding sources; identifies gaps in and barriers to treatment; and provides three “big picture” strategies for improving the system. This document is a culmination of nine months of research, including 83 in-person interviews with mental health professionals, government officials, parents, and philanthropic leaders, as well as dozens of telephone and email interviews with statewide experts. This is a “living document” designed to give readers a snapshot of children’s mental healthcare as of November 2017. Unfortunately, not every organization involved in serving the behavioral health needs of our community’s children could be included due to limitations of space and time. It is the sincere hope of the author and funders that the community will embrace and expand upon this project, so the next phase will be to broaden the scope by including more professionals, families and organizations willing to take bold action to affect positive change. Mental health, also referred to as “behavioral health,” is defined as the general condition of one’s mental and emotional state. It is characterized by the absence of mental illness. The term also refers to healthcare services and support dealing with the promotion and improvement of mental health and the treatment of mental illness. Contents

Executive Summary ...... i Introduction ...... 1 An Overview of the Ecosystem ...... 2 A Brief History of National Reforms ...... 3 Recent Reforms in North Carolina and their Impact on Charlotte ...... 4 An Overview of Key Stakeholders ...... 6 Funding Sources, Revenue Models ...... 14 System of Care ...... 15 Britney, Deon and Nicolás’ Stories Continue ...... 16 Substance Use Disorder ...... 17 Intellectual and Developmental Disabilities ...... 18 Gaps in Services, Barriers to Treatment ...... 19 What are the Medicaid Service Definitions for Residential Treatment? ...... 24 The Dilemma of Hard-to-Place Youth ...... 25 The Roles of Socioeconomics, Trauma and Intergenerational Racism ...... 27 Mental Health in Public Schools ...... 30 Britney, Deon and Nicolás Show Signs of Progress ...... 31 Privatization vs. Government-Run Mental Health ...... 33 Fee-for-Service vs. Value-Based Care ...... 34 Has Anything Good Come from Managed Care? ...... 35 Britney, Deon and Nicolás Receive the Help They Need ...... 36 Conclusion: Suggestions for Improving the System ...... 37 What’s the Mental Health Task Force? ...... 43 Acknowledgments ...... 47 Endnotes ...... 48 Alphabet Soup: Abbreviations Used in this Report ...... 49 Appendix: Cardinal Innovations’ Responses to Common Complaints ...... 50

Research, text and graphic design by Jonathan Scott, consultant to the funders [email protected] Cover artwork, girl in bunny costume (page 13) courtesy Jessica C. White www.jessicacwhite.com Executive Summary

ubert Humphrey’s admonition Hthat the moral test of government is how it In 2016, in Mecklenburg County... treats its weakest members holds true for communities as well. There may be no greater test adults used their of a community’s will to provide for a reason- Medicaid12,616 benefits for mental healthcare able standard of living for all its citizens than how it handles the crisis facing our children’s mental healthcare system. children Our community is not alone in this chal- and10,294 adolescents ages 3 to 17 lenge. Nationally, one in five children at some used Medicaid for mental healthcare point during their lives has had a mental disorder considered to be debilitating. Many others of Medicaid are affected by social and emotional challenges recipients34% were white that are less severe or persistent. Because intergenerational poverty and 57%were African prevalence of mental health disorders are in- were American terlinked, much of this report revolves around Hispanic5% or Latino Medicaid; however, behavioral health is an Source: Cardinal Innovations issue that impacts every socioeconomic group, including families with private insurance. Experts in the mental health field say that everywhere in the nation, the system is in crisis. They use words like “fragmented” and Number1,973,084 of North Carolinians who were “siloed” to describe the ecosystem, noting that enrolled in Medicaid as of February 2017 lack of access and stigma are the biggest issues. Source: N.C. Health News The sheer complexity of the bureaucracy, coupled with the profusion of community agencies and other healthcare organizations Mecklenburg1,054,835 County’s general population whose services are reimbursed by Medicaid, Source: U.S. Census estimate, July 2016 make navigating the system extremely difficult for families and even professionals. A host of MEDICAID BY THE NUMBERS case managers, care coordinators and non-licensed professionals supplement the work of Managed Care Organization licensed clinicians (psychiatrists, psycholo- Mecklenburg County’s MCO is Cardinal In- gists, social workers and licensed professional novations Healthcare. Cardinal’s service area counselors) who provide direct mental health includes 20 counties served by a private-sector services to children and adolescents. workforce of 800 employees, making it the Although Medicaid is a federal entitlement state’s largest Medicaid plan. Cardinal took for low-income people, the North Carolina control of Medicaid funds for Charlotte-Meck- General Assembly decides how the state par- lenburg when the state forced the county to ticipates in the insurance program. The state close MeckLINK. Department of Health and Human Services Before MeckLINK was the Area Mental (DHHS) has carved North Carolina into a Health Authority. In those days, the county handful of “catchment areas” and established a was in the business of delivering mental health system of managed care organizations (MCOs) services and managing Medicaid reimburse- to administer Medicaid funds. ment. The state ended counties’ ability to both

i deliver and manage services in an attempt to workers and six substance use counselors to rein in costs. North Carolina is now in the era serve 150,725 students. Assistance is available of managed care, whereby Cardinal is per- to any student through CMS Student Services, ceived by some providers as a mechanism for including individual, group, family and com- delaying and denying treatment to save the munity-based support ranging from coun- state money. However, Cardinal says it ap- seling and intervention plans to home visits, Mental health proves 98 percent of the services requested; 92 family assessments and training for parents. service percent of the $680 million it collects annually However, the ratio of psychologists to stu- A service that is paid from Medicaid is spent on providing care; and dents makes it challenging for many schools to for by an insurance only 8 percent is used for administrative costs, do much more than evaluations for exceptional company or Medic- including salaries and real estate. children. So CMS partnered with Mecklenburg aid to address recov- In addition to Cardinal, some of the major County to launch a school-based mental health ery from a diagnosis stakeholders in children’s mental health are: (SBMH) program three years ago. Available of an individual. to students at 101 of 170 schools, SBMH is a Mental health Mecklenburg County Government program whereby six community agencies support a The Behavioral Health Division (BHD) provide clinical counseling within schools that manages a network of 16 mental health pro- elect to utilize the service. The care provided that is not strictly viders (separate from Cardinal’s network) and medical but is none- supports the other county entities involved in The Two Hospital Systems a theless considered to mental health through its clinical consulting In June 2017, Novant Health began imple- be necessary to the team. mentation of an integrative care model, which recovery and treat- a The Health Department’s main programs joins mental health with medical care, in its ment process for children’s behavioral and developmental primary care offices. For children and adoles- (supports to main- health are Child Development-Community cents, Novant provides inpatient, outpatient tain independent Policing (CD-CP) and the Children’s Develop- and recreational therapy, as well as partial housing, education, mental Services Agency (CDSA). hospitalization and emergency mental health employment, or a Youth and Family Services (YFS), a services. And Novant is teaming with Caroli- other activities division of the Department of Social Services nas HealthCare System (CHS) to find ways to associated with com- (DSS), takes children into custody in cases of improve medical and behavioral health ser- munity integration). abuse and neglect, and works with the courts vices in Charlotte’s lower-income, underserved system and Cardinal to find residential place- neighborhoods. ment and treatment as deemed medically a Carolinas HealthCare System’s mental necessary. health facility, Behavioral Health-Charlotte a Community Support Services (CSS) (BH-C), contains the only dedicated psychi- provides training to public-school-system staff atric emergency department in the region. on issues such as teen-dating violence and In 2015, about 50 percent of those patients cultural competence. were Medicaid recipients. CHS has integrated a The Forensic Evaluations Unit acts as a mental health with pediatric services, placed liaison to the juvenile and family courts system mental health telemedicine technology in its and provides psychological and parenting- regular emergency departments, and in July capacity evaluations to the courts. 2017 began a psychiatric residency program.

The Public School System N.C. Juvenile and Family Courts System Charlotte-Mecklenburg Schools (CMS) has A common pathway for children and adoles- the equivalent of one full-time psychologist for cents to come into the mental health system every 2.74 schools, as well as a total of 42 social is through juvenile or family court. Children

ii GAPS IN SERVICES, BARRIERS TO TREATMENT Private Insurance Health insurance policies tend to have high annual deductibles; for mental health, there are more limitations, fewer services and higher co-payments.

Medicaid Eligible recipients may be denied services on technical grounds or for being “noncompliant.” And the denial rate for certain services is too high, or Cardinal will approve lower levels of services than recommended by the service providers. (Cardinal disputes these allegations.)

Birth to Age 5 The same array of mental health services available for children covered by Medicaid who are over the age of 5 are available to children ages 3 to 5, but few clinicians statewide provide these services in an evidence-based, developmentally appropriate manner. And the services are not available to children under age 3.

Intellectual/ The waiting list for individuals with intellectual or developmental disabilities (I/DD) to Developmental receive an Innovations Waiver can be several years, and the Medicaid services available while Disabilities they wait for a waiver are much more limited and don’t include such services as personal care.

Bureaucratic Two barriers to treatment are bureaucratic delays and time-consuming paperwork. For certain Delays Medicaid services, pre-authorization can take 14 days.

Child The American Academy of Child and Adolescent Psychiatry says Mecklenburg County has a Psychiatrists “severe shortage” of practicing child and adolescent psychiatrists.

Trauma-Certified Treating trauma effectively requires training and specialized certification; Charlotte-Mecklen- Clinicians burg doesn’t have enough credentialed clinicians, according to experts.

Charlotte- Lack of parental consent was cited as the No. 1 barrier within the school system to children Mecklenburg receiving clinical mental health services. A second barrier is a federal statute prohibiting Schools undocumented individuals from receiving Medicaid. A third is the stipulation that students meet with a school counselor to be referred to a licensed therapist. A final barrier is only 59 percent of public schools have a SBMH intervention program.

Latino/Hispanic Hurdles to providing mental health services include cultural stigma, the lack of Spanish- Children speaking counselors, a shortage of trauma-trained clinicians, the challenge of overcoming stereotypes and, in some families, the fear of deportation.

Residential While Cardinal maintains that the overall inventory of residential placements is “sufficient,” Placements there is common agreement among those interviewed for this report that Charlotte-Mecklen- burg doesn’t have adequate supply.

Adolescent In Mecklenburg County, no group homes exist for girls in need of primary substance use treat- Females ment who require round-the-clock supervision. Part of the challenge is a reluctance to treat teenage girls, who may be viewed as difficult to work with.

Therapeutic Cardinal maintains that the deficiency in therapeutic foster care (TFC) is not an overall short- Foster Homes age of licensed beds but rather the availability of specialized treatment for youth with highly complex mental health needs. Others say the issue is a shortage of effective therapeutic foster parents, especially parents who are willing to foster teens, and lack of support from providers.

LGBTQ Youth The national rate of suicide attempts is four times greater for lesbian, gay and bisexual youth and two times greater for questioning youth than that of heterosexual youth. Yet many interviewees said the support available to local LGBTQ youth doesn’t come close to meeting the demand.

iii involved in the courts system have either been private insurance, nearly all rely on donations, accused of committing a crime or have been re- fundraising events and grants to operate. ported as victims of abuse or neglect. The latter One of the most significant grants in recent may be taken into custody of the county and years was for “system of care” (SOC)—a fami- placed in a group living facility, foster home, ly-centered framework for coordinating mental or permanent placement through adoption. health and child welfare services. When the Virtually every child involved with the courts federal grant expired in 2012, the county not system receives a clinical assessment. The only lost funding, but also a trove of data on state Department of Juvenile Justice employs outcomes. Today, the data collected varies 30 juvenile court counselors (JCCs) who are widely, has no central repository, and may be responsible for the supervision of adjudicat- difficult to obtain, making it impossible for ed, undisciplined and delinquent juveniles to policymakers to make fact-based decisions. assure their compliance with court-ordered Another issue is the dilemma of hard-to- dispositions. They also make referrals to place youth who come into the system via YFS, community agencies for children who require the Juvenile Detention Center, or the psychi- mental health services. atric emergency departments. For a variety of reasons, children get stuck in limbo because Community Agencies/Service Providers there’s no appropriate placement ready at the More than 250 not-for-profit agencies com- time of discharge. prise Cardinal Innovations’ provider network Finally, to fully understand our communi- in Charlotte-Mecklenburg. Three of the larg- ty’s mental health crisis, one must recognize est are Thompson Child and Family Focus, the roles of socioeconomics, intergenerational Alexander Youth Network, and Monarch. racism and trauma. Research shows dispro- Generally speaking, for an agency to receive portionate prevalence of mental health inci- reimbursement from Medicaid for providing a dence among children of color; this is true in mental health service, authorization from Car- Charlotte and across the country. According dinal is required. Some experts interviewed for to U.S. Census estimates, Mecklenburg Coun- this report say this inherent conflict between ty’s population in 2016 was 58 percent white, managed care and “fee for service” creates an 33 percent African American, and 13 percent atmosphere of distrust between Cardinal and Hispanic or Latino. Yet, among Medicaid ben- its own network. eficiaries who received a mental health service in 2016, 34 percent were white, 57 percent were Private Insurance Carriers black, and 5 percent were Hispanic or Latino, Insurance companies’ “panels” of clinicians according to Cardinal estimates. provide services to children whose families are The reasons for this imbalance can be covered through an employer or individual traced back to intergenerational racism, Char- plan or who receive subsidies through the Af- lotte’s history of segregation, and the concen- fordable Care Act (ACA). Blue Cross and Blue tration of lower-opportunity communities to Shield of North Carolina is by far the largest the west and north of the center city. Children private insurance carrier in the state and the who experience trauma or are living with only one to participate in the ACA subsidies. scarcity may not reach the early brain-development milestones necessary to avoid develop- What Are Some of the Systemic Issues? ing mental health issues later in life. This leads Just as lack of access is believed to be the to a higher incidence of contact with the school biggest issue for children who need services, disciplinary, juvenile justice, child welfare and lack of resources is perhaps the biggest chal- mental health systems. lenge for providers. While some community We simply cannot ignore the link between agencies are set up to bill both Medicaid and poverty and poor mental health. iv The full report details three strategies and 16 tactics focused on prevention, access and quality, to more strategies effectively serve children with mental health needs.

Raise awareness and increase education on the 1.importance of prevention and Establish a live-time early intervention, as well as the database for crisis placements impacts of trauma on early brain development Create more adolescent treatment beds Provide more Develop a trauma provider training clearinghouse

PREVENTION ACCESS

Raise awareness about Facilitate more the importance of early community- brain development wide training Expand school-based mental health to Adopt the more schools Child First model Increase access to mental health services 2. and support for children and families v The full report details three strategies and 16 tactics focused on prevention, access and quality, to more effectively serve children with mental health needs.

Reward best practices and encourage 3. collaboration and communication

Create a data warehouse Explore alternative approaches Increase cultural Adopt a common competence assessment Transition to a whole-person model

QUALITY

Eliminate duplication of management and coordination

Include mental health- Evolve to an care in community outcome- resource centers based model

vi Britney, Deon and Nicolás are fictional characters whose stories are based on realistic scenarios and compilations of anecdotes told by parents and professionals working in Charlotte’s mental health, juvenile courts, child welfare and public school systems. Their stories are composites created to ensure client confidentiality. Throughout this report, we’ll follow their journeys from diagnosis to treatment to illustrate the unique situations and common stumbling blocks along the path from illness to (hopefully) recovery.

Britney is a 17-year-old student at one of Charlotte’s suburban high schools. When she feels overwhelmed or hopeless about getting into college, Britney cuts herself with a razor blade on her upper arms or abdomen where her parents won’t notice. She has written about suicide in her journal and on her Tumbler page. Britney’s high school doesn’t have a school-based mental health program, so her increased absences, declining grades, and disengagement from other school activities largely go unno- ticed. It takes an outburst—uncontrollable crying and threats to jump in front of a car—for Britney to be referred to a mental health specialist. Treatment is covered by her family’s health insurance policy, although the annual deductible is so high and the waiting list so long that Britney’s parents decide to forgo selecting a counselor from their insurance carrier’s panel of in-network clinicians. Instead, they choose a licensed therapist who is out-of-network and doesn’t accept insurance, thinking that her treatment costs will be less than their deductible. However, the initial assessment costs several hundred dollars, and Britney’s parents worry about whether they can afford ongoing therapy. They had thought one or two sessions would fix the problem. Deon begins selling marijuana soon after his 12th birthday. He thinks if he can earn enough money by convincing some of his classmates in middle school to smoke, his mother will stop prostituting herself to support him and his younger siblings. Deon is arrested for possession with intent to distribute, a felony charge, and is sent to the Juvenile Detention Center. At his disposition, the judge orders a comprehensive clinical assessment to include a substance use assessment and a psychological evaluation. The court psychologist diagnoses Deon as having attention-deficit hyperactivity disorder (ADHD). Cardinal Innovations authorizes him to receive intensive in-home services from an agency in its provider network since he’s enrolled in Medicaid. The court professionals are unaware of his mother’s prostitution and therefore determine she can provide adequate safety and supervision for him. Six-year-old Nicolás’ mother is killed in a car accident a few months after she and her husband and only child came into the U.S. without documentation. Although his father doesn’t know the English word for it, Nicolás has autism, a neurodevelopmen- tal disorder characterized by impaired social interaction, verbal and nonverbal communication, and restricted and repetitive behavior. Nicolás’ parents first noticed his symptoms around the time he turned 2 but didn’t seek a diagnosis, although they did have access to healthcare in their home country. His father knows Nicolás needs help to function, but without insurance he has no good options. Shortly after the accident, Nicolás’ father leaves him in the lobby of the Department of Social Services (DSS), hoping someone will take him in and give him the services and support he deserves. Introduction

ubert Humphrey once said “the ABOUT moral test of government is how that govern- In 2016, among local children and adolescents MEDICAID H ages 3 to 18 who received Medicaid services... ment treats those who are in the dawn of life, RECIPIENTS the children; those who are in the twilight of life, the elderly; and those who are in the shad- a were As of February ows of life, the sick, the needy and the handi- 9,534mental health patients 2017, more than capped.” This report is dedicated to children 1.97 million North who have mental health needs in the dawn of Carolinians were life in the hope that they won’t be destined to enrolled in Medic- live in the shadows. were803 intellectually or aid.2 This compares Research shows people who have behav- developmentally with Mecklenburg ioral disorders early in life—an incidence of disabled (I/DD) County’s general 328were for mental health disturbance in childhood that population of 1.05 substance use rises to the level of clinical attention—are 3 diagnoses million people. prone to have mental illness follow them into a Last year, 12,616 adulthood. Sadly, they may never fully recov- received an Mecklenburg Coun- er. Similarly, focusing resources on the mental assessment419 without treatment ty adults used their wellbeing of children and adolescents, in terms Medicaid benefits of prevention and intervention, can result in Source: Cardinal Innovations for a mental health fewer hospitalizations, incarceration and other service, compared costs to society within the adult population. MEDICAID BY THE NUMBERS with 10,294 children 4 “The issues of mental illness, developmen- ages 3 to 18. tal disabilities, and substance abuse do not and licensed professional counselors—and the a 281 local chil- discriminate,” says Mebane Rash, director of case coordinators and school, court and peer dren and adoles- law and policy for the North Carolina Center counselors who provide support services but cents were served for Public Policy Research. “They touch the are not licensed to provide clinical treatment. by the state’s benefit lives of the rich and poor, those living in urban And people who have been diagnosed as hav- plan, the Integrated and rural areas, all ages and races, and both ing a mental health or behavioral health need Payment and Reim- genders.” (these terms are synonymous) tend to be cat- bursement System 5 Among children and adolescents, behav- egorized as having an intellectual or develop- (IPRS). ioral health disorders are common and can mental disability, a substance abuse diagnosis, a Of the overall be particularly difficult for their families and or some other mental health need. Mecklenburg Coun- caregivers, especially when the child suffers Because poverty and the prevalence of ty population (chil- from a seriously debilitating mental illness. mental health disorders tend to go hand-in- dren and adults) One in five children at some point during their hand, much of the following discussion is who were served by lives have had a mental disorder considered to about Medicaid. However, the private system Medicaid in 2016, 1 be debilitating. Others are affected by social of commercial insurance is not immune to 56 percent were and emotional challenges that are less severe some of the same systemic issues. African American, or persistent but can still create significant “Everywhere in the country, the systems 34 percent were problems for themselves and their families. are broken in one way or another,” says Dr. white, and 5 per- People who have dedicated their careers John Santopietro, a psychiatrist and former cent were Latino or to helping people with mental health challeng- chief clinical officer of behavioral health for Hispanic, according es generally fall into two categories: licensed Carolinas HealthCare System (CHS) who now to Cardinal Innova- clinicians providing direct services—including runs a mental hospital in Connecticut. “Lack of tions’ preliminary 6 psychiatrists, psychologists, social workers access and stigma are the biggest issues.” numbers.

1 An Overview of the Ecosystem

wo analogies explain the jumbled the bureaucracy. Another is the profusion of Tpatchwork of mental health services for chil- community agencies, governmental entities dren and adolescents in Mecklenburg County. and private practitioners who have their First is the parable of the blind men and the el- hands around only one part of the elephant. ephant. In the oral traditions of several Eastern Yet another is competition: No matter whether religions, a group of blind men use their sense an organization is for-profit or not-for-profit, of touch to try to understand what an elephant economics drive the system. “It’s more accu- is. Each one feels a different part of the animal. rate to call it a non-system than a system given The man who explores one of the fragmentation,” says Dr. ‘It’s more the massive legs declares the Santopietro. accurate to elephant to be like a pillar; the The second analogy that one who feels the trunk says explains the overall ecosystem call it a it’s like a tree branch; the one is a typical roadside construc- non-system who touches the tail says the tion crew. Imagine four work- than a system elephant is like a whip. It’s ers in hard hats and safety not until a sighted man walks vests laboring by the side of the given the by and describes the entire road. One person is chest-deep fragmen- animal that the blind men gain in a hole wielding a shovel. tation.’ a complete picture of what an The others are standing around elephant truly is. the hole supervising the dig. In Dr. John Santopietro Like the blind men, the many ways, this scene depicts formerly of Carolinas hundreds of organizations in the infrastructure of the men- HealthCare System Charlotte-Mecklenburg in- tal health system. For every volved in mental health have clinician working directly with little understanding of what their counterparts a family by counseling a child or teen, many are doing. Practitioners in the private sector, more non-licensed professionals are providing who accept only out-of-pocket payment or an ancillary resource or support—or adminis- whose clients are covered by insurance, often tering to the bureaucracy of compliance. may not know how Medicaid works—and People who’ve been laboring in mental increasingly may not be interested in serving health for decades describe a system organized Medicaid patients. And, according to those around Medicaid eligibility guidelines and interviewed, many of the agencies who utilize reimbursement schedules for “service defi- public funding sources largely are unaware of nitions.” If a particular service comes with a gaps in and barriers to services for consumers higher reimbursement rate, anecdotal evidence who have private insurance. Even among the suggests, that service is prescribed more often major players, as well as community agencies than one tied to a lower rate. Some critics of operating in the same arena, at times it seems the system say it’s not uncommon for psychi- as if they, too, wear blinders. The majority are atric assessments calling for one mental health licensed experts in their respective fields and service to be changed to another if the service likely do very good work within their own do- prescribed isn’t offered by the agency, or if mains but have little connection, collaboration Cardinal Innovations deems the service too or communication with their peers who work expensive. for other organizations. The word most com- These practices—and the larger issue of a monly used to describe the system is “silos.” system driven by financial incentives—come The reasons cited for this fragmentation at the expense of the very families the system are many. First is the sheer complexity of was designed to serve.

2 A Brief History of National Reforms

he sorry state of children’s mental tients aside from clinical services. Components FACTS Thealthcare begs the question, how did we get included housing, outreach and advocacy, cri- ABOUT here? Before World War II, mental illness was sis intervention, social and vocational rehabili- MEDICAID viewed as incurable. Patients were housed in tation, and family support and education. The overcrowded state mental institutions. The community support program that NIMH ini- a The objective war sparked the realization that post-traumatic tiated in 1977 placed heavy emphasis on case of Medicaid is to stress disorder (PTSD) is indeed curable and management: No longer was mental health the provide states with can be treated successfully in outpatient set- exclusive domain of licensed clinicians. matching federal tings. Soon after the war ended, the National The Eighties were an era of sweeping funds to help people Mental Health Act of 1946 made mental health federal budget cuts. Responsibility for mental with low income ob- funding and reform a national priority. It also health was delegated to the state level with tain services deemed established the National Institute of Mental passage of the Comprehensive Mental Health “medically neces- Health (NIMH), which today is the world’s Service Act of 1986. In just four decades, the sary.” largest research organization for mental illness. primary responsibility of caring for people a States are not re- In the 1950s and 1960s, funding for mental with mental illness had shifted from the states quired to participate. health research and services increased dramat- to the federal government back to the states. a North Carolina ically. In 1963, Congress passed the Commu- Yet the 1980s also saw scientific advances chose not to expand nity Mental Health Act to shift emphasis from in understanding the functions of the human its program under institutionalization in psychiatric hospitals brain. In 1989, Congress passed a resolution the Affordable Care to community-based care. Community- and designating the Nineties as the “Decade of Act (ACA), common- home-based services allow individuals to re- the Brain.” The emerging fields of neurosci- ly called Obamacare. main with family and in school, and to live in ence and neuropsychiatry held the promise of a Each state formu- the community instead of mental institutions. addressing clinical disorders of cognition and lates its own pro- The 1960s also saw new federal funding behavior caused by brain defects. gram, including eligi- for people with intellectual and developmen- The Nineties were bookended by two bility requirements, tal disabilities; NIMH research centers were landmark events: In 1990, Congress enacted the scope and types founded for schizophrenia, child and family the Americans with Disabilities Act (ADA) to of services covered, mental health, crime and delinquency, suicide, prohibit discrimination against people with and the correspond- rape, urban problems, minority-group mental disabilities, including those with mental disor- ing rate of payment. health disorders, and victims of natural disas- ders and intellectual disabilities. And, in 1999, a It’s unclear what ters. With an increased awareness of substance the U.S. Supreme Court ruled in Olmstead the future holds for abuse as a mental health issue, national centers v. L.C. that people with mental disabilities Medicaid. Not only for the study and prevention of alcoholism and have the right to live in community settings, has the U.S. Congress drug abuse were established. if appropriate, rather than in institutions. The failed to repeal and Arguably, the most significant healthcare ruling paved the way for statewide reform replace Obamacare, legislation of the Sixties was the establishment legislation across the country. the N.C. General As- of Medicaid. Congress created the entitlement Finally, three milestones in the first decade sembly may dissolve program in 1965 by adding Title XIX to the of the new century include a Surgeon General the current system Social Security Act, which was passed 30 years report in 2001 stating that the U.S. faces a pub- and replace it with earlier during the Great Depression. lic crisis in children’s mental health, a NIMH capitated contracts In the 1970s, breakthroughs in drug report in 2002 showing that early intervention with prepaid health research led to the now common practice of can reduce the harmful effects of exposure to plans. The new prescribing antidepressants, resulting in sharp violence, and a 2004 clinical trial of adolescents system may integrate drops in inpatient stays and suicides. Commu- with severe depression that found a combina- mental health with nity-based care was greatly expanded in the tion of medication and psychotherapy to be the medical side of Seventies to include ways of supporting pa- the most effective treatment. healthcare.

3 Recent Reforms in North Carolina and their Impact on Charlotte

olicy experts say North Carolina’s jour- them with local management entities (LMEs). Pney along the highway to mental health reform Further, the law required the quasi-govern- has been a bumpy ride at best and, at worst, mental LMEs to contract with private provid- the state has driven the car into the ditch.7 The ers to deliver mental health services. Thus, the Department of Health and Human Services Mental Health System Reform Act was the first (DHHS) and its Division of Mental Health, De- step towards privatization of the system. velopmental Disabilities and Substance Abuse As Rash writes in a 2012 article in North Services are the state agencies that manage the Carolina Insight: delivery of medical and mental healthcare ser- In theory, North Carolina’s approach was sup- Managed care vices, especially for children, low-income fam- posed to accomplish four things: to increase admin- A system that inte- ilies, the elderly and people with disabilities. istrative efficiency by segregating management and grates the financ- DHHS crafts policies to implement health-re- oversight of mental health services from the actual ing and delivery of lated bills ratified by the General Assembly. provision of services; to promote innovation and healthcare using a In 2001, the state legislature passed the utilize new technologies; to enhance provider qual- comprehensive set of Mental Health System Reform Act in response ity; and to stimulate competition among providers. services; any method to the 1999 Olmstead decision by the U.S. But the transition has not been easy. For consum- of organizing health- Supreme Court. The new law transferred re- ers, the loss of a one-stop shop has been tough. ... care providers to achieve the dual sponsibility for the vast majority of treatment This led to concerns that the private sector might goals of controlling of mental health from North Carolina’s psychi- not be sufficiently responsive to the needs of people 8 costs and managing atric hospitals to community-based care. with mental illness and that the profit motive could quality of care. “A large network of private providers was result in a reduction in the quality or quantity built up to increase service capacity in local of services, particularly for those with severe and communities across the state, but questions persistent mental illness. were raised about provider quality. However, Despite the transition to privatization, the biggest problem with mental health reform the state’s Medicaid spending—the fastest in North Carolina has been the state’s endless growing program in the budget—continued to stream of changes in policy, funding levels, skyrocket. In fiscal year 2008-09, North Caroli- and leadership,” according to Mebane Rash, na spent $3.2 billion on Medicaid. The annual director of law and policy for the North Caroli- growth from 2001 to 2009 was 9.3 percent.9 na Center for Public Policy Research. From 2008 to 2016, the state’s Medicaid rolls The 2001 law also required area mental swelled from 1.2 million to 1.9 million people, health authorities to separate the management or nearly 20 percent of the population. of mental health services from the delivery of What about North Carolina’s children? those services. Created in the 1970s, regional In 2008, nearly 800,000 children were covered authorities such as the Mecklenburg County by Medicaid or North Carolina Health Choice Area Mental Health Authority had been in the for Children, a state insurance program that business of providing direct mental health ser- covers children from families whose income is vices utilizing public dollars. The new law did too high for Medicaid but can’t afford private away with the area authorities and replaced insurance. By 2015, more than 1 million chil-

Timeline of mental health reforms in N.C. 2001 2005

General Assembly Piedmont Behavioral passes Mental Health Health (now Cardinal) System Reform Act begins pilot program for managed care 4 dren were covered, for an annual growth rate served only one county. North Carolina initial- of 3.7 percent. About a third of U.S. children ly had 33 LMEs serving all 100 counties, but are covered by Medicaid, but in North Caroli- the General Assembly was intent on consoli- na 41 percent are covered by Medicaid or N.C. dating them. In a state where the norm was for Health Choice.10 an LME to manage multiple counties, Meck- Meanwhile, the federal government contin- LINK stuck out like a sore thumb. ued to tinker with Medicaid to allow states In late 2012, then County Manager Harry more flexibility in administering their pro- Jones announced to the County Commis- grams. In 1991, the Medicaid Waiver Programs sioners that the state had pulled MeckLINK’s were created to give states the option to set up contract over negative reports that it wasn’t ‘...the biggest managed care systems in order to rein in costs. adequately prepared to implement managed In North Carolina, DHHS devised a plan to roll care. The County Commission threatened to problem with out the waivers gradually, turning the LMEs sue the state and won an extension to allow mental health into managed care organizations (MCOs) at a MeckLINK to continue to ramp up to become reform has steady clip of one or two at a time. The initial Mecklenburg’s LME-MCO. In March 2013, pilot program for waivers was implemented MeckLINK began operations. been the state’s in 2005 by Piedmont Behavioral Health (now Then, three months later, the state voted to endless stream called Cardinal Innovations Healthcare), which strip the county of control over Medicaid. The of changes in at the time was the LME for five rural counties county was given the choice to join one of two in North Carolina. After several years of eval- LME-MCOs whose footprints were contiguous policy, funding uating the pilot program, the state added two to Mecklenburg. By November, the commis- levels and more sites. But, in 2011, the General Assembly sioners had worked out an agreement with leadership.’ hit the accelerator with a bill to expand the Cardinal to serve as the county’s LME-MCO. Mebane Rash waivers statewide within two years. By this time, the county had poured at N.C. Center for Public Medicaid policy experts assert that North least $8 million into MeckLINK, which had Policy Research Carolina transitioned from area mental health grown to more than 200 employees. The agen- authorities to LMEs to the LME-MCO model— cy had more debt than assets. When Cardinal which is in place today—far too quickly. And, took over on April 1, 2014, about 100 Meck- they say, the road to managed care in Char- LINK employees were hired by Cardinal, 55 lotte-Mecklenburg was full of potholes. were reassigned or retired, and about 40 lost Mecklenburg County was scheduled to their jobs. Four former MeckLINK employees implement the waivers in 2011 but ran into were assigned the job of shutting down the delays. The county formed an agency called agency and forming a new county department, MeckLINK Behavioral Healthcare that initially the Behavioral Health Division (BHD), under employed 131 workers to oversee about $200 the Consolidated Health and Human Services million in Medicaid payments to more than Agency. 500 community agencies providing mental The closing of MeckLINK and the rise of health services to residents. MeckLINK was Cardinal represented the final step in what is unique among the state’s 23 LMEs in that it now a fully privatized system of mental health.

2 011 2012 2013 2014

General Assembly North Carolina pulls MeckLINK begins Cardinal becomes passes bill to expand MeckLINK’s contract; operations as managed care managed care statewide county commissioners county’s managed organization for within two years threaten a lawsuit care organization Mecklenburg County 5 An Overview of Key Stakeholders

hile hundreds of public, private, pace. In July 2016, Cardinal absorbed the four Wnot-for-profit and for-profit organizations con- counties that had constituted the CenterPoint stitute the ecosystem of mental health services Human Services catchment. Today the compa- and support for local children, a handful of ny manages benefits for about 850,000 Med- key stakeholders form the backbone of the icaid enrollees, who are served by Cardinal’s system. Some of them include: private-sector workforce of 800 employees. North Carolina currently has seven LME- Cardinal Innovations Healthcare MCOs, but DHHS has proposed an overhaul Cardinal is the LME for IPRS, a state program of managed care that would integrate medical for indigent people who don’t qualify for Med- and behavioral health into a “whole person” icaid, and the MCO for administering Medic- system. The new system, which would require aid reimbursement for mental health services. legislative approval, would utilize capitated Cardinal’s “catchment area,” or footprint, contracts with prepaid health plans. Medicaid includes Mecklenburg and 19 other counties.11 members would choose between three com- Cardinal evolved from an area authority mercial plans or from one of a dozen “provid- 13 providing behavioral health services to resi- er-led entities.” While the long-term impact dents of three rural counties of North Caroli- on the existing LME-MCOs is uncertain, ex- na in the mid-1970s. When it expanded into perts say their role would be greatly reduced. Mecklenburg in April 2014, its territory had Meanwhile, Cardinal has moved its grown to 15 counties. With the addition of corporate offices from Kannapolis to leased Mecklenburg as the sixteenth county, its catch- space in the NASCAR Hall of Fame in uptown ment area increased by nearly 75 percent.12 Charlotte, put its real estate holdings on the Cardinal has continued to expand at a rapid market, and transitioned much of its workforce

Vaya Partners Sandhills Alliance Eastpointe Trillium Health Behavioral Center Behavioral Health Health Healthcare Resources

North Carolina is divided into seven regions or “catchment areas” for managed care organizations. Cardinal Innovations’ footprint currently is comprised of 20 counties, including Mecklenburg. Source: N.C. Dept. of Health and Human Services

6 to a “mobile-based” model with employees providers in Charlotte-Mecklenburg. Its focus working from home or on-site—all part of a is North Carolina children ages 5 to 18, pro- corporate-wide effort to become more scalable viding them with outpatient, residential and and flexible. community-based services. The not-for-profit In Charlotte-Mecklenburg, Cardinal organization was founded in 1888 as a wom- contracts with 262 agencies or “service provid- en and children’s rescue mission. In 1946, the ers”—collectively referred to as the “provider agency began serving children with emotional network”—which represent the front lines of and behavioral problems. mental health treatment.14 “We consider ourselves as a specialty Monarch health plan,” says Laurie Whitson, senior com- Another of Charlotte’s largest service provid- munity executive for Cardinal’s Mecklenburg ers, Monarch provides support statewide to Community Office. But for the clinicians who 31,340 people, including 4,061 children. The work directly with Medicaid patients, Cardinal not-for-profit agency began in 1958 with a has the final say in whether or not a particular focus on helping people with intellectual and ‘We consider mental health service is medically necessary. developmental disabilities. Today it also serves ourselves as That means if Cardinal says “no,” the service individuals with mental illness and substance provider won’t be reimbursed. And if there’s use disorder. Monarch has service locations in a specialty no reimbursement, there’s no treatment. 45 counties across North Carolina and operates health plan.’ But Cardinal says it approves 98 percent of The Arc of Stanly County, which is a chapter of Laurie Whitson the services requested; 92 percent of the $680 The Arc of North Carolina and The Arc of the Cardinal million it collects annually from Medicaid is United States. Innovations spent on providing care; and only 8 percent is Healthcare used for administration costs, including sala- Blue Cross and Blue Shield ries and real estate, even though federal rules By far the largest health insurance carrier in 15 allow up to 15 percent. the state is Blue Cross and Blue Shield of North Carolina. In a 2016 ranking of top carriers by Thompson Child and Family Focus the number of policies written in the state, One of the largest agencies in Cardinal’s pro- Blue Cross was nearly seven times larger than vider network, Thompson Child and Family its closest competitors, UnitedHealthcare and Focus was founded as an orphanage in 1886. Humana.16 Today it operates a family services center and Children who aren’t eligible for Medicaid a child development center, both in Char- or N.C. Health Choice may be covered under lotte; early childhood outreach programs in their parents’ health insurance policies or may Mecklenburg, Cabarrus and Union counties; a not have any insurance. The state Department psychiatric residential treatment facility (PRTF) of Insurance regulates insurance companies in Matthews for children ages 5 to 13; and a and their agents and policies. The authority community counseling center in Fort Mill, S.C. to regulate private insurance is delegated to In the fiscal year 2015-16, Thompson impacted the Commissioner of Insurance by the Gen- more than 12,000 individuals in the Carolinas. eral Assembly. Prior to Obamacare, private health insurance policies didn’t necessarily Alexander Youth Network include coverage for behavioral health. Under Serving approximately 8,800 children a year in Obamacare, a health insurance plan is required more than a dozen programs, Alexander Youth to cover at least some of the costs for mental Network is also one of the largest service health and substance abuse services.17

7 Mecklenburg County Manager

Deputy County Manager Chief of Staff

Assistant County Manager Assistant County Manager County Administration Financial Services Health & Human Services l County Manager’s Office l Business Process Management l Financial Services Department Consolidated Health & Project Management l Central Finance Human Services Agency l Asset & Facility Department of Financial Services l l Behavioral Health Division Management Procurement l Child Support Enforcement Human Resources Office of the Tax Collector l Community Support Services Public Information Information Technology l Health Department l Risk Management Department of Social Services Public Safety & Criminal Justice l Criminal Justice Services Mecklenburg County’s Consolidated Health and Human Services l Agency provides essential services designed to protect and enhance the Medical Examiner health and well-being of its residents. Highlighted on the organizational chart, four of the five county entities involved in children’s mental health are housed here; the fifth is part of Criminal Justice Services.

Mecklenburg County Government team, which includes two psychologists and Although Mecklenburg County no longer is in two clinicians. Another BHD staffer serves as the business of providing clinical mental health project manager of Reid Park Initiative, which services to its residents, five separate govern- is discussed on pages 30-31. mental departments and divisions provide a The Health Department is a key stakehold- management, consultation and training in the er in mental health through its Trauma and behavioral health arena. This represents a sea Justice Partnerships division. Although Crisis change in the way mental health services are Intervention Teams, Carolina Alcohol and provided. Drug Resources, and Officer Wellness and Re- Four of the county governmental entities silience also are part of the division, the Child fall under the umbrella of the Consolidated Development-Community Policing (CD-CP) Health and Human Services Agency. (A fifth program is the partnership in which children’s county entity, the Forensic Evaluations Unit, mental health is the focus. is discussed under N.C. Juvenile and Family The CD-CP collaboration began in 1996 to Courts System, on page 12.) They are: increase officer awareness and identification of a The Behavioral Health Division rose from children at risk. Another goal was to increase the ashes of MeckLINK, which in turn evolved clinical assessment of and intervention with from the Mecklenburg County Area Mental children at risk. The program provides coun- Health Authority. BHD manages a network of seling to children ages 0 to 18 who are victims 16 behavioral health providers (separate from of violent crime or who have witnessed violent Cardinal’s network). BHD has five employees crime. On-call clinicians work in tandem with tasked with oversight of the providers’ con- specially trained police officers to provide tracts with the county. Through this network acute trauma services to children and their of providers, BHD minimizes some of the gaps families. Police-clinician teams make multiple in services and support because county-fund- follow-up visits with families in their homes ed programs and initiatives aren’t subject to to provide additional support following an Medicaid guidelines. In addition, BHD sup- incident report. Roughly 10 percent of those ports the other county entities involved in cases are referred to outside service providers. mental health through its clinical consulting During the 20 years that the program has been

8 Assistant County Manager Sustainable Communities

Land Use & Environmental their needs are met, including mental health. Services Agency If the child’s mental health assessment deter- l Air Quality mines a residential therapeutic service is med- l Code Enforcement ically necessary, YFS is responsible for finding l Solid Waste & Recycling l a “therapeutic placement.” Being placed in Water & Land Resources l GIS the county’s custody automatically qualifies a child to receive Medicaid, so Cardinal must Park & Recreation Legal authorize the treatment of children whose fam- Economic Development Budget Office ilies are no longer legally responsible for them. YFS also works with children who are Strategic Planning Internal Audit & Evaluation Department legally cleared for adoption to find permanent homes for them. In 2016, YFS found permanent Workforce Development Office of the homes for 60 children, a 20 percent increase & Literacy Tax Assessor from 2015. a While its primary emphases are home- lessness, veterans, substance abuse, domestic violence and the prevention of violence, in place in Charlotte, nearly 40,000 cases have Community Support Services (CSS) also been referred to CD-CP, and more than 1,500 should be noted here. CSS provides training to officers have been trained. In 2016, 7,658 chil- Charlotte-Mecklenburg School (CMS) employ- dren from 4,460 families were served. Eighty- ees about teen violence to support lesbian, eight percent of those cases also were referred gay, bisexual, transgender and questioning to Child Protective Services (CPS) for suspicion (LGBTQ) youth. Through a community part- of abuse or neglect. Forty percent of children nership with Time Out Youth, CMS teachers referred last year were under the age of 6, and also receive training on cultural competence 39 percent of incidents involved intimate part- with LGBTQ youth. As part of the partnership, ner violence. which is funded through a federal Department The local office of the statewide Children’s of Justice grant, Time Out Youth handles case Developmental Services Agency (CDSA) management for teen dating violence targeting became part of the Health Department in 2015. LGBTQ youth. CDSA is discussed on pages 19-20. Another CSS initiative, the Healthy Rela- a A division of DSS, Youth and Family tionships “Start Talking” curriculum, teaches Services (YFS) works with families whose teens and preteens about dating abuse and children’s health, welfare and safety are at risk. conflict resolution. And CSS provides direct YFS receives mandatory reports of child abuse mental health services for eligible children and neglect from the medical community, law who have witnessed violence or who are vic- enforcement, the school system, a relative or tims of intimate partner abuse. For the transi- neighbor, or anyone within the community. tion-age group of 18 to 24, CSS provides victim YFS conducts family assessments and investi- counseling and substance abuse treatment for gates these reports through CPS. When family people who are in jail or homeless shelters. interventions fail to reduce the risk to children, As a non-state-mandated agency, CSS has they may be taken into legal custody by judi- more flexibility than those governed by the cial order. state; and although CSS contracts with Car- As of Sept. 1, a total of 565 Mecklenburg dinal to provide mental health services for County children were in custody of the county. substance abuse counseling for adults, it does YFS is their legal guardian and must ensure all not bill Medicaid for the children it serves.

9 Novant Health tients were treated last year. The partial hospi- Headquartered in Winston-Salem, Novant talization program began in 2014 and currently Health is a not-for-profit healthcare system has a waiting list. serving 4.4 million patients annually in Geor- a Outpatient therapy- Novant has three gia, Virginia and the Carolinas. Novant was specialty clinics for mental health. Of the formed in 1997 when Presbyterian Health 1,637 children who received outpatient mental Services, in Charlotte, merged with Carolina health services last year, 552 were on Medicaid Medicorp, in Winston-Salem. Novant oper- and 78 were covered by N.C. Health Choice. ates two hospitals and three medical centers a Emergency services- Two staff psychia- in Mecklenburg County, including Hemby trists in the pediatric emergency department Children’s Hospital, which is located inside at Presbyterian evaluate patients ages 0 to 18 Presbyterian Medical Center. A fourth medical and make referrals for mental health treat- center is under construction in Mint Hill. ment. In 2016, the department saw 908 pa- In June 2017, Novant began to implement tients; 435 were on Medicaid. The emergency an integrative care model, which joins mental departments in Matthews and Huntersville health with medical care by screening patients are served by licensed clinical social workers; for depression and other behavioral health physician assistants and nurse practitioners concerns. A licensed clinical social worker is trained in mental health provide services to immediately available if a physician deter- community hospitals via telepsychiatry. mines during a medical exam that a patient a Recreational therapy- Novant provides needs mental health services. A psychiatrist as- a gym staffed by a recreational therapist for signed to the primary care office consults with children who are receiving inpatient mental patients by telephone to make integrative care health services. available throughout Mecklenburg County. In addition, Novant’s Women’s Cen- For local children and adolescents specifi- ter screens all new mothers for postpartum cally, Novant’s mental health services include: depression. If they screen positive, they’re a Inpatient therapy- Presbyterian Medical evaluated by a specialist who can treat their Center has a behavioral health center which in- depression if needed. “Studies show women cludes 20 beds for patients ages 7 to 18. Staffed who suffer from postpartum depression have a by one psychiatrist, one recreational therapist, harder time bonding with their infant, so early one social worker and two nurses, 286 children treatment is critical,” Moore said. “We also get received inpatient treatment in 2016. Nearly referrals from our pediatricians and OB/GYNs half (47.9 percent) were Medicaid recipients. when they recognize these symptoms during “All inpatient team members are trained on follow-up care.” And Novant is teaming with trauma-informed care,” said Judy Moore, CHS to evaluate “resource deserts”—particu- director of Behavioral Health Services, Novant larly in the zip code 28208—to find ways to im- Health Presbyterian Medical Center. The inpa- prove services in neighborhoods that have few tient unit also provides patients with a school clinics and a disproportionately high incidence teacher to keep them from falling behind on of medic calls to 911.18 schoolwork and help them cope with stressors related to school. Carolinas HealthCare System a Partial hospitalization- Patients ages 13 CHS is one of the leading healthcare organi- to 18 receive treatment from two therapists at zations in the Southeast and one of the most Presbyterian weekdays from 9 a.m. to 2 p.m. comprehensive public, not-for-profit systems The therapists’ combined caseload ranges from in the nation. The 234-bed Levine Children’s 10 to 12 teenagers at any given time; 97 pa- Hospital was recently named a Best Children’s

10 Hospital in four specialties by U.S. News & in 2013 with the termination of the $40-million, World Report. “no-cost” contract.19 Whether the end of the To a large extent, the responsibility for contract resulted in a decrease in services is treating children with urgent behavioral health open to question. needs often falls to CHS, in particular the emergency departments of its eight hospitals Charlotte-Mecklenburg Schools and six freestanding emergency clinics in The public school system in Mecklenburg Mecklenburg County. County is the 17th largest system in the nation School-based CHS highlighted five mental health initia- by some estimates. CMS is comprised of 170 mental health tives the hospital system has implemented: schools with 9,253 certified teachers serving A collaborative a Integrating mental health services with pri- 150,725 students enrolled in kindergarten effort between mary care, including pediatric services, which through 12th grade. A host of professionals CMS, Mecklenburg minimizes stigma and eliminates barriers to assist teachers and principals to address stu- County, CHS and treatment; dents’ behavioral problems. They include be- five community a Opening a new, state-of-the-art facility in havior management technicians, social work- agencies to provide Davidson serving adults with mood disorders ers, school counselors and school resource clinical counseling to students within and co-occurring substance use disorders; officers, who are police officers employed by the school setting. a Training 9,000 community members, in- the school system or municipal police depart- cluding teachers, athletic trainers, emergency ments. CMS has the equivalent of 62 full-time medical technicians, clergy and firefighters in school psychologists, a ratio of one psycholo- Mental Health First Aid in conjunction with gist for every 2.74 schools. Novant Health; A distinction is made about the work a Using “virtual mental health” teams to school counselors, social workers and psy- reach out to 25 emergency departments, by chologists do as compared with the clinical using telemedicine technology to speak to services provided by licensed therapists. The patients about mental health and medication counselors, social workers and psychologists issues; and who work for CMS technically do not provide a Extending the physician residency pro- mental health treatment; instead, they provide grams to include psychiatry. educational counseling and behavior and crisis CHS’s 66-bed behavioral health hospital, interventions. Their focus is on factors that Behavioral Health-Charlotte (BH-C), houses directly affect children in the school environ- the only dedicated psychiatric emergency ment. Often this means teaching coping strat- department in the region. In 2015, BH-C’s egies and behavioral intervention rather than emergency department served a total of 11,863 an emphasis on the underlying causes. While patients (adults and children); about 50 percent most high schools have multiple counselors, were Medicaid recipients. BH-C’s mental their work is primarily concerned with absen- health services include an inpatient psychiat- teeism, academic performance, credit accrual, ric unit, outpatient medication management, and getting into college. substance abuse counseling, telepsychiatry, fa- Recognizing the need for clinical counsel- cility-based crisis programs and school-based ing in the school setting, CMS implemented mental health (SBMH). an SBMH intervention program beginning For years, CHS benefited from a relation- with the 2014-2015 school year. SBMH is a ship with the county in which Area Mental collaboration between CMS, Mecklenburg Health reimbursed the hospital system for any County, CHS and five community agencies.20 financial losses from providing mental health The agencies—Cano Family Services, Family treatment to residents. That relationship ended First Community Services, Pride in North

11 Carolina, Thompson Child and Family Focus professionals and service providers involved and Turning Point Family Services—are part in child and family matters. The unit also con- of Cardinal’s provider network. The agencies tracts with other local psychologists to com- also accept Blue Cross and Blue Shield and plete specialized court-ordered evaluations. most accept other insurance as well. Now in its In 2012, the Charlotte Mecklenburg Police Adjudication hearing third year, SBMH is available in 59 percent of Department arrested 5,717 children aged 15 A hearing when the public schools. Students who participate in the or younger; 23 were incarcerated in a Youth juvenile has the right intervention program showed positive trends Development Center. Under very strict circum- to admit or deny the for attendance, academics and behavior. stances, children who are accused of a crime charges alleged in the and are waiting for their cases to be heard in petition. Also called an “arraignment.” N.C. Juvenile and Family Courts System court, or who’ve been adjudicated and are A common pathway for children and adoles- waiting to be sentenced, are detained in the Disposition hearing cents to come into the mental health system Juvenile Detention Center. At the time of this The sentencing phase is through the Department of Juvenile Justice writing, 13 children ages 12 and up were being in which the judge section of the N.C. Department of Public Safe- detained. While in detention, juveniles don’t considers evidence ty, Division of Adult Correction and Juvenile receive mental health services because Medic- about the needs of the Justice. Children involved in the courts sys- aid rules prevent them from receiving services juvenile and outlines tem have either been accused of committing during the time of incarceration. a plan to both meet a crime or have been reported as victims of For children who have been reported as the child’s needs abuse or neglect. Virtually every child in- victims of abuse or neglect, their interests are (including treatment volved with the courts system receives a clini- represented by the attorney for YFS, which is and rehabilitation) cal assessment from a licensed clinician. mandated by law to protect children while at- and protect the The department also employs 30 juvenile tempting to preserve the family unit. Its role is public. to prevent further harm from intentional phys- court counselors (JCCs) to serve as mentors, Delinquent juvenile advocates, case managers, and probation and ical or mental injury, sexual abuse, exploitation or neglect. Child victims also are appointed Any juvenile aged 6 compliance officers. During the intake process, to 15 who commits the JCCs evaluate petitions and complaints guardians ad litem (GALs) whose role is to a misdemeanor or against juveniles and determine whether to advocate for them in the courtroom. felony crime, includ- close the cases, initiate court action or divert The following types of cases are heard in ing motor vehicle juveniles to community programs. juvenile or family court: violations. They also are responsible for the supervi- a Juvenile cases, including abuse and sion of adjudicated, undisciplined and de- neglect, dependency, termination of parental Juvenile detention linquent juveniles to assure their compliance rights, delinquency, undisciplined, contempt, Temporary confine- with court-ordered dispositions. JCCs don’t violations and emancipation; ment in an autho- provide direct mental health services, but a Mental health, including voluntary admis- rized youth facility rather make referrals to outside agencies. If the sion and involuntary commitment; pursuant to a secured child receives Medicaid, the agency responsi- a Domestic relations, including child custody order, pend- ble for treatment is part of Cardinal’s provider support, child custody, visitation, post-sepa- ing a court hearing or network. ration support, alimony, domestic violence, until another placement can be found, Although the court system is a function of modification and contempt, divorce from bed either in a communi- state government, Mecklenburg County plays and board, paternity, equitable distribution, ty-based program or a support role. The county’s Forensic Evalua- uncontested and contested divorce; and in a Youth Develop- tions Unit has two full-time psychologists who a Domestic violence, including criminal and ment Center. provide evaluations to the courts, and a liaison civil, child support, custody, visitation, spousal who adds another layer of accountability for support and child sexual abuse.

12 Community Agencies/Service Providers

C a r d i n a l I n n o v a t i o n s H e a l t h c a r e

Novant’s Presbyterian Department of Hospital Social Services’ Youth and Family mmunity Co agen Services cie s pr ov id in g S c h

Carolinas Health- Charlotte- B a

Care System’s s

Mecklenburg e d

Behavioral Health- Schools M

Charlotte n

Primary care e a

t physicians, h pediatricians

Mecklenburg North Carolina County Health Juvenile and Department Family Courts System

THE MEDICAID MENTAL HEALTHCARE MAZE

Medicaid recipients may also contact Cardinal directly by calling the 24-hour access/crisis line at (800) 939-5911 to receive a referral or assessment. Funding Sources, Revenue Models

onprofit and for-profit organizations For the community agencies that bill Nin the business of mental health generate rev- Medicaid, their business models must change enue in a variety of ways; however, they may annually to adapt to revisions to service defini- be broadly divided into public and private. tions and reimbursement schedules. “You can’t Agencies that receive public funding rely on develop a strategic plan for more than a year at reimbursement from Medicaid and grants a time because the expectations change all the from federal, state and county government. time,” said Dr. Dawn O’Malley, a psychologist Not-for-profit agencies also sustain themselves who has worked in the North Carolina public in part through donations, fundraising, and mental health sector for 20 years. And, since grants from private foundations. some service definitions are highly profitable In the private sector, mental healthcare while others are provided at a loss to the professionals are credentialed by commer- agency, the elimination of a Medicaid service cial health insurance companies and join the or a reduction in pay means other services carriers’ provider panels. Insurance companies may face the chopping block, too. It may even set their own reimbursement rates, so private spell the shuttering of an agency if its business practices may choose to be part of some panels model isn’t diversified. For example, intensive but not others. Increasingly, private providers in-home service is a money generator because are choosing to forgo the bureaucracy of insur- it’s an “enhanced service” and therefore has ance reimbursement by opting out of accepting a higher reimbursement rate, so it subsidizes insurance altogether. Their business models less-profitable services. are based on serving clients who can afford to Staying afloat in a constantly changing pay out of pocket. funding climate is an exercise in creativity for providers. For example, Teen Health Connec- tion shares infrastructure costs with CHS and receives community grants from the county, an Alcoholic Beverage Control grant from the state, direct donations from individuals, and funding from United Way of Central Caroli- nas. The outpatient medical and mental health clinic also holds annual fundraising events like “Stand Up and Get Down for Teens,” which Public Private includes sponsorships and a silent action. Although the agencies and institutions involved in children’s mental health don’t share a common business model, they do share the collective quandary of insufficient resources. The struggle to do more with less may be most evident in our public school system. Recogniz- ing the need for more funds for mental health A minority of service providers accept both public in public schools, the General Assembly is and private funding. For example, they may be preparing a bill that would direct the Depart- part of Cardinal’s provider network for clients who ment of Public Instruction to study the issue have Medicaid, and Blue Cross and Blue Shield’s panel to serve clients with private insurance. But and make recommendations. In April, the bill the majority choose one business model or the other was passed by the house, and it also passed since having the ability to bill either system creates the first reading by the senate before apparent- more overhead. ly stalling out in committee.21

14 System of Care

he importance of grants in a system young people function within their families, Tthat lacks adequate resources can’t be overstat- schools, neighborhoods and peer groups; ed. Grants plug some of the gaps left by the they’re not “little adults.” A pediatric mental two primary funding sources—Medicaid and healthcare system built on a holistic modus private insurance. So what happens when a operandi considers mental health not in isola- grant goes away? As was the case with the sys- tion but as part of a network of human services tem of care (SOC) grant that expired in 2012, which provides a safety net for children and “I would argue that we have no mental health their families. system anymore,” says Dr. Jim Cook, a psy- Research demonstrates that SOC is espe- chology professor at the University of North cially effective for youth who are at risk for Carolina-Charlotte. committing crimes, using drugs or alcohol, Dr. Cook doesn’t mean to imply that getting pregnant, or being expelled from people no longer are receiving mental health or dropping out of school. It recognizes the services. His point is that Charlotte doesn’t importance of a healthy home environment have a cohesive system of coordinated care and gives parents the tools they need to work that is family-centered. “And there are almost collaboratively with service providers. System of care no efforts made to assess the degree to which Consider our fictional character Deon’s A spectrum of services are implemented in a way that would home life: If his mom continues to work as a effective, commu- likely lead to positive outcomes,” Dr. Cook prostitute, with strangers coming and going nity-based services adds. at all hours… if he and his siblings are contin- and supports A nationally recognized expert in SOC, Dr. ually exposed to drug and alcohol abuse… if for children and Cook wrote the SOC grant proposal for Meck- they’re worried about their safety, about hav- youth with, or at lenburg County and served as its lead evalua- ing enough food, about becoming homeless risk for mental or tor when the program was implemented. He’s again… would an hour or two of counseling other challenges, been involved in statewide SOC initiatives each week really do Deon much good? As one and their families. since 1997 and for 15 years has served as part interviewee put it, “You can’t polish an apple, SOC is organized of a national team of site visitors who evaluate put it back in the basket, and expect it not to into a coordinated SOC programs around the country. rot when the rest of the basket is bruised.” network, builds To put Dr. Cook’s rather gloomy evalu- Conversely, if the human services profes- meaningful partnerships with families ation of the state of children’s mental health sionals charged with Deon’s safety, housing, and youth, and in Charlotte-Mecklenburg into context, some transportation, academic performance, mental addresses their cul- background is helpful. The federal SOC grant, health and so on were to collaborate as a Child 23 tural and linguistic which the county received directly from the and Family Team (CFT), statistically speak- needs to help them Substance Abuse and Mental Health Services ing he would stand a much better chance of function better at Administration (SAMHSA) from 2005 to surviving his childhood and succeeding as an home, in school, in 2012, was intended to transform the system. adult. CFTs are supposed to meet regularly the community and MeckCARES was the name given to the SOC with children and families to develop goals throughout life. program locally. MeckCARES provides train- and plan for services—but, according to Dr. ing throughout the mental health community Cook, local CFTs often didn’t do much plan- as a best practice approach to serving children ning and weren’t much different from a case and their families.22 manager working with the parent and child. At the heart of the SOC philosophy is a Another big part of SOC is to help parents “family-centered” methodology, as opposed to understand the complex system of human “person-centered” modalities that may work services available to them. A common theme well for adults but don’t necessarily apply to expressed in interviews for this assessment is, children and adolescents. SOC recognizes that if clinicians and case managers have a hard

15 BRITNEY, DEON AND NICOLÁS*: time steering families through the bureaucra- THEIR STORIES CONTINUE cy of mental health services, how are parents to navigate the maze? Britney sits in the waiting room of her therapist’s Unfortunately, when the SOC grant from office. Her face is flushed. She feels anxious. She’s SAMHSA ended—about $9 million over sev- been working with this therapist for three months and en years for training programs, child evalu- feels shame and guilt that her parents are spending so ations, counseling and case management for much money on her treatment. Although her parents families, and MeckCARES salaries—the ser- don’t discuss finances in front of her, she worries that vices provided through MeckCARES ended, they’ll have to dip into her college fund. Most of all, too.24 Without adequate Medicaid funding to she’s afraid the therapist will discover that last week pay for SOC services on an ongoing basis, the she cut herself again. Even though it’s unethical to financial incentive to continue to utilize the discontinue services if a child is still harming herself, model evaporated. her therapist has said if Britney continues cutting she That’s not to say the SOC philosophy isn’t won’t be allowed to continue therapy with her. being incorporated into children’s mental Deon is back in the Juvenile Detention Center, health services to this day, or that Medicaid this time for a violent outburst at school. A second offers no reimbursement for some SOC-based court-ordered evaluation recommends multisystemic services. MeckCARES’ ghost lives on in pro- therapy (MST). That means the intensive in-home grams ranging from Reid Park Initiative, to treatment is terminated, and a new agency and team the Thompson Wraparound program funded of professionals enter Deon’s life, forcing him to by a SAMHSA expansion grant, to CFTs in undergo another circumstance where his life is on dis- the juvenile justice system, to MeckCARES play. He has to tell his story again and trust another SOC Community Collaborative volunteers group of adults, while being careful not to reveal his who continue to offer training. mother’s prostitution. The court counselor assigned But when the new, reduced SAMHSA to Deon warns his mom if he continues his disruptive funding began flowing into North Carolina behavior, CPS could hold a hearing to remove him counties again, it flowed through Raleigh from his home and place him in foster care—or even a first. With a state government intent on sav- locked facility. His mother pleads, “But Deon is only ing money, SOC became more of a buzzword 12.” than a way of doing business. Governments When DSS workers discover Nicolás wandering pick their priorities by choosing which pro- alone through their lobby, he’s unable to communi- grams to fund: Cardinal has one SOC coor- cate. He has nothing but the clothes he’s wearing and dinator for all of Mecklenburg County, and no identification. He has a note stuffed in a pocket some of the other counties in its catchment of his jeans saying his mom has passed away, he has area share a single SOC coordinator. no family in his home country who can care for him, What the community lost when the SOC and his dad must find work to survive. Written at the grant expired wasn’t just money. It lost a bottom of the crumpled note is a simply worded plea: trove of data on outcomes collected by the “Please take care of little Nicolás. Thank you and god university. Dr. Cook and his colleagues lost bless.” Nicolás is placed temporarily in a foster home a clearing house for obtaining information as a complicated legal process begins in juvenile court. in order to analyze which approaches are Although he’s no longer considered undocumented, working and which are a waste of taxpayers’ he remains in the U.S. without permanent residency money. In effect, Charlotte-Mecklenburg lost status, so no federal or state funds are available to pay the ability to determine quantitatively wheth- for his foster care. er children are getting healthier or getting *Britney, Deon and Nicolás are fictional characters. worse.

16 Substance Use Disorder

oung people who are adversely requires health care providers who deliver FACTS ABOUT Yaffected by drugs and alcohol can be broadly babies testing positive for alcohol or drugs to OPIOIDS divided into two camps: children growing report it to their local DSS. The goal is to screen up in households where abuse is present and newborns for drug toxicity and withdrawal a Opioids are a adolescents who are substance users them- symptoms and determine if foster care is ap- class of drugs that 30 selves. More than 7 million children in the U.S. propriate. include heroin as live in a household where at least one parent is While it’s difficult to gauge how prevalent well as prescription dependent on or has abused alcohol.25 the use of drugs and alcohol is among our pain relievers such In Mecklenburg County, between half and community’s children, data from the Youth as oxycodone, hy- three-quarters of individuals under the age of Drug Survey indicate the most commonly used drocodone, codeine, 21 who were arrested between 2003 and 2011 drugs were alcohol and marijuana. The survey morphine, fentanyl tested positive for some type of drug other also shows a sharp increase in the abuse of and others. 31 than alcohol.26 prescription drugs. Among the 10,294 local a Prescription News media coverage of the dramatic children ages 3 to 18 who received Medicaid opioid sales quadru- escalation of overdose deaths since 2010 has services in 2016, 328 were for substance use. pled between 1999 brought increased attention to the national Three of the largest local agencies for sub- and 2010.32 opioid epidemic. Overdose deaths are now stance use treatment are: a Heroin produc- the leading cause of accidental death in the a Anuvia Prevention and Recovery Center ers now add fentan- U.S.27 Between 2005 and 2015, North Carolina contracts with Mecklenburg County to operate yl and carfentanyl, experienced a 73 percent spike in opioid-relat- a substance abuse service center for detoxi- drugs 50 to 100 ed deaths.28 fication, residential, outpatient and chronic times stronger than Charlotte is not immune to the epidemic. care programs. It is the primary recipient of heroin, which dra- In 2016, police arrested 368 people for heroin the local grant from the Alcoholic Beverage matically increases possession, including a 16-year-old. Last year, Control Board. Last year, 80 young people ages the risk of overdose. 203 nonfatal overdoses resulted from hero- 12 to 18 were served by Anuvia’s adolescent a 82 percent of in use, up from 108 in 2015. Fatal overdoses outpatient treatment center—15 of them were fentanyl overdose declined in 2016, with 24 last year and 38 the in treatment for opioid use. deaths in 2013 previous year, including a 14-year-old. a McLeod Addictive Disease Center is the involved illegal- Young people ages 20 to 29 comprised the largest provider of alcohol and drug treatment ly manufactured largest group of fatal overdoses from heroin, in North Carolina. Last year, 83 adolescents fentanyl, while with 12 deaths in 2014, 11 in 2015 and eight in received outpatient treatment (87 percent were only 4 percent were 2016. Whites overdosed from heroin at much male, 13 percent female) and 35 were in resi- suspected to origi- higher rates than African Americans and were dential treatment (100 percent were male). The nate from a prescrip- much more likely to be arrested for possessing average length of stay for residential services tion.33 it. In 2016, Charlotte police arrested 202 whites was 102 days, and 91 percent were Medicaid a As efforts to and 126 African Americans for possession of recipients. curb the abuse of heroin. a Dilworth Center provides intensive out- prescription opioids As with alcohol and other drugs, children patient treatment, including group, individual began around 2010, are affected by the opioid epidemic even if and family counseling on weekends and eve- heroin use skyrock- they don’t use. Although a direct link to opioid nings. It also has programs specific to ado- eted. Four in five use is not quantifiable, the number of children lescents and young adults. And the Dilworth new heroin users entering foster care statewide because of pa- Kids Program for Children helps 6- to 11-year- started out misusing rental drug use has increased 41 percent from olds understand chemical dependency as a prescription pain- 2012 to 2016.29 disease and how it impacts the family. About killers,34 which are In July, a new Substance Affected Infants 65 percent of clients have private insurance; far more expensive plan was put in place by DHHS. The plan 35 percent are self-pay. and harder to obtain.

17 Intellectual and Developmental Disabilities

rofessionals in children’s mental health For families waiting for a waiver, some Poften use the word “silos” to describe the frag- Medicaid services are available, such as mentation of the ecosystem. The word also assistance in locating community resources, Intellectual is applicable to the three branches of the pro- in-home skill building, peer support, respite, disability fession—mental health, substance abuse and psychiatric consultation, supported employ- A group of disor- intellectual/developmental disability (I/DD). ment, transitional living and other supports. ders characterized What makes I/DD different from mental However, these services—called “(b)(3) ser- by a limited mental health and substance abuse is the fact that vices”—are very limited compared to the Inno- capacity and diffi- there is no cure for I/DD. Thus, the focus is vations Waiver. Services such as personal care, culty with adaptive not on recovery but on increasing individuals’ community networking and case management behaviors. It origi- ability to function in society. are available only to families with waivers. nates before the age In 2016, of the 10,294 Medicaid enroll- The division between the “haves” and of 18 and may result ees ages 3 through “have-nots” doesn’t from physical caus- 17 who received a mean families with es, such as autism or cerebral palsy, or mental health service, waivers are living from nonphysical 803 were children a life of ease. The causes, such as lack with I/DD. For these I/DD waivers are capped at of stimulation and children and their $135,000 per child per adult responsive- families, it’s a tale of year. And I/DD sup- ness. “haves” and “have- port professionals cit- nots”—those who ed many of the same Developmental have an N.C. Inno- gaps and barriers that disability vations Waiver and Mental Substance apply to the system A severe, long-term those on the waiting health use disorder overall, including disability that can list, officially called limited resources, dif- affect cognitive the Registry of Unmet ficulty navigating the ability, physical Needs. system, and too much functioning, or The waivers paperwork. both. These disabil- provide services and Gaps and barri- ities appear before 3 SILOS OF MENTAL HEALTH age 22 and are support to children ers specific to I/DD likely to be lifelong. with I/DD so they include Cardinal not Some developmen- may remain with their families and live in accepting school evaluations as evidence of an tal disabilities may their communities rather than receive care in I/DD diagnosis, the requirement to show be solely physical, an institution or assisted living facility. The proof of a continuing diagnosis every three such as blindness state Division of Medical Assistance (DMA) years (remember, there is no cure for I/DD), from birth. Others allocates waiver slots based on county popu- and a limited number of clinicians who are involve both physi- lation, and there aren’t enough slots to meet qualified to serve individuals with a dual-diag- cal and intellectual the demand. Anecdotal evidence suggests the nosis, such as I/DD and substance use disor- disabilities stem- wait time for a slot can be as long as 10 years der, or I/DD and a mental health diagnosis. ming from genetic or other causes, or more. Some of the state and local organizations such as Down syn- Meeting the guidelines for a waiver slot re- serving children with I/DD are the Autism drome. quires a psychological evaluation that consists Society, Easterseals, Disability Rights N.C., of adaptive skills and cognitive testing to reach UMAR, First in Families, the N.C. Council on an accurate diagnosis. To be placed on the wait Developmental Disabilities, InReach, Devel- list, Cardinal Innovations also requires medical opmental Disabilities Resources, LIFESPAN, records and guardianship papers. and The Arc of Mecklenburg County.

18 Gaps in Services, Barriers to Treatment

rue or false? Children covered by of 21, over the age of 65, blind or disabled, and Tprivate health insurance have better access to are in need of long-term care. To be eligible, mental health services than those who qual- an individual must be a U.S. citizen or provide ify for Medicaid. Answer: It depends on the proof of eligible immigration status, provide insurance policy and family income, among proof of state residency, and have a Social Se- other factors, but the answer is probably false. curity number or have applied for one. Why? Because health insurance policies have Each of the 31 service definitions and 19 annual deductibles requiring families to pay enhanced services definitions36 come with their up to thousands of dollars out of pocket before own set of eligibility requirements, billing insurance kicks in. codes and reimbursement rates. Service defini- For example, a family of three in Charlotte tions and reimbursements change annually. with annual household income of $80,650 “The service definitions from the state would pay $2,140 in monthly premiums to get don’t necessarily mesh with what kids need,” the lowest annual deductible of $1,500 from said Sarah Greene, program administrator of Blue Cross and Blue Shield. If they wanted to Trauma and Justice Partnerships, Mecklenburg ‘The service lower their premium by accepting the highest County Health Department. definitions deductible available, their monthly payment Medicaid members may be denied services from the state would shrink to $1,396—and the annual deon technical grounds or for being “noncompli- ductible would swell to $7,150.35 ant.” And many interviewees said the denial don’t neces- For middle-class and upper-income fami- rate for certain services is too high, or Cardinal sarily mesh lies who have the ability to pay high premiums will approve lower levels of services than rec- with what and deductibles, affordable access to mental ommended by the service providers. (Cardinal health services may still be limited. disputes these allegations.) kids need.’ “Insurers historically have placed more Sarah Greene limitations on mental health treatment, as well Birth to Age 5 Mecklenburg as higher co-payments for mental health care, One of the most glaring gaps in mental health County Health than for other healthcare services,” accord- services is for infants and toddlers. While some Department ing to the Judge David L. Bazelon Center for services and supports designed to enhance the Mental Health Law. Certain group plans, such social/emotional development of infants and as those offered by employers of 100 or more toddlers are available through CDSA, there is workers, are required by law to cover mental no single state agency fully charged with the health services at the same level as medical responsibility of assuring mental health ser- care. However, private insurance typically has vices to this age group. The behavioral health stricter limits and fewer services covered for LME-MCOs in North Carolina have no statu- mental health. “Many of the services needed torily defined responsibility to provide mental by people who have the most serious disorders health services to children from birth to age 3. are not included… Those services are gener- Other factors that interfere with the pro- ally only covered under Medicaid,” the center vision of mental health services for children noted. birth to age 3 include the shortage of qualified service providers, the difficulty inherent in ap- Medicaid plying prevailing diagnostic criteria to children Families apply for Medicaid online through under age 3, the reluctance to apply labels to the DHHS website, in person at the local very young children, and a “let’s-wait-and-see- DSS office, or by phone or mail. The govern- what-happens” attitude. ment-funded healthcare plan is available to Medicaid does provide funding for pedia- low-income individuals who are under the age tricians to do screenings, such as the Ages and

19 Stages questionnaire for developmental delays, dysregulation. The program works with parents or and for early developmental interventions— other caregivers to help them learn how to 1) behave but not strictly for mental health. Zero to Three in nurturing ways when children are distressed; is a national organization working to change 2) follow their child’s lead to behave in delighted that, as is the North Carolina Infant Mental ways when children are not distressed; and 3) avoid Health Association, ZFive of Mecklenburg behaving in frightening or intrusive ways. County, the Whole Child Initiative, and other Children with developmental delays are organizations. at risk of having problems in adolescence and This points to a common misunderstand- adulthood. Early intervention is essential. The ing about Medicaid services available for ages connections infants and toddlers make with birth to 3. Asked if mental health services are others are critical to their well-being and de- available for this age group, two county offi- velopment. However, the lack of funding and cials cited the CDSA as responsible. While the a mandate for infants and toddlers with mental ‘Trying to do CDSA is the local provider for state-mandated health needs is a not-so-obvious gap in services traditional infant/toddler services under the Individuals that should be addressed. with Disabilities Education Act for children “Once a child turns 3, services through mental health birth to age 3, it isn’t responsible for providing CDSA are no longer available. Charlotte-Meck- out of CDSA a full array of mental health services to the lenburg Schools picks up the responsibility for is like trying children it serves, as is the case with the state’s developmental issues including mental health behavioral health LME-MCOs. for children 3 years old and up,” according to a to fit a square As Dr. John Ellis, a psychologist and early 2008 report by The Lee Institute conducted on peg in a round childhood consultant, pointed out, “trying behalf of Smart Start of Mecklenburg County. hole.’ to do traditional mental health out of this However, CMS picks up the tab only if program is like trying to fit a square peg in a the developmental or mental health concerns Dr. John Ellis round hole.” cause substantial delay in the child’s academic, Psychologist That’s not to say that CDSA’s work isn’t social or language skill development. The 2008 and Early Child- vital. As the Mecklenburg CDSA director, Joey study, which was guided by the ZFive Infant hood Consultant Bishop-Manton, explained in an email: Mental Health Working Group, estimated that The CDSA provides a wide variety of services only 5 percent of local children birth to age 5 focused on building parent competence and capacity with a diagnosable mental health disorder are in supporting child development. Family training receiving treatment. and counseling are mandated services provided by “This indicates that approximately 95 licensed mental health clinicians and psychologists percent of children with a diagnosable mental who address the social/emotional needs of young health disorder are not receiving the treatment children and their families. As a specific method of they need,” the report concluded.37 family training and counseling, the Mecklenburg Dr. Cotrane Penn, the school system’s CDSA also provides attachment and biobehavioral mental health program specialist, clarified by catch-up (ABC) which is a parent-training inter- email: vention aimed primarily at children between 6 and We do not ‘pay’ for any mental health services 24 months of age and their caregivers. ABC targets for children unless you count those delivered by young children who have experienced early adversi- CMS school counselors, school social workers, ty, such as maltreatment or disruptions in care, and and school psychologists. In that case, the work is addresses several issues that have been identified as covered by these salaried positions. We have grant problematic among children who have experienced funds that pay for services for eligible students in early adversity, including behaving in ways that grades 6 to 8 to receive mental health treatment push caregivers away, and behavioral and biological from agency therapists, but those dollars do not

20 originate from within CMS or Mecklenburg Coun- migrants from receiving Medicaid, so the first ty. We have a pro bono agreement with our SBMH step is to become documented. partners that is available to any eligible CMS As with Nicolás, one of our three fictional student ages 3 and up, but there is no exchange of characters, navigating the maze may require funds for the rendering of those students’ services. a team of professionals, including a DSS case Children being served by CMS at age 3 typically manager, a YFS attorney to represent him in have severe developmental disabilities and tend not family court, and an immigration attorney to to be candidates for mental health therapy. apply for special immigrant juvenile status. In 2015, Smart Start commissioned another “Unlike civil child protection courts, which report on mental health services for children are governed by a doctrine of ensuring ‘the ages birth to 5 by some of the same researchers best interests of the child,’ immigration courts involved in the previous study. treat children essentially as adults and provide The second study, which was prepared by no additional protections or representation,” Dr. Ellis and Dr. Natalie Conner, conservative- according to Dr. Kiara Alvarez and Dr. Mar- ‘We’ve ly estimated that 9,177 children in Mecklen- garita Alegría in an article for the American created an burg County under the age of 5 demonstrate Psychological Association. problem behaviors that rise to the level of a “In the absence of pro bono attorneys or a administrative diagnosable mental health issue.38 family’s ability to afford one, children go with- nightmare for The study recommended replication of out orientation to the court system, assistance families.’ the Child First model in Mecklenburg Coun- in representing their case, or support in re- ty. Child First is a national, evidence-based, counting traumatic experiences to strangers,” Dr. Diana Moser-Burg two-generation model that works with vulner- they added.40 Smith Family able young children and families by providing More than half of Charlotte Communi- Wellness Center intensive, home-based services. ty Health Clinic’s patients are Hispanic or at Project 658 A statewide Child First office was estab- Latino. A free clinic offering primary care and lished in 2016, and the program is being imple- behavioral health services to Medicaid recipi- mented by five affiliate agencies in 24 counties ents, and uninsured adults and children on a in eastern North Carolina, the catchment area sliding fee scale, it’s one of 20 free and low-cost for the Trillium Health Resources. However, clinics in the county. Until recently, the clinic the program hasn’t been adopted in Mecklen- had only one mental health counselor—and burg County, although a Cardinal executive he’s a part-time employee. His average case- said the organization now is looking into the load at any given time was about 100 patients, feasibility of implementing it. roughly half of them teenagers, allowing him time to see them only once every three or four Latino/Hispanic Children weeks. (The clinic recently hired more counsel- Another population of underserved children ors to try to keep up with demand.) is the Latino/Hispanic community. Hurdles to providing mental health services to this com- Bureaucratic Delays, munity include cultural stigma, lack of Span- Time-consuming Paperwork ish-speaking counselors, a shortage of trau- According to interviewees, two of the most ma-trained clinicians, overcoming stereotypes significant barriers to treatment are bureau- and, in some families, fear of deportation. cratic delays and time-consuming paperwork. For undocumented immigrant minors, the For certain services, such as enhanced services path to receiving public funding for mental for special populations, pre-authorization from health is a protracted, rigorous legal process. Cardinal can take up to 14 days. And, if mis- A federal statue prohibits undocumented im- takes are made in the paperwork, pre-autho-

21 TRANSITION- rization can drag out for months, according to of offering SBMH services to students enrolled AGE YOUTH interviewees. That’s because when an error is in 101 of its 170 schools. made by a service provider, the 14-day approv- But getting cooperation from parents can Although this real period could begin all over again. be tricky, says CMS’s Dr. Cotrane Penn, espe- port focuses on ages The bureaucracy of compliance takes time cially those with transportation or employ- 0 to 18, another vul- away from direct care; it increases agencies’ ment hurdles. Parents are required to provide nerable population costs, so it’s a disincentive to provide more ser- written consent for their children to receive is transition-age vices; and evidence-based services have such an intake assessment, which happens about youth: people be- strict procedures that they don’t allow enough half of the time. The other parents either don’t tween the ages of 18 flexibility, interviewees said. return CMS’s phone calls or don’t show up for and 24, particularly “We’ve created an administrative night- their scheduled parent-clinician appointments. those in transition mare for administrators and families,” said Lack of parental consent was cited by Dr. Penn from foster or cus- Dr. Diana Moser-Burg, integrated care clinical as the No. 1 barrier within the school system. todial care under manager of Smith Family Wellness Center at A second barrier to students receiving YFS supervision to Project 658. services through the school system is a federal being fully indepen- statute prohibiting undocumented individuals dent. Typically, once Children with Dual-Diagnosis and from receiving Medicaid, so schools provide they become adults Intellectual or Developmental Disabilities pro bono mental health services to undocu- they can no longer Another barrier to treatment is for children mented students. The same goes for some stu- receive financial with I/DD. Medicaid funding for I/DD is dents who have private insurance since many assistance from capitated, meaning a set amount of money is policies don’t pay for long-term therapy. publicly funded provided each year through the North Caroli- A third barrier within CMS is the stipula- systems of care, but na Innovations Waiver. tion that students must meet with their school a new law went into The waiting list to receive such financial counselor to be referred to a licensed therapist. effect in January assistance is several years long; one parent While the requirement itself seems innocuous, 2017 extending fos- interviewed for this assessment waited more the result can be a lengthy delay in treatment: ter care benefits for than five years to receive funding for her A single school counselor is responsible for individuals ages 18 adopted son. And an I/DD services provider hundreds of students, while a school-based to 21. Often, when estimated the current wait list at 10 years. clinician’s average case load typically is 25 to people “age out” In theory, children with I/DD can access 30 students. of YFS care they mental health and substance use treatment in A final barrier within CMS may be obvious wind up homeless. conjunction with I/DD services. “We know but deserves emphasis here. Analysis by the During daytime these things go hand-in-hand,” says Candace school system of data collected during the first hours when shelters Wilson, ParentVOICE program director for year of SBMH indicates positive outcomes for are closed, many Mental Health America of Central Carolinas. participating students. Yet only 59 percent of find companion- However, the resources of providers who public schools are involved in the intervention ship in unsafe can serve co-occurring or dual-diagnoses “are program. environments slim to none,” noted Dr. Moser-Burg. “There where chronically are not enough clinicians who can serve both Shortage of Residential Placements homeless people needs. This is a gap both in the inpatient and When a mental health disorder becomes de- gather. Although outpatient settings.” bilitative or poses a safety threat to the child some young adults or family, treatment in a residential setting choose to remain in Charlotte-Mecklenburg Schools may be necessary. Residential placements are foster care, many As noted previously, CMS is one of the prima- expensive, and Medicaid has cut funding for try to make it on ry avenues to children receiving mental health certain types of residential care in favor of 39 their own. services and support. CMS is in its third year community-based treatment. According to

22 local mental healthcare experts, this has led Therapeutic Foster Homes to a gap in services: a shortage of residential Another gap in mental health treatment place- placements. Exacerbating the situation is the ments is therapeutic foster care (TFC). The issue of adolescents from outside the commu- deficiency is not an overall shortage of licensed nity taking Mecklenburg County’s residential beds but rather “the availability of special- placements. ized treatment for youth with highly complex While Cardinal officials have asserted that mental health needs,” according to Cardinal the overall inventory of residential placements Innovations. in Charlotte-Mecklenburg is “sufficient,” However, “there is a shortage of effective there is common agreement among behavior- therapeutic foster parents,” noted one inter- al health professionals interviewed for this viewee. “Foster parents have long complained assessment that the community doesn’t have about the lack of support they receive from adequate supply. their agencies to be able to manage the issues Out-of-town In 2014, the General Assembly allocated and behaviors that children and youth are residential $2.2 million to the Crisis Solutions Initiative dealing with, especially with teenagers. Hav- to enhance crisis service capacity across the ing trained foster care coordinators who can treatment state. In Charlotte, Cardinal has partnered with provide adequate support and training to their ‘places a Monarch to apply for a grant from the initia- foster parents is also an issue.” tremendous tive, which is a program of DHHS, to build a burden on 16-bed crisis center. The new crisis center is Shortage of Trauma-Certified Clinicians scheduled to open later this year, yet many Treatment methods such as trauma-focused families.’ interviewees said 16 beds isn’t nearly enough cognitive behavioral therapy (TF-CBT) require Jefforey Best to meet the demand. trauma training and specialized certification to Anuvia Prevention ensure the modality is provided to patients in and Recovery Center Adolescent Females an effective manner. The shortage of residential placements is While the number of clinicians who have particularly dire for adolescent females: There been certified in TF-CBT has slowly increased, are no group homes located in Mecklenburg Mecklenburg County doesn’t have enough cre- County for girls in need of primary substance dentialed clinicians. Further, in other types of use treatment and around-the-clock supervi- modalities where it’s not specifically required sion. that clinicians have special certification, best The clinical supervisor for Anuvia Preven- practices call for clinicians who have addition and Recovery Center, Jefforey Best, refers tional training and experience with treating teenage girls in need of substance use treat- children with a history of trauma. ment to Youth Villages in Knoxville, Tenn. For This lack of experience can lead clinicians their children to receive treatment in a facility to misunderstand the origin of problems. A located more than 200 miles from Charlotte child who is noncompliant or frequently angry “places a tremendous burden on families,” may be misdiagnosed with a conduct problem Best said. Part of the challenge is a reluctance if the clinician doesn’t know that these symp- on the part of providers to treat teenage girls, toms often are associated with trauma. who are viewed by some providers as difficult Charlotte AHEC, CHS, and the Mecklen- to treat. So local residential providers focus on burg County Trauma Informed Care Work- serving preadolescent girls instead. group are working to change that outcome by “Where we really struggle as a community offering trauma training to professionals in the is specialized care for female teenagers,” said school, courts, mental health and child welfare Cardinal’s Laurie Whitson. systems.

23 Lack of Child Psychiatrists WHAT ARE THE MEDICAID SERVICE DEFINITIONS According to the American Academy of Child FOR RESIDENTIAL PLACEMENT AND TREATMENT? and Adolescent Psychiatry, Mecklenburg County has 34 practicing child and adoles- When a young person who is enrolled in Medicaid can no lon- cent psychiatrists for nearly 250,000 children, ger be safely managed in their own home, behavioral health pro- which the academy deems to be a “severe fessionals turn to residential placement and treatment options. shortage.”40 North Carolina’s shortage of child Varying levels of treatment are provided in different residential psychiatrists also is considered severe, just like settings, ranging from foster care to locked facilities. every state in the country except for a handful Some of them include: for which the shortage is considered merely a Psychiatric residential treatment facilities (PRTFs) pro- “high.” No states were considered to have a vide non-acute inpatient facility care for individuals who have “mostly sufficient supply.” a mental illness or a substance use disorder and need 24-hour supervision and specialized interventions. LGBTQ Youth a Residential treatment provides a structured, therapeutic, The national rate of suicide attempts is four and supervised environment. The LME-MCO is the established times greater for gay, lesbian and bisexual portal of entry and completes an assessment and determines youth and two times greater for questioning the appropriate level of care. There are four levels of residential youth than that of heterosexual youth, accord- treatment; none include reimbursement for room and board. ing to The Trevor Project. And 40 percent of Level I provides a low to moderate structured and supervised transgender adults reported having made a environment in a family setting (foster home); Level II provides suicide attempt; 92 percent reported having a moderate to highly structured and supervised environment attempted suicide before the age of 25.41 Yet in a family setting (therapeutic foster home) or program setting many interviewees said the support available (group home); Level III has a highly structured and supervised to lesbian, gay, bisexual, transgender and ques- environment in a program setting only; and Level IV has a tioning (LGBTQ) youth doesn’t come close to physically secure, locked environment in a program setting only. meeting the demand. a Facility-based crisis service for children and adolescents The Time Out Youth Center is working provides an alternative to hospitalization for an eligible benefi- to change that. Executive Director Rodney ciary who has escalated behavior due to a mental health or Tucker said the center has trained more than I/DD need, or a substance use disorder, and who requires treat- 3,000 public school personnel on issues facing ment in a 24-hour residential facility with 16 beds or less. It’s LGBTQ students. The center’s waiting list for an intensive short-term, medically supervised service provided support services swelled last year; howev- in a physically secure setting. And it’s available 24 hours a day, er, the community responded and Time Out seven days a week, 365 days a year. The only facility-based crisis Youth received an influx of financial support service in Charlotte will be operated by Monarch. (See page 23). for the purchase and renovation of an office a Inpatient psychiatric treatment services provide treatment building to be a hub for its programs, as well in a hospital setting 24 hours a day. Supportive nursing and as a planned shelter for LGBTQ homeless medical care are provided under the supervision of a psychia- youth. trist or physician. This service is designed to provide continuous The Time Out Youth Center’s client visits treatment for individuals with acute psychiatric or substance doubled in 2016 with 357 youth visiting the use problems. center for the first time, compared to 162 in a An intermediate care facility is an institution that functions 2015. The drop-in space was used 4,683 times primarily for the diagnosis, treatment or rehabilitation of indi- in 2016, compared with 2,370 in 2015, and viduals with I/DD. It provides ongoing evaluation, planning, discussion group participants numbered 3,419, 24-hour supervision, coordination and integration of services in compared with 1,930 in 2015. a residential setting.

24 The Dilemma of Hard-to-Place Youth

ne of the most complex and trou- However, that situation hasn’t occurred in Obling findings of this report is the dilemma of over a year, according to YFS Director Charles hard-to-place youth who come into the system Bradley. via the Juvenile Detention Center, YFS, or the The challenge of hard-to-place youth also psychiatric emergency departments of Novant was lessened when the county approved a or BH-C. waiver to allow YFS to place children in Level Whether this represents a gap in services III residential facilities in the Cardinal net- is debatable: Cardinal officials maintain that work. Prior to the waiver, which was imple- the network of therapeutic residential place- mented in January 2017, differences between ‘...these ment and treatment facilities is adequate, but YFS’s network and Cardinal’s network result- matters others disagree. The problem is so vexing that ed in Cardinal having placements available but a stakeholders’ group, lately called the “Com- YFS being unable to place the child. Providers continue to munity Transition for Youth Collaborative,” who contract with Mecklenburg County were put larger was formed more than a year ago to try to find subject to special auditing requirements that and larger solutions. surpassed Cardinal’s requirements. Hard-to-place youth enter YFS custody Despite the progress that’s been made, strains on because a juvenile court has ruled they can’t problems remain. One of the most trouble- the juvenile be discharged to their homes due to abuse or some is the issue of YFS sending young people court system, neglect, or because they’ve been abandoned across the state line to New Hope Carolinas, a not to by family members who can’t be reached or PRTF in Rock Hill. New Hope is a “placement refuse to pick them up from one of the two of last resort” because it’s a locked facility: mention the hospitals. Sometimes children whose clinical recommen- Constitutional Finding appropriate placement and treat- dations don’t support being placed in a locked issues they ment for them isn’t easy because they require facility are sent there anyway because no other intensive care—often due to violent or self-de- beds are available. Mecklenburg County has raise.’ structive behavior. Convincing foster families a contract with New Hope to use its beds on Judge Louis Trosch, Jr. to take them in is a tough sell: Even if a foster an emergency basis, which costs the county North Carolina family is willing, the foster parents may lack over $400 per day per child. Last fiscal year, 26th Judical District special training to provide the intensive ther- the county spent over $594,000 for emergen- apeutic care the child needs. Securing appro- cy-placement beds at New Hope for children priate placement is only half the battle, as they in custody who had no other placement usually require treatment from counselors who option. Although children in custody automat- are trained in trauma-informed care. ically qualify for Medicaid, New Hope isn’t Compounding the issue is the limited part of Cardinal’s network, so the county pays capacity of residential facilities such as Level the bill. Children have stayed at this facility III group homes and PRTFs. These placement for up to two months before transitioning to a facilities often are filled with adolescents from facility in North Carolina. Because New Hope other counties. If the facilities already are at is located in South Carolina, where children capacity, local youth in the secure custody of don’t have the same rights as in North Caroli- juvenile justice may get stuck in the detention na, they aren’t entitled to judicial hearings to center; others may be stranded at one of the determine if they meet the medical criteria to psychiatric emergency departments of the remain in a locked facility. two hospitals. And, occasionally, they would Asked about New Hope, Bradley re- spend one or more nights in an office at YFS. sponded, “YFS has been diligently working to Since YFS began tracking the problem nearly significantly reduce or eliminate placements” four years ago, 18 children have slept there. there. He added that the responsibility of con-

25 NUMBER OF CHILDREN IN YFS CUSTODY er strains on the juvenile court system, not to mention the Con- stitutional issues they raise.” 373 2017 The number of children in the 878 During an interview for this custody of Youth and Family report, Judge Trosch described 347 2016 Services has declined by nearly 969 New Hope as a “lawsuit wait- 60 percent in the last decade. ing to happen.” He said that as 427 2015 a district court judge involved 1,072 in the Child Victims Project Model Court, he’s obligated Overall number of children 462 2014 1,044 to use his judicial position to in custody at some time advocate for change. during the year, including 364 2013 966 In Charlotte, the Model new children entering Court was established in 1998 custody 392 2012 to improve the juvenile courts’ 1,019 handling of child neglect and New children entering 328 2011 abuse cases. The “one judge- custody 1,116 one family” system ensures that cases involving the same 350 2010 1,270 child or family are assigned to the same judge. Juvenile court 454 2009 judges strive to reduce unnec- 1,438 essary, prolonged out-of-home 380 2008 placement; expedite adop- 1,539 tions when parental rights are Source: Youth and Family Services terminated; and keep juveniles out of the custody of the county tract solicitation and management of out-of- whenever possible by diverting them to com- home placement recently was transferred from munity-based programs. YFS to BHD, resulting in “increased oversight, DSS Director Peggy Eagan summed it up: care coordination and discharge planning for All members of the stakeholders’ collaborative all children placed at New Hope.” acknowledge that this is a significant problem, and In addition to cutting its contract with New we have committed countless hours to developing Hope in half, in 2016 YFS added With Friends a community response that meets the needs of the in Gaston County to its network of emergency youth, their families, and our community. While 42 placement facilities. the perfect solution has not yet been found, it After months of meetings between mem- appears that responsible parties have moved toward bers of the stakeholders’ group, in Decem- better understanding and a willingness to work ber 2016 Judge Louis Trosch, Jr. subpoenaed together. It should be noted that this same problem officials from YFS, Novant, BH-C and Cardinal has been identified in other North Carolina com- after three youth were discharged to New munities, and Mecklenburg County was invited to Hope before the holidays—even though none present the collaborative process that is currently met the criteria to be placed in a locked facility. underway at a statewide conference earlier this In an email to the collaborative group year. The conclusion of that work will hopefully explaining his rationale, Judge Trosch wrote move our community toward a long-term solution “these matters continue to put larger and larg- for this population.

26 The Roles of Socioeconomics, Trauma and Intergenerational Racism

lthough Charlotte-Mecklenburg In that year, the authority served 8,395 people Alacks a central database of statistics on be- under the age of 18. The data indicated African havioral health incidence, data collected by Americans disproportionately were affected Cardinal Innovations (and previously by the by mental health incidence: 63 percent of the county Area Mental Health Authority) suggest authority’s clients were African American. disproportionate prevalence among African Among African American children, the most Americans. common diagnosis was ADHD, followed by According to the U.S. Census, in 2016 the oppositional defiant disorder (ODD) and con- county’s population was 58 percent white duct disorder (CD).44 and 32 percent African American. Yet, in the RMJJ is a local collaborative leadership same year, among Medicaid beneficiaries who group working to reduce disproportionali- received a mental health service, Cardinal’s ty and disparate outcomes for children and preliminary numbers indicate 34 percent were families of color through institutional organiz- ‘We create white and 57 percent were black. (Five percent ing, education, and workforce development. were Latino or Hispanic.)43 The group has developed five modules in its mental health Why do African Americans appear to expe- speakers’ bureau series aimed at increasing issues through rience disproportionate contact with the men- the community’s understanding of issues socioeconomic tal health system? “Certain ethnic and racial related to racial justice. One of the presenta- groups suffer from high rates of mental illness tions, the School to Prison Pipeline, examines issues.’ because they are disproportionately affected the over-representation of children of color in Amber Pierce by the deleterious effects of poverty, includ- school disciplinary actions. Assuring Better ing stigma, lack of access to healthcare, and Critics of the school system allege that Child Health and limited education,” said Dr. Richard McAnulty, CMS treats children of color with mental Development associate professor of psychology, University health challenges differently from other school of North Carolina-Charlotte. children. This phenomenon is not unique to our “CMS responds to children of color who community and is particularly noticeable in have disabilities from a punishment stand- the juvenile justice system. In 2010, across the point as opposed to treating the mental health U.S., “African American youth were almost needs,” said one interviewee. “The punish- five times as likely (than whites) to be incarcer- ment often leads to a child missing school, ated, while Latino and American Indian youth dropping out, and becoming part of the prison were two to three times as likely to be placed system.” in a juvenile residential placement,” Shantel Another critic faulted the school system Crosby wrote in the March 2016 issue of Juve- for not recognizing the symptoms of PTSD and nile & Family Court Journal. how it affects classroom behavior, resulting in Since the majority of youth involved with punishment, misdiagnoses and over-medica- Charlotte’s courts are identified as having tion. Whether or not these criticisms apply to behavioral health needs and receive court-or- isolated situations or are systemic, they point dered treatment, the juvenile justice and men- to the fact that racialization not only is a factor tal health systems are intrinsically linked. in the juvenile justice system but also in public In 2013, Race Matters for Juvenile Justice schools. (RMJJ) convened law enforcement officers, Since mental illness doesn’t discriminate school leaders, judges, county officials, GALs, on the basis of race or ethnicity (nor by gender child advocates, DSS officials, and other or sexual orientation), what factors contribute community leaders. They looked at data from to involvement in the mental health system by the Area Mental Health Authority from 2009. disproportionate numbers of African American

27 CMS SUSPENSIONS BY RACE/ETHNICITY coordinator of Assuring Better Child Health and Data for CMS students Development for in all grades show the greater Meck- African Americans and lenburg region. Hispanics receive short- Early brain 18,646 18,612 term, out-of-school development,

17,537 suspensions at dispro- which begins portionate rates. before a child is born and is most critical up African Americans to age 5, is a key determinant to Hispanics mental health. Early childhood is a time of extraor- Whites dinary cognitive, emotional and All other races/ social develop- ethnicities combined ment. Too often 2,746 2,686 2,466 in low-income 1,869 1,551 1,484 households, 860 799 709 parents are Source: N.C. Dept. of Public Instruction Source: 2013-14 2014-15 2015-16 confronting the urgent demands of employment, youth? Dissecting the myriad causes of racial transportation, food, shelter and safety, which disproportion begins with a brief discussion of can impact their ability to provide the care intergenerational racism. and supervision children need to optimize The fact is, we live in a segregated society their development. Basic parenting capacity and a segregated community. In Charlotte- may be limited because people experiencing Mecklenburg, concentrations of low-income intergenerational poverty may lack the ability families of color lie to the west and north of the or opportunity to transfer parenting skills from center city, forming a “crescent” of lower-op- one generation to the next. portunity neighborhoods. This didn’t happen “What happens to children who do not overnight but rather is the legacy of intergen- form secure attachments?” asks Kendra erational poverty resulting from centuries of Cherry, a psychosocial rehabilitation specialist. racism. “Research suggests that failure to form secure The impacts of poverty on early childhood attachments early in life can have a negative development and family stability directly cor- impact on behavior in later childhood and relate to a greater prevalence of mental health throughout life. Children diagnosed with an disorders. ODD, CD or PTSD frequently display attach- “We create mental health issues through ment problems, possibly due to early abuse, socioeconomic issues,” says Amber Pierce, neglect or trauma.”45

28 According to Shantel Crosby, author of trauma-informed care emphasizes physical, the Juvenile & Family Court Journal article cited psychological and emotional safety for both previously, 90 percent of youth in detention individuals in treatment as well as mental have experienced previous trauma, which is health providers who are subject to second- linked to an increased likelihood of further ary trauma. delinquency. Young people who are victims Secondary traumatic stress (STS), also of or witness to violence tend to perpetuate known as “compassion fatigue,” can result violence. from counseling people who’ve been directly “In general, African American youth are traumatized; it can lead to burnout or a grad- more than twice as likely as white youth to ual lessening of compassion over time. be raised in poverty-stricken areas, increasing The need for service providers in Char- Trauma-specific their overall exposure to crime, community lotte-Mecklenburg to routinely address STS violence, stress and trauma,” Crosby writes. in the workplace is explored in the Trauma treatment Even for children who don’t grow up with Informed Systems training sessions led A clinical inter- violence in their households, living with scar- by Dr. George Ake and Dr. Angela Tunno vention following a city can cause toxic stress, which can affect of the Center for Child & Family Health, specific, evidence- their developmental trajectory and lead to in Durham. A program of Charlotte Area based model to facilitate healing self-defeating behavior. Health Education Center (AHEC), CHS, and in individuals A groundbreaking study conducted the Mecklenburg County Trauma Informed diagnosed with a by the Centers for Disease Control (CDC) Care Workgroup, the training is for profes- trauma disorder. demonstrated the relationship between expo- sionals in the school, juvenile justice, mental sure to childhood emotional, physical or sex- health and child welfare systems who want Trauma-informed ual abuse, and household dysfunction during to learn about the prevention of burnout care childhood, and risky health behavior and from STS. An organizational disease in adulthood. The Adverse Childhood Although trauma is harmful to clini- structure and treat- Experiences (ACE) study found that adults cians and clients alike, to children and their ment framework who had experienced significant trauma as families, and to people of all races, intergen- that involves under- children were more likely to suffer from alco- erational trauma places children from poor standing, recogniz- holism, drug abuse, depression, and suicide neighborhoods at the greatest risk. ing and responding attempt. The study also found that childhood Clearly, if Charlotte-Mecklenburg is to to the effects of all trauma increased the risk of chronic disease, reduce the disproportionate incidence of types of trauma. including asthma, heart disease and diabetes. mental health needs among low-income chil- Secondary To stem the adverse effects of socio- dren of color, clinicians, case managers, law traumatic stress economics on mental health, “we need to enforcement and educators should be trained place more emphasis on trauma,” suggests to recognize the impacts of trauma and A condition charac- Sarah Greene, head of Trauma and Justice chronic stress in early brain development. terized by a gradual Partnerships. Greene distinguishes between According to local mental health experts, lessening of compassion over time, trauma treatment—which refers to clinical treatment interventions shouldn’t focus common among intervention for individuals diagnosed with a exclusively on maladaptive behaviors, but on individuals that trauma disorder—and trauma-informed care, increasing capacity to cope with the stress of work directly with an organizational structure and treatment scarcity and violence. And, because poverty trauma victims. framework that involves understanding, and poor mental health are intertwined, our recognizing and responding to the effects of community should work to eliminate ineq- all types of trauma. To help survivors re- uities among families in low-opportunity build a sense of control and empowerment, neighborhoods to break the cycle of trauma.

29 Mental Health in Public Schools

FACTS ABOUT n the absence of a safe and nurturing tional needs similar to those in the intervention TEEN SUICIDES Ihome environment, meeting the social/emo- group but didn’t receive SBMH services. tional needs of children and adolescents often In the 2014-15 school year, the first year of a From 2001 to falls to the public school system. Today’s stu- SBMH and the only year for which data was 2011, Mecklenburg dents face threats from cyber bullying, opioid available, County averaged use and gun violence that didn’t exist for prior a More male than female students were in approximately three generations. Now more than ever, educators both groups; teen suicides each must be aware of the risk factors, early warn- a The vast majority of students in both year. ing signs and treatment options available to groups were African American, followed by a In 2012, a students with behavioral health needs. Hispanic and then white; marked increase of Safeguarding the well-being of 150,725 a About 25 percent of participants in the seven teen suicides CMS students from pre-kindergarten through intervention group and 18 percent of students was observed by the high school requires an enormous commit- in the comparison group were exceptional Mecklenburg Child ment of time, energy and resources. The public children (children with I/DD diagnoses) and Fatality Team. school system employs the equivalent of 62 about 11 percent were limited English profi- a Although the full-time school psychologists, plus 42 social cient; number of adoles- workers and six substance use counselors. As- a The agencies provided an average of 14 cent suicides has sistance is available to school children through hour-long counseling sessions per student; decreased steadily CMS Student Services, including individual, a Both intervention and comparison group since then—with six group, family and community-based support students’ academic performance significantly in 2013, four in 2014, ranging from counseling and intervention increased compared to the prior school year, and one in 2015— plans to home visits, family assessments and with the exception of end-of-course scores the prevalence of training for parents. However, critics say the (state-required tests for some high school issues that increase assistance is limited and is related to CMS’s classes); the risk of suicides legal obligations, such as truancy or special a Comparison group students experienced among adolescents education. a significant decrease in school attendance is an ongoing In addition, school-based clinicians from compared to the prior year, whereas the concern. CHS and five community agencies work in 101 intervention group experienced an increase in a From 2011 of the public school system’s 170 elementary, attendance, though not significant; to 2015, suicides middle and high schools. The SBMH inter- a Students who completed the SBMH pro- among children vention program is funded by Mecklenburg gram showed positive trends for both atten- ages 10 through 14 County and is available in most Title I ele- dance and behavior-related indicators from equaled nearly half mentary schools. (Title I is a federally funded pre- to post-treatment; and of all childhood program for schools that serve at-risk students a Students who began but didn’t complete suicides. in low-income areas.) the SBMH program experienced a signifi- a A recent analysis SBMH services may include individual, cant decrease in attendance and a significant of data for 2012-2014 group and family therapy, medication evalu- increase in unexcused absences and out-of- by the Mecklenburg ation and monitoring, intensive in-home ser- school suspensions. Child Fatality Sui- vices, and referral to day treatment or inpatient A pilot project that shows signs of prom- cide Prevention Task facilities. Agencies that provide SBMH services ise is Reid Park Initiative, located next to Force shows the pri- are evaluated annually by the school system to Reid Park Academy, a K-8 school in one of mary risk factors are measure outcomes related to academics, atten- Charlotte’s oldest crescent communities. Six family conflict and dance and behaviors. An annual report com- independent agencies provide SOC coordina- violence, academic pares students who participated in the pro- tors to Reid Park Initiative, helping families issues, bullying, and gram to a comparison group. Students in the harness public assistance resources as well as bereavement. comparison group had behavioral and emo- mental health services. The initiative focuses

30 on children who require help with reading and BRITNEY, DEON AND NICOLÁS* math, have three or more unexcused absences SHOW SIGNS OF PROGRESS or suspensions, change schools frequently, or pose an immediate threat to themselves or Britney tries to use the tools her therapist has others. The initiative is designed to attend to suggested in order to stop cutting her skin when the physical and mental health and econom- she’s upset, like listening to music or calling a ic challenges of the family and the academic friend, but nothing else seems to help. She feels like needs of their children. The model focuses on a failure and is too embarrassed to tell her thera- the whole family through comprehensive case pist the truth. During a visit to her pediatrician’s management. office for a sports physical, the doctor notices fresh The project began in 2011 as a collabora- incisions on her arm and asks about them. Britney tion between the Junior League of Charlotte tells the pediatrician about how stressed she feels and the Council for Children’s Rights. When over her grades, how cutting herself with a razor the original grant expired in 2016, the county blade makes her feel better. Her pediatrician tells stepped in to fund it. her about a colleague to whom she has referred Reid Park Initiative currently serves 126 many girls with similar stressors, and how the girls children from 46 families, or nearly 15 percent really seem to trust her and feel much better after of the school’s enrollment. The six coordinators working with her. Britney and the pediatrician from A Child’s Place, Pride in North Carolina, tell her mother about her continued struggles, and Communities in Schools, Catholic Charities about the therapist who specializes in working with Diocese of Charlotte, Charlotte Housing girls with similar problems. The pediatrician makes Authority and DSS have the capacity to serve a referral to the new therapist, who is covered by 150 students. the family’s insurance and is available to meet with One of the advantages of the collaboration Britney within a few days. between independent agencies working within After having multiple professionals and mul- the SOC framework is the ability to share tiple teams enter his life, Deon is able to identify data.46 Each CFT has access to the family’s one male clinician who helps guide him through records on academics, employment, housing, the process of juvenile court and the mental health mental health and any involvement with social system. Cardinal Innovations provides the mental services or the courts system, providing a com- health service requested by his male clinician. Slow- plete picture of family stability. ly, Deon’s clinician builds trust and rapport. Deon Even for stable families whose children begins to confide about how his traumatic past and feel safe and secure, who have two involved present troubles are affecting his life. parents with financial resources and access Two weeks after Nicolás begins living with a to private health insurance, the challenges of foster family, a family court judge officially places being a teenager can become overwhelming. him in the custody of the county. YFS contacts an Common teenage struggles include depres- immigration attorney to seek help applying for spe- sion, social anxiety, eating disorders, body cial immigrant juvenile status, the first step toward negativity, self-injury and suicide. granting Nicolás legal residency so he can gain In the last school year, CMS Student Ser- access to permanent placement and care, including vices conducted 1,760 suicide risk assessments. mental health treatment. YFS can’t make any prom- According to Mental Health America, as many ises about how long the process will take. His foster as one-third to one-half of adolescents in the care providers, who have received no compensation U.S. have engaged in some type of non-suicid- or reimbursement, are exhausted. But they agree to al self-injury, often beginning around the ages keep Nicolás for a few more weeks. of 12 to 14. *Britney, Deon and Nicolás are fictional characters.

31 TEEN SUICIDE For Britney, a composite character, self-in- a variety of community organizations and the RISK FACTORS jury is a way to cope with distressing emo- two hospital systems have created programs to tions. She’s been told many times that this be- serve young adults. The 2015 Youth havior isn’t healthy, but it doesn’t seem all that Two examples include: Risk Behavior abnormal to her. She knows girls at school who a Teen Health Connection provides behav- Survey conducted starve themselves, girls who make themselves ioral and medical healthcare to young people by CMS and the vomit, girls who obsessively pull their hair ages 11 to 22 regardless of whether they have Health Depart- and pick at their skin. She doesn’t realize all of Medicaid, private insurance or no insurance. ment shows: these behaviors are warning signs for mental The outpatient clinic employs seven clinicians a 30 percent of disorders that disproportionately affect girls: who provide same-day services if patients are teens reported anorexia, bulimia, body dysmorphia, trichotil- identified during medical exams as having not doing some lomania and dermatillomania. behavioral health needs. regular activities A collaborative survey conducted every Patients are screened for potential issues during the past two years by CMS and the Health Department and receive immediate counseling if a need year because they assesses health risk behaviors that contribute for mental health services is established. This felt sad or hopeless to some of the leading causes of morbidity and “triage model” eliminates any delay between almost every day mortality in youth. The Youth Risk Behavior diagnosis and treatment. Clinicians may also for two weeks or Survey, produced by CDC, measures behaviors recommend other services. Another advantage more in a row; such as unintentional injuries and violence; to the outpatient clinic’s business model: By a 17 percent tobacco, alcohol and other drug use; sexual integrating medical and mental health ser- seriously consid- behaviors that result in HIV infection, other vices, the stigma of psychological counseling is ered attempting sexually transmitted diseases and unintended reduced. suicide; and pregnancies; nutrition and physical activity. a Time Out Youth runs a school outreach a 15 percent The 2015 survey was administered to 2,078 program in partnership with Equality NC and made a plan about students in 29 CMS high schools. It identified the HRC Foundation. The Welcoming Schools how they would five areas for improvement: program works to create respectful, supportive attempt suicide a Almost half of the students surveyed think elementary schools for embracing diversity, in the past 12 bullying is a problem at their school, even as creating LGBTQ-inclusive schools, preventing months. reports of bullying have decreased; bias-based bullying and gender stereotyping, “We have a a Students reporting symptoms of depres- and supporting transgender students. growing number sion increased to 32 percent in 2015 from 28 In middle schools and high schools, Time of young adoles- percent in 2007; Out Youth supports Gay-Straight Alliances, cents with un- a Approximately one-third of students which are student-led clubs for LGBTQ youth derlying mental reported having at least one alcoholic drink in and students who support LGBTQ causes. health issues due the past 30 days; Time Out Youth offers workshops on topics to exposure to a Over 25 percent of students had sexual in- such as healthy relationships, advocating for trauma and not tercourse with one or more people in the past safe schools and how to be an ally. The center enough prima- three months; and also works to eliminate bias, homophobia and ry prevention a About 42 percent of students played a vid- transphobia. and community eo or computer game or used a computer for For K-12 teachers, staff and administration, services to address something that was non-school-related three Safe Zone Training is offered to help identi- them,” says Sara or more hours a day during an average school fy issues facing LGBTQ students, articulate Lovett, an epide- day, up from 26 percent in 2007. appropriate terminology, and tap additional miologist with the Recognizing that no public education resources. And Transgender 101 Workshops Health Depart- system should be solely responsible for the focus on topics related specifically to gender ment. physical and mental health of school children, identity and expression.

32 Privatization vs. Government-Run Mental Health

hether the topic is education, a It allowed service providers to “cherry Wretirement savings or mail delivery, conserva- pick” their clients. “No one wants to work tives and liberals have long debated who can with a kid when things get really nasty,” one best fulfill the function—government or the interviewee confided. private sector. a It produced a system that revolves around Champions of the private sector argue reimbursement rates for services rather than that competition in a free market produces the children and families. The most profitable best service at the lowest cost. They point to services are the ones with the highest reim- examples of fraud and wasteful spending by bursement rates that can be performed by governmental bureaucracies. unlicensed, low-wage employees. Liberals maintain that the essential duties a It stifled collaboration. The more than 250 of society are best left to government because community agencies that comprise Cardinal’s the profit motive of the private sector will provider network in Charlotte-Mecklenburg trump altruism every time. “You cannot make have little interaction with each other because money on human services,” says Robert Evans, they’re all competing for the same 10,294 kids. ‘You cannot president of the Charlotte chapter of the Na- Did anything good come from privatiza- make money tional Alliance on Mental Illness (NAMI-Char- tion? Many interviewees credit Cardinal with on human lotte). “It’s just not profitable.” “cleaning up” the Medicaid provider network, Three years have passed since Medicaid’s citing lack of accountability, poor quality and services. mental healthcare system was fully privatized rampant fraud under the previous systems of It’s just not in Charlotte-Mecklenburg. Perhaps that’s not government-run mental health. In the process enough time to evaluate whether managed of switching providers from MeckLINK’s profitable.’ care is working. And now the state is consider- network to its own network, Cardinal consoli- Robert Evans ing yet another overhaul. Yet Cardinal asserts dated the pool from 557 to about 420 agencies. National privatization is working—at least from the Agencies that scored too low on Cardinal’s Alliance on standpoint of cost containment. Cardinal has “sanction grid” were given the opportunity to Mental Illness managed the state’s Medicaid and IPRS dollars improve. Many made the transition, but hun- so well that it has “continued to provide a full dreds chose to forgo Medicaid reimbursement array of services while state-funded mental or go out of business altogether. Further con- health budgets were cut,” according to Ashley solidation has decreased the network to fewer Conger, Cardinal’s vice president of corporate than 300 agencies. “We’re trying to shape the communications and public relations. She said network and move to value-based care,” said the company charges the state slightly more Laurie Whitson, senior community executive than 8 percent for administrative costs and for Cardinal’s Mecklenburg office. salaries, even though federal rules allow LME- Proponents of privatization argue Meck- MCOs to keep 15 percent of the public funds lenburg County had its chance to implement they receive. managed care during the MeckLINK era and However, critics of the state’s privatization failed. of mental health point to four chief problems: But for those who think government is best a It created a fragmented system. “In the old able to care for the poorest among us, Cardinal days, there used to be a community mental will be the antagonist in this saga no matter health center. Everybody in the community what. Bridging the divide between the two knew where it was. That changed since we pri- viewpoints may be moot: No matter what hap- vatized mental health. It’s not readily visible,” pens to Medicaid and the LME-MCO model in Debra Dihoff, former director of NAMI-North the near future, managed care is probably not Carolina, said in a 2014 TV interview. going to fade away anytime soon.

33 Fee-for-Service vs. Value-Based Care

f you put two youngsters in a canoe and With either hypothetical extreme, there’d be no Igave one a single-bladed paddle and the other financial incentive for patients to recover. a paddle with two blades, they’d probably Since Cardinal and its provider network go around the lake in circles. That’s because employ two vastly different business models, they’d be trying to accomplish the same it’s no wonder they often go around in circles. thing—paddle in a straight line—with con- How can the system change so the LME-MCO siderably different tools. A similar scenario is and its provider network can learn to paddle playing out in Mecklenburg County with Car- in tandem? The answer may lie in a value- dinal Innovations and its provider network. based care model. First, some definitions: If it’s true that the profit motive drives the Managed care is a cost containment system system, then all you have to do is follow the whereby a third-party (Cardinal) mediates money to see between service providers (Cardinal’s provider the inher- network) and patients (Medicaid enrollees), ent conflict negotiates fees for services, and authorizes between the treatment and payment. LME-MCO Capitated reimbursement is a lump-sum pay- model and ment to a service provider based on a set (or the agencies “capped”) amount for each patient placed in that pro- its care. The amount of remuneration is based vide men- on the average expected services required by tal health the patient for a set amount of time. services to Fee-for-service is a system in which a Medicaid provider performs a service and collects a fee. recipients. It’s the old business model of health care, and LME-MCOs the one nearly every non-healthcare compa- were estab- ny has always used: You take your car to the lished to mechanic, she replaces the master cylinder and save the state charges you for parts and labor. money. Critics say they’re incentivized to limit, Now imagine if you offered your mechan- delay and deny services. ic a lump sum to take care of your car for an Conversely, Cardinal’s provider network is entire year. If she could keep your car working incentivized by the fee-for-service model: The for less than the agreed price, she’d make a more services they provide… and the more profit. But, if the car broke down more often clients they serve… and the longer they keep than she estimated, she’d lose money. them as clients, the more fees they collect. Under a capitated payment arrangement, By design, managed care and fee-for-ser- a smart mechanic would spend more time vice are in direct opposition. Managed care on maintenance to avoid costly breakdowns. was put in place to control runaway costs, She’d know the more time she spent preven- giving the state more predictability in bud- ting mechanical failures, the less time she’d geting for mental health. At the far ends of spend diagnosing and repairing them. the spectrum, an LME-MCO would deny Value-based care goes a step further by more services than it approved… and service rewarding providers who produce positive providers would manipulate assessments so patient outcomes. It encourages providers to clients would be prescribed the most expen- use “evidence-based modalities,” that is, meth- sive services at the lowest cost to the provider, ods that have been proven effective through for as many times as they could be approved. the measurement of outcomes. Thus, “value”

34 refers to services and supports having the HAS ANYTHING GOOD COME FROM MANAGED CARE? greatest potential to produce positive results. Cardinal’s Ashley Conger wrote about the As the state government considers another major overhaul of its potential to transition to a value-based model: Medicaid and N.C. Health Choice programs, mental health pro- To this day, capitated health plans largely fessionals continue to bemoan the transition to privatization. The utilize fee-for-service provider payment methodol- latest DHHS proposal would consolidate medical and mental ogies to reimburse providers for services rendered healthcare and expand Medicaid coverage. Yet experts predict that to members. It is well known that fee for service managed care, in some form or fashion, is here to stay. provides a financial incentive for providers to pro- In Mecklenburg County alone, the behavioral health LME- vide a higher volume of services in order to receive MCO, Cardinal Innovations Healthcare, employs 24 care coordi- higher total reimbursement. Further, there is no nators for mental health and substance abuse and 53 for I/DD; relationship between the fee for service payment and five network engagement specialists who work with the provider the value, or outcomes, derived from that service. network; and a senior community executive who acts as a liaison Recognizing the volume vs. value dilemma, Cardi- with county commissioners, social services and other stakeholders. nal Innovations, like other health plans, is focusing That’s in addition to its community operations staff. on value-based contracting, which ties provider Because so many interviewees were critical of Cardinal specifi- payments to the clinical outcomes achieved, in part. cally and the LME-MCO model generally, it prompted the question, Where outcomes are not easily measured, provider has anything good come from managed care? payments are tied to the prevalence of nationally ac- Cardinal provided the following information about four accom- cepted processes or training deployed by the provid- plishments it says it has achieved locally in the three years it has er that have been correlated to improved outcomes served Mecklenburg County: generally. Regardless, the benefit of value-based a In 2015, Cardinal introduced a TFC “value based contracting contracting is that the payment methodology, initiative,” which includes a quarterly measurement and scoring of whether fee-for-service, capitated, or something else all TFC providers. Designed to reward high-performing providers altogether, is irrelevant, thus removing the issue of with enhanced payment and the opportunity to add more homes in whether the provider was incentivized to provide the network, the initiative promotes access to increasingly higher- more or less care. Instead, providers are incentiv- quality treatment services. “Since inception, this initiative has ized to focus on the quality of care they provide, increased TFC provider performance by 71 percent,” said Cardinal leading to better outcomes for all of our members. spokesperson Ashley Conger. “The result is better assessment by Value-based contracting is in its infancy and to psychiatrists early in treatment, greater therapy for childhood trau- date represents a small minority of total provider ma, and greater child and family team performance.” payments. As the ability to measure and collect a In 2014, Cardinal implemented “transitional living services,” a outcome data and the ability to analyze large data community-based service specifically for youth with mental health sets improves, Cardinal Innovations will continue needs who are “aging out” of the foster care setting, or transition- to expand the use of value based contracting. ing to independent living. Outcomes in Mecklenburg County, and Value-based care likely would require pro- across Cardinal’s service area, include reducing legal involvement viders to gather and report more data on their and crisis episodes, securing employment and following through patients, adding another layer of paperwork. with schooling. But, if it has the potential to transform the a In late 2015, Cardinal introduced “family-centered treatment.” system from one that revolves around Medic- “This intensive family-based service diverts children from residen- aid service definitions to a system focused on tial treatment and reduces lengths of stays in residential. This is an recovery, value-based care might be the next, evidenced-based model that focuses on the entire family system best wave of mental healthcare reform. It may and the development of supports in the community,” Conger said. have the potential to transition providers from a Cardinal is working with Monarch to build a 16-bed crisis treating disorders to preventing them from facility, which is scheduled to open later this year. It will be the only happening in the first place. facility-based crisis service in Charlotte.

35 BRITNEY, DEON AND NICOLÁS* RECEIVE THE HELP THEY NEED

After several months of working with her new therapist, Britney feels significantly less distressed and more hopeful about her future. Her new therapist has training and expertise in the development of specific emotional regulation skills, and Britney trusts her enough to be completely honest during their sessions together. She and her parents are grateful their pediatrician connected them with the right therapist, but they also wish they’d known what to do to avoid wasting time and money on the wrong services. Deon’s new clinician adheres to best treatment practices and teaches him coping skills to deal with the symptoms of the trauma he has experienced in his life. Deon is included in the development of a person-centered plan which establishes treatment and life goals for him to achieve with help from his clinician. These goals are reviewed monthly to ensure there is progress and that Deon has input into the goals. Deon embraces the coping skills he has been taught, begins achieving his goals, and is able to refrain from illegal activities. It takes many years, several mental healthcare providers, and significant resources to get him to this outcome. It’s been a four-year journey for Nicolás to obtain a visa. He’s now 10 years old, Raise awareness and and after bouncing from foster home to foster home, YFS finally was able to place him increase education on the in a residential treatment facility specializing in I/DD. The special immigrant juvenile importance of prevention status he was granted as a result of being abandoned by his father makes him eligible and early intervention, as well as the impacts of trauma on for Medicaid; without that, he wouldn’t have been able to live in the group home. For early brain development the last four years, he’s been receiving mental health services—but not for his autism. Because autism is classified as an I/DD disorder, Nicolás had to apply for an Innova- tions Waiver from Medicaid. Funding for the waivers is capitated, so the wait list is several years long. But Nicolás is safe and well-cared for and, if he’s lucky, by the time he enters middle school he’ll be able to receive treatment for his autism. By that time, he will have been in the country for almost half of his life.

Nicolás, Britney and Deon’s stories illustrate the complexity and magnitude of some of the systemic issues—and how decisions at the macro-level have a very real impact on specific situations facing real families. Their stories beg the question, what can we as a community do to improve the lives of children and adolescents with mental health needs? In August 2017, the funders who supported this project convened leaders from the key stakeholders identified on pages 6-12 to review the three “big picture” strategies and 16 implementation tactics discussed in the conclusion to this report. The collaborative problem-solving sessions were simply a first step. The final plan should be incorporated into the implementation plans for the Economic Opportunity Task Force since poverty and mental health incidence are interlinked. Only through honest conversations about causation and the roles of trauma, socioeconomics and intergenerational poverty can we as a community come to realistic conclu- sions about how to ensure all of our children grow up healthy—in mind, body and spirit. *Britney, Deon and Nicolás are fictional characters.

36 Conclusion: Suggestions for Improving the System

roviding children and their families with viewed, a different priority for improving the Pthe behavioral healthcare they deserve is a system was emphasized. Thus, there is no clear complex and multi-dimensional problem— consensus on a single path forward. there is no magic wand we can wave to create Rather than attempt to provide a “set in equal access for everyone. As a community, we stone” action plan, this final section of the as- must realize the issue goes far beyond mental sessment is an invitation to think more broadly health: We need to resolve the socioeconomic about the mental health system overall, the disparities that contribute to disproportionality various roles being fulfilled by some of the main the courts, in our schools, and in the child jor stakeholders, and a few critical ways they welfare and mental health systems. Having could impact positive changes in the future. A a comprehensive report on children’s mental preliminary draft of this portion of the report

Raise awareness and increase education on the importance of prevention 1.and early intervention, as well as the impacts of trauma on Reward best practices and early brain development encourage collaboration and 3. communication PREVENTION ACCESS QUALITY

Increase access to mental health services 2. and support for children and families health and an understanding of how the major was presented to 21 stakeholders47 in advance stakeholders are responding to the crisis are of two brainstorming sessions. Their input, important first steps to setting an agenda for advice and constructive criticism were a valu- the future. able part of the process and will be even more The following key strategies and imple- important during the next phase of the project: mentation tactics are works in progress. They deciding which suggestions to implement and emerged during nine months of research, who will spearhead the work. The author and which included face-to-face interviews with project funders hope the stakeholders and 83 local mental health professionals, public community-at-large will expand upon it so the policymakers and parents, as well as dozens next phase will include more people willing of telephone conversations with experts from to collaborate in a broad-based endeavor to across the state. For nearly every person inter- improve the system for the benefit of all.

37 Raise awareness and increase education on the importance1. of prevention and early intervention, as well as the impacts of trauma on early brain development

Provide more trauma training

PREVENTION

Raise awareness about the importance of early brain development

Adopt the Child First model

erhaps the most critical void in Medic- A more recent study by Drs. John Ellis and Paid-funded mental healthcare is services for Natalie Conner estimated that more than 9,000 infants and toddlers. local children under age 5 demonstrate prob- Although Medicaid does reimburse pedia- lem behaviors that rise to the level of a diag- tricians to screen for developmental delays and nosable mental health issue. intellectual disability, it doesn’t include mental Research shows a child’s earliest years health service definitions specific to children have a profound impact on the rest of their under the age of 5. lives. Early brain development is essential for Instead, Medicaid funding for infants and children’s health and welfare: Safe, stable and toddlers is more focused on developmental nurturing relationships with caregivers are issues from birth to age 3. According to a study fundamental to healthy maturation during by The Lee Institute, only 5 percent of Char- these critical first few years of life. lotte-Mecklenburg children ages 0 to 5 with a Conversely, neglect and abuse, chronic diagnosable mental health disorder are receiv- stress, scarcity, trauma, and exposure to vio- ing treatment. lence are detrimental to children of all ages.

38 To fully understand our community’s men- to accurately diagnose and treat children ex- tal health crisis, one must acknowledge the posed to scarcity, trauma and toxic stress. impact of intergenerational racism and poverty on these adverse childhood circumstances. a Child First We simply cannot turn a blind eye to the link Adopt and implement the Child First mod- between poverty and poor mental health. Tac- el in Mecklenburg County to promote the tics to be considered to raise awareness about healthy development of children from birth to trauma, early brain development, prevention age 5. In 2015, a study commissioned by Smart and intervention include: Start of Mecklenburg County recommended the adoption and implementation of Child a Early Brain Development First, a national, evidence-based, two-genera- Raise awareness among parents and other tion model that works with vulnerable young caregivers about the critical importance of children and families by providing intensive, positive early brain development on the social home-based services. A statewide Child First and emotional impacts of children’s growth. office was established in 2016 and the program A key recommendation from the Opportu- is now being implemented in eastern North nity Task Force report is echoed here: “Educate Carolina. parents, early educators, and other caregiv- However, the Child First model has yet to ers on the importance of positive early brain be implemented in Charlotte-Mecklenburg. development, social/emotional development, Representatives from the ZFive Infant Mental and early literacy, and provide training on how Health Working Group, CMS, CDSA, Smart to best support and interact with their children Start of Mecklenburg County, Assuring Better from an early age.” (Strategy E-1) Child Health and Development, Intensive Feedback from the stakeholders indicated Home Visitation programs, Mecklenburg that multiple, evidence-based models should County Consolidated Health and Human Ser- be used and suggests “the LME-MCO needs vices, Cardinal Innovations, local pediatricians to recognize there’s not just one.” The model and other relevant early childhood partners must be a good fit for the clinician and the pa- should collaborate to develop an early-child- tient. Psycho-education for the family should hood SOC. help them understand the process of treat- This working group, or its designated ment, including the family’s role and what the leaders, should then integrate the Child First diagnosis means for the child and caregiver. model into a wider early-childhood SOC, which would be responsible for promoting a Trauma the healthy development of young children Reduce the shortage of trauma-certified and strengthening family capacity throughout clinicians and raise awareness of trauma’s Mecklenburg County. impact on children; determine what addition- Next, these organizations should work al resources are required to support Charlotte with the Child First National Program Office AHEC, CHS and the Mecklenburg County in Bridgeport, Conn., and the regional clinical Trauma Informed Care Workgroup in their director in Wilmington to identify a lead orga- ongoing effort to provide trauma training for nization. Finally, the lead organization should professionals in schools, juvenile and family identify affiliate agencies with the necessary courts, and continuing education for clinicians qualifications to implement the model, and in the mental health and child welfare systems; develop a financing plan for start-up and sus- and increase the number of licensed clinicians tainability so Mecklenburg County can become who receive trauma training and certification an official replication site.

39 f lack of access is the greatest barrier to a Adolescent treatment beds Ichildren and adolescents receiving treatment Create more 30- to 90-day adolescent treat- for behavioral health problems, increasing ment beds, especially for hard-to-place chil- their ability to receive help is where reform dren and adolescent females with substance should begin. Ideally those resources should use disorder, where they can receive a quality be located in the neighborhoods where they assessment. live. Among the stakeholders who convened Given the current political climate in in August 2017 to brainstorm these tactics, Washington and in Raleigh, funding for Med- disagreement arose about whether Char- icaid may very well be reduced over the next lotte-Mecklenburg has a shortage of residential decade. And, because parity is unlikely to be placements or whether the issue is that some achieved in the commercial insurance market, residential placement facilities refuse to take middle class families increasingly will have to certain adolescents. If there is indeed a short- pay out of pocket or forgo mental healthcare age, it appears to be exacerbated by children altogether. from outside the county taking up beds in The burden on community agencies and Mecklenburg County, as well as the high cost service providers—who already are trying to of such placements coupled with cuts to Med- do more with less—will rise dramatically in icaid for this service definition. the future. Opening later this year, Monarch’s 16- That said, the gaps in services and barriers bed crisis center certainly will help alleviate to treatment identified in this report must be the problem, but some service providers say addressed if we as a community are serious Charlotte-Mecklenburg could fill many times about doing a better job of helping our most that number. vulnerable youth. We cannot rely on Medicaid Also, teenage girls in need of round-the- and private insurance alone to fund gaps in clock supervision and substance use treatment services. currently are being referred to group homes The Mecklenburg County BHD manages outside the state. a network of 16 providers separate from the Since different levels of residential place- Medicaid provider network. Could the coun- ment require specific licensure from the state— ty find more funding in its annual budget to and there are significant differences of opinion expand BHD’s ability to identify and minimize over the mental health services most need- (or even eliminate) gaps in services and sup- ed—a feasibility study should be undertaken port? Could Mecklenburg County’s Consol- to determine the best type of facility to meet idated Health and Human Services Agency the highest demand. lead the charge in aggressively pursuing feder- For example, could a first-of-its-kind “hy- al grants to eliminate gaps in services? brid” facility be funded outside the restraints And could philanthropic organizations of Medicaid guidelines to allow flexibility in “adopt” specific components of this assess- placement options? ment to expand access to care? Certainly, the priorities for the potential Acknowledging that additional funding new beds should be adolescent females with sources will need to be identified and substance use disorder and hard-to-place discussed in order to implement this key youth in custody of YFS. At a minimum, any strategy, some specific ways to increase access new residential placements should eliminate include: these two glaring gaps.

40 Establish a live-time database for crisis placements

Create more Increase cultural adolescent competence treatment beds Develop a provider clearinghouse

ACCESS

Facilitate more community- wide training Expand school-based mental health to more schools Include mental healthcare in community resource centers Increase access to mental health services 2. and support for children and families a School-based mental health CMS recognized the need for behavioral health Expand SBMH services to more schools in treatment in the school setting and implement- the CMS system and consider making the pro- ed a SBMH intervention program in 2014-15. gram available to pre-K and charter schools. The program has grown to include nearly 60 Our public school system has the equiva- percent of schools, and participating students lent of one psychologist for every 2.74 schools. have shown positive trends for attendance, The school psychologists and other student academics and behavior. services professionals (social workers and However, a barrier to expanding the pro- school counselors) don’t provide clinical coun- gram to more schools is buy-in from school seling per se but rather focus on factors that principals. (As one SBMH agency staffer put directly affect children in the school environ- it, “CMS should have SBMH in every school, ment. While their work is vitally important, and don’t leave the decision to the principal.”)

41 Other barriers include written consent from care coordinators at YFS and Cardinal with parents for their children to receive an intake information about each provider, the level of assessment, and consent from the school coun- care they provide, and whether any beds are selor and CMS administration for students to available right now. Thus, to be effective it be placed in the program, creating delays to must be in real time to eliminate the potential receiving treatment. problem of a placement being available in the Could all three barriers be mitigated morning and finding out it’s gone by the time through a streamlined process of consent? the child has a court hearing in the afternoon. Would more school principals sign up for While such a database wouldn’t eliminate the SBMH if they understood the benefits to their problem of facilities rejecting certain individu- students and the promising, early successes of als, it would go a long way toward improving the program? the current system. A survey of parents, students, principals, teachers, SBMH providers, and student a Provider clearinghouse services professionals should be conducted Develop a web portal to serve families and to better understand the underlying issues so professionals by providing a “clearinghouse” these barriers may be removed. The survey of of direct service providers, support organi- SBMH providers should address the challenge zations, and their eligibility requirements, of sustaining the program and whether the qualifications and services. schools’ expectations of clinicians are too high, As a community, we need to do more to placing undo time constraints on counselors in help families stay intact by wrapping services proportion to their billable time. around the entire family. A web portal should be developed to help navigate the system of a Crisis placements services and support. It would provide up-to- Establish a live-time database for available date information on direct service providers crisis placements for children in the custody and support organizations. It would give fam- of YFS. ilies a comprehensive directory of resources, The availability of residential placements both public and private, for children’s mental within the facilities that provide housing and healthcare. And it would allow community treatment to children in YFS custody changes agencies to see how other providers fit into from day to day, hour to hour. The status of the overall ecosystem so they can make timely the providers also changes frequently, mak- referrals. ing it difficult to know which are in good standing (and therefore authorized to accept a Community-wide training placements), which are being investigated, and Train more community members to recog- which are no longer part of Cardinal’s pro- nize the signs of potential behavioral health vider network or the YFS placement network. incidence so they may connect them with the Even if the two provider networks were to re- appropriate resources. main static, the only way to determine if a bed When people who work with children and is available would be to call the providers. adolescents are aware of the mental health A further complication is the providers challenges they face, as well as the resources offer different levels of care, serve different available to help them, early intervention is populations, and provide different types of more likely. Identifying and resolving a mental clinical services. Therefore, a live-time data- health issue before it becomes a crisis is less base should be created to manage placement traumatic for the child and less expensive for availability. The database would provide society as a whole.

42 The two hospital systems, Novant and WHAT’S THE MENTAL HEALTH TASK FORCE? CHS, together have trained about 9,000 teachers, athletic trainers, emergency medi- Many of the tactics suggested in this report overlap with those of the cal technicians, clergy, firefighters and other Mental Health Task Force. Every four years, the Health Department non-mental health professionals in Mental conducts an extensive examination of community health indicators Health First Aid. Since 2012, Mental Health through a state-developed Community Health Assessment (CHA). The America of Central Carolinas has trained more department uses findings from the CHA to develop or support collabo- than 5,700 people in Mental Health First Aid. rative community action addressing issues identified as priorities. And the Health Department has facilitated In 2013, the CHA advisory committee reviewed the nine priori- training for more than 1,500 police officers in ties from the 2010 assessment, and county residents were surveyed CD-CP. These and other training programs to re-prioritize the focus areas. More than 100 community agencies should be expanded to ensure greater numbers participated in a priority-setting meeting and ranked mental health as of non-mental healthcare professionals, such the No. 2 priority, second to chronic disease and disability. (No. 3 was as bus drivers and cafeteria workers, receive access to care.) Participants also developed specific recommendations education about children’s mental health and for the top four priority areas. how to put families in touch with appropriate The second phase of the CHA was to develop a community action resources. plan to address mental health issues. Chaired by Connie Mele, assistant director of the Health Department, the Mental Health Task Force was a Cultural competence formed in 2014.48 The task force determined these steps to be taken: Address cultural competence and language a Increase funding for mental health services, numbers of beds for barriers that limit immigrant populations from acute and residential care, and number of providers; accessing mental health services and support a Increase the number of providers representing varied ethnic and for their children. cultural backgrounds through scholarships and incentives; Due to a federal statute prohibiting undoc- a Promote school-based programs; umented individuals from receiving Medicaid, a Make available free or low-cost counseling; CMS provides pro bono mental health services a Increase education and prevention services; to undocumented students, but community a Ensure comprehensive care, including physical and mental health; agencies are said to lack sufficient numbers a Work to decrease the stigma of seeking mental healthcare; of bilingual clinicians to adequately serve this a Promote Mental Health First Aid training for mental health profes- population. sionals; CMS should consider providing training a Promote communication and collaboration among mental health to teachers about the effects of trauma on providers and other disciplines, such as substance abuse, the criminal children who have immigrated to the U.S., justice and education systems, hospitals and social services; especially those who may have been abused by a Raise awareness of infant mental health, dual-diagnosis, and the human traffickers or were separated from their idea that with appropriate treatment people can get better; parents in detention centers. Children born to a Develop a central repository/hub for mental health resources, immigrants and the trauma they face should including more materials in languages other than English; be considered, too. And community agencies a Extend mental health training to non-mental health professionals could make bilingualism a bigger priority in and workplaces including law enforcement, the school system, hospi- their hiring practices. tals and social services, and consider non-traditional partners such as frontline workers and transit staff; and a County Resource Centers a Limit access to firearms. Finally, behavioral health services and sup- Whether the task force will continue after the 2017 CHA is complet- port should be included as a component of ed hasn’t been decided. “Unfortunately,” one county official lamented, the County Resource Centers being built in “the task force didn’t receive the backing and support it needed to our crescent communities. accomplish much.”

43 Reward best practices and encourage collaboration and communication ecause the 3. Bpublicly funded mental healthcare system revolves around Med- Create a data icaid’s reimbursement warehouse schedules for specific service definitions, the most significant way to reform the system Adopt a common itself is to redesign the financial incentives. assessment Is there a means Transition to a and a will to evolve whole-person beyond the traditional model fee-for-service model? And is there a better way to incentivize LME-MCOs so they’re not tempted to deny QUALITY and delay services merely to avoid spending the state’s Eliminate duplication Explore Medicaid dollars? of management and alternative Value-based care coordination approaches may hold the potential to transform the system to align the profit motive with what’s Evolve to an best for children, by outcome- focusing on preven- based model tion and intervention rather than treatment after a crisis. Further, what can be done to minimize ates hardships for families with children who the “silo effect” in order to join back together have dual-diagnoses. Breaking down the silos a fragmented mental healthcare system? And would involve communication and collabo- how can medical and mental health services be ration between the community agencies that integrated into a “whole person” approach? comprise Cardinal’s provider network. Medical and psychological healthcare Mental health professionals should be shouldn’t be treated apart from one another. encouraged to learn best practices from each Likewise, mental health, substance abuse and other, and the agencies’ financial incentives I/DD shouldn’t be treated in isolation with should be restructured to reward accurate separate funding streams for each; that cre- diagnoses and evidence-based treatments.

44 a Data warehouse a Elimination of duplication Create an electronic mental health record and Determine the specific situations and scenar- data warehouse accessible to all providers in ios in which the duplication of case manage- good standing in the Cardinal network as well ment or care coordination commonly occurs. as policymakers. While too many cooks in the kitchen is better Much of the data collection that took place than none, if the system overall must continue during the era of the Area Mental Health to make do with fewer and fewer resources, Authority, and in the years Charlotte-Meck- then it can’t afford to pay for duplicate services lenburg received a federal SOC grant from from separate agencies. SAMHSA, is no longer taking place. And the data that is being collected is hard to obtain. a Common assessment Although patients’ privacy must be pro- Streamline comprehensive clinical assess- tected, a mental health system where informa- ments and evaluations where possible by tion, including statistical data, is freely shared adopting a common, unbiased, independent would help to eliminate the silo effect and psychological assessment. This would elim- provide a “single view of the citizen.” inate wasting resources on duplication, and Without data we cannot see how children it would minimize the potential for further from low-income neighborhoods are dispro- traumatizing children through multiple assess- portionately affected, how needs and gaps ments and evaluations by multiple agencies. in children’s services can be identified, how financial resources can be directed to services a Outcome-based model which have the most impact, how strategies Evaluate the feasibility of transitioning can be developed for treatment, how peer the LME-MCO provider network away networks can be formed to enable parents, from the fee-for-service model towards an teachers and others to collaborate and seek outcome-based reimbursement model that support. would incentivize treatment plans utilizing An electronic mental health record, similar evidence-based modalities. According to to the idea of a “universal healthcare card,” Cardinal, “as the ability to measure and collect would help both families, providers and outcome data and the ability to analyze large policymakers. It would allow clinicians to see data sets improves, (we) will continue to ex- assessments, evaluations and records of mental pand the use of value based contracting.” Are health, school, juvenile justice, detention and there ways to bring private providers into an child welfare contact so they could obtain a evidence-based model as well? complete picture of a child and family’s mental health history and socioeconomic circum- a Whole-person model stances. Determine the systemic changes needed to It would reduce or eliminate multiple move towards a whole-person model, a holis- (and expensive) assessments and the risk of tic approach to medical and mental health that further traumatizing children through having can reduce barriers and eliminate stigma. to repeat their stories again and again. And it would enable policymakers to make deci- a Alternative approaches sions based on facts gathered from analysis of Explore ways the community can increase the robust data and predictive analytics, including use of alternative approaches to mental health evidence-based modalities, academic perfor- care, including self-help, diet and nutrition, mance, graduation rates, college entry rates, expressive therapies such as play therapy, yoga and other key measures. and relaxation and stress reduction techniques.

45 SUGGESTIONS FOR MOVING TO ACTION

This assessment has provided an overall the Charlotte-Mecklenburg Opportunity Task description of the ecosystem of services and Force report by augmenting the community’s support for children and adolescents with understanding of the pediatric mental health mental health needs, the underlying issues and system and by developing tangible strategies reforms that created the system as it is today, to address needs and gaps. The strategies and some of the major gaps in services and discussed on the preceding pages are intend- barriers to treatment. ed to provide an overall context and general In addition, it has suggested three key framework for taking decisive action as a strategies and 16 implementation tactics to: community. a Raise awareness about the importance of During our meetings with nearly two prevention and early intervention; dozen stakeholders, one of the main topics of a Increase families’ access to services and discussion was the various roles each type of support; and organization should fulfill in the next phase a Reward best practices while breaking of this work. The stakeholders’ input about down the silos that may exist among service which organizations should be involved and providers and other organizations involved in what roles they should play is illustrated in the children’s mental healthcare. chart below. The overarching goal of this project is to So where do we go from here? The next jump-start the implementation of Strategy R of phase of this project will be for the funders to convene the stakeholders again, in addition to others who are committed to improving the POTENTIAL IMPLEMENTATION ROLES system. The funders will designate a neutral facilitator to engage the group in discussions Supply Raise Provide Improve Facilitate Reduce Collect about how to address the issues and percep- Funding Awareness Leadership Access Training Stigma Data tions raised in this report. The group also will Business Community a a a a study the recommendations contained in this Charlotte-Mecklenburg a a a a a a a report to help determine priorities, roles and Schools responsibilities moving forward. Faith-based a a a a An important point made by many of the Organizations stakeholders time and again is that no single Managed Care a a a a a organization is in a position to oversee or Organization implement all of the suggested strategies and Mecklenburg County a a a a tactics. Transforming the system will require Government collective action from everyone involved in Philanthropic a a a a a children’s mental health, as well as the busi- Organizations ness and academic communities, faith-based Service Providers a a a a a a organizations, and philanthropy. Two Hospital Systems a a a a a As stated in the Opportunity Task Force UNC-Charlotte a a a report, “Our hope is that everyone can find a Note: All groups can impact each role above; however, the checks indicate where groups place to connect with this work and help make could have the greatest potential impact. a difference.”

46 ACKNOWLEDGMENTS

Many thanks to the parents, educators, administrators, care coordinators, support personnel, policymakers, doctors, psychiatrists, psychologists, social workers and other licensed clinicians who contrib- uted their time and expertise to this report. Without their patience and generosity, the project wouldn’t have been possible. Thanks to Casandra Alexander, Carolyn Allison, Dr. Barbara Agnello, Victor Armstrong, Lori Avery, Isabel Bader, Adelaide Belk, Megan Bengur, Jefforey Best, Joey Bishop-Manton, Jerry Boyce Jr., George Boykin, Dr. Alan Bozman, Charles Bradley, Nancy Brandon, Elizabeth Brotman, Annie Burton, Stacey Butler, Laura Clark, Brian Collier, Ashley Conger, Ashley Conrad, Brent Cook, Dr. James Cook, Mona Cooper, Matt Dillworth, Dena Diorio, Wanda Douglas, Peggy Eagan, Dr. John Ellis, Corey Ellison, Ericka Ellis-Stewart, Robert Evans, Mitchell Feld, Ellis Fields, Terri-Lynn Fite, Jordan Forsythe, Paul Foushee, Lynda Fuller, Diane Gavarkavich, Dr. Tom Gettelman, Ann Glaser, Priscila Grabowski, Jenny Greene, Sarah Greene, Michael Hansen, Penny Hawkins, Jamie Ross Hayes, Rebecca Herbert, Dr. Erica Herman, Lisa Holmes, Tabatha Howard, Mackie Johnson, Rona Karacaova, Lisa Krystynak, Cathy Morlu Ladson, Dr. Lee Beth Lindquist, Sara Lovett, Dr. Darcy Lowell, Stacy Lowry, Janelle Martin, Carlos Martinez, Wendy Pascual, Kate McAllister, Dr. Richard McAnulty, Dr. Susan McCarter, Christopher McCullough, Meg McElwain, Kaye McMullen, William McMullen, Angie Meindl-Walker, Connie Mele, Dr. Lisa Mills, Jessica Montana, Judy Moore, Lisa Murray, Karen de la O Medina, Charles Odell, Dr. Rebecca Parilla, Mary Peniston, Dr. Cotrane Penn, Justin Perry, Amber Pierce, Russell Price, Mebane Rash, Jack Register, Brendan Riley, Tracy Russ, Libby Safrit, Dr. John Santopietro, Carrie Sargent, Angela Simmons, Robert Simmons, Shonta Smith-Walker, Larry Snider, Dr. Jonathan Studnek, Chris Thompson, Judge Elizabeth Thornton Trosch, Judge Louis Trosch Jr., Anthony Trotman, Rodney Tucker, Wade Tyrone, Rosa Underwood, Kirsten Vaca, Mary Ward, Stacy Warren, Mike Weaver, Sharon Welling, Billy West, Marie White, Martha Whitecotton, Jessica White, Laurie Whitson, Christopher Williams and Will Woodell. Thanks also to the one dozen professionals who agreed to be interviewed anonymously and declined to be named here. Special thanks to the fact-checking team of Heather Johnson, Dr. Diana Moser-Burg, Dr. Dawn O’Malley and Candace Wilson; ... to Children’s Medical Fund, Foundation For The Carolinas, and Mitchell’s Fund for their funding and support; ... and especially to Carol Morris for her expert guidance and constant encouragement.

47 ENDNOTES

1 http://tinyurl.com/z5ogrdc concept of SOC. Skills are developed in CFT coor- 2 http://tinyurl.com/y94ejb9d dination through a strengths-based approach, 3 http://tinyurl.com/y8nsax9y which emphasizes cultural discovery and natural 4, 5, 6 Preliminary numbers are from Cardinal supports. Wrap-around facilitation, strengths Innovations Healthcare’s 2017 Community assessments, effective child plan development Mental Health, Substance Use and Developmen- and crisis planning are additional course topics. 23 tal Disabilities Services Needs and Gaps Analysis, SOC team plans go by different names, including which had not been finalized at press time. the “Child and Family Plan,” “One Child One 7 http://tinyurl.com/zjnyd94 Plan” or “1 Family/1 Team/1 Plan.” 8 24 From 2001 to 2011, the number of persons served According to a top-ranking county official, Meck- at the state’s psychiatric hospitals declined from lenburg made significant efforts to sustain the more than 17,000 people to fewer than 6,000 grant. Asked why it was not sustained, Dr. Cook people, according to the N.C. Center for Public replied “...probably the majority of the SOC Policy Research. grants in the state didn’t sustain well. ...The lack 9 http://tinyurl.com/glq23kn of sustainability in this state is not surprising, 10 http://tinyurl.com/gt2m78r given the chaos and poor policymaking at a state 11 http://tinyurl.com/ycrd4ryb level resulting in policies that were inconsistent 12 The 20 counties in Cardinal’s catchment area are with SOC implementation.” 25 organized into five geographic regions. Mecklen- http://tinyurl.com/zslxmza 26 burg is the only county in its region, and that Statistic from Charlotte-Mecklenburg Drug Free region has the largest general population. The Coalition as provided by the Dilworth Center 27 county’s Medicaid beneficiaries comprise 37.4 http://tinyurl.com/677gtz8 28 percent of Cardinal’s total membership. http://tinyurl.com/yccs95tg 13 29 http://tinyurl.com/ybu72ey6 http://tinyurl.com/y82nt8pg 30 http://tinyurl.com/y9yoe66b http://tinyurl.com/y9668pyo 31 http://tinyurl.com/ycm4n28x The Youth Drug Survey is conducted every two 14 Included in the 262 figure are agencies serving to four years by the Center for Prevention Ser- adults only, and service providers located in vices in collaboration with CMS. The 2015 self- Mecklenburg County that do not serve local report survey was administered to 3,892 youth residents. Asked how many agencies are in its ages 12 to 18. 32 local provider network for children’s mental http://tinyurl.com/yamf5buz 33 health, Cardinal did not provide the number of Statistic from CDC as provided by the Charlotte- local agencies serving local children. Mecklenburg Police Department 15 34 Two state audits have called into question http://tinyurl.com/y9bp4wjr 35 Cardinal’s high salaries and overspending, result- With an annual household income of $80,650, a ing in its board passing a resolution on October family of three would be just over the limit to 17, 2017, to cut CEO pay from $617,526 to qualify for an ACA subsidy. The same family $204,195. http://tinyurl.com/y7c3hu9y earning $50 less per year would qualify for an 16 http://tinyurl.com/me7hpxq estimated monthly subsidy of approximately 17 http://tinyurl.com/ksvb7hd $1,000 to offset private insurance premiums. 18 http://tinyurl.com/mcz3b3q Rate quotes are based on 2017 Blue Cross and 19 http://tinyurl.com/kbl3vva Blue Shield plans and on hypotheticals such as 20 CMS receives $330,000 annually from Mecklen- family members’ ages (51, 40 and 2) and appli- burg County to support SBMH. cants’ zip code (28202). 21 36 http://tinyurl.com/ycpbpb4n http://tinyurl.com/lsur8dw 22 MeckCARES Community Training Institute is http://tinyurl.com/lqgcnuv 37 one of only three sites in North Carolina http://tinyurl.com/kk4l9x5 38 authorized to provide comprehensive SOC The estimate of 9,177 is based on national training, which is required in the first 90 days averages of prevalence of mental health issues of employment with service providers such as the among infants, toddlers and preschoolers, apply- Department of Juvenile Justice, YFS, DSS, all ing the metric to 2010 U.S. Census data. 39 comprehensive behavioral health service Mecklenburg County provided funding in 2017 providers and various positions in the school to hire two transition-age youth peer sup- system. Courses introduce participants to the port staff. One has been outsourced to On

48 ALPHABET SOUP: ABBREVIATIONS USED IN THIS REPORT

Ramp, the other to Youth Treatment Court and ABC Attachment and Biobehavioral Catch-Up Reid Park Initiative. ACA Affordable Care Act (commonly called Obamacare) 40 http://tinyurl.com/lpfy48l ACE Adverse Childhood Experiences 41 http://tinyurl.com/ojlkoa8 42 ADA Americans with Disabilities Act With Friends is a youth shelter, not a specialized ADHD Attention-Deficit Hyperactivity Disorder care facility. 43 AHEC Area Health Education Center (Charlotte AHEC) In 2016, Hispanics and Latinos represented 13 AMHA Area Mental Health Authority* (now extinct) percent of the county’s general population, BH-C Behavioral Health-Charlotte (a CHS facility) the U.S. Census estimates. 44 Children exposed to violence may exhibit the BHD Behavioral Health Division* same behaviors and symptoms of ADHD and CD Conduct Disorder ODD, which can lead to misdiagnoses. CDC Centers for Disease Control 45 http://tinyurl.com/lp8fwgq CD-CP Child Development-Community Policing* 46 Asked if Reid Park Initiative has evidence to CDSA Children’s Developmental Services Agency* support its effectiveness, a BHD staffer replied, CFT Child and Family Team “...we have some data, but several aspects of this CHA Community Health Assessment multi-faceted initiative have yet to grow and CHS Carolinas HealthCare System mature (e.g., housing, mentorship, etc.) to yield CMS Charlotte-Mecklenburg Schools meaningful data.” 47 CPS Child Protective Services* Attendees of the stakeholder brainstorming CSS Community Support Services* sessions included Victor Armstrong, BH-C; DHHS Department of Health and Human Services** Adelaide Belk, United Way of Central Carolinas; Joey Bishop-Manton, CDSA; Charles Bradley, DMA Department of Medical Assistance** YFS; Annie Burton; Ashley Conrad, Alexander DSS Department of Social Services* Youth Network; Matt Dillworth, Thompson Child GAL Guardian ad litem and Family Focus; Peggy Eagan, DSS; Dr. John I/DD Intellectual and Developmental Disabilities Ellis, psychologist and early childhood consul- IPRS Integrated Payment and Reimbursement System tant; Penny Hawkins, Novant Health Foundation; JCC Juvenile Court Counselor Heather Johnson, Council for Children’s Rights; LGBTQ Lesbian, Gay, Bisexual, Transgender, Questioning Janelle Martin, Novant Health Foundation; Angie LME Local Management Entity Meindl-Walker, Forensic Evaluations Unit; MCO Managed Care Organization Connie Mele, Health Department; Dr. Diana MST Multisystemic Therapy Moser-Burg, Smith Family Wellness at Project NAMI National Alliance on Mental Illness 658; Wendy Pascual, Camino Community Center; NIMH National Institute of Mental Health Dr. Elizabeth Peterson-Vita, BHD; Judge Louis Trosch, Jr., N.C. 26th Judicial District; Laurie OB/GYN Obstetrics and Gynecology Whitson, Cardinal; Candace Wilson, Mental ODD Oppositional Defiant Disorder Health America of Central Carolinas/Parent PRTF Psychiatric Residential Treatment Facility VOICE program; and Will Woodell, Cardinal. PTSD Post-Traumatic Stress Disorder 48 Other members of the Mental Health Task Force RMJJ Race Matters for Juvenile Justice include Victor Armstrong, BH-C; Nancy Brandon, SAMHSA Substance Abuse and Mental Health Services Novant Health; Kerry Burch, Epidemiology; Administration*** Cherene Caraco, Promise Resource Network; SBMH School-Based Mental Health Dr. Ken Dunham, Novant Health; Bob Evans, SOC System of Care NAMI-Charlotte; Ellis Fields, formerly of Mental STS Secondary Traumatic Stress Health America of Central Carolinas; Andrea TFC Therapuetic Foster Care Gardin, Novant Health; Keshia Ginn, Sante TF-CBT Trauma-Focused Cognitive Behavioral Therapy Group; Dr. Erica Herman, Novant Health; Teri Herrmann, The SPARC Network; Dennis Knasel, THC Teen Health Connection BHD; Melissa Neal, Criminal Justice Services; Dr. YFS Youth and Family Services* Cotrane Penn, CMS; Dr. Elizabeth Peterson-Vita, BHD; Libby Safrit, Teen Health Connection; Anita * A division or department of county government Schambach, CHS; Bob Simmons, Council for ** A department of state government Children’s Rights; and Laurie Whitson, Cardinal. *** A branch of the U.S. Department of Health and Human Services

49 APPENDIX: Cardinal Innovations’ Responses to Common Complaints

common theme in many of the interviews conducted for this assessment was the heavy- A handed bureaucracy of Cardinal Innovations Healthcare’s administration of Medicaid funds. In Charlotte-Mecklenburg, more than 250 community agencies contract with the MCO to provide direct mental health services to children and families who receive Medicaid and state IPRS benefits. In interviews with many of these organizations, Cardinal’s role in the authorization of and payment for those services was a dominant topic of conversation. Making sure the agencies comply with the rules is an important, thankless task—but, as one interviewee put it, “Cardinal has superimposed stricter standards than the state has set.” The interviewees’ most common complaints were compiled and provided to Ashley Conger, Cardinal’s vice president of corporate communications and public relations, in order to provide the MCO the opportunity to respond. The unedited responses are as follows:

The most common complaint, and this is nearly across the board, 1 is Cardinal finds ways to delay, limit and deny treatment. Cardinal Innovations’ mission is to improve the health and wellness of our members*—individuals who often have complex needs. We accomplish this by ensuring our members have access to and engage in healthcare services unique to their clinical needs and thus have the greatest probability of clinical success. As it relates to the complaint that Cardinal Innovations finds ways to delay treatment, the data requires a different conclusion. Cardinal Innovations processes 99.9 percent of all complete requests for routine services, and 99.6 percent of expedited requests within required timeframes. We approved 97.6 percent of all service requests in the last fiscal year. Unfortunately, many times service requests for individuals with complex needs are incom- plete, lacking a comprehensive clinical assessment or other key clinical information to support the service being requested. In these cases, Cardinal has little choice but to ask that an appropriate assessment be conducted or additional clinical information be obtained in order to support a conclusion that the services requested are medically necessary. Cardinal Innovations exercises care and caution when authorizing care for our members, particularly in situations where a child may be removed from his or her home. Finally, Cardinal’s historic clinical denial rate is the second lowest in the state. In fiscal year 2016 Cardinal denied 2.4 percent of requests, while the statewide average clinical denial rate was 4.0 percent. Importantly, every clinical denial of a particular service request issued by Cardinal Innovations includes at its core a recommendation for more evidenced based or clinically appropriate assessments and/or services based on the member’s current clinical presentation and the history of prior clinical interventions. It is a recommendation for a more appropriate treatment based on the clinical information available.

A similar complaint is treatment is authorized at the lowest level so children have to fail their way up through the levels of service to obtain the treatment they need. 2 Clinical best practice is to provide services that are appropriate to the clinical presentation of the individual child and delivered in the least restrictive setting. That is good medicine, and it is Medicaid policy. Children are not required to “fail their way up”. Clinical best practice is, whenever possible, to provide trauma informed, family preserving services to youth in their home, kinship setting, or community-based setting in order to provide the highest likelihood for long term success for the child. Cardinal Innovations recommends

* “Members” refers to Medicaid enrollees in the Cardinal catchment who have behavioral health needs.

50 services to promote long term success for each child based upon the individual clinical situation, even if occasionally such recommendations are more challenging to arrange. Cardinal Innovations regularly receives requests for services which would require a child be removed from their home and sent to a residential facility, sometimes a locked facility, for as long as 6 to 12 months at a time, without an assessment indicating such treatment is necessary, and without first attempting to provide trauma-focused outpatient therapy or family-centered therapy delivered directly in the home setting. Additionally, a complex case or unique clinical situation often requires care at a specialized facility which may not always be immediately available. Cardinal does not equate “any care” with “the right care”. In lieu of approving a request for a service by less appropriate providers who have immediate openings but are poorly equipped for therapeutic success for the child, Car- dinal Innovations will approve care to a provider who can offer specialized services, which are much more appropriate for a specific child’s situation. In each of these situations, we recommend relevant transitional services to support the member during the period until the most appropriate treatment becomes available.

Cardinal’s high turnover and lack of experience among care coordinators means providers spend an inordinate amount of time getting care managers up-to-speed, only to have to do it all again when that care manager leaves Cardinal. 3 Cardinal Innovations prides itself on its ability to recruit and retain talented staff, as evidenced by a voluntary termination rate of 11 percent, a rate that is well below industry averages. Each Cardinal Innovations care coordinator has relevant experience in providing behavioral health services to youth, and for most care coordinators, that prior experience has been in Meck- lenburg County. Cardinal is highly selective in its recruitment of care coordinators for children and youth. We have made an intentional effort over the past 12 months throughout its 20-county service area to improve the clinical and management capabilities of the care coordination staff, in part, which has included addition of new staff, reorganization of management, and changes to work flows, supervision, and roles. Granted, that intentional work has meant more than usual changes over the past year. The current Mecklenburg care coordination team is the highest performing Mecklenburg care coordination team overall since Cardinal Innovations assumed management of behavioral health services in Mecklenburg in 2014.

Another complaint is the paperwork and proofs are too time-consuming and too rigid. As with No. 3, that takes time away from providing direct services. 4 Cardinal Innovations’ requirements for care plans and service orders are those prescribed by NC Medicaid. No more or less. Cardinal Innovations does require that clinical assessments performed are comprehensive, appropriate to the complexity of the case, and instructive to the treatment to be determined for each individual and are not to be provided as some fulfillment of a pro forma service request requirement. This is especially true for our most complex or clinically unique cases. We regularly require providers to obtain more complete or apt assessments so the most appropriate treatment can best be determined. Children with highly complex or unique clinical presentations require and deserve comprehensive, skilled assessments so one can fashion treatments that have a higher likelihood of success and provide these children with wellness, meaningful and healthy relationships, and opportunities to participate effectively in school or work.

51 One of the more serious allegations is Cardinal cut some services three days after the state mandated that Cardinal spend the money it had bankrolled. The mandate 5 was to spend the surplus on providing services to members. Cardinal Innovations’ state-funded service array has remained unchanged despite the fact that State budgets for mental health services were cut significantly in fiscal year 2016 and again in 2017. During that same time, Cardinal Innovations has made up the difference, maintaining the same level of funding for services for the uninsured and underinsured as existed prior to the budget cuts, at a cost of approximately $12 million in fiscal year 2016, and $25 million in fiscal year 2017. In order to maintain that funding, and attempt to provide increased access to care for our non-Medicaid members*, Cardinal Innovations undertook significant efforts in the fall of 2015 to maximize the coverage of services under our Medicaid health plans. In November 2015, Cardinal Innovations issued a series of communications to our provider network to encourage each provider to critically evaluate whether members currently receiving certain state-funded services** could receive the same or similar services, as clinically appropriate, through Medicaid. For example, we found that a small number of children receiving Intensive In-Home services paid by state funding could receive the exact same service by the same provider, but was funded instead by Medicaid, if Medicaid eligibility for the children was pursued more assertively. By ensuring members were appropriately accessing public resources for which they were eligible, including identifying and assisting individuals with enrollment in Medicaid, we were able to maximize limited state funding available for the benefit of individuals who cannot access Medicaid.

Cardinal’s power to interpret Medicaid regulations and to do “report cards” on providers gives it the ability to “play favorites.” That favoritism translates into 6 higher rates for the same services, and more referrals given to its favorites. One of the key tenets of managed care is the closed network. Under fee-for-service Medic- aid, Medicaid enrollees are allowed to receive services from, and the State Medicaid Agency is required to pay any qualified provider of those services. Under managed care, states give MCOs the right to contract with those providers who are willing to meet certain quality standards, ensuring Medicaid enrollees have access to quality healthcare that achieves their wellness goals. Cardinal Innovations uses various tools to ensure the quality of its closed network of providers, including training and incentive-based mechanisms to encourage its providers to meet certain quality criteria. Over the last two years, Cardinal Innovations has implemented value-based contracting for Therapeutic Foster Care, Multi Systemic Therapy, and Family Centered Treatment. Provider payments are tied to provider performance. Explicit criteria are provided to each provider, training is provided on a group and individual provider basis, member specific performance under the criteria is reported to each provider, and providers are given the chance to provide additional information before scores are finalized. It is entirely open code. We want every provider to thrive under value-based contracting, resulting in more effective services and outcomes for our members and increased payment levels to providers. The payment level for each provider under value-based contracting is determined expressly by each provider’s performance. The only favoritism exercised by Cardinal Innovations has been the extra individual training and consultation provided to low-scoring providers in attempts to assist the providers to improve performance and enhance the effectiveness of care to members. Cardinal Innovations implemented value-based contracting for Therapeutic Foster Care in late 2015. The performance criteria encourage TFC agencies to work with fostering families to

* “Non-Medicaid members” refers to recipients of IPRS funds, which are available to certain individuals who don’t qualify for Medicaid. ** “State-funded services” refers to IPRS funds 52 make sure that children are assessed by a psychiatrist early upon placement in the home and an effective treatment plan implemented, that children are regularly engaged in therapy, and that families are engaged in family therapy so that families are better able to be successful once children are restored to their natural home. There are 17 total measures. In a little over a year the providers’ overall performance has improved by 43 percent. More therapy, more family engagement, better opportunities for better outcomes and healthier children and families. Cardinal’s denial rate for basic outpatient services is too high. 7 Outpatient therapy using clinical best practices is the most readily accessible, efficacious, and most cost effective generally available treatment modality. Cardinal Innovations was one of the first LME-MCOs to implement Comprehensive Care Clinics covering all of our 20 counties where members could receive same day walk in assessments and care. Effective, accessible outpatient therapy is a high priority for Cardinal Innovations and we work with providers to make outpatient assessment and therapy readily accessible. For fiscal year 2016, almost 40,000 members covered by Medicaid received outpatient therapy. We issued 45 denials for outpatient therapy (0.1 percent). These denials typically were where the number of visits requested greatly exceeded 24 per year and the clinical presentation indicated that continuing with the same therapy was not going to provide the desired clinical outcome and alternate therapy was preferable. Cardinal Innovations allows 24 visits each fiscal year before an authorization is required. 92 percent of members receiving outpatient therapy do not exceed the 24 visits and no authorization request needed to be submitted. The similar state requirement is 16 visits for children. Cardinal Innovations allows 24 visits without authorization required to promote the easy access and provision of appropriate outpatient services. Two years ago, there were a handful of outpatient therapy providers in Mecklenburg which showed outlier utilization patterns. A systematic retrospective review of actual clinical records conducted by licensed therapists using consistently applied review criteria showed that in some cases the utilization pattern was justified, and the clinical record documented that clinically appropriate, evidence-based services were being provided. In other cases, there was no, or scant, support for the number or nature of services provided. Some of these latter providers were placed on a performance plan and improved, others are no longer participating in the Medicaid program. Cardinal’s denial rate for intensive in-home services is too low. 8 Intensive In-Home is a service that can be effective if utilized correctly, ineffectual if not. Cardinal Innovations has worked with providers and its utilization management program to promote the use of clinical best practice and more appropriate use within the delivery of IIH services. Through these efforts, the use of IIH in Mecklenburg today is 38 percent of what it was when Cardinal Innovations began managing services in Mecklenburg in Spring 2014. The clinical appropriateness of use of IIH in Mecklenburg is much greater now than previously. Even at this more clinically appropriate level of utilization, currently one out of every 11 Mecklenburg IIH requests is denied and, upon clinical review by a PhD psychologist or child psychiatrist, other more clinically appropriate services for the specific clinical situation are recommended instead. Cardinal Innovations recognized the limitations of IIH and innovated to obtain NC Medicaid exception approval for two new alternative services to increase the milieu of services available and allow more effective treatment for children. Family Centered Treatment, a nationally recognized, evidenced based treatment was implemented in Mecklenburg in late 2015 under a value based contract. Early results have been promising. FCT has been especially helpful in certain complex cases and in other cases that otherwise would have resulted in long term treatment in a residential program away from the child’s home. 53 In mid-2015, Cardinal Innovations also rolled out In Home Therapy Service with a greater emphasis on outpatient therapy performed by a licensed professional in the youth’s home. This service has a greater therapy intensity than IIH and is informed by the dynamics of the child’s actual home environment. These two new services, together with outpatient therapy, IIH, Multisystemic Therapy, and Respite provide a richer milieu of community based services which can be better tailored to each child’s clinical situation. Our goal is to promote access to the most clinically effective service with data that supports the best outcomes, much like what is done for heart disease or cancer. As such, these alternative services provide children and their families with the greatest opportunity for success. In fact MST was specifically designed for youth who are engaged with the court system who have complex family issues, educational difficulties and require coordination across all systems. There are specific rules that direct the treatment and providers must be certified and adhere to standards. We will often deny IIH and recommend MST for youth who meet the criteria as it is the most appropriate treatment. Cardinal Innovations plans to launch value based contracting for IIH in Summer 2017. 9 Cardinal is too quick to label a patient as noncompliant and cut off services. Cardinal Innovations seeks to give every child every chance to be successful in treatment and have the greatest opportunity for recovery, resilience, symptom abatement, wellness, family pres- ervation, and success at school or work. Behavioral health rehabilitative services are provided with a child, not to a child. Rehabili- tative services require the ability of a youth to participate in therapy. In rare cases, the record of a youth’s repeated failure to engage or participate in therapy demonstrates convincingly that the youth will not be able to participate in the treatment requested. If one persists in the face of non-participation, the treatment will not prove effective, the child is at risk for further treatment failure and trauma, other alternative treatments that may prove more likely to be helpful are forgone and valuable time is squandered. And, in the case of congregate settings like residential or PRTF, other youth are at high risk for treatment disruption, treatment failure, or injury. Such cases require a complex set of professional and clinical considerations. Recommenda- tion for alternate therapy due to the demonstrated inability of a youth to participate successfully in the requested treatment is entered into soberly and with exhaustive consideration by a board-certified child psychiatrist and the treatment review team. Determinations about reduc- tions or denials of services for all members can only be made, per Medicaid rules, by a doctorate level clinician. In Cardinal Innovations’ case, we have 3 BC/BE Child and Adolescent Psychi- atrists on staff (including our CMO) as well as 3 PhD Psychologists with expertise treating the under 21 population. In addition, we have methods of identifying and escalating complex cases to each of these doctors and cases are reviewed daily on a scheduled basis. Our team looks at all elements which impact the child and their family and as such consider the social, emotional, psychiatric, developmental and educational needs consistent with standards of practice when making decisions. When necessary our team pulls together all key stakeholders to address treatment needs. 10 The compensation paid to Cardinal’s top-level management is far too high.* Cardinal Innovations pays market compensation for all of our staff based on the healthcare industry and paid out of the administrative fee we charge the state. The federal rule allows us to charge up to 15 percent for our administrative fee. We charge only 8.05 percent and for the past two years, have continued to provide a full array of services while state-funded mental health budgets were cut. Importantly, market compensation of our staff in no way restricts or limits the amount of services we are able to provide to our members. Our pay for performance model ensures our employees are compensated based on how well they serve our members.

* http://tinyurl.com/ydxtnjor http://tinyurl.com/y75btnza http://tinyurl.com/yd7obla9 http://tinyurl.com/y7ch2uq9 http://tinyurl.com/h8lpxsc http://tinyurl.com/yb7osugb