2019 Community Mental Health, Substance Use and Developmental Disabilities Services Network Adequacy and Accessibility Analysis

July 1, 2019

Partners Behavioral Health Management 901 S. New Hope Road Gastonia, NC 28054 Partners 2019 Network Adequacy and Accessibility Analysis Table of Contents i Table of Contents Section One: Network Availability & Accessibility ...... 1 Section 1.1 Access & Choice Standard Tables ...... 1 1.1.1 Outpatient Services ...... 1 1.1.2 Location-Based Services ...... 2 1.1.3 Community/Mobile Services ...... 3 1.1.4 Crisis Services ...... 4 1.1.5 Inpatient Services ...... 4 1.1.6 Specialized Services ...... 5 1.1.7 C-Waiver Services ...... 6 Section 1.2 Geo Maps ...... 7 Section 1.3 Access to Care ...... 7 Section Two: Accommodation ...... 10 Section 2.1 Catchment area demographics & special populations ...... 10 Section 2.2 Obstacles and barriers to serving specific populations ...... 17 Section 2.3 Social Determinants of Health ...... 18 Section 3: Acceptability ...... 21 Section 3.1 Methods to get input from consumers and family members ...... 21 Section 3.3 Methods to get input from other stakeholders ...... 26 Section 3.4 Service Gaps and Barriers to Service – Other Stakeholders...... 27 Section 3.5 Using Survey Data ...... 29 Section Four: Special Populations ...... 30 Section 4.1 Transitions to Community Living Initiative (TCLI) ...... 30 Section 4.2 Children with Complex Needs ...... 34 Section 5: Network Access Plan ...... 35 Appendix A: Geo Maps ...... 36 Location Based Services ...... 36 Community Mobile Services ...... 43 Crisis Services ...... 55 Specialized Services ...... 60 C-Waiver Services ...... 76 Additional Opioid Services ...... 79 Appendix B: Registry of Unmet Needs ...... 83

Partners 2019 Network Adequacy and Accessibility Analysis Table of Contents ii Appendix C: Provider Ratios...... 86 Appendix D1: Demographic & Special Population Data ...... 88 Appendix D2: Social Determinants of Health Data ...... 101 Appendix E1: Community Assessment Survey Response Index ...... 106 Appendix E2: Community Assessment Blank Surveys ...... 165 Appendix F: Network Access Plan ...... 192 Section 5.1 Executive Summary ...... 192 Section 5.2 Access Plan ...... 196 Section 5.3 In Lieu of and Alternative Services ...... 196 Appendix G: Impact of NC 1115 Medicaid Waiver ...... 204 Appendix H: Network Development Plan ...... 205 Appendix I: Request for Exception ...... 213

Partners 2019 Network Adequacy and Accessibility Analysis Section One: Network Availability & Accessibility 1 Section One: Network Availability & Accessibility ∗ The total number of unique individuals receiving at least one state funded/non-Medicaid funded service is different than the numbers reported in the tables. Not all the individuals who received a service had addresses within the catchment area. Total number receiving services was 11,257. ∗ The number of Medicaid enrollees was 188,185. However, not all had addresses within the Catchment Area. Therefore, the numbers reflected in the tables are different than 188,185.

Section 1.1 Access & Choice Standard Tables 1.1.1 Outpatient Services Medicaid Non-Medicaid Funded Categories # of providers # of enrollees # of Medicaid % (# of # of providers # of consumers # of % (# of accepting new with choice of enrollees enrollees with accepting new with choice of consumers consumers Medicaid two providers choice/# of non-Medicaid two providers with choice/# consumers within 30/45 enrollees) funded within 30/45 of consumers) miles/ minutes consumers miles/minutes Reside in urban counties 343 132,763 132,763 27 8,546 8,546 Reside in rural counties 343 39,890 39,890 27 2,002 2,002 Total (standard = 100%) 343 172,653 172,653 100% 27 10,548 10,548 100% Adults (age 18+) 197 87,132 87,132 18 10,346 10,346 Children (age 17 and younger) 184 85,521 85,521 8 204 204 Total (standard = 100%) 343 172,653 172,653 100% 27 10,550 10,550 100% *The number of providers accepting new consumers for adult and children outpatient services was calculated using encounter data. This means the number may be underreported due to some of the contracted outpatient providers not serving the specific age group during FY18 or becoming a contracted agency after the fiscal year, but before 1/1/19. ** The number of providers may not equal the Total when simply added together because some providers serve both adults and children. These providers were counted in both the adult and children lines but not double counted in the total. The total is the unique, unduplicated count.

Partners 2019 Network Adequacy and Accessibility Analysis Section One: Network Availability & Accessibility 2 1.1.2 Location-Based Services Medicaid Non-Medicaid Funded # of providers # and % of enrollees with Total # of # of providers # and % of consumers with at Total # of accepting new choice of two providers within Medicaid accepting new least one provider within 30/45 consumers Medicaid 30/45 miles/minutes of their enrollees non-Medicaid miles/minutes of their consumers residences funded residences Location-based Services # % consumers # % Psychosocial Rehabilitation 23 87,132 100% 87,132 8 6,627 100% 6,627 Child and Adolescent Day 28 85,521 100% 85,521 5 167 100% 167 Treatment SA Comprehensive Outpatient Treatment 16 171,405 99% 172,653 6 3,947 90% 4,397 Program SA Intensive Outpatient 31 172,653 100% 172,653 10 4,397 100% 4,397 Program Opioid Treatment 39 87,132 100% 87,132 13 4,388 100% 4,388 Day Supports 16 542 100% 542 *Opioid providers were determined by the appendix provided procedure code H0020, as well as contract language which included provision of opioid services along with claims data for the Cures funded project, a substance use grant funded project.

The SACOT request for exception can be found in Appendix I.

Partners 2019 Network Adequacy and Accessibility Analysis Section One: Network Availability & Accessibility 3 1.1.3 Community/Mobile Services Medicaid Non-Medicaid-Funded # of providers # and % of enrollees with Total # of # of providers # and % of consumers with Total # of accepting new choice of two provider Medicaid accepting new access to at least one Consumers Community/Mobile Service Medicaid agencies within the LME- enrollees non-Medicaid provider agency within the consumers MCO catchment area consumers LME-MCO catchment area # % # % Assertive Community Treatment Team 14 87,132 100% 87,132 8 6,627 100% 6,627 Community Support Team 18 87,132 100% 87,132 3 9,858 100% 9,858 Intensive In-Home 31 85,521 100% 85,521 6 172 100% 172 Mobile Crisis 9 172,653 100% 172,653 3 10,550 100% 10,550 Multi-systemic Therapy 4 85,521 100% 85,521 1 172 100% 172 (b)(3) MH Supported Employment Services 12 172,653 100% 172,653 (b)(3) I/DD Supported Employment Services 33 172,653 100% 172,653 (b)(3) Waiver Community Guide 16 172,653 100% 172,653 (b)(3) Waiver Individual Support (Personal 29 172,653 100% 172,653 Care) (b)(3) Waiver Peer Support 36 172,653 100% 172,653 (b)(3) Waiver Respite 34 172,653 100% 172,653 I/DD Supported Employment Services (non- 16 542 100% 542 Medicaid-funded) Long-term Vocational Supports (non- 8 507 100% 507 Medicaid-funded) MH/SA Supported Employment Services (IPS- 15 9,858 100% 9,858 SE) (non-Medicaid-funded) I/DD Non-Medicaid-funded Personal Care 17 542 100% 542 Services I/DD Non-Medicaid-funded Respite 6 542 100% 542 Community Services I/DD Non-Medicaid-funded Respite Hourly 11 542 100% 542 Services not in a licensed facility Developmental Therapies (Non-Medicaid) 10 542 100% 542 *Access & Choice standards are two agencies within the LME/MCO catchment area. Access & Choice standards are calculated based on the two agencies within the LME/MCO catchment area. Counts are all parent agencies regardless of physical location (inside and outside of the catchment area).

Partners 2019 Network Adequacy and Accessibility Analysis Section One: Network Availability & Accessibility 4 1.1.4 Crisis Services Medicaid Non-Medicaid Funded # of providers # and % of enrollees with access Total # of # of # and % of consumers with Total # of accepting new within the LME-MCO catchment Medicaid providers access within the LME-MCO Consumers Medicaid area to at least one provider Enrollees accepting catchment area to at least one consumers agency new Non- provider agency Medicaid Crisis Service # % consumers # % Facility-Based Crisis - adults 6 87,132 100% 87,132 3 10,346 100% 10,346 Noted in Appendix C of the State Requirement document – Facility-Based Respite 4 10,550 100% 10,550 Change in 2019, not a Medicaid service Detoxification (non-hospital) 2 172,653 100% 172,653 2 4,397 100% 4,397 FOR INFORMATION PURPOSES ONLY: Facility- 2 0* 0% 85,521 0 0 0% 204 Based Crisis – children** *Partners is contracted with two providers (one in Mecklenburg & one in Beaufort) **Rapid response is used for children

1.1.5 Inpatient Services Medicaid Non-Medicaid-Funded # of providers # and % of enrollees with access Total # of # of # and % of consumers with Total # of accepting within the LME-MCO catchment Medicaid providers access within the LME-MCO Consumers new Medicaid area to at least one provider Enrollees accepting catchment area to at least one consumers agency new Non- provider agency Medicaid # % # % Service consumers Inpatient Hospital – Adult 8 87,132 100% 87,132 3 9,858 100% 9,858 Inpatient Hospital – 9 85,521 100% 85,521 6 172 100% 172 Adolescent/Child

Partners 2019 Network Adequacy and Accessibility Analysis Section One: Network Availability & Accessibility 5 1.1.6 Specialized Services Number Parent Agencies with Number Parent Agencies with Current Service Current Medicaid Contract Contract for Non-Medicaid Funded Services Partial Hospitalization 9 2 MH Group Homes 36 Psychiatric Residential Treatment Facility* 16 N/A Residential Treatment Level 1` 11 N/A Residential Treatment Level 2: Therapeutic Foster Care 30 2 Residential Treatment Level 2: other than Therapeutic Foster Care 8 1 Residential Treatment Level 3` 24 N/A Residential Treatment Level 4^` N/A N/A Child MH Out-of-home respite `* N/A N/A SA Non-Medical Community Residential Treatment 2 1 SA Medically Monitored Community Residential Treatment 1 1 SA Halfway Houses * N/A I/DD Out-of-home respite (non-Medicaid-funded) 11 I/DD Facility-based respite (non-Medicaid-funded) 6 I/DD Supported Living (non-Medicaid-funded) * N/A (b)(3) I/DD Out-of-home respite 12 (b)(3) I/DD Facility-based respite 2 (b)(3) I/DD Residential supports 7 Intermediate Care Facility/IDD 45 N/A * = Not covered by Partners IPRS plan. ` = No procedure code given in Appendix C of the State Requirement document ^ = Residential Treatment Level 4: Residential Level III and PRTF are utilized in place of Residential Level IV

Partners 2019 Network Adequacy and Accessibility Analysis Section One: Network Availability & Accessibility 6 1.1.7 C-Waiver Services C-Waiver Services-Choice of two providers # and % of enrollees with choice of two provider Services Adult Child agencies within the LME/MCO catchment area Total # of C-Waiver Enrollees # % Community Living and Supports   1440 100% 1440 Community Navigator   1440 100% 1440 Community Navigator Training for Employer of Record   1440 100% 1440 Community Networking   1440 100% 1440 Crisis Behavioral Consultation   1440 100% 1440 In Home Intensive   1440 100% 1440 In Home Skill Building   1440 100% 1440 Personal Care   1440 100% 1440 Crisis Consultation   1440 100% 1440 Crisis Intervention & Stabilization Supports   1440 100% 1440 Residential Supports 1   1440 100% 1440 Residential Supports 2   1440 100% 1440 Residential Supports 3   1440 100% 1440 Residential Supports 4   1440 100% 1440 Respite Care - Community   1440 100% 1440 Respite Care Nursing – LPN & RN   1440 100% 1440 Supported Employment 16 & older 1319 100% 1319 Supported Employment – Long Term Follow-up 16 & older 1319 100% 1319 Supported Living 18 & older 1230 100% 1230 C-Waiver Services – Access to at least one provider Day Supports   1440 100% 1440 Out of Home Crisis   1440 100% 1440 Respite Care - Community Facility   1440 100% 1440 Financial Supports   1440 100% 1440 Specialized Consultative Services (at least one provider   1440 100% 1440 of one of multiple services)

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 7 Section 1.2 Geo Maps Please see Appendix A for the Geo Maps.

Section 1.3 Access to Care Current DMA and DMH/DD/SAS contracts include requirements related to consumer access to care for emergent, urgent and routine services. Describe how your LME/MCO assures adequate provider capacity and service access for new persons who go directly to provider agencies. What mechanisms do you have in place to monitor providers adhering to access to care standards?

The Partners service system assures provider capacity and service access by operating as if there is no wrong door, and the MCO is committed to timely, consumer focused service. Screening and triage protocols are standardized across the State as directed by The North Carolina Department of Mental Health, Intellectual & Developmental Disability and Substance Abuse Services. The Partners Member Services process initiates with the collection of basic information such as residence and Medicaid enrollment status within the eight-county catchment area. Partners staff assess probable MH, IDD, or SU treatment needs, triage level, and offer to schedule first appointment with choices given. Consumers with private health insurance or Medicare are instructed to locate and call the manager of their behavioral health benefit or general insurance company to gather information about their specific policy and recommended providers through that plan. Employed individuals are educated about potential opportunities through Employee Assistance Programs (EAP), when appropriate. Consumers with Medicaid and those appearing to meet criteria for State Funded target populations are linked through Screening Triage & Referral (STR) to providers for an initial assessment/evaluation and treatment. Consumers who do not appear to qualify for any benefits under State Funds are linked to community resources.

Standardized screening, triage and referral protocols focus on timely access to the most needed level of care. Triage is a brief process aimed at determining the intensity of the consumer’s need and results in prioritizing their level of care into the following categories: a. Emergent (2 hours & 15 minute maximum for service initiation) • Consumer has a moderate or severe risk related to safety or supervision, or • Consumer is at moderate or severe risk for substance abuse withdrawal symptoms, or • Consumer presents a mild, moderate, or severe risk of harm to self or others, or • Consumer has severe incapacitation in one or more area(s) of physical, cognitive, or behavioral functioning related to MH/DD/SU problems.

Emergent Care Consumers will be seen face-to-face within 2 hours and 15 minutes or directly linked to 911 depending on severity due to medical needs. This level of care applies to consumers whom are experiencing psychiatric instability such as intense and disturbing delusions, command hallucinations, or a gross inability to care for self. This level of acuity also includes consumers who are intoxicated or experiencing withdrawal and unable to access services without immediate assistance. Mobile Crisis is always available to a first responder for consultation and/or assistance when appropriate. For persons being evaluated for involuntary commitment, local law enforcement is encouraged to ensure the transportation of individuals requiring first level commitment evaluations to screening facilities such as Facility Based Crisis prior to referring to a local hospital emergency department.

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 8 b. Urgent (48 hours maximum for service initiation) Consumers presenting with moderate risk or incapacitation in one or more area(s) of physical, cognitive, or behavioral functioning related to MH/IDD/SA problems. Urgent Care is provided within 48 hours of initial contact if the consumer is experiencing a more slowly evolving crisis and a catastrophic outcome is not imminent. The consumer may be experiencing or expressing hopelessness, helplessness, or other intense feelings or life stressors. Providing rapid access to care is likely to avert the development of a behavioral health emergency. This includes consumers who are intoxicated or in withdrawal seeking treatment whose motivation for treatment might be enhanced by rapid entry to services.

c. Routine (14 calendar days maximum for service initiation) Consumers presenting with mild risk or incapacitation in one or more area(s) of safety, or physical, cognitive, or behavioral functioning related to MH/IDD/SA problems. Routine Care will be provided to consumers within 14 calendar days of initial contact. This includes all other consumers that have a request for help with no evident acute need or imminent crisis. Consumers will be scheduled for their first appointment with a clinical home provider of their choice through the ALPHA MCS ACCESS TO CARE slot scheduler. Any provider in the Partners Provider Network that offers Psychiatry in their array of services may offer appointments through the ALPHA MCS ACCESS TO CARE Slot Scheduler. This allows Access to Care staff to search for appointments based on consumer preference and choice. Searches can be conducted by provider agency name, location, age and disability served and appointment days and time. Consumers determined to fit the Routine need level of care are provided with information of available provider appointments to make an informed choice in selecting the provider for their Clinical Home.

In FY 18 Q4, the percentage of emergent calls that received timely services was 100%; above the standard of 97%. The percentage of urgent service requests that received timely follow-up was below the standard of 82% in FY 18 Q4. The percentage of routine service requests that received timely follow-up was below the standard of 75% in FY 18 Q4. Partners has found scheduling appointments is not an issue. However, our root cause analysis indicates appointment no shows are a large portion of the problem in meeting the timely follow-up standard. Partners continues to identify additional barriers to attending appointments. Some of these identified barriers are unreliable transportation, childcare issues, employment restraints and consumers choosing to wait on seeking services. Partners will continue to work on developing a plan to reduce these barriers and improve the percentage of consumers who receive timely follow-up.

The provider portal and management of the slot scheduler described below provides additional information regarding how Partners monitors and assures adequate provider capacity and service access for new members engaging in services.

Provider Portal & Management of the Slot Scheduler 1. Providers using the slot scheduler will enter appointments on a consistent basis to include the following information: a) Funding source State Funds/Medicaid/Medicare b) Child/Adolescent/Adult c) Disability MH/IDD/SU d) Other – any other pertinent restrictions 2. Providers will maintain their schedules so there are always appointments available 14 days out. 3. Providers will acknowledge (accept the referral) all referrals made to them via the slot scheduler by checking the acknowledgement checkbox in the referral. If a Provider is unable to acknowledge

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 9 (accept) the referral they will email Access to Care at [email protected] and inform Access to Care the consumer will need to be scheduled with another provider and why. 4. Providers who acknowledge and accept a referral will also be expected to resolve referral slots by entering the “status” of the referral to include (show, no show, cancelled, re-scheduled etc.) 5. Access to Care will notify providers who offer referral slots of all unacknowledged and/or unresolved slots via email daily. Providers will be expected to acknowledge and resolve all unmanaged slots.

IDD State Funded Waitlist Referral Process Partners also assures adequate provider capacity and service access for new members engaging in services by requiring providers to contact Partners for referral(s) when the provider has available funds to serve a new individual. This process is being implemented to ensure a process of moving individuals from the Registry of Unmet Needs for state funded service into the needed service when it becomes available. Please see the full policy Registry of Unmet Needs for the details of this process in Appendix B.

Integrated Behavioral and Physical Health Partners has additionally partnered with several behavioral health providers to create integrated care sites within the community that offer physical medicine and behavioral health under the same roof. This provides a known, safe place, for consumers to present for the medical needs and their behavioral health needs, which can include crisis services. Providers have agreed to adopt an advanced access model and in two of our more rural sites (Cleveland and Lincoln) telemedicine is employed as a back up to in person Comprehensive Clinical Assessments (CCAs). The responsibility of triaging and assessing an individual presenting for services for the first time is shared by the providers at those centers and the time from arriving at the center to triage is tracked at each center.

Partners has continued to support the co-location and collaborative efforts of providers in 5 community- based sites in our catchment area. The co-location of behavioral health providers servicing children and adults has allowed for smoother transition to the appropriate level of care for individuals presenting in the community directly. Additionally, the use of Peer Support Specialists has promoted linkage between referral sources and efforts to engage individuals presenting for treatment for the first time. Development of the Whole Person Integrated Care model is facilitating the process of individuals being introduced to behavioral health clinicians through an initial contact with primary care physicians. In the 2017-2018 fiscal year, three of five sites offered physical health services on site with our behavioral health providers. In our 4th site (Cleveland County), protocols were developed to increase connectivity with the free medical clinic and the local health department. Partnership with the health department and federally qualified health center (FQHC) also evolved in our 5th county (Lincoln), however both facilities moved into new sites during this time.

5,373 individuals engaged in a Comprehensive Clinical Assessment in the 2017-2018 fiscal year. Over 650 individuals made one of these sites their medical home. Individuals are triaged and assessed by trained qualified professionals as noted above. These centers follow the same expectations as stated above for treatment of presenting needs for individuals emergent, urgent and routine. The triage status of individuals who present to one of these centers in a given month are reported to the LME/ MCO. The time of presentation to the time of triage is also tracked at the centers by a method of providers’ choosing. This is available for spot checking by request. Provider adherence is also monitored through the grievance process to address any trends around wait times or access to care.

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 10 Partners was also awarded a multi-year grant from SAMHSA seeking to expand the System of Care in four counties. This grant allows the opportunity for individuals to link to services through presentation at their primary care facility. A team employing High Fidelity Wrap Around supports is embedded in an initial practice during the 17/18 fiscal year. They are staffed to assist with triage, linkage and referral.

Section Two: Accommodation LME/MCOs must ensure the availability and delivery of services in a culturally competent manner to all beneficiaries, including those with limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and regardless of gender, sexual orientation or gender identity.

Section 2.1 Catchment area demographics & special populations Describe the population make‐up of the LME/MCO’s catchment area, including the size and geographic locations/distribution of specific cultural and special populations. Please include sources for demographic information provided. Address the supports available for each of the populations below and include additional populations that are present in your area. If you are not serving these populations what are the potential barriers and what efforts are you taking to reach out to them.

A comprehensive analysis, additional numbers, and population level data sources can be found in Appendix D1. The following is a summary of the Partners catchment area demographics and special populations. The numbers reported for those served are for all funding sources combined unless otherwise specified.

General Overview The Partners catchment area is in the western third of the state of North Carolina. The catchment area consists of eight counties: Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Surry, and Yadkin. These counties cover 3,465 square miles, running approximately 125 miles from the southwest corner to the northeast corner and is approximately 90 miles wide. Based on the definitions established by the North Carolina DHHS, Partners catchment area consists of six urban counties (Burke, Catawba, Gaston, Iredell, Lincoln and Yadkin) and two rural counties (Cleveland and Surry). The total population for the Partners service region is approximately 932,895 people. Gaston has the largest population out of the eight counties at 220,182 people and Yadkin County has the smallest population at 37,774.

Age: Partners catchment area is slightly older than the state of North Carolina and the United States. The population served within the Partners catchment area was slightly younger than the ages represented within the catchment area. Of those served, 18.8% (n = 7,7441) were ages 3 through 12, 13.7% (n = 5,6201) were ages 13 through 17, and 4.8% (n = 1,9861) were ages 18 through 20. Along with this, 24.2% (n = 9,9571) of those served within the catchment area were ages 21 through 34, 37.4% (n = 15,3611) were ages 35 through 64, and 4.0% (n = 1,8911) were ages 65 and older.

Gender: The Partners catchment area population has slightly more females (51.2%) than males (48.8%); this is similar to the state of North Carolina and the U.S. The population served within the Partners catchment area contained slightly more females (53.9%, n = 22,1601) and less males (46.1%, n = 18,9711) than what are represented within the catchment area.

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 11 Ethnic Groups Race and Hispanic Origin: Partners catchment area overall is less diverse in terms of race and Hispanic Origin than the state or the nation. Nevertheless, there are significant differences across the catchment area.

For the catchment area population, 7.3% are of Hispanic Origin. Proportional to the county population, Yadkin and Surry have the largest concentration of those with Hispanic origin at 10.9% and 10.2% respectively. In FY18, Partners served 8261 individuals whom reported having Hispanic origin. Of those with data, which is approximately 3.0% of those served in FY18.

The table below looks at the racial self-identification of those living in the catchment area as well as those served by Partners. Information was not available for all of those served by Partners.

% of Population % Served # Served White 81.4% 80.4% 33,049 Black or African American 11.0% 15.4% 6,337 American Indian & Alaska Native 0.3% 0.3% 104 Native Hawaiian & Other Pacific Islander <0.1% 0.1% 24 Asian 2.0% 0.4% 159 Other 3.2% 1.2% 477 Multiracial (Two or more races) 2.0% 0.8%% 333

Languages Spoken: Overall, the catchment area population is less diverse in languages spoken compared to state and national rates, with the most predominant language spoken at home being English (91.4%). Within the catchment area, Spanish is the second highest reported language spoken at home at 6.1%. This is low, however, compared to state and national rates. Catawba County has the highest rates of household Spanish speakers at 8.3%, while Cleveland County has the lowest rates at 2.7%.

Information on language spoken was not available for all the individuals served by Partners in FY18. Of those served with known/reported language, 98.3% (n = 33,8771) speak English, 1.4% (n = 4911) speak Spanish, with less than 0.1% speaking French, German, or another language. Additionally, 0.1% (n = 301) use sign language.

Partners has developed an internal task group for analyzing the language and interpretive service needs for the catchment area. The task force is identifying interpretive resources and marketing solutions for bilingual members as well maintaining recruitment for bilingual providers on the Continuously Recruited List. Options for the deaf and hard of hearing are also being analyzed as this is a costly service and funding is limited.

Disabilities People with physical disabilities: Partners catchment area has a higher proportion of residents living with physical disabilities compared the proportion living in North Carolina and the United States. Burke County has the highest proportion of residents with an ambulatory (11.6%) and independent living (7.2%) difficulty, while Cleveland has the highest proportion of residents with a self-care difficulty (6.4%).

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 12 Based on claims data diagnoses*, 152 individuals served by Partners in FY18 are living with an ambulatory difficultly and 4032 are living with an independent living difficulty. *Claims data may underreport the true number served.

People with visual impairment: Partners catchment area has a higher proportion of residents living with visual impairments (0.4%) compared the proportion living in North Carolina (0.04%) and the United States (0.01%). Yadkin County has the highest proportion of residents (0.7%) with a visual impairment. Based on claims data diagnoses*, Partners served 132 individuals living with a visual impairment. *Claims data may underreport the true number served.

People who are deaf or hard of hearing: Partners catchment area has a higher proportion of residents living with hearing difficulty (4.7%) compared the proportion living in North Carolina (3.7%) and the United States (3.6%). Burke County has the highest proportion of residents (6.7%) living with a hearing difficulty. Eight individuals who are deaf or are hard of hearing scheduled services through Partners Access to Care department. Also, there were 162 individuals served by Partners in FY18 with a hearing impairment as identified by claims diagnostic data*. *Claims data may underreport the true number served.

Barriers to serving those who are hard of hearing has to do with funding. The allocated funding for assistance to provide interpretation or other services is small, which in turn, passes the high cost onto the provider.

Through the community analysis efforts of the Whole Person Integrated Care Team, Partners has incorporated physical health and wellness into a basic philosophy of care for all members and is not only supporting providers at the 5 integrated care centers, but also began a survey campaign to educate providers on the benefits of integrated care and establish interest among physical health providers and behavioral health providers moving toward integrated care. The Whole Person Integrated Care Team plays in integral role with a partnership with NC Med Assist, a nonprofit pharmacy program providing access to lifesaving prescription medications, patient support, advocacy and related services to poor, vulnerable, and uninsured North Carolina residents. Last year, NC MedAssist dispensed over $63 million in medicines for our community members. Currently, 21% of the prescription medications are secured from the Patient Assistance Programs (PAP) available through participating pharmaceutical companies and 79% are purchased generics.

As a result of NC MedAssist’s positive impact on the community, it has been named as one of the top 25 non-profit organizations in Charlotte by the Charlotte Business Journal. In March 2009, Attorney General Roy Cooper and the North Carolina Association of Free Clinics named MedAssist of Mecklenburg the Statewide Pharmacy for all eligible uninsured residents in North Carolina. Partnerships such as this, form a basis for growing integrated care relationships among providers in the community.

Veterans, military members and their families Overall, the proportion of veterans living in Partners catchment area is slightly lower (8.2%) than the North Carolina average (8.7%), but higher the United States average (7.7%). The number of veterans and their family members served by Partners through the State Funded service system in FY18 was 8143. This is approximately 7.0% of those served through the State Funded system and 2.0% of all of those served by Partners in FY18. Of the veterans served, 75.6% (n = 6153) received mental health services, 23.6% (n = 1923) received substance use disorder services, and 0.9% (n = 73) received

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 13 intellectual/developmental disability services. Additionally, 1145 veterans scheduled an appointment through Partners Access to Care department for services during FY18.

Partners participates annually in the Veteran Stand Down, a resource fair for Veterans and their families. The 2019 Veteran Stand Down was the 8th annual event. Partners had 59 agencies at the Stand Down. Lenoir Rhyne nursing students were also onsite assisting with blood pressure and glucose readings. The Partners ACCESS staff was there to assist with counseling and setting up appointments, as well as a Partners sponsored booth. We had approximately 140 volunteers assisting with the event as well as JROTC students from Hickory High and St. Stephens. Three hundred and thirty-seven registered for the event, 220 individuals went through the clothing lines, and 100 individuals were seen in the dental lab. Veterans are also given priority to receive access to the Mental Health Assistance Program (MhAP).

Pregnant women with substance use disorders According to the National Institute on Drug Abuse (NIDA), estimates suggest approximately 5% of pregnant women use one or more addictive substances. The specific numbers for pregnant women with substance use disorders are hard to come by. It has been noted, “the number of women with opioid use disorder at labor and delivery quadrupled from 1999 to 2014”. Additionally, the NIDA reports “the number of women who use marijuana while pregnant is unknown, but one study reported about 20% of pregnant women 24-years-old or younger screen positive for marijuana”. The study also found “women were about twice as likely to screen positive for marijuana via a drug test than in self-reported measures”. Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. Partners claims data indicates there were 302 pregnant women served during FY18. Of these, 112 also had a substance use diagnosis*. Partners does have SAPTBG funds that support pregnant women with SUD issues – one program is providing transportation to the women who attend Phoenix’s treatment programs – however, they are not all pregnant women. *Data on pregnant women with substance use disorders served by Partners is limited. Claims data was utilized and may underreport the true number served.

People who are Lesbian Gay Bisexual Transgender Queer Based on information from the Williams Institute, the population proportion of those who identify as LGBT in North Carolina is 4%4. Four percent of the estimated population of North Carolina (10,273,419) is approximately 410,000 LGBT residents. Of these, 26%4, approximately 106,000, couples are currently raising children. LGBT individuals also make up many ethnicities with 58%4 being white, 29%4 being African American, and 11%4 being Latino/a. Identification of those who are LGBTQ served by Partners is difficult at this time. Partners Whole Person Integrated Care Team Leads are beginning to develop resources available in the community for the LGBTQ population. This is in infancy stages at this time, as this is not a demographic screened for during service enrollment.

People who are in jails or prisons Within the Partners catchment area, there were 2,984 prison admissions in 2018. Prison entries vary significantly within the catchment area. The county with the highest number of prison admissions is Gaston County with 797, while the county with the lowest number of prison admissions is Yadkin County with 118. Overall, the crime rate in the Partners catchment area is 14%, falling below the North Carolina crime rate. Crime rates vary significantly within the catchment area.

Partners served 100 individuals in FY18 in the jails or in prisons. Daymark Recovery Services provides services to incarcerated individuals in Yadkin and Iredell counties. Through funding support from Partners, Daymark Recovery Services provides pre-release planning for inmates preparing to return to the community. The jail liaison works with assigned persons in planning for community re-entry. Individuals

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 14 can receive referrals to treatment providers, housing specialists, and other services for which they may be required or entitled to receive upon their release. Catawba Valley Behavioral Health (CVBH) provides service in the Burke, Catawba and Lincoln jails. The services include Mental Health/Substance Use Disorder (MH/SUD) assessments, Substance Use Disorder (SUD) treatment, and peer support services in the local jail. ACPP provides services for consumers incarcerated in Gaston and Cleveland.

Partners was awarded an Early Diversion SAMHSA Grant on 9/29/2018. The grant, known in the community as the Mental Health Assistance Program (MhAP), is to serve those individuals who have serious mental illness and/or co-occurring substance use disorder and have come to the attention of Law Enforcement Agencies (LEAs) but do not necessarily need to be taken to jail or to an Emergency Department. The grant allows for the LEAs to take individuals with the above noted conditions to the Daymark Facility Based Crisis center (FBC) in Iredell County. When taken or referred to the FBC, those individuals who meet criteria for admission (i.e. are not in need of immediate medical care, are non- violent and have a BAL under the allowable level) are assessed by the Peer Engagement Services staff at the FBC. Their information is gathered, and recommendations are made regarding ongoing needs and engagement with other service/treatment providers in the community. Additionally, the Peer Support staff at the MhAP will refer all indicated individuals for ongoing case management services to community- based PQA Peer Support Specialists; they will provide a “warm hand-off” for ongoing follow up. PQA staff will assist with helping link referred individuals to indicated community-based services. These PSS will continue to work with those referred for a period up to 12 months.

The goal of this grant is to reduce contact with law enforcement agencies by 70% within the first 12 months and 85% will increase positive Social Determinants of Health using peer support specialists ongoing involvement and continued support. Lowering the recidivism at the contact level, not just the arrest level will be a key outcome. The primary Evidenced Based Practice will be the Crisis Intervention Team Training Memphis model of LEA staff, first responders. This program is available to Iredell County residents 18 years and older. Veterans are also given priority to receive access to the MhAP.

LEAD Program – The Law Enforcement Assistance Program is part of the continuum of services available to those who have contact with LEAs. Persons with low level drug and/or sex work charges can be offered the option of working with the LEAD staff, composed of a LEAD Coordinator and Peer Support Specialist, to receive treatment and supportive services in the Iredell community. This option is available as an option to jail confinement. Referrals are made by police officers, reviewed by the State’s Attorney for legal appropriateness. Social referrals from other sources can be made directly to the local police department for review and possible inclusion in the LEAD program.

In Iredell County, this resource is funded through the NC Harm Reduction program. The program was implemented in May 2018, so numbers presented reflect the period from 5/2018 – 1/2019. The total number of referrals is 23. Of the 23 referrals, 6 were charge diversions and 17 were social referrals. After the initial referral, 6 were referred out to services in their home county and therefore, are not followed by the case manager of LEAD Catawba due to residency requirements. Eleven of the remaining 17 clients are actively participating in the program and doing well. Six of the 17 clients are not presently active in the program. The LEAD case manager makes weekly attempts to contact them. Only two of the original 23 referrals have been charged with another crime since being referred into LEAD.

Burke County LEAD program implementation begin in October 2018 and has had 9 referrals between then and May 2019.

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 15

Local Reentry Council – Iredell County – Iredell County, at the recommendation of the State of North Carolina, Governor’s Crime Commission, has established a Local Reentry Council. This Council is working with entities, other stakeholders, and providers throughout the county to address the needs of individuals returning to the community from prison. All aspects of needs are being examined and the Council will be providing education and guidance to the community around all issues affecting the quality of life of released inmates. Partners staff is serving an active role on this council and providing technical assistance and ongoing collaboration around community supports available to this specific population.

For Gaston/Cleveland: Jail Treatment Services include individual and group counseling for alcohol and substance abuse with linkage to outside services where appropriate. and assessment, drug education and relapse prevention. The Jail Liaison Services in Cleveland County assists the medical staff to diagnose mental health and safety concerns for inmates who present a danger to themselves or others within the jail. Staff works with the Sheriff and the Courts to find services and divert inmates to those services safely, which alleviates jail medical costs and overcrowding. Halfway House Beds are to assure that residents of Gaston and Cleveland County are afforded opportunities to receive treatment and employment in a residential facility for a minimum of 90 days upon release. For Cleveland/Gaston there has been issues of Medical treatment for inmates and access to psychotropic medications.

Youth in the juvenile justice system Seven out of the eight catchment area counties had higher undisciplined rates than North Carolina. Gaston County has the highest undisciplined rate with 5.49 juveniles per 1,000, and Iredell County has the lowest undisciplined rate at 0.92 juveniles per 1,000. Six out of eight catchment area counties had higher juvenile delinquency rates than the state. Yadkin County has the highest delinquent rate with 31.05 juveniles per 1,000, and Gaston County has the lowest delinquent rate at 14.33 juveniles per 1,000. Juvenile delinquency is defined as the participation in illegal behaviors by minors. Undisciplined juveniles are defined as those who are disobedient beyond the control of their guardians, regularly hang out in places unlawful to minors, or run away from home for more than 24 hours.

Two-hundred seventeen youth were linked to Partners Care Coordination during FY18. Partners System of Care team members participate on the Juvenile Justice Collaboratives across the catchment area. Each collaborative develops a plan for the year that involves assisting with referrals to family care teams, Partners Care Coordination when appropriate, and access to enhanced screening tools for assessment. ______

1 Data cubes & claims data 2 Claims data 3 DMH/DD/SAS: Veterans and Military Annual Report" North Carolina Department of Health and Human Services, https://files.nc.gov/ncdhhs/documents/files/SFY_18_VeteransMilitaryReport.pdf. 4 LGBT People in North Carolina." The Williams Institute, williamsinstitute.law.ucla.edu/wp-content/uploads/North-Carolina- fact-sheet.pdf. Accessed 13 Aug. 2018. 5 Partners Access to Care Department

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 16 Section 2.1.2 Traumatic Brain Injuries (TBI) a. Describe how individuals with TBI are identified, where they are in the catchment area, challenges in service provision as well as gaps and needs of this population.

Individuals with Traumatic Brain Injury (TBI) are identified and tagged through Access to Care/Intake. We have identified individuals with TBI from all 8 counties of our catchment area. Partners claims data indicates 36 individuals with a TBI diagnosis were served in FY18.

On a national level, problems and solutions with the identification of TBI consumers are identified by the CDC (2015) report to Congress. These researchers report “ongoing surveillance of TBI- related disability does not exist. The only nationally representative estimates of TBI-related disability are based on extrapolations of one-time state-level estimates of lifetime TBI-related disability (Selassie et al., 2008; Zaoshnja et al., 2008). The limited data available result in the following limitations: no true national-level estimates; no 12-month prevalence estimate of TBI- related disability; an inability to examine state-level variation; no recent estimates; an inability to monitor trends; and an inability to examine variation in TBI-related disability by important demographic subgroups such as race/ethnicity or military status. Source: Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA.

Challenges in service provision, as well as gaps and needs of this population, include eligibility to Innovations Waiver, limited state funding, a Medicaid funding mechanism (TBI Waiver Pilot in Alliance, not yet rolled out statewide), lack of specialty providers (including residential providers), lack of education and staff training.

b. Describe the mental health, developmental disabilities and substance use services this population accesses. Partners TBI population has access to Outpatient and Medication Management services. Additionally, our TBI population has access to Enhanced Behavioral Health Services on a person-centered basis. On an individual clinical basis, our TBI population has access to SAIOP. Our TBI population has limited access to State funds and often don’t meet the eligibility criteria for the Innovations Waiver, given the onset of their injuries. Services accessed by the individuals identified in the claims data with a TBI diagnosis received a variety of services including, but not limited to, residential and other living supports, SA Comprehensive Outpatient Treatment, Assertive Community Treatment Teams (ACTT), peer supports, respite, therapy (group, family, individual), hospitalization, and crisis services.

c. Describe any other service(s) and system(s) this population accesses. Additional services accessed by this population are Skilled Nursing, CAP-DA, Personal Care Services.

d. Describe the services and supports identified as a need for this population but that are unavailable for them. Waiver Services

e. Describe what service gaps were identified by consumers and family members. Service gaps identified by consumers and family members include Residential Supports, Day Supports, Respite, Specialized Consultative Services, i.e. Behavioral Supports, Assistive Technology, Home and Vehicle Modifications and more resources for those with Long-Term Care Needs. Of the consumers who completed the Community Assessment Survey and identified themselves as recipients of TBI services, one-third said in the past 12 months, they were not able to obtain

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 17 understandable information on the services offered and how to access them. However, 78% stated they always or usually get the help they want. Of the family members/caregivers who completed the Community Assessment Survey and identified the person receiving services as recipients of TBI services, two-thirds said they always are usually get the help they want. Like the consumers, one-third reported in the past 12 months, they were not able to obtain understandable information on the services offered and how to access them.

f. Describe what service gaps were identified by other stakeholders. Other stakeholders identified similar service gaps as consumers and family members including Residential Supports, Day Supports, Respite, Specialized Consultative Services, i.e. Behavioral Supports, Assistive Technology, Home and Vehicle Modifications. Additionally, in the Community Assessment survey, they noted making sure individuals and medical providers have knowledge of the behavioral health services available for individuals with brain injury. This includes post-acute care follow-up even a year or two after.

g. Describe the level of satisfaction of consumers and family members regarding services received. Consumers and family members are thankful for the services they receive, but disappointed with limited resources for those with Long-Term Care Needs. Of those who responded to the Community Assessment survey as primary TBI receipts or family members/caregivers of TBI receipts all said they were either very satisfied or satisfied with the services they receive.

h. Describe the TBI specific training offered to families, consumers and professionals. TBI training are often met through BIANC (Brain Injury Association of North Carolina) State or Regional Offices. The Traumatic Brain Injury (TBI) Online Curriculum, a program developed by Dr. Stephen Hooper at The Carolina Institute for Developmental Disabilities in partnership with the NC Department of Public Instruction (DPI). These online courses are designed to help school psychologists, families, and other school professionals work with students with TBI.

Section 2.2 Obstacles and barriers to serving specific populations Describe obstacles and barriers to serving specific geographic, cultural or special populations, including those listed above, as well as gaps they experience in mental health, developmental disabilities and substance use disorder services access, quality, or outcomes.

Providing quality behavioral health services across eight counties, with varying populations, a variety of demographics and socioeconomic factors, can be quite a challenge. There are a range of needs throughout the catchment area and even when they are similar, the obstacles and barriers faced vary.

Those in the northern counties, specifically Surry and Yadkin counties, are still experiencing obstacles and barriers to receiving substance use services. Some of the new and existing barriers include: (1) The notion of “Narcan Parties” continues to be a difficult perception to dispel and replace with the tenants of harm reduction. Syringe exchange is another harm reduction strategy that the county does not want to pursue at this time; (2) the District Attorney is not supportive of Law Enforcement Assisted Diversion; (3) physical plant issues that have hampered Daymark’s ability to expand and introduce SACOT; (4) providers providing Suboxone without the counseling components thus making it difficult for other providers to attract these potential clients; (5) there are also affordability issues that create barriers. Clients can pay cash and sell a portion of their prescriptions to recoup their expenses. The Opioid Response Director has been notified of this issue; (6) challenges within the certain communities to have SUD treatment in/near

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 18 the city limits; (7) lack of public transportation options for individuals needing to access SUD services; and (8) stigma.

However, positive gains have been made: (1) Northern Hospital of Surry reached out for assistance with acquiring an expedited CON (out of network) agreement to convert acute care beds to gero-psychiatric beds and we are assisting them with this process. They hope to hire a psychiatrist that will be able to serve this population and provide consultation to other departments (ED) at the hospital; (2) Northern Hospital is coordinating a meeting with the new Sheriff to discuss the IVC issues in Surry and wants to include Partners staff members. (3) Pinnacle Therapeutic Services in State Road reached out and is experiencing an increase in indigent referrals for SUD services and are seeking State dollars. They have been supplied them with the funding request form and we are maintaining communication with them.

For people who are in jails or prisons barriers include lack of “re-entry” programs – residential treatment or otherwise, vocational opportunities and funding to pay for treatment. This population does not qualify for many of the funding resources available.

Data on the LGBTQ community is not readily collected at the time of service or access to service. It is only collected if it is an issue for the member involved, so it is not always disclosed.

Barriers to serving those who are hard of hearing or speak a language other than English has to do with funding. The allocated funding for assistance to provide interpretation or other services is small, which in turn, passes the high cost onto the provider. Another barrier to supporting special population is the ability to collect data on the specific populations and where they are located.

Partners is not alone in these challenges, as limited dollars, waitlists, stigma, and knowledge gaps, coupled with a lack of outcomes data are challenges faced by all MCO’s across North Carolina and nationally. We continue to partner with our local communities to work toward creative solutions that strengthen our communities and improve lives.

Section 2.3 Social Determinants of Health Conduct a preliminary environmental review of the availability and needs for community supports related to social determinants of health for the catchment area, including:

A preliminary environmental review of the availability and needs for community supports related to the social determinants of health for our catchment area was conducted. Partners is also in the process of conducting a more comprehensive analysis on the Social Determinants of Health (SDOH) through an external contractor and the results will be out late Summer 2019. More comprehensive numbers on the social determinants of health can be found in Appendix D2.

Employment The Partners catchment area has more unemployment and less employment than the state or nation. Cleveland County has the highest proportion of unemployed individuals at 5.9%, followed by Burke County at 5.2%. Surry County has the lowest proportion of unemployed individuals within the catchment area at 2.8%. From 2018 to 2019, all unemployment rates have dropped.

Lack of employment was listed last year, 2018 Community Assessment Survey, as the fourth highest barrier to receiving services with 17.7% of respondents reporting to have experienced this barrier within

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 19 the past year. For 2019, lack of employment is was listed as the third highest barrier to receiving services, with 30.0% of consumers reporting having experienced this barrier within the past year.

Housing Homelessness: On January 25, 2018, a point in time homeless count was conducted for the state of North Carolina. The total number of homeless individuals counted in the catchment area was 580. Out of the 580, 51.2% of the individuals were in emergency shelters, 18.6% in transitional housing, and 30.2% were in an unsheltered situation. The number of homeless individuals counted in the catchment area fell from 727 in last year’s report to 580, which is a decrease of approximately 20%.

This year, when asked if in the Community Assessment Survey whether clients are worried about having stable housing, 34.6% of mental health, 52.1% of substance use disorder (SUD), and 10.7% of intellectual/developmental disability (I/DD) consumers answered ‘Yes.’ In 2018, the proportion of consumers who responded ‘Yes’ were 26.5% of mental health consumers, 11.1% of SUD consumers, and 6.6% of I/DD consumers. From 2018 to 2019, we see an increase in rates of worries about stable housing for all consumers, with a sharp increase in the rates of SUD individuals.

Homeless/housing issues was listed last year, 2018 Community Assessment Survey, as the eighth highest barrier to receiving services with 14.0% of consumer respondents reporting to have experienced this barrier within the past year. For 2019, homeless and housing issues are now the second highest barrier to receiving services, with 32.7% of consumers reporting having experienced this barrier within the past year.

Eviction*: Of the seven counties where data was available, all 7 counties have a higher eviction rate than the National average. Cleveland County has the highest eviction rate of all the counties (7.3%), even higher than the State average. Gaston has the highest eviction filing rate of these counties (14.9%), well above the state average, followed by Cleveland (10.5%). One out of 10 renters had an eviction filed on them in Cleveland County and 1 out of 7 renters in Gaston County had an eviction filing. Both Cleveland (33.2%) and Gaston (32.2%) have a higher rent burden than the State average. *Data source not updated since last year.

Transportation Based on surveys of Partners consumers, families, and stakeholders lack of reliable transportation is a barrier to receiving services. In the 2019 Community Assessment Survey, transportation was listed as the highest influence in a decision to stop seeking treatment, with 40.6% of respondents selecting this reason. Both Catawba and Burke Counties received funding to expand public transportation routes which will include increased integrated health care access.

Additionally, when asked in the Community Assessment Survey this year whether they have needed healthcare but could not go because they lacked the ability to get there, 31.0% of mental health consumers, 45.1% of SUD consumers, and 11.1% of I/DD consumers answered ‘Yes.’ In 2018, the proportion of consumers who responded ‘Yes’ were 30.6% of mental health consumers, 22.6% of SUD consumers, and 8.2% of I/DD consumers. From 2018 to 2019, we see an increase in rates of an inability to get to healthcare due to a lack of a way to get there, with a sharp increase in the rates of SUD individuals.

Lack of reliable transportation was listed last year, in the 2018 Community Assessment Survey, as the seventh highest barrier to receiving services with 14.6% of respondents reporting to have experienced this barrier within the past year. This year, 2019, in the Community Assessment Survey lack of reliable

Partners 2019 Network Adequacy and Accessibility Analysis Section Two: Accommodation 20 transportation was now the number one barrier to receiving services, with 37.8% of consumers reporting having experienced this barrier within the past year.

Food Insecurity This year, when asked in the Community Assessment Survey whether consumers eat less due to a lack of food, 27.7% of mental health consumers, 46.5% of SUD consumers, and 7.1% of I/DD consumers answered ‘Yes.’ In 2018, the proportion of consumers who responded ‘Yes’ were 30.6% of mental health consumers, 20.4% of SUD consumers, and 6.6% of I/DD consumers. From 2018 to 2019, we see a decrease in rates for mental health individuals, with a sharp increase in the rates of SUD individuals and a slight increase for I/DD individuals.

Economics Poverty: 16.04% of the catchment area population is below the poverty level; which is at North Carolina’s level and above the national level. Iredell county has the lowest poverty rate at 12.7%, whereas Cleveland County has the highest poverty rate at 19.9%. All these poverty rates have fallen from 2018, except for Lincoln County (15.2%), which grew by approximately 1%.

This year, when asked in the Community Assessment Survey whether cost will affect the decision to see a doctor, 30.6% of mental health consumers and 43.1% of SUD consumers answered ‘Yes.’ In 2018, the proportion of consumers who responded ‘Yes’ were 32.7% of mental health consumers, 16.7% of SUD consumers, and 9.8% of I/DD consumers. From 2018 to 2019, we see a decrease in rates of mental health and I/DD individuals not seeing a doctor when needed due to cost, and a sharp increase in rates for SUD consumers.

Also, when asked if consumers have lost utilities due to not paying bills, 23.1% of mental health consumers, 34.7% of SUD, and 7.1% of I/DD consumers answered ‘Yes.’ Last year, the proportion of consumers who responded ‘Yes’ were 28.6% of mental health consumers, 9.3% of SUD consumers, and 9.8% of I/DD consumers. From 2018 to 2019, we see a decrease in rates of SUD and I/DD individuals having utility services shut off for not paying bills, and an increase in rates for mental health consumers.

When asked in the Community Assessment Survey to identify reasons that may influence a decision to stop seeking treatment, 25.7% of respondents stated that money needed for monthly expenses is one of these influencers. This is the second highest identifiable reason, behind transportation. Cannot pay for services/medications was listed last year, in 2018, in the Community Assessment Survey as the second highest barrier to receiving services with 23.2% of respondents reporting to have experienced this barrier within the past year. For 2019, cannot pay for services/medications is now the seventh highest barrier to receiving services, with 21.2% of consumers reporting having experienced this barrier within the past year.

The table below compares the 2018 and 2019 Community Assessment Survey results by population for specific social determinant questions. Social Determinant Gap Mental Health SUD I/DD 2018 2019 2018 2019 2018 2019 Food 30.6% 27.7% 20.4% 46.5% 6.6% 7.1% Paying Bills/Utilities 28.6% 23.1% 9.3% 34.7% 9.8% 7.1% Stable Housing 26.5% 34.6% 11.1% 52.1% 6.6% 10.7% No Doctor Due to Cost 32.7% 30.6% 16.7% 43.1% 9.8% 0.0% Transportation 30.6% 31.0% 22.6% 45.1% 8.2% 11.1%

Partners 2019 Network Adequacy and Accessibility Analysis Section Three: Acceptability 21 Section 3: Acceptability To ensure the LME/MCO’s assessment reflects consumer and stakeholder experience, seek direct input from consumers and from a variety of existing service system partners. Discuss service gaps with local leaders, staff and consumers of disability-specific agencies to learn about service gaps for people with co- occurring physical, sensory (visual, hearing) and other disabilities. Engage the LME/MCO’s Consumer and Family Advisory Council (CFAC) per § 122C-170, partners such as juvenile justice, DSS, education and disability advocacy groups in dialogue about service gaps and corresponding strategies and solutions. Use the information gathered to address the following items. If surveys were used please include a copy of the survey and a description of the distribution methodology as appendix documents.

Section 3.1 Methods to get input from consumers and family members Describe methods used to get input from consumers and family members regarding service needs, gaps and strategies. Include efforts to achieve geographic and disability-specific representation.

Community Gaps and Needs Assessment Survey (Community Assessment Survey): The primary method used to reach a broad scope of consumers, family members, and caregivers across the Partners community utilized a standardized service gaps survey instrument developed with Integrated Behavioral Health Analytics (IBH Analytics). Partners promoted the survey on social media sites such as the Partners Facebook page, LinkedIn, and Partners home page. An educational article describing the purpose of the survey and a link to the survey was featured in the Partners Provider Bulletin. To promote the survey, Provider Account Specialists sent out an email blast to all providers promoting survey participation and added the survey link to their email signatures in all outgoing electronic correspondence. Additionally, announcements were made at Community Collaborative meetings and at the Provider Forum, where copies of the survey were made available to providers to distribute to their consumers and family members. Lastly, Partners staff surveyed consumers and family members at various provider agencies, Consumer and Family Advisory Committee meetings, community workgroups, and during home visits.

NC-TOPPS Outcomes: NC-TOPPS is a web-based system for gathering outcome and performance data on behalf of consumers with mental health and substance use disorders in North Carolina’s public system of treatment services.

2018 Perception of Care Survey: The North Carolina Department of Health and Human Services (DHHS), Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH), in partnership with the Local Management Entities/Managed Care Organizations (LME/MCO), annually administers the Mental Health and Substance Abuse Services Perception of Care Survey. This survey assesses consumer satisfaction and perceptions of quality and outcomes of publicly funded Mental Health (MH) and Substance Use (SU) services. Adult consumers ages 18 years and over (Adult Survey), youth ages 12-17 years (Youth Survey), and parents of children under 12 years of age (Child Family Survey) complete the confidential surveys at their provider agencies during a specified time-period each year. The 2018 survey was administered between May 7, 2018 and June 5, 2018.

2018 Member Satisfaction Survey: All members of Partners are mailed a satisfaction survey to assess member experience with their provider, access to care department, with accessibility of services and integrated care. The information is then analyzed and processed internally by the Quality Improvement Committee along with the support of the Operations Team to identify areas of improvement.

Partners 2019 Network Adequacy and Accessibility Analysis Section Three: Acceptability 22 2018 ECHO Survey: Results from the Consumer Satisfaction Survey for North Carolina Adult Medicaid enrollees provide a comprehensive tool for assessing consumers' experiences with their health care. DataStat, Inc. conducted the survey on behalf of North Carolina Medicaid (NC Medicaid) and The Carolinas Center for Medical Excellence (CCME). The instrument selected for the survey was the Adult Experience of Care and Health Outcomes (ECHO®) Survey 3.0 (which is the CAHPS® behavioral health survey) for use in assessing the performance of the health plans. The survey instrument used for the NC Medicaid adult Medicaid survey project consisted of fifty-one core questions and twelve care coordination questions. Partners reports all provider & enrollee survey (ECHO, Perception of Care & National Core Indicators) results based on analysis to multiple committees both internally and externally. Internal committees include Quality Improvement Committee and Operations Team. External committees include Provider Forum, Provider Council & Global CQI Committee.

3.2 Disability Group Service Gaps – Consumers and Family Members For each disability group (mental health, developmental disabilities and substance use disorder) what service gaps were identified by consumers and family members?

Most of the service gaps identified by consumers and family members/caregivers were related to the social determinants of health and service availability.

The Community Assessment Survey provided important insights regarding how social determinants are a barrier to receiving services. The magnitude of social determinant factors varied substantially by population. As demonstrated in the table below, substance use consumers are more at risk for food deprivation, utility services shut off, housing, not able to see a doctor because of cost and transportation than mental health and intellectual/developmental disability consumers.

Social Determinant Gap Mental Health Substance Use I/DD Food 27.7% 46.5% 7.1% Paying Bills/Utilities 23.1% 34.7% 7.1% Stable Housing 34.6% 52.1% 10.7% No Doctor Due to Cost 30.6% 43.1% 0.0% Transportation 31.0% 45.1% 11.1%

Mental Health/Substance Use

Transportation: Transportation was identified by as a gap to receiving services by consumers. Lack of reliable transportation was the most commonly experienced barrier to receiving services reported by mental health (MH) consumers in the 2019 Community Assessment Survey. This is up from 9th last year. Transportation was also reported by almost half of the Substance Use (SUD) consumers as a barrier experienced to receiving services and was the 3rd most frequently reported experienced barrier to services; up from 8th last year. Additionally, transportation was listed as the most frequent influencer in a decision to stop seeking treatment for both MH and SUD consumers and MH family members/caregivers. It was the second most reported influencer in stopping treatment reported by SUD family members/caregivers. Most consumers currently rely on family members and/or friends when they want to go somewhere.

Partners 2019 Network Adequacy and Accessibility Analysis Section Three: Acceptability 23 Housing: In the 2019 Community Assessment Survey, when asked “what would improve the quality of life for them in their community?”, the most selected response was housing by both MH (45.1%) and SUD (56.8%) consumers. Additionally, homeless/housing was listed as the 2nd most select barrier experienced to receiving services by MH consumers (35.8%) and the 4th most selected by SUD consumers (44.6%). Over half of the SUD respondents said they were worried about having stable housing and just over one-third of MH consumers were worried about having stable housing.

Lack of Employment: The fifth most experienced service barrier by mental health consumers was lack of lack of employment and was experienced by 1 out of 4 mental health consumers. This service barrier was also experienced by half of the substance use consumers and was their 2nd most commonly experienced barrier to service.

Cost: Money needed for monthly expenses was the 2nd most frequently reported reason for stopping treatment after transportation by both MH and SUD consumers; it was the most frequently reported reason by SUD family members/caregivers. Additionally, 43% of SUD consumers said not being to pay for services/medications was a barrier to receiving services they have experienced; 30% of MH consumers reported the same thing.

Mental Health/Substance Use Issues: Substance use consumers reported Mental Health/Substance Use as their #1 service barrier; experienced by over half of the substance use consumers. Mental health consumers reported mental health/substance use issues as the 3rd most experienced service barrier and Family members/caregivers of mental health consumers reported mental health/substance use issues as the most experienced barrier to services when a barrier was experience. The most frequently selected response was no barriers experienced.

Stigma & service perceptions: One out of four mental health consumers and one out of three SUD consumers listed lack of support from family/friends to seek out help as a barrier experienced to receiving services in the past year. Additionally, one out of four SUD consumers and one out of five MH consumers listed feelings of fear or embarrassment as a barrier to receiving services. When asked what reason(s) may influence you to stop seeking treatment one out of five SUD consumers and 15% of MH consumers said they did not feel treatment was working. This was also the second reported reason by MH family members/caregivers. Also, 26% of SUD consumers and 14% of MH consumers do not have someone they can depend on to listen to them, support them emotionally, or encourage them to get help for their problems. Additionally, one out of four children reported they usually/always had someone to talk to for counseling/treatment when troubled (ECHO). Perceived improvement composite score from the ECHO 66% for adults and 66% for children, meaning 33% of consumers did not perceive there to be noticeable improvement a year after starting services.

Mental health and substance use consumers were also asked to identify what would improve the quality of life in their community. The top five responses from each group are below: Mental Health Substance Use Response Percentage Response Percentage Housing 45.1% Housing 56.8% Dental care access 35.8% Substance use support 52.7% Mental health services 35.8% Dental care access 44.6% Public transportation 34.0% Mental health services 40.5% Community activities 30.9% Employment opportunities 40.5%

Partners 2019 Network Adequacy and Accessibility Analysis Section Three: Acceptability 24

Intellectual/Developmental Disabilities The top barriers to services reported by I/DD consumers were lack of reliable transportation, reading skill level/education level, feelings of fear or embarrassment, homeless/housing issues, and lack of employment. The top barriers to services reported by I/DD family members/caregivers were medical/health issues, frequency of services, physical disability/mobility issues, and homeless/housing issues. Additional service gaps identified by I/DD consumers and family members were lack of employment, transportation, and providers not close to their home.

Additional Community Assessment Survey Analysis can be found in Appendix E1. Blank Community Assessment Surveys can be found in Appendix E2.

Additional Findings

NC-TOPPS: Partners has engaged in a concerted effort to strengthen the quality of its service delivery system by measuring clinical outcomes and the barriers to achieve outcomes. Partners NC-TOPPS data indicates areas of treatment gains for our consumers and areas to strengthen. The table below demonstrates strong evidence of decreasing symptoms and improved quality of life for Partners mental health and substance use consumers as demonstrated by the June 2018 percentage of consumers exceeding the standard for all five age/disability group combinations. Areas to strengthen include MH Symptoms, SA symptoms, and treatment engagement as most age/disability group combinations fall below the standard. Areas of focus also include session attendance for substance use consumers and transportation for MH and SA adults.

Legend Exceeds Standard Below Standard

Episode Completion Decreasing Symptoms Improve Quality of Life Session Attendance Population Reason (Completed TX) Standard Jun-18 Standard Jun-18 Standard Jun-18 Standard Jun-18 Adolescent SA 60% 100.0% 50% 100.0% 50% 33.3% 70% 66.7% Adult SA 60% 73.9% 50% 78.3% 50% 8.4% 70% 40.8% Adolescent MH 60% 83.3% 50% 91.7% 50% 52.4% 70% 73.8% Adult MH 60% 96.4% 50% 96.4% 50% 23.5% 70% 55.4% Child MH 60% 95.2% 50% 100.0% 50% 53.6% 70% 78.6%

Transportation MH Symptoms SA Symptoms TX engagement Population Standard Jun-18 Standard Jun-18 Standard Jun-18 Standard Jun-18 Adolescent SA < 5% 0.0% < 5% 0.0% < 5% 0.0% < 5% 33.3% Adult SA < 5% 12.6% < 5% 13.6% < 5% 31.1% < 5% 13.6% Adolescent MH < 5% 0.0% < 5% 9.8% < 5% 0.0% < 5% 13.1% Adult MH < 5% 8.9% < 5% 26.8% < 5% 12.5% < 5% 8.9% Child MH < 5% 0.0% < 5% 7.1% < 5% 0.0% < 5% 7.1%

Partners 2019 Network Adequacy and Accessibility Analysis Section Three: Acceptability 25 Member Experience Survey: Partner’s collected responses from seventy-five consumers to measure consumer satisfaction with services to determine areas to improve member experience. Consumers were able to decline answering any of the questions, and thus all the questions were not included in the final analysis due to inconsistencies. Some respondents were excluded because they responded “No” when asked if they had received BH services in the last 12 months. Of the 25 questions which could be analyzed, Partners achieved our benchmark goal of 80% in 21 – or in 84% of the measures.

Of the measures that did not meet the goal, two of them were used to evaluate member access to care: • Wait time for the first appointment with a Partners Provider was longer than 1 hour • Wait time for first appointment within 2 weeks The other two measures we did not meet the goal for are outcome measures based on member perception, specifically: • Rating your provider • Happiness with getting into treatment

These are driven by the member’s health status and emotions as perceived by the member when responding to the survey questions. These factors are driven in part how easily they can obtain the care they need in a timely manner. In order to address these two measures, Partners must first be sure that members do not experience access issues and members are getting the treatment they need in a timely manner.

2018 Perception of Care Surveys Perception of Care Adult Survey Results: In three of the seven domains of from the 2018 Perception of Care survey, Partners scored above 90%. The three domains were access, quality and appropriateness, and general satisfaction. Partners Access to Care composite score (93.2%) was the highest LME/MCO score and a 3-percentage point increase from last year’s score. The Treatment Planning composite score (88.2%) was above the state average and a 3-percentage point increase from last year. The Quality and Appropriateness composite score (95.9%) was above the state average, highest out of the LME/MCO’s, and saw a 1-percentage point increase from 2017. The Outcomes composite score (75.0%) was below the state average but did increase slightly from 2017. The Functioning composite score (76.2%) was below the state average and decreased 2-percentage points from last year. The Social Connectedness composite score (73.9%) was below the state average was below the state average and decreased 2-percentage points from last year. The General Satisfaction composite score (93.9%) was higher than the state average and increased 3-percentage points from last year.

Reviewing the data from the survey over the last four years, the quality and appropriate domain continues to be the highest scoring domain. The next two are general satisfaction and access. Domains to strengthen are outcomes, functioning, and social connectedness. These three domains are slightly below the state average and have seen either a slight decrease or little change over the past years.

Perception of Care Youth Survey Results Four of the five domain scores for Partners youth survey were below the state average and decreased from 2017. Partners Access to Care composite score was 8.2 percentage points below the state average, Treatment Planning composite score was 9.2 percentage points below the state average, Cultural Sensitivity composite score was 4.8 percentage points below the state average, and general satisfaction was 9.1 percentage points below the state average. The Outcomes composite score was 0.9 percentage points above the state average.

Partners 2019 Network Adequacy and Accessibility Analysis Section Three: Acceptability 26 Reviewing the data from the survey over the last four years, cultural sensitivity continues to be the highest scoring domain. However, it dropped 3 percentage points from last year and is 4 percentage points lower than the state average. Outcomes continues to be at around 70%, which aligns with the state average. Areas to focus on for improvement are access, which dropped 9 percentage points from 2017 and is 8 percentage points lower than the state average; general satisfaction, which dropped 6% from last year and is 9 percentage points lower than the state average; treatment planning, which only slightly decreased but is 9% lower than the state average.

Perception of Care Family Survey Results: Partners Access to Care composite score (94.6%) was above the state average, Treatment Planning composite score (96.2%) above the state average, Cultural Sensitivity composite score (96.8%) below the state average, Outcomes composite score (73.6%) above the state average, Functioning composite score (74.4%) above the state average, Social Connectedness composite score (85.0%) below the state average, and General Satisfaction composite score (95.4%) was above the state average.

Reviewing the data from the survey over the last four years, four domains saw an increase by at least 10 percentage points. The four domains were treatment planning, outcomes, functioning and general satisfaction. Access saw an increase of 8 percentage points, and social connectedness and cultural sensitivity increased by 1 percentage point.

Experience of Care and Health Outcomes (ECHO) Survey Partners’ overall rating for the 2018 Adult Survey showed little change from the 2017 results. In addition, there was only a 0.8 percentage point difference between Partners’ overall rating and the NC Overall rating (with the NC Overall rating being higher). Partners’ overall rating for the 2018 Child Survey showed a decrease of 12.6 percentage points compared to the 2017 results. The overall rating was also 7.6 percentage points below the NC Overall rating. The highest composite score for both surveys was how well clinicians communicate (Adults – 91.8%; Child – 84.1%). The lowest composite scores were Getting Treatment & Information from the Plan (Child: 31.7%) and Information About Treatment Options (Adult: 50.5%). Partners saw improvement in 12 items where the increase from last year to this year was 10 or more percentage points.

Section 3.3 Methods to get input from other stakeholders Describe methods used to get input from stakeholders other than consumers and family members regarding service needs, gaps and strategies.

Community Gaps and Needs Assessment Survey (Community Assessment Survey): The primary method used to reach a broad scope of consumers, family members, and caregivers across the Partners community utilized a standardized service gaps survey instrument developed with Integrated Behavioral Health Analytics (IBH Analytics). Partners promoted the survey on social media sites such as the Partners Facebook page, LinkedIn, and Partners home page. An educational article describing the purpose of the survey and a link to the survey was featured in the Partners Provider Bulletin. To promote the survey, Provider Account Specialists sent out an email blast to all providers promoting survey participation and added the survey link to their email signatures in all outgoing electronic correspondence. Additionally, announcements were made at Community Collaborative meetings and at the Provider Forum, where copies of the survey were made available to providers to distribute to their consumers and family members. Lastly, Partners staff surveyed consumers and family members at various provider agencies, Consumer and Family Advisory Committee meetings, community workgroups, and during home visits.

Partners 2019 Network Adequacy and Accessibility Analysis Section Three: Acceptability 27

NC Medicaid Provider Satisfaction Survey: The North Carolina (NC) Provider Satisfaction Survey is a tool designed to assess how well the State and the Managed Care Organizations (MCOs) are meeting providers’ expectations and needs. The survey is conducted by DataStat, Inc. on behalf of North Carolina Medicaid (NC Medicaid) and the Carolinas Center for Medical Excellence (CCME). The 2018 survey was conducted between October 29, 2018 and December 10, 2018. This report summarizes the results of the analysis completed by Partners Behavioral Health Management’s (Partners) Quality Management (QM) Department, utilizing the results from the NC Medicaid 2018 Provider Satisfaction Survey Report. This report reviews the percentage of positive responses for each survey question, compares the positively rated items from the current survey and the two (2) previous years, citing those items that increased, showed no change, or decreased from year to year. Other notable information from the data is summarized and included.

Other than the primary method of surveys, input is gathered from stakeholders during Provider Council Meetings, through the Licensed Independent Practitioner Collaborative, Crisis Collaboratives, Juvenile Justice Collaborative, Child and Family Collaborative, and Residential Collaboratives. These community collaboratives encourage discussion and community partnerships to strengthen community resources. They are an integral part of the Partners System of Care team and input from these groups is reflected throughout the report, but not specifically in the section below.

Section 3.4 Service Gaps and Barriers to Service – Other Stakeholders For each disability group (mental health, developmental disabilities and substance use disorder) what service gaps were identified by other stakeholders?

Two different stakeholder groups were asked about service gaps, needs, and barriers. The tables in the following section display the information identified by providers of services and other community stakeholders. Specifically, perceived barriers to services and gaps in services were identified in rank order.

Providers of services: Providers of services representing all disability groups participated in the Community Assessment Survey. Providers were to allowed select more than one disability group based on the populations they serve. Therefore, there is some overlap in the answers when reported by disability group served as opposed to reviewed together.

The most frequently reported service barriers identified by providers include (1) lack of transportation (71%), (2) homelessness/housing issues (52%), (3) lack of support from family/friends to seek out help (48%), (4) paying their bills, rent, mortgage payment, phone etc. (44%), and (5) cannot pay for services/medications (42%).

Top reasons they believe consumers stop seeking treatment: (1) transportation (69%), (2) money/monthly expenses (46%), (3) doesn’t believe interventions/treatments are successful (40%), (4) waitlist for services (36%), and (5) stigma (35%).

Mental Health The top five perceived service barriers reported by mental health providers were lack of reliable transportation, housing/homelessness, lack of support from family/friends to seek out help, mental health/substance abuse issues, and the inability to pay for their bills (i.e. utility bills, rent/mortgage payments, phone, etc.). The mental health providers top reported service gaps were residential treatment

Partners 2019 Network Adequacy and Accessibility Analysis Section Three: Acceptability 28 levels 1-4, facility-based crisis, child/adolescent day treatment, partial hospitalization, and opioid treatment. Additionally, 36% of providers believe consumers never or only sometimes receive services as soon as they want. One out of four providers do not believe consumers are informed of the services available to them. Mental Health providers also reported transportation (65%) being the top reason they thought a person would not continue to stay in treatment, followed by money/monthly expenses (42%), doesn’t believe interventions/treatments are successful (36%), not engaged with the clinician (32%), and stigma (32%).

Substance Use Disorder The top five perceived service barriers reported by substance use providers were lack of reliable transportation, homeless/housing issues the inability to pay for services/medications, mental health/ substance abuse issues, and lack of support from family/friends. The substance use providers top reported service gaps were residential treatment levels 1-4, detoxification (non-hospital), partial hospitalization, child/adolescent day treatment, and opioid treatment. Additionally, 1 out of 3 of providers believe consumers only sometimes or never receive services as soon as they want. Substance Use Disorder providers also reported transportation (68%) being the top reason they thought a person would not continue to stay in treatment, followed by money/monthly expenses (49%), stigma (36%), lack of child care (35%), and doesn’t believe interventions/treatments are successful (33%).

Intellectual Developmental Disabilities The top five perceived service barriers reported by I/DD providers were the lack of reliable transportation, waitlist, lack of support from family/friends, homeless/housing issues, and they do not know what services are available. The I/DD providers top reported service gaps were I/DD out of home respite, I/DD supported employment, and facility-based crisis, and residential treatment levels. Additionally, 43% of providers believe consumers never or only sometimes receive services as soon as they want. One out of four providers do not believe consumers are informed of the services available to them. I/DD providers also reported transportation (55%) being the top reason they thought a person would not continue to stay in treatment, followed by waitlist for services (44%), money/monthly expenses (39%), doesn’t believe interventions/treatments are successful (36%), and medical reasons (30%).

Other Community Stakeholders: Seventy-four (n=74) community stakeholders participated in the Partners Community Assessment Survey. Community stakeholders from the Department of Social Services (DSS), the school systems, Division of Juvenile Justice, Hospitals, Public Health, Advocacy Groups, Department of Justice and others participated in the survey.

Community stakeholders were asked about consumers receiving services as soon as they need and want. When asked if, “In your opinion, do consumers receive treatment or services as soon as they need?”, 8% said always, 47% said usually, and 45% said sometimes. When asked if, “In your opinion, do consumers receive treatment or services as soon as they want?”, 8% said always, 37% said usually, 53% said sometimes and 2% said never.

Community Stakeholders reported transportation (77%) , mental health/substance abuse issues (63%), lack of support from family/friends (59%), the inability to pay for services/medications (57%), and homeless/housing issues (55%), and waiting lists (53%) as barriers to consumers receiving services. The Community Stakeholders top reported service gaps residential levels 1-4, child and adolescent day treatment, mobile crisis, opioid treatment, and detoxification (non-hospital).

Partners 2019 Network Adequacy and Accessibility Analysis Section Three: Acceptability 29 Additional Community Assessment Survey Analysis can be found in Appendix E1. Blank Community Assessment Surveys can be found in Appendix E2.

Provider Satisfaction Survey The North Carolina (NC) Provider Satisfaction Survey is a tool designed to assess how well the State and the Managed Care Organizations (MCOs) are meeting providers’ expectations and needs. Overall the providers in Partners network are satisfied working with us, with an overall LME/MCO satisfaction score of 90.5%, which is 3.9 percentage points above the state average. Partners had the highest average MCO score for the domain Satisfaction with Authorizations & Appeals Process for the 2018 survey. Additionally, Partners had the highest survey question score of all MCOs for the following: (Q27) LME/MCO website has been a useful tool for helping providers find the tools and materials needed to provide services. (Satisfaction with Information Technology: 89.6%); (Q14) Provider Network keeps providers informed of changes that affect the local provider network. (Satisfaction with Provider Network: 91.2%); (Q23) Authorizations for treatment are made within the required timeframes. (Satisfaction with Authorizations & Appeals Process: 95.5%); and (Q25) The authorizations issued are accurate. (Satisfaction with Authorizations & Appeals Process: 97.7%). Opportunities for improvement are within the domain of Satisfaction with the LME/MCO staff, with a domain score of 84.5% the lowest domain average for Partners in the 2018 survey. This domain also contained Partners’ lowest scoring question for the entire survey (Q6) LME/MCO staff referring consumers whose clinical needs match the services of the provider with a score of 76.3%, 10.5 points below the NC Overall score.

Section 3.5 Using Survey Data Describe how you use survey data including the ECHO survey, the Perception of Care survey and National Core Indicators to inform the LME/MCO on issues related to access to care and network adequacy and accessibility. Who do you share the data with and what efforts are occurring to address low scoring items?

Partners reports all provider & enrollee survey (ECHO, Perception of Care & National Core Indicators) results based on analysis to multiple committees both internally and externally. Internal committees include Quality Improvement Committee and Operations Team. External committees include Provider Forum, Provider Council & Global CQI Committee.

The analysis conducted on survey results includes identification of areas for improvement with attention specifically to access to care and network adequacy & accessibility. Quality Improvement Activities are developed to address low scoring items based on trending data from current and previous surveys.

Upon receiving the raw data and the completion of an analysis, a small workgroup is created based on subject matter experts [depends on the area identified for improvement] and interventions are developed and reported out to the Quality Improvement Committee in the form of recommendations. Comparison reports are created as well with correlations to satisfaction from year to year. Outcomes will be posted on our website using the language of strengths and improvement areas by June 2019.

Partners 2019 Network Adequacy and Accessibility Analysis Section Four: Special Populations 30 Section Four: Special Populations

Section 4.1 Transitions to Community Living Initiative (TCLI) A. Community-Based Supportive Housing Slots 1. Describe service gaps and needs, obstacles and barriers, and recent activities and projects in the LME/MCO to: a. Identify and engage eligible individuals in the TCLI priority population: Partners TCLI In-Reach has not experienced problems with this. TCLI In-reach has been able to identify individuals in the priority population. This is achieved through working with the State hospital, visiting individuals at the Adult Care Home, and reaching out to individual through the diversion process. b. Provide access and transition individuals to community-based supported housing: As of December 2018, Partners TCLI In-Reach has successfully transitioned 344 individuals (over the life of the program) into the community with no problems. Grants were submitted for housing funds, and education and training opportunities have been provided to landlords. Improved access to Targeted Key units has been offered by the Department of Health and Human Services (DHHS) after Partners did an analysis and identified lack of vacancy information. This assists in increasing housing capacity more quickly. Partners TCLI In-Reach has also provided education and training for consumers, providers and employers on employment options available for individuals with mental health, intellectual/developmental disability and substance use disorder diagnoses. Lastly, benefit counseling for individuals with disabilities has been provided over the last year to encourage employment without losing benefits. c. Transition individuals within 90 days of assignment to a transition team: Barriers experienced by the Partners TCLI In-Reach team within the first 90 days include: criminal history, financial problems, medical problems, finding places to live in the individuals chosen area, and not enough handicapped accessible units. Partners hired an additional Housing Coordinator to assist TCLI staff in locating housing and making referrals, including reducing housing barriers, such as limited housing resources, inspections, and background checks. Recent activities and projects related to transitioning individuals within 90 days: (1) Partners is actively pursuing the Master Leasing option. The funding for Master Leasing was not available until November 2018. Without confirmation from DMH that Master Leasing funds will continue to be available at necessary rates for the next fiscal year, the agency who was interested in Master Leasing isn’t comfortable signing one-year leases in March 2019 on a contract with Partners that expires June 30, 2019. Another alternative for diversion is being explored in Burke County rather than Master Leasing. In addition, Partners collaborated with Easter Seals CTI team and Davis Regional Hospital to pilot a Rapid Housing Project. The project would have emphasized diversion from Adult Care Homes and utilize hotel pilot funds. This project was ended due to the inability of the two community partners to reach an agreement. Partners will continue to focus the TCLI team on trouble- shooting moves and tracking the 90-day timeframe. Our goal was to increase available housing units by 30 through submission of building proposals in FY17-18 using TCLI Community Living Trust Funds at North Carolina Housing Finance Agency (NCHFA). Sixteen units were approved by NCHFA out of the 30 requested due to lack of funding at the state level as well as priority funding being sent to eastern NC from hurricane damage. This will increase the availability of units for those that are more difficult to house since Partners will have sole referral option. TCLI team will ensure that individuals are placed on hold when criteria are met. The current follow-up at 30 days was adjusted from the previous 45 day follow up. After the 30-day mark, follow-up will take place every 14 days. TCLI staff will identify individuals currently in the transition process and

Partners 2019 Network Adequacy and Accessibility Analysis Section Four: Special Populations 31 establish timeframes for move-in dates within 90 days. We will focus the TCLI team lead functions on trouble-shooting moves and tracking the 90-day timeframe. d. Support individuals’ housing tenure and ability to maintain supportive community-based housing: Partners has identified contractual issues as a barrier to transitioning individuals into housing. The individual has care coordination for 90 days after transition then could be closed to care coordination. Unless TCLI staff is notified, TCLI staff do not know there are problems with the individuals housing tenure. We have tried to manage this by having weekly calls with the TMS to discuss each person.

B. IPS – Supported Employment 1. Describe the network adequacy of IPS-Supported Employment services including: a. Number: 2 – Partners currently has two approved fidelity IPS-SE providers; Monarch Inc. and Coastal Southeastern United Care. Both providers meet fidelity and are approved IPS-SE providers. A Caring Alterative (ACA) will meet fidelity this summer, therefore increasing the number to three. b. locations of fidelity teams: Monarch Inc. provides IPS-SE services in Cleveland, Lincoln and Gaston Counties. Coastal Southern United Care serves Gaston, Lincoln, and Cleveland counties. c. capacity of fidelity teams: Monarch hired two additional Employment Specialists and will have the capacity to serve at least 80 consumers once all training is completed. Prior to this, Monarch served 38 consumers with IPS-SE services. Coastal Southeastern United Care serves consumers in Gaston, Lincoln and Cleveland. Coastal currently has 30 consumers in IPS-SE services. Coastal has hired a new Employment Specialist, so they will be able to increase the number of IPS-SE consumers they serve once training is completed. A Caring Alternative (ACA) was awarded the RFP for 2018 IPS-SE from Partners. ACA will be the third team providing IPS-SE services once they complete fidelity requirements and are approved to provide the IPS-SE services. ACA will provide IPS-SE services for Burke and Catawba. d. the LME-MCO’s total service capacity requirements (including but not limited to the TCLI population): 220 e. service gaps and needs: Partners has only two providers that meet fidelity and limits meeting this goal. Coastal Southeastern United serves consumers in Gaston, Lincoln, and Cleveland counties. Coastal served 30 consumers to date. Monarch provides this service in Cleveland, Lincoln and Gaston counties. Monarch served 38 consumers with IPS-SE services. ACA will provide services for Burke and Catawba counties once they complete fidelity requirements.

2. Describe obstacles and barriers as well as recent activities and projects to engage and refer individuals in the TCLI priority population, including individuals with SMI living in community-based supportive housing and individuals living in or at risk of entry to adult care homes. Obstacles and barriers to sustainability of this service include concerns about the rates and how fidelity scoring is implemented. Providers express concerns about being able to maintain the service with the current payment structure and individuals are concerned about changes to the benefits they receive. We have focused on the recruitment of additional IPS-SE providers. Partners released a Request for Information (RFI) on Individual Placement and Support-Supported Employment (IPS-SE) for Burke and Catawba counties on May 23, 2018. Nine providers attended the Bidder’s conference held on June 6, 2018. It appeared that several were interested in the RFI. However, only two responses were received. Partners initiated a Root Cause Analysis (RCA) involving our interdepartmental team, current IPS-SE providers and A Caring Alternative (ACA) Provider. TCLI staff will consult with and utilize technical assistance from the Supportive Employment/Enhanced

Partners 2019 Network Adequacy and Accessibility Analysis Section Four: Special Populations 32 Services Learning Collaborative on an ongoing basis. A Quality Improvement Project (QIP) was developed that included marketing IPS-SE to all individuals. We increased our focus on the referral management process for TCLI consumers at an individual level and increased consumer engagement with Supported Employment services. This resulted in reaching the total of 344 engaged consumers by end of December 2018. Partners will develop a script for TCLI and Care Coordination staff and will develop a strategic communication and marketing plan for IPS-SE. We are working internally to complete a cost analysis of the IPS-SE service. The report that we have created assesses IPS-SE effectiveness on an individual basis. Additionally, we have built into provider contracts IPS-SE incentives for adding members of the in/at risk population to increase IPS- SE service utilization. The feedback received from the providers who do deliver this service across the state and meet fidelity is this service needs to start at the good fidelity rate for baseline and then move up from there to be viable. This feedback is being assessed.

C. Community-Based Mental Health Services 1. Describe the array and intensity of community-based mental health services provided to individuals living in supportive housing, as well as their sufficiency: Individuals in supportive housing are linked with tenancy support and have access to the full-service array including but not limited to, mobile crisis, outpatient services, care coordination, Assertive Community Treatment Teams (ACTT), as well as respite. Tenancy support is a short-term service to transition individuals from a higher level of residential living to a community-based setting.

2. Describe personal outcomes indicative of greater integration in the community. Personal outcomes addressed in response should include the following: The numbers below were gathered two ways: (1) They are reflective of individuals that were participating in TCLI and Supported housing. The total number of surveyed individuals = 988. Personal Outcomes are not tracked specifically for the TCLI population after 90 days. Therefore, some of the items below do not reflect solely the TCLI population. (2) Claims FY18 data where an individual received a service with the DJ modifier. There were 188 individuals tracked this way during FY18. a. supportive housing tenure and maintenance of chosen living arrangement; 344 individuals have been successfully transitioned into their chosen living arrangement in the community. On the of barriers to tracking individuals is the individual has care coordination for 90 days after transition then could be closed to Care coordination. Unless TCLI staff is notified, TCLI staff do not know there are problems with their housing tenure. We have tried to manage this by having weekly calls with the TMS to discuss each person. b. hospital, adult care home, or inpatient psychiatric facility admissions; After completion of service: Out of 342 participants 14.9% reported a psychiatric inpatient episode. FY18 claims data shows, out of 188 individuals, 14.4% (n = 27) had a psychiatric inpatient episode and 19.1% (n = 36) had an initial hospital visit, subsequent hospital visit, or hospital discharge. c. use of crisis beds and community hospital admissions; Out of 342 participants, 21.6% reported a crisis contact. Additionally, FY18 claims data shows out of 188 individuals, 4.3% (n = 8) had a crisis intervention – facility based; 2.7% (n = 5) had a crisis assessment & intervention; and 6.4% (n = 12) had a mobile crisis service. d. emergency room visits; 22.5%; FY18 claims data shows out of 188 individuals, 21.3% (n=40) had an ER visit during the fiscal year. e. incidents of harm; 5% f. time spent in congregate day programming; .6% g. employment; Out of 647 respondents, 39% were in the labor force, 17% were employed full

Partners 2019 Network Adequacy and Accessibility Analysis Section Four: Special Populations 33 time, and 23.9% were employed part time; FY18 claims data reports, of the 188 individuals 5.3% (n = 10) received supported employment services. h. school attendance/ enrollment; out of 716 respondents, 92% were enrolled in an academic program i. engagement in community life: out of 647 respondents, 13% participated in community/leisure events, and 7% in recovery related activities

3. Describe gaps and needs in the community-based mental health services provided to individuals in TCLI supportive housing. Note that this item refers to gaps and needs related to the provision and outcomes of services for the TCLI population, and not solely to the access and choice standards. In the past, individuals have reported difficulty in reaching providers when they needed service. There has been a focus to train peers to provide support in daily living skills, adherence to leases, and financial guidance.

4. Describe obstacles and barriers as well as recent activities and projects to address gaps in the array, intensity, and sufficiency of community-based mental health services provided to individuals in supportive housing: One of the obstacles is conflict between provider staff and TCLI individual. If there is a conflict between individuals and provider staff, individuals will not engage with the provider and disengage from services and ultimately could lead to eviction. In some cases, consumers engaged in services lose their housing due to firing their providers. Projects to address the gap includes (Assertive Community Treatment Team) ACTT and other high intensity service providers having a formal process to notify Partners Access when they have been terminated from providing services. However, for ACTT the team has a high intensity caseload with a large caseload, and sometimes they cannot respond as quickly as the TCLI member may need. Additionally, there are some geographic limits on certain service availability. For example, Surry, Yadkin and Iredell have only ACTT, PSR, Peer Support and TMS, so there is no continuum of services in that area. Another obstacle is medication adherence which can result in housing problems due to psychiatric instability. Projects to address this issue include solving transportation issues, psychoeducation on taking medications, improved treatment engagement, leasing violations, and compliance with appointments to renew medications. Individuals are happy to let their buddies sleep on their couch or bring pets in without adding them to their lease. Improving daily living skills and more face to face visits by providers may also positively impact this issue. Treatment teams are built into the process and have occurred to address the issues. Lastly, B3 peer service funding is limited and therefore, limits peer engagement.

D. Crisis Services * Note that this item refers to gaps and needs related to the provision and outcomes of services for the TCLI population, and not solely to the access and choice standards addressed in Section One. 1. Describe the network adequacy of the LME/MCO crisis service system including: a. the geographic availability: There is no difference in the availability of services for TCLI consumers across the catchment area. The whole catchment area has access to the crisis service system. All consumers, including the TCLI population, have access to mobile crisis, integrated care centers, and behavioral health urgent care and access to care. b. crisis service array and intensity of services: The comprehensive crisis service array is available to all TCLI individuals. This includes, but is not limited to, mobile crisis, facility-based crisis, psychotherapy for crisis, Assertive Community Treatment Teams (ACTT), Facility based crisis, TMS, BHUC.

Partners 2019 Network Adequacy and Accessibility Analysis Section Four: Special Populations 34 c. the sufficiency to offer timely and accessible services and supports to individuals experiencing a behavioral health crisis: Consumers with Medicaid and those appearing to meet criteria for State Funded target populations are linked through Screening Triage & Refer (STR) to providers for an initial assessment/evaluation and treatment. This applies to TCLI consumers as well as individuals across the catchment area. Consumers who do not appear to qualify for any benefits under State Funds are linked to community resources. Standardized screening, triage and referral protocols focus on timely access to the most needed level of care. Triage is a brief process aimed at determining the intensity of the consumer’s need and results in prioritizing their level of care into the following categories: Emergent Care Consumers will be seen face-to- face within 2 hours and 15 minutes or directly linked to 911 depending on severity due to medical needs. Consumers presenting with moderate risk or incapacitation in one or more area(s) of physical, cognitive, or behavioral functioning related to MH/IDD/SA problems. Urgent Care is provided within 48 hours of initial contact if the consumer is experiencing a more slowly evolving crisis and a catastrophic outcome is not imminent. Consumers presenting with mild risk or incapacitation in one or more area(s) of safety, or physical, cognitive, or behavioral functioning related to MH/IDD/SA problems. Routine Care will be provided to consumers within 14 calendar days of initial contact. d. service gaps and needs: The only concern here is Transition Management Services are not a clinical service and those providing the service do not have the training needed to conduct assessments in a crisis.

2. Describe the extent to which crisis services are provided in the least restrictive setting and consistent with an already developed individual community-based crisis plan or in a manner that develops such a plan as a result of the crisis situation, and in a manner that prevents unnecessary hospitalization, incarceration or institutionalization: A crisis plan is developed prior to crisis episodes and assists with providing community supports that are helpful to each individual during a crisis to prevent hospitalization. These plans are made available to mobile crisis providers and/or ACTT team staff.

3. Describe obstacles and barriers as well as recent activities and projects to address gaps related to crisis service availability, delivery, sufficiency, and outcomes: Transition Management is not a clinical service and is often the first response for a TCLI consumer. Partners has offered some training with Transition Management Services (TMS) to assist with the crisis referral process and the state is looking to add TMS services to the Community Support Team service definition that will give clinical oversight. They are scheduled to release this definition July 1, 2019.

Section 4.2 Children with Complex Needs “Children with Complex Needs” are defined as Medicaid eligible children ages 5 to 21 with a developmental disability (including Intellectual Disability and Autism Spectrum Disorder) and a mental health disorder, who are at risk of not being able to enter or remain in a community setting due to behaviors that present a substantial risk of harm to the child or to others. A. Describe service gaps and needs as well as obstacles and barriers to identifying and linking children with complex needs to appropriate levels of services including Case Management and all services provided by NC START. Service gaps and needs include not enough IAFT/TFC for Dually Diagnosed Children, Residential Level III Group Homes for Dually Diagnosed Children, Group Homes for Adults with Dual-Diagnosis providers. Obstacles and barriers to addressing these gaps is the low reimbursement rate with no State funding to offset the cost. Additionally, there are not enough psychologists to provide the Psychological Services for the in-depth evaluations that are required.

Partners 2019 Network Adequacy and Accessibility Analysis Section Four: Special Populations 35 Behavioral Programming Services, Pharmacological evaluation services, Community Navigator/ Advocacy Services, Crisis Respite, ABA / RH-BHT services are also lacking providers willing to provide the service due to lack of funding.

B. Describe recent activities, projects, and initiatives in the LME/MCO to identify children with complex needs, link them with services including Case Management, ABA therapy and NC START services, and address related service gaps and needs, obstacles, and barriers. We do not have an issue with identifying the children who need the services. The gaps have been in having service providers to provide the services to the children with complex needs. To close this gap, we have RFP/RFI for additional providers of TCM, under EPSDT, ABA Collaborative, as well as RFPs for providers IAFT, Group Homes and Residential Level III for Dually Diagnosed populations. Ongoing RFPs for Psychological Services as providers for psychological evaluations are very limited, causing consumers to travel great distances to have get the evaluations done.

Section 5: Network Access Plan

Section 5: Network Access Plan can be found in Appendix F.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 36 Appendix A: Geo Maps Provide separate geo maps for each service listed in these requirements, except for outpatient services. On geo maps, show only provider agencies with current (as of 1/1/2019) LME/MCO.

Location Based Services

Instructions: One geo map for each Medicaid and Non-Medicaid funded location-based service. Show provider locations with a radius of 30 miles for providers located in urban counties and 45 miles for providers located in rural counties.

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 37 Psychosocial Rehabilitation

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 38 Child and Adolescent Day Treatment

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 39 SA Comprehensive Outpatient Treatment

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 40 SA Intensive Outpatient Treatment

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 41 Opioid Treatment

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 42 Day Supports

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 43 Community Mobile Services Instructions: One geo map for each Medicaid and Non-Medicaid funded community/mobile service. Show provider coverage on each map. For example, if a provider serves only enrollees who live in a particular county, shade in the county that is covered.

Assertive Community Treatment Team

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 44 Community Support Team

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 45 Intensive In-Home

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 46 Mobile Crisis

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 47 Multi-Systemic Therapy

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 48 (b)(3) MH Supported Employment Services

(b)(3) I/DD Supported Employment Services

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 49 (b)(3) Waiver Community Guide

(b)(3) Waiver Individual Support (Personal Care)

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 50 (b)(3) Waiver Peer Support

(b)(3) Waiver Respite

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 51 I/DD Supported Employment Services (non-Medicaid-funded)

Long-term Vocational Supports (non-Medicaid-funded)

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 52 MH/SA Supported Employment Services (IPS-SE) (non-Medicaid-funded)

I/DD Non-Medicaid-funded Personal Care Services

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 53 I/DD Non-Medicaid-funded Respite Community Services

I/DD Non-Medicaid-funded Respite Hourly Services not in a licensed facility

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 54 Developmental Therapies (Non-Medicaid)

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 55 Crisis Services Instructions: One geo map for each Medicaid and Non-Medicaid funded crisis service that shows provider locations within the LME/MCO’s catchment area.

Facility-Based Crisis – Adults

*Additional provider locations are in Beaufort, Cabarrus, Mecklenburg, Union, Wake, and Wilkes.

*Additional provider locations are in Cabarrus, Union, and Wilkes.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 56 Facility-Based Respite

*Additional provider locations are in Alamance, Caldwell, McDowell, New Hanover, and Rutherford.

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 57 Detoxification (non-hospital)

*Additional provider location in Wake.

*Additional provider location in Davidson.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 58 Inpatient Services Instructions: One geo map for each Medicaid and Non-Medicaid funded inpatient service that shows provider locations within the LME/MCO’s catchment area.

Inpatient Hospital – Adults

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 59 Inpatient Hospital – Adolescent/Child

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 60 Specialized Services Instructions: One geo map for each Medicaid and Non-Medicaid funded specialized service that shows provider locations within North Carolina.

Partial Hospitalization

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 61 MH Group Homes

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 62 Psychiatric Residential Treatment Facility

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 63 Residential Treatment Level 1

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 64 Residential Treatment Level 2: Therapeutic Foster Care

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 65 Residential Treatment Level 2: other than Therapeutic Foster Care

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 66 Residential Treatment Level 3

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 67 Residential Treatment Level 4

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 68 Child MH Out-of-home Respite

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 69 SA Non-Medical Community Residential Treatment

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 70 SA Medically Monitored Community Residential Treatment

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 71 SA Halfway Houses

I/DD Out-of-home respite (non-Medicaid-funded)

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 72 I/DD Facility-based respite (non-Medicaid-funded)

I/DD Supported Living (non-Medicaid-funded)

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 73 (b)(3) I/DD Out-of-Home Respite

(b)(3) I/DD Facility-Based Respite

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 74 (b)(3) I/DD Residential Supports

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 75 Intermediate Care Facility/IDD

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 76 C-Waiver Services Instructions: One geo map for each C-Waiver residential and day supports service.

Residential Supports 1

Residential Supports 2

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 77 Residential Supports 3

Residential Supports 4

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 78 Day Supports

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 79 Additional Opioid Services Instructions: One geo map for prescribers of Buprenorphine that the LME/MCO has a contract/MOU/MOA with that addresses opioid use disorder needs for persons in the LME/MCO network. In addition to the map, provide the prescribers names, group affiliation (organization or facility name), address (street, city, county, zip), counties served by service location.

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 80 Prescriber Table ∗ If there is no prescriber mentioned, then all the agency's clinicians are contracted with Partners to prescribe. ∗ If there is no agency name, the prescriber is an Independent provider. ∗ Providers serve all counties. (i.e. if a member from Morganton wants to see a provider in Surry, they can do so, and the provider will accept them.

Location Prescriber Name Group Affiliation Address Counties Served County Thompson's Family 1006 Union Rd Suite B, Gastonia, NC, Burke, Catawba, Cleveland, Gaston, Julie Thompson PA GASTON Psychiatric Care 28054 Iredell, Lincoln, Surry, Yadkin Dr. Brenda Willis Piedmont Psychiatric Burke, Catawba, Cleveland, Gaston, 1040 X-ray Drive, Gastonia, NC, 28054 GASTON M.D. Associates Iredell, Lincoln, Surry, Yadkin Northern Medical Burke, Catawba, Cleveland, Gaston, Dr. Richard Stork 110 Dutchman Court, Elkin, NC, 28621 SURRY Group Iredell, Lincoln, Surry, Yadkin Northern Medical Burke, Catawba, Cleveland, Gaston, Dr. Ben Raines D.O. 110 Dutchman Court, Elkin, NC, 28621 SURRY Group Iredell, Lincoln, Surry, Yadkin Dr. Emidio Northern Medical Burke, Catawba, Cleveland, Gaston, 110 Dutchman Court, Elkin, NC, 28621 SURRY Novembre D.O. Group Iredell, Lincoln, Surry, Yadkin Burke, Catawba, Cleveland, Gaston, Dr. Jay Synn Hickory Psychiatric Ser 1109 2nd Ave SW, Hickory, NC, 28602 CATAWBA Iredell, Lincoln, Surry, Yadkin Gaston Family Medical 111 E 3rd Avenue, Gastonia, NC, Burke, Catawba, Cleveland, Gaston, Dr. Robert Forinash GASTON Center 28052 Iredell, Lincoln, Surry, Yadkin Burke, Catawba, Cleveland, Gaston, McLeod 117 W Medical Ct, Marion, NC, 28752 MCDOWELL Iredell, Lincoln, Surry, Yadkin 1170 Fairgrove Church Rd, Hickory, Burke, Catawba, Cleveland, Gaston, McLeod CATAWBA NC, 28602 Iredell, Lincoln, Surry, Yadkin Burke, Catawba, Cleveland, Gaston, Larry Cummins M.D. 1333 Fallston Rd, Shelby, NC, 28150 CLEVELAND Iredell, Lincoln, Surry, Yadkin Burke, Catawba, Cleveland, Gaston, McLeod 150 Den Mac Dr, Boone, NC, 28607 WATAUGA Iredell, Lincoln, Surry, Yadkin Burke, Catawba, Cleveland, Gaston, McLeod 150 Den Mac Dr, Boone, NC, 28607 WATAUGA Iredell, Lincoln, Surry, Yadkin

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 81 Location Prescriber Name Group Affiliation Address Counties Served County Psychiatric Services of 1530 Union Rd Unit 1, Gastonia, NC, Burke, Catawba, Cleveland, Gaston, Dr. Nilima Shukla GASTON Carolina 28054 Iredell, Lincoln, Surry, Yadkin Ernest Chander Carolina Psychiatric Burke, Catawba, Cleveland, Gaston, 1552-C Union Rd, Gastonia, NC, 28054 GASTON M.D. Associates Iredell, Lincoln, Surry, Yadkin Cornelius Okonkwo Carolina Mercy Medical 2101 West Franklin Boulevard, Burke, Catawba, Cleveland, Gaston, GASTON D.O. Clinic Gastonia, NC, 28052 Iredell, Lincoln, Surry, Yadkin Center Street 211 South Center St Suite 217-A, Burke, Catawba, Cleveland, Gaston, Dr. Patricia Hill M.D. IREDELL Counseling Statesville, NC, 28677 Iredell, Lincoln, Surry, Yadkin Piedmont Healthcare Dr. Amy Singleton 211 South Tradd St, Statesville, NC, Burke, Catawba, Cleveland, Gaston, Psychiatry and IREDELL M.D. 28677 Iredell, Lincoln, Surry, Yadkin Behavioral Medicine 222 Morganton Blvd SW, Lenoir, NC, Burke, Catawba, Cleveland, Gaston, McLeod CALDWELL 28645 Iredell, Lincoln, Surry, Yadkin Dr. Mario Zapata 276 Old Mocksville Rd Suite 100, Burke, Catawba, Cleveland, Gaston, IREDELL M.D. Statesville, NC, 28625 Iredell, Lincoln, Surry, Yadkin 3000 Bethesda Place, Suite 801, Burke, Catawba, Cleveland, Gaston, Family Behavioral FORSYTH Winston Salem, NC, 27103 Iredell, Lincoln, Surry, Yadkin 301 E Meeting St, Morganton, NC, Burke, Catawba, Cleveland, Gaston, Cognitive Connections BURKE 28655 Iredell, Lincoln, Surry, Yadkin 301 E Meeting St, Morganton, NC, Burke, Catawba, Cleveland, Gaston, Rudisill at BIH Burke Integrate Care BURKE 28655 Iredell, Lincoln, Surry, Yadkin 301 E Meeting St, Morganton, NC, Burke, Catawba, Cleveland, Gaston, Rudisill at BIH Burke Integrate Care BURKE 28655 Iredell, Lincoln, Surry, Yadkin Burke, Catawba, Cleveland, Gaston, ARMS 31 E Main Ave, Taylorsville, NC, 28681 ALEXANDER Iredell, Lincoln, Surry, Yadkin Burke, Catawba, Cleveland, Gaston, Cognitive Connections 423 7th Ave SW, Hickory, NC, 28602 CATAWBA Iredell, Lincoln, Surry, Yadkin Burke, Catawba, Cleveland, Gaston, Kathy Rudisill PA Rudisill Family Practice 425 7th Ave SW, Hickory, NC, 28601 CATAWBA Iredell, Lincoln, Surry, Yadkin Dr. Elbert Rudisill Jr., Burke, Catawba, Cleveland, Gaston, Rudisill Family Practice 425 7th Ave SW, Hickory, NC, 28601 CATAWBA M.D. Iredell, Lincoln, Surry, Yadkin

Partners 2019 Network Adequacy and Accessibility Analysis Appendix A: Geo Maps 82 Location Prescriber Name Group Affiliation Address Counties Served County 438-1 East Long Ave, Gastonia, NC, Burke, Catawba, Cleveland, Gaston, Subhash Patel GASTON 28054 Iredell, Lincoln, Surry, Yadkin Dr. Noel Ibanez 484 Williamson Rd#101, Mooresville, Burke, Catawba, Cleveland, Gaston, Act on Addiction IREDELL M.D. NC, 28117 Iredell, Lincoln, Surry, Yadkin 505 West Fleming Drive, Morganton, Burke, Catawba, Cleveland, Gaston, Greg Clary Sandhills Neurology BURKE NC, 28655 Iredell, Lincoln, Surry, Yadkin MECKLENBU Burke, Catawba, Cleveland, Gaston, McLeod 515 Clanton Rd, Charlotte, NC, 28217 RG Iredell, Lincoln, Surry, Yadkin Dr. Bobby Kearney 536 Signal Hill Drive Ext, Statesville, Burke, Catawba, Cleveland, Gaston, ARMS IREDELL M.D. NC, 28625 Iredell, Lincoln, Surry, Yadkin Burke, Catawba, Cleveland, Gaston, McLeod 549 Cox Rd, Gastonia, NC, 28054 GASTON Iredell, Lincoln, Surry, Yadkin Dr. Timothy Sloand 609 South New Hope Rd Suite 200D, Burke, Catawba, Cleveland, Gaston, Act on Addiction GASTON M.D. Gastonia, NC, 28054 Iredell, Lincoln, Surry, Yadkin 636 Signal Hill Drive, Statesville, NC, Burke, Catawba, Cleveland, Gaston, McLeod IREDELL 28625 Iredell, Lincoln, Surry, Yadkin 665 W 4th St, Winston Salem, NC, Burke, Catawba, Cleveland, Gaston, Insight FORSYTH 27101 Iredell, Lincoln, Surry, Yadkin Pushpa Chander Pain Management Burke, Catawba, Cleveland, Gaston, 7005 Wallace Rd, Charlotte, NC, 28212 GASTON M.D. Services Iredell, Lincoln, Surry, Yadkin 839 Magestic Court, Gastonia, NC, Burke, Catawba, Cleveland, Gaston, Vikram Shukla M.D. GASTON 28054 Iredell, Lincoln, Surry, Yadkin 847 Westlake Drive, Mt Airy, NC, Burke, Catawba, Cleveland, Gaston, Daymark SURRY 27030 Iredell, Lincoln, Surry, Yadkin

Partners 2019 Network Adequacy and Accessibility Analysis Appendix B: Registry of Unmet Needs I/DD Waitlist 83 Appendix B: Registry of Unmet Needs

Partners 2019 Network Adequacy and Accessibility Analysis Appendix B: Registry of Unmet Needs I/DD Waitlist 84

Partners 2019 Network Adequacy and Accessibility Analysis Appendix B: Registry of Unmet Needs I/DD Waitlist 85

Partners 2019 Network Adequacy and Accessibility Analysis Appendix C: Provider Ratios 86 Appendix C: Provider Ratios

Practitioner Type Ratios

Ratios were calculated in two ways due to differing consumer count numbers: 1) based on the total number of consumers eligible per the Consumer data provided to IBHA pulled on 01302019 without any data cleaning (considered total) 2) Using those eligible in the catchment area with just Medicaid funds (considered Catchment) Practitioner Type definitions can be found below. All practitioners had to have an expiration date on or after 1/1/19 & an end date of blank or on or after 1/1/19.

Total Catchment Total Practitioner Type Measure: Ratio Standard Ratio Ratio Population # 224,438 Total Catchment Psychiatrist Psychiatrist to members 1:2,000 1:472 1:363 Medicaid # 172,653

Clinical Psychologist Clinical psychologist to member 1:10,000 1:1986 1:1528 Licensed Clinical Social Worker Licensed clinical social worker to member 1:1000 1:354 1:272 Licensed Professional Counselor Licensed Professional Counselor to members 1:1000 1:304 1:234

Practitioner Type Defined as Count License code = MD & Taxonomy beginning Psychiatrist 476 with 2084P Taxonomy code = 103T00000X & License Clinical Psychologist 113 code of LP or LPA Licensing code LCSW or LCSW-P & Licensed Clinical Social Worker 634 Taxonomy of 1041C0700X Taxonomy codes: 101YA0400X, Licensed Professional Counselor 101YP2500X, 101YM0800X, 101Y00000X & 739 License Code LPC, LPCS, LPCA

Partners 2019 Network Adequacy and Accessibility Analysis Appendix C: Provider Ratios 87

Facility Type Ratios

Ratios were calculated in two ways due to differing consumer count numbers: 1) based on the total number of consumers eligible per the Consumer data provided to IBHA pulled on 01302019 without any data cleaning (considered total) 2) Using those eligible in the catchment area with just Medicaid funds (considered Catchment) Facility Type definitions can be found below.

Total Catchment Total Facility Type Measure: Ratio Standard Ratio Ratio Population # 224,438 Inpatient Hospitals to Total Catchment Inpatient Hospitals 1:10,000 1:24,938 1:19,184 members Medicaid # 172,653 Residential Facilities to Residential 1:7,500 1:1,592 1:1,224 member Ambulatory Services to Ambulatory Services 1:750 1:257 1:198 member

Facility Type Defined as Count Inpatient From the state requirement document Appendix C. Organization Type = Hospital & 9 Hospitals matching procedure code when applicable. Using the information from Appendix C of the State document all those sites with Residential Treatment Level 1, 2, 3, or 4. Physical location was counted only once Residential per provider but if multiple agencies were at the same physical address it was 141 counted once for each provider parent agency. This means treatment level was not considered for the final count.

Outpatient service from Appendix C of the state requirement document. Physical location, not just parent agency was counted. Physical location was counted only Ambulatory 873 Services once per provider but if multiple parent agencies were at the same physical address it was counted once for each provider parent agency.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 88 Appendix D1: Demographic & Special Population Data

Partners Catchment Area Partners service region is located in the Western third of the state of North Carolina. Their service region is also referred to as their “catchment area” and includes eight counties: Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Surry, and Yadkin. Partners catchment area covers 3,465 square miles. The catchment area runs approximately 125 miles from its southwest corner to its northeast corner and is about 90 miles wide. NC DHHS uses information from the United States Office of Management and Budget (OMB) to designate counties as either Rural or Urban. According to the designations done by NC DHHS, Partners catchment area consists of six urban counties (Burke, Catawba, Gaston, Iredell, Lincoln, and Yadkin) and two rural counties (Cleveland and Surry). Gaston has the largest population out of the eight counties at 220,182 people and Yadkin County has the smallest population at 37,774. The total population for the Partners service region is approximately 932,895.

Table 1A. Service Region Population and Area within the Catchment Area Compared to State and National Averages. County Population Area (sq. mi) (People/sq. mi) Burke 89,293 507.1 176.09 Catawba 157,974 398.72 396.20 Cleveland 97,334 464.25 209.66 Gaston 220,182 356.03 618.44 Iredell 175,711 573.83 306.21 Lincoln 82,403 297.94 276.58 Surry 72,224 532.17 135.72 Yadkin 37,774 334.83 112.82 Partners 932,895 3,465 269.24 North Carolina 10,273,419 48,617.91 211.31 United States 325,719,178 3,531,905.43 92.22 Source: U.S. Census Bureau, 2017 Estimates; 3/20/2019

Table 1B. Service Region Population Served and Area within the Catchment Area. Population County n % of Total Served Burke 4,575 11.12% Catawba 6,728 16.36% Cleveland 5,600 13.62% Gaston 11,634 28.29% Iredell 5,032 12.23% Lincoln 3,334 8.11% Surry 2,817 6.85% Yadkin 1,253 3.05% Other 928 2.26% Partners 41,131 100.00% Source: Data cubes and claims data Partners total and the sum of the counties may differ due to movement within the catchment area. Partners total is the unduplicated count.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 89 Age and Gender Demographics The table below shows the distribution of age for the Partners catchment area. Nearly 30% of the population are 24 and under, whereas, 24.12% are between 25 and 44 years and 28.52% are between 45 and 65 years. Lastly, 16.54% of the Partners population is 65 years and older.

Table 2A. Age breakdown of the Catchment Area compared to State and National Averages. County Ages 0-14 Ages 15-24 Ages 25-44 Ages 45-64 65 and Over Burke 15.84% 12.54% 23.31% 29.54% 18.76% Catawba 18.71% 12.54% 23.92% 28.26% 16.57% Cleveland 18.10% 13.54% 22.58% 28.26% 17.51% Gaston 18.97% 12.41% 25.60% 27.73% 15.29% Iredell 19.24% 12.65% 24.81% 28.42% 14.88% Lincoln 17.78% 11.55% 23.95% 30.41% 16.31% Surry 17.71% 12.11% 22.56% 28.46% 19.16% Yadkin 17.65% 12.15% 22.58% 28.91% 18.71% Partners 18.32% 12.50% 24.12% 28.52% 16.54% North Carolina 18.88% 13.63% 26.07% 26.34% 15.07% United States 19.01% 13.62% 26.39% 26.12% 14.87% Source: U.S. Census Bureau, 2017 American Community Survey 5-Year Estimates, 2017; 4/12/2019

The table below shows the age breakdown of those served by Partners in FY18.

Table 2B. Age breakdown of those served by Partners in FY18 Ages 3-12 Ages 13-17 Ages 18-20 Ages 21-34 Ages 35-64 65 and Over County % % % % % % n n n n n n Served Served Served Served Served Served Burke 794 17.36% 506 11.06% 215 4.70% 1,208 26.40% 1,812 39.61% 178 3.89% Catawba 1,240 18.43% 915 13.60% 306 4.55% 1,575 23.41% 2,596 38.59% 307 4.56% Cleveland 1,089 19.45% 749 13.38% 231 4.13% 1,326 23.68% 2,107 37.63% 290 5.18% Gaston 2,190 18.82% 1,589 13.66% 596 5.12% 2,707 23.27% 4,508 38.75% 477 4.10% Iredell 1,053 20.93% 820 16.30% 262 5.21% 1,214 24.13% 1,600 31.80% 253 5.03% Lincoln 644 19.32% 499 14.97% 160 4.80% 826 24.78% 1,152 34.55% 161 4.83% Surry 579 20.55% 387 13.74% 150 5.32% 661 23.46% 988 35.07% 167 5.93% Yadkin 251 20.03% 209 16.68% 66 5.27% 285 22.75% 421 33.60% 65 5.19% Partners 7,744 18.83% 5,620 13.66% 1,986 4.83% 9,957 24.21% 15,361 37.35% 1,891 4.04% Source: Data cubes and claims data Partners total and the sum of the counties may differ due to movement within the catchment area. Partners total is the unduplicated count.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 90 The table below shows the distribution of gender for the Partners catchment area. The total population is evenly distributed between males and females, with 48.82% identifying as male, and 51.18% identifying as female.

Table 3A. Gender breakdown of the Catchment Area compared to State and National Averages. County Male Female Burke 49.39% 50.61% Catawba 48.94% 51.06% Cleveland 48.16% 51.84% Gaston 48.21% 51.79% Iredell 49.22% 50.78% Lincoln 49.52% 50.48% Surry 48.63% 51.37% Yadkin 49.11% 50.89% Partners 48.82% 51.18% North Carolina 48.70% 51.30% United States 49.23% 50.77% Source: U.S. Census Bureau, 2017 American Community Survey 5-Year Estimates, 20717; 4/12/2019

The table below shows the gender breakdown of those served by Partners in FY18.

Table 3B. Gender breakdown of those served by Partners in FY18 Male Female County n % Served n % Served Burke 2,118 46.30% 2,457 53.70% Catawba 3,097 46.03% 3,631 53.97% Cleveland 2,583 46.13% 3,017 53.88% Gaston 5,291 45.48% 6,343 54.52% Iredell 2,317 46.05% 2,715 53.95% Lincoln 1,482 44.45% 1,852 55.55% Surry 1,257 44.62% 1,560 55.38% Yadkin 565 45.09% 688 54.91% Partners 18,971 46.12% 22,160 53.88% Source: Data cubes and claims data Partners total and the sum of the counties may differ due to movement within the catchment area. Partners total is the unduplicated count.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 91

Race and Ethnicity Demographics The table below describes the distribution of ethnicity for the Partners catchment area. It can be seen that the vast majority of the population, 81.39%, describes themselves as White Alone, whereas 21.48% of the population describes themselves as Black or African American, 3.09% as some other race alone, and 2.68% or less for each ethnic group described themselves as American Indian and Alaska Native alone, Asian alone, Native Hawaiian and other Pacific Islander alone, and two or more races.

Table 4A. Race Breakdown of the Catchment Area compared to State and National Averages. Black or American Native Hawaiian Some Two or County White African Indian and Asian and Other Pacific Other More American Alaska Native Islander Race Races Burke 84.66% 5.96% 0.54% 3.65% 0.13% 3.52% 1.55% Catawba 78.78% 8.09% 0.28% 4.11% 0.00% 6.44% 2.30% Cleveland 75.21% 20.81% 0.22% 0.97% 0.00% 1.26% 1.53% Gaston 76.91% 15.71% 0.39% 1.48% 0.07% 3.07% 2.38% Iredell 81.46% 12.45% 0.32% 2.33% 0.01% 1.87% 1.56% Lincoln 88.60% 5.35% 0.20% 0.54% 0.04% 2.83% 2.43% Surry 91.50% 3.74% 0.37% 0.61% 0.05% 2.08% 1.66% Yadkin 90.82% 3.35% 0.13% 0.10% 0.06% 3.90% 1.64% Partners 81.39% 11.04% 0.33% 2.03% 0.04% 3.21% 1.96% North Carolina 69.01% 21.48% 1.17% 2.68% 0.06% 3.09% 2.50% United States 73.01% 12.65% 0.82% 5.35% 0.18% 4.85% 3.14% Source: U.S. Census Bureau, 2017 American Community Survey 5-Year Estimates, 2017; 3/12/2019

The table below shows the distribution of ethnicity of those served by Partners in FY18.

Table 4B. Race breakdown of those served by Partners in FY18. American Native Black or Indian and Hawaiian & Two or More White African Asian Unknown Alaskan Other Pacific Races County American Native Islander % % % % % % % n n n n n n n Served Served Served Served Served Served Served Burke 4,075 89.07% 327 7.15% 8 0.17% 25 0.55% 7 0.15% 81 1.77% 21 0.46% Catawba 5,421 80.57% 904 13.44% 20 0.30% 61 0.91% 4 0.06% 160 2.38% 53 0.79% Cleveland 4,142 73.96% 1,293 23.09% 15 0.27% 7 0.13% 1 0.04% 41 0.73% 53 0.95% Gaston 8,876 76.29% 2,303 19.80% 34 0.29% 36 0.31% 5 0.05% 141 1.21% 98 0.84% Iredell 3,818 75.87% 954 18.96% 14 0.28% 20 0.40% 6 0.12% 105 2.09% 59 1.01% Lincoln 2,933 87.97% 252 7.56% 6 0.18% 8 0.24% 0 0.00% 62 1.86% 21 0.59% Surry 2,578 91.52% 150 5.26% 2 0.07% 2 0.07% 0 0.00% 40 1.42% 21 0.95% Yadkin 1,129 90.10% 71 4.75% 4 0.32% 0 0.00% 1 0.08% 21 1.68% 8 0.65% Partners 33,049 80.35% 6,337 15.41% 104 0.25% 159 0.39% 24 0.06% 647 1.57% 333 0.81% Source: Data cubes and claims data Partners total and the sum of the counties may differ due to movement within the catchment area. Partners total is the unduplicated count.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 92

The table below describes the percentage of those who have Hispanic origin for the Partners Catchment area. Over 7% of those in the Partners Catchment area come from Hispanic origins. Cleveland county has the lowest percentage of their population that is of Hispanic origin, and Yadkin county has the largest percent.

Table 5A. Hispanic Origin of the Catchment Area residents compared to State and National Averages. County Hispanic Origin Burke 5.88% Catawba 9.33% Cleveland 3.31% Gaston 6.62% Iredell 7.36% Lincoln 7.03% Surry 10.17% Yadkin 10.92% Partners 7.29% North Carolina 9.10% United States 17.60% Source: U.S. Census Bureau, 2017 American Community Survey 5-Year Estimates, 2017; 3/12/2019

The table below describes the percentage of those who have Hispanic origin of those served by Partners in FY18.

Table 5B. Hispanic Origin of those served by Partners in FY18. Hispanic Origin County % Served n % Served without N/A Responses Burke 53 1.16% 1.76% Catawba 172 2.56% 4.19% Cleveland 46 0.82% 1.26% Gaston 266 2.29% 3.17% Iredell 97 1.93% 3.43% Lincoln 74 2.22% 3.29% Surry 80 2.84% 4.23% Yadkin 42 3.35% 6.05% Partners 830 2.05% 3.13% Source: Data cubes and claims data Partners total and the sum of the counties may differ due to movement within the catchment area. Partners total is the unduplicated count.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 93

Languages Spoken Data on language spoken at home were derived from answers to questions 14a and 14b in the 2017 American Community Survey (ACS). These questions were asked only of persons 5 years of age and older. Instructions mailed with the ACS questionnaire instructed respondents to mark “Yes” on Question 14a if they sometimes or always spoke a language other than English at home, and “No” if a language was spoken only at school, or if speaking was limited to a few expressions or slang. For Question 14b, respondents printed the name of the non-English language they spoke at home. If the person spoke more than one non-English language, accompanying instructions instructed them to report the language spoken most often. If the language spoken most frequently could not be determined, the respondent was instructed to report the language learned first.

Overall, the catchment area is less diverse in languages spoken compared to state and national rates, with the most predominant language spoken at home primarily is English. 91.37% of households in the Partners catchment area reporting English as the primary language, which is a larger proportion compared to 88.58% in North Carolina and 78.67% nationally. Within the catchment area, Spanish is the second highest reported language spoken at home at 6.13%, this is low however compared to state and national rates. Catawba County has the highest rates of household Spanish speakers at 8.34%, while Cleveland County has the lowest rates at 2.74%.

Table 6A. Percentage of languages spoken at home by the resident in the Catchment Area Compared to State and National Averages. Other Indo- Asian and Pacific Other County English Spanish European Island Languages Languages Languages Burke 92.03% 4.49% 0.44% 2.86% 0.18% Catawba 87.53% 8.34% 0.83% 3.19% 0.12% Cleveland 95.68% 2.74% 0.54% 0.64% 0.40% Gaston 92.05% 5.80% 0.96% 0.91% 0.28% Iredell 90.69% 6.02% 1.40% 1.69% 0.20% Lincoln 92.67% 6.35% 0.65% 0.26% 0.07% Surry 91.14% 7.94% 0.43% 0.41% 0.08% Yadkin 91.46% 7.94% 0.55% 0.03% 0.02% Partners 91.37% 6.13% 0.83% 1.47% 0.20% North Carolina 88.58% 7.46% 1.74% 1.64% 0.58% United States 78.67% 13.21% 3.62% 3.46% 1.04% Source: U.S. Census Bureau, 2017 5-Year American Community Survey, S1610; 3/14/2019

Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 94

The table below shows the breakdown languages spoken of those served by Partners in FY18, excluding those who responded N/A.

Table 6B. Languages spoken breakdown of those served by Partners in FY18, excluding those who responded N/A. Sign English French German Spanish Other Unknown Language County % % % % % % % n n n n n n n Served Served Served Served Served Served Served Burke 3,864 98.57% 3 0.08% 0 0.00% 12 0.31% 32 0.82% 6 0.15% 0 0.00% Catawba 5,397 96.93% 3 0.05% 0 0.00% 3 0.05% 137 2.46% 11 0.20% 12 0.22% Cleveland 4,762 98.96% 0 0.00% 0 0.00% 2 0.04% 29 0.60% 1 0.02% 11 0.23% Gaston 9,888 97.49% 5 0.05% 0 0.00% 11 0.11% 146 1.44% 6 0.06% 76 0.75% Iredell 3,667 96.73% 0 0.00% 1 0.03% 0 0.00% 57 1.50% 2 0.05% 64 1.69% Lincoln 2,789 98.10% 1 0.04% 0 0.00% 1 0.04% 33 1.16% 2 0.07% 14 0.49% Surry 2,339 97.01% 1 0.04% 0 0.00% 0 0.00% 40 1.66% 0 0.00% 30 1.24% Yadkin 961 96.68% 0 0.00% 0 0.00% 1 0.10% 15 1.51% 1 0.10% 15 1.52% Partners 33,877 97.65% 13 0.04% 1 0.00% 30 0.09% 491 1.42% 30 0.09% 222 0.64% Source: Data cubes and claims data Partners total and the sum of the counties may differ due to movement within the catchment area. Partners total is the unduplicated count.

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 95

Disability Partners catchment area has a higher proportion of residents living with disability characteristics compared to the proportion in North Carolina and the United States. Definitions on each difficulty can be found below the table.

Partners has an overall average of 4.72% of those that have hearing difficulty, 0.39% with vision difficulty, 5.84% with cognitive difficulties, 8.75% with ambulatory (walking) difficulty, 3.18% with self- care difficulty, and lastly, 5.56% with independent living difficulties. Burke County has the highest proportion of residents with difficulty in Hearing, Ambulatory, and Independent Living. Surry has the highest proportion of residents with a Cognitive difficulty, Yadkin has the highest proportion of residents with a Vision difficulty, and Cleveland has the highest proportion of residents with a Self-Care difficulty. Iredell has the lowest proportion of residents with difficulty in Hearing, Cognition, Ambulatory, Self-Care, and Independent Living, while Gaston county has the lowest proportion of residents with difficulty in Vision.

Table 7A. Disability status of Catchment Area residents compared to State and National Averages. Hearing Vision Cognitive Ambulatory Self-Care Independent County Difficulty Difficulty Difficulty Difficulty Difficulty Living Difficulty Burke 6.73% 0.52% 7.48% 11.60% 3.85% 7.21% Catawba 4.24% 0.28% 5.36% 7.78% 2.99% 4.89% Cleveland 5.19% 0.56% 5.42% 9.82% 4.08% 6.42% Gaston 4.19% 0.24% 6.17% 9.03% 3.01% 5.76% Iredell 4.05% 0.29% 4.56% 6.57% 2.55% 4.12% Lincoln 4.15% 0.49% 5.90% 8.07% 2.74% 4.99% Surry 6.37% 0.60% 7.56% 11.01% 3.91% 6.88% Yadkin 4.98% 0.69% 5.67% 8.86% 3.47% 6.28% Partners 4.72% 0.39% 5.84% 8.75% 3.18% 5.56% North Carolina 3.74% 0.04% 5.17% 7.37% 2.76% 4.83% United States 3.57% 0.01% 4.73% 6.57% 2.50% 4.44% Source: U.S. Census Bureau, 2017 American Community Survey 5-Year Estimates, 2017; 3/12/2019

The following are definitions for the difficulties listed in Table 7A provided by the American Community Survey (ACS).

• Hearing difficulty: deaf or having serious difficulty hearing (DEAR). • Vision difficulty: blind or having serious difficulty seeing, even when wearing glasses (DEYE). • Cognitive Difficulty: Because of physical, mental or emotional problem, having difficulty remembering, concentrating or making decisions (DREM). • Ambulatory difficulty: Having serious difficulty walking or climbing stairs (DPHY). • Self-care difficulty: Having difficulty bathing or dressing (DDRS). • Independent living difficulty: Because of a physical, mental, or emotional problem, having difficulty doing errands alone such as visiting a doctor’s office or shopping (DOUT).

Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 96 The table below shows the distribution of disability status of those served by Partners in FY18.

Table 7B. Disability status of those served by Partners in FY18. Independent Hearing Vision Cognitive Ambulatory Living Difficulty Difficulty Difficulty Difficulty County Difficulty % % % % % n n n n n Served Served Served Served Served Burke 0 0.00% 1 0.02% 2,422 53.3% 1 0.02% 20 0.44% Catawba 0 0.00% 1 0.02% 3,029 46.0% 2 0.03% 63 0.96% Cleveland 5 0.09% 5 0.09% 2,287 41.2% 3 0.05% 34 0.61% Gaston 0 0.00% 4 0.04% 4,566 40.7% 7 0.06% 139 1.24% Iredell 2 0.04% 2 0.04% 2,269 45.5% 1 0.02% 63 1.26% Lincoln 0 0.00% 0 0.00% 1,381 42.4% 1 0.03% 36 1.11% Surry 1 0.04% 0 0.00% 1,175 41.9% 0 0.00% 36 1.28% Yadkin 2 0.16% 0 0.00% 534 43.5% 0 0.00% 12 0.98% Partners 16 0.04% 13 0.03% 18,016 44.0% 15 0.04% 403 0.99% Source: Paid claims data

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 97 Veterans Veterans’ data looks at the population that is over 18 years old. Lincoln County has the highest proportions of veterans at 8.73%, followed by Burke, Catawba, and Cleveland counties. Overall, the proportion of veterans living in Partners catchment area is lower than the North Carolina average, but higher the United States average.

Table 8A. Percentage of Veterans who reside in the Catchment Area Compared to State and National Averages. County Percentage Burke 8.68% Catawba 8.57% Cleveland 8.38% Gaston 8.20% Iredell 7.57% Lincoln 8.73% Surry 7.97% Yadkin 7.92% Partners 8.23% North Carolina 8.74% United States 7.69% Source: U.S. Census Bureau, 2017 American Community Survey 5-Year Estimates, 2017; 3/20/2019

The table below shows the breakdown of services received from Partners in FY18 by Veterans and Family members.

Table 8B. Percentage of Veterans and Family Members served by Partners in FY18 by the Services Received. Services Received n % Served Mental Health 615 75.55% Substance Use Disorder 192 23.59% Intellectual and Developmental Disability 7 0.86% Source: "DMH/DD/SAS: Veterans and Military Annual Report" North Carolina Department of Health and Human Services, https://files.nc.gov/ncdhhs/documents/files/SFY_18_VeteransMilitaryReport.pdf. Accessed 2 May, 2019.

Pregnant Women with Substance Use Disorders Table 9. Percentage Served of Pregnant Women with Substance Use Disorders by the Catchment Area. Pregnant Women with SUD County n % Served Burke 0 0.00% Catawba 0 0.00% Cleveland 2 0.04% Gaston 3 0.03% Iredell 5 0.10% Lincoln 1 0.03% Surry 0 0.00% Yadkin 0 0.00% Partners 11 0.03% Source: Paid claims data

Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 98

People who are LGBTQ Based on information from the Williams Institute, the population proportion of those who identify as LGBT in North Carolina is 4%. Four percent of the estimated population of North Carolina (10,273,419) is approximately 410,000 LGBT residents. Of these, 26%, approximately 106,000, couples are currently raising children. LGBT individuals also make up many ethnicities with 58% being white, 29% being African American, and 11% being Latino/a.

Source: "LGBT People in North Carolina." The Williams Institute, williamsinstitute.law.ucla.edu/wp-content/uploads/North- Carolina-fact-sheet.pdf. Accessed 20 March, 2019.

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 99 People who are in jails or prisons In North Carolina prisons, there were 25,493 admissions for 2018. Within the Partners catchment area, there were 2,984 prison admissions in 2018. The county with the highest number of prison admissions is Gaston County with 797, while the county with the lowest number of prison admissions is Yadkin County with 118.

Table 10A. Prison Entries of Catchment Area compared to the State County Total Prison Entries Burke 268 Catawba 470 Cleveland 476 Gaston 797 Iredell 427 Lincoln 228 Surry 200 Yadkin 118 Partners 2,984 North Carolina 25,493 Source: DPS Research and Planning Automated System Query http://webapps6.doc.state.nc.us/apps/asqExt/ASQ Accessed 3 May 2019

The total crime index for North Carolina was 3,061.50, which is slightly higher than the national total crime index and slightly higher than the average index within the catchment area. Overall, the crime rate in the Partners catchment area is 14% below the North Carolina crime rate. Crime rates vary significantly with in the catchment area, with Lincoln having the lowest crime rate index score of 1,856.40and Gaston having the highest at 3,532.20. *Index Crime includes the total number of violent crimes (murder, rape, robbery, and aggravated assault) and property crimes (burglary, larceny, and motor vehicle theft).

Crime Index Table 10B. Crime Index Offenses of Catchment Area compared to State and National Average County Total Index Burke 2,252.20 Catawba 3,264.10 Cleveland 2,089.10 Gaston 3,532.20 Iredell 2,696.70 Lincoln 1,856.40 Surry 3,006.50 Yadkin 2,409.30 Partners 2,638.31 North Carolina 3,061.50 United States 2,745.13 Source: Crime In North Carolina - 2017 Annual Summary Report of 2017 Uniform Crime Reporting Data. North Carolina State Bureau of Investigation December 2018. Accessed 20 Mar. 2019

Partners 2019 Network Adequacy and Accessibility Analysis Appendix D: Demographic & Special Population Data 100 Youth in the Juvenile Justice System The table below shows the rate of complaints that were undisciplined for ages 6 to 17. The table also describes the Juvenile crime rate, the number of delinquent complaints out of the youth population age 6 to 15 for the Partners catchment area. Juvenile delinquency is defined as the participation in illegal behaviors by minors. Undisciplined juveniles are defined as those who are disobedient beyond the control of their guardians, regularly hang out in places unlawful to minors, or run away from home for more than 24 hours. There are over 143,000 juveniles ages 6 - 17 who reside in the Partners catchment area. Of those, 2,256 youth have been involved in community justice programs. Most of these youth have received services from the Juvenile Crime Prevention Councils (JCPC). Here they assess the needs for juveniles that are at risk, or have already found themselves delinquent, and then will provide funds for treatment, counseling, or rehabilitation services.

Table 11. Juvenile Undisciplined and Delinquent Rate Undisciplined Rate per Delinquent Rate per County 1,000 Age 6 to 17 1,000 Age 6 to 15 Burke 5.29 23.15 Catawba 5.34 15.11 Cleveland 5.10 24.41 Gaston 5.49 14.33 Iredell 0.92 24.84 Lincoln 1.84 18.61 Surry 2.58 19.86 Yadkin 2.50 31.05 North Carolina 1.45 16.18 Source: 2018 County Databook, North Carolina Department of Public Safety, 17 Apr. 2019, www.ncdps.gov/documents/2018 county-databook. Accessed 3 May 2019.

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix E: Social Determinants of Health Data 101 Appendix D2: Social Determinants of Health Data

Employment In Table 12, employed refers to the percentage of people employed out of the civilian labor force population. This category includes all civilians 16 years old and over who did any work at all during the reference week as paid employees, worked in their own business or profession, worked on their own farm, or worked 15 hours or more as unpaid workers on a family farm or in a family business; those who did not work during the reference week but had jobs or businesses from which they were temporarily absent due to illness, bad weather, industrial dispute, vacation, or other personal reasons. Excluded from the employed are people whose only activity consisted of work around the house or unpaid volunteer work for religious, charitable, and similar organizations; also excluded are all institutionalized people and people on active duty in the United States Armed Forces.

Unemployed refers to the percentage of people unemployed out of the civilian labor force population. All civilians 16 years old and over are classified as unemployed if they were neither “at work” nor “with a job but not at work” during the reference week, were actively looking for work during the last 4 weeks and were available to start a job. Also included as unemployed are civilians who did not work at all during the reference week, were waiting to be called back to a job from which they had been laid off and were available for work except for temporary illness.

Partners service region has a slightly higher percentage of those that are unemployed than North Carolina and the United States. It can also be seen that the Partners Catchment area has lower percentage of those that are employed than the rest of the country and the state of North Carolina.

Table 12. Employment Status of those who reside in the Catchment Area Compared to State & National Averages. County Employed Unemployed Burke 50.44% 5.20% Catawba 57.86% 4.63% Cleveland 51.68% 5.92% Gaston 56.43% 5.09% Iredell 60.04% 4.65% Lincoln 56.99% 4.89% Surry 51.84% 2.80% Yadkin 51.34% 3.21% Partners 55.70% 4.75% North Carolina 56.98% 4.39% United States 58.87% 4.13% Source: U.S. Census Bureau, 2017 American Community Survey 5-Year Estimates, 2017; 3/15/2019

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E: Social Determinants of Health Data 102 People who are Homeless or have Unstable Housing On January 25, 2018 a point in time homeless count was conducted for the state of North Carolina. The total number of homeless individuals counted in the catchment area was 580. Out of the 580, 51.2% of the individuals were in emergency shelters, 18.6% in transitional housing, and 30.2% were in an unsheltered situation.

Partners had a total of 49 homeless families living within the catchment area. There were also 521 homeless individuals who did not have families, and 9 children who did not have guardians. Ninety-two individuals were considered chronically homeless, 12 of them being veterans. There were 33 veterans who were homeless during this time.

Based on the 2018 Annual Homeless Assessment Report to Congress, North Carolina had 9,268 total homeless individuals, this corresponds to approximately 9 in every 10,000 individuals who experienced homelessness. This, though, was a 3.4% increase in homelessness from 2017 to 2018. While there is an overall decrease, North Carolina experienced a decrease of 6.1% homeless veterans from 2017 to 2018.

Source: "PART 1: Point-in-Time Estimates of Homelessness." The 2017 Annual Homeless Assessment Report (AHAR) to Congress, www.hudexchange.info/resources/documents/2017-AHAR-Part-1.pdf. Accessed 9 Apr. 2019. Source: 2018 Point-in-Time Count Balance of State: by County, North Carolina Coalition to End Homelessness, 2018, www.ncceh.org/media/files/files/7ad70fa1/BoS_2017_PIT-by_County.pdf. Accessed 9 April 2019. Point-in-Time Count NC-509 Gastonia/Cleveland, Gaston, Lincoln Counties CoC. 2018.

Eviction A contributing factor to the number of homeless individuals is evictions. The average rent burden, the percentage of household income spent on rent, for most of the catchment area counties is approximately 30%. The table below shows the eviction rates and eviction filing rates for the Partners catchment area. The eviction rate shows the number of evictions per 100 renter homes, whereas, the eviction filing rate indicates the number of eviction filings per 100 renter homes. No data was available for Iredell County. Of the seven counties where data was available, all 7 counties have a higher eviction rate than the National average. Cleveland County has the highest eviction rate of all the counties, even higher than the State average. Gaston has the highest eviction filing rate of these counties, well above the state average, followed by Cleveland. One out of 10 renters had an eviction filed on them in Cleveland County and 1 out of 7 renters in Gaston County had an eviction filing. Both Cleveland and Gaston have a higher rent burden than the State average, as well.

Table 13. Eviction, Eviction Filing Rate, and Rent Burden Catchment Area compared to State Average Eviction Eviction Filing County Rent Burden Rate Rate Burke 4.01% 5.39% 29.3% Catawba 2.48% 4.88% 28.6% Cleveland 7.33% 10.25% 33.2% Gaston 4.37% 14.92% 32.2% Iredell - - - Lincoln 3.81% 5.82% 28.8% Surry 2.99% 4.42% 28.0% Yadkin 2.51% 3.25% 28.8% North Carolina 4.61% 10.85% 30.3% United States 2.34% - - Source: The Eviction Lab, 2018, evictionlab.org/. Accessed 20 March 2019.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E: Social Determinants of Health Data 103 People who have transportation barriers The table below show the public transportation provided by county. Each county has between 1 and 3 different public transportation systems.

Table 14: Public Transportation Services by County County Public Transportation Burke Western Piedmont Regional Transportation Authority Catawba PWTS (Piedmont Wagon Transit System), Western Piedmont Regional Transit System Cleveland CCT (Transportation Administration of Cleveland County, Cleveland County Transit) Gaston CATS (Charlotte Area Transit System), GCA (Gaston County ACCESS), Gastonia Transit (City of Gastonia Transit Division, GT) Iredell CATS (Charlotte Area Transit System), ICATS (Iredell County Area Transportation System) Lincoln Lincoln County Transportation System Surry YVTA (Yadkin Valley Economic Development District, Yadkin Valley Transportation Authority), PART (Piedmont Authority for Regional Transportation) Yadkin YVTA (Yadkin Valley Economic Development District, Yadkin Valley Transportation Authority), Piedmont Authority for Regional Transportation Source: "North Carolina Transit Links." American Public Transportation Association, www.apta.com/resources/links/unitedstates/Pages/NorthCarolinaTransitLinks.aspx. Accessed 14 Mar. 2019.

People with Food Insecurity The table below shows the distribution of food insecurities for the Partners catchment area. Overall, Partners has 15% of its population who struggle with where they may get their next meal. Iredell, Lincoln and Yadkin counties have the lowest rate of food insecurity at 13%, whereas Cleveland county has the highest rate of food insecurity at 18%. According to the USDA, the national level of food insecurity was 11.8% in 2016.

Table 15. Food Insecurities of Catchment Area compared to State Average Percent with Food County Insecurities Burke 15% Catawba 14% Cleveland 18% Gaston 16% Iredell 13% Lincoln 13% Surry 14% Yadkin 13% Partners 15% North Carolina 17% Source: County Health Rankings and Roadmaps, A Robert Wood Johnson Foundation Program, 2017, http://www.countyhealthrankings.org/app/north-carolina/2018/measure/factors/139/data. Accessed March 20, 2019

Source: USDA, Economic Research Service, Household Food Security in the United States in 2016, ERR-237, September 2017

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E: Social Determinants of Health Data 104 Poverty Level The table below shows the percentage of those in poverty in the Partners catchment area. Overall Partners has 16.04% of their population in poverty. Iredell county has the lowest poverty rate at 12.67%, whereas Cleveland county has the highest rate of poverty at 19.92%.

Table 16. Poverty Level Breakdown of those who reside within the Catchment Area Compared to State and National Averages. Percent Below Poverty County Level Burke 19.33% Catawba 14.21% Cleveland 19.92% Gaston 16.53% Iredell 12.67% Lincoln 15.18% Surry 17.58% Yadkin 17.29% Partners 16.04% North Carolina 16.15% United States 14.58% Source: U.S. Census Bureau, 2017 American Community Survey 5-Year Estimates, 2017; 3/15/2019

Income Partners catchment area has a lower median household income than both North Carolina and the United States. There is wide variance in county median household income across the catchment area. Surry has the lowest median income at $39,071 and Iredell has the highest median household income in the Partners BMH service area at $55,957.

Table 17. Median household income of Catchment Area residents compared to State and National Averages. Median Household County Income Burke $40,854 Catawba $48,649 Cleveland $40,002 Gaston $46,626 Iredell $55,957 Lincoln $50,782 Surry $39,071 Yadkin $41,126 North Carolina $50,320 United States $57,652 * Estimated based on weighted average of median county household incomes Source: U.S. Census Bureau, 2017 American Community Survey 5-Year Estimates, 2016; 4/24/2019

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E: Social Determinants of Health Data 105 Medicaid The table below shows the percentage of individuals out of the total civilian noninstitutionalized population (described above) on Medicaid for each of Partners catchment area counties, the catchment area overall, the state of North Carolina, and the United States. Six out of the eight catchment area counties have a larger proportion of individuals with Medicaid than North Carolina and five out of the eight catchment area counties have a larger proportion of individuals with Medicaid than the United States. Cleveland has the largest proportion of individuals with Medicaid (23.31%) and Iredell has the smallest (15.15%).

Table 18A. Percentage of Individuals with Medicaid in the Catchment Area Compared to State and National Averages. County With Medicaid % Burke 23.17% Catawba 18.76% Cleveland 23.31% Gaston 20.71% Iredell 15.15% Lincoln 18.13% Surry 21.83% Yadkin 22.13% Partners 19.78% North Carolina 18.23% United States 19.57% Source: U.S. Census Bureau, 2016 5-Year American Community Survey, C27007; 8/7/2018

The table below shows the distribution of those served by Partners in FY18 with Medicaid

Table 18B. Percentage Served of Individuals with Medicaid of those served by Partners in FY18. With Medicaid % County n % Served Burke 3,350 73.76% Catawba 4,821 73.19% Cleveland 4,510 81.16% Gaston 8,769 78.19% Iredell 4,006 80.30% Lincoln 2,539 78.00% Surry 2,201 78.41% Yadkin 956 77.85% Partners 31,152 76.15% Source: Paid claims data

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 106 Appendix E1: Community Assessment Survey Response Index

Partners created a specific survey to gather input from clients receiving services, family members/caregivers, providers, and other community members/stakeholders. Each survey was designed specifically for the target group.

The total number of completed community assessment surveys was five hundred and sixty-eight (n=568). There were two hundred and twenty-eight (n=228) responses from clients receiving services, one hundred and eighteen (n=118) from family members/caregivers, two hundred and eighty-one (n=281) from providers of services, and ten (n=10) from other community members/stakeholders.

Please note that respondents did not have to answer every question. Therefore, the total number of respondents per question varies. Due to rounding, percentages may appear to not add up to exactly 100%.

The complete set of survey questions and results are provided below. A blank copy of each of the surveys is included in Appendix E2.

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 107 Clients Receiving Services The total number of completed community assessment surveys for clients receiving services was 228. Of these, 162 were Mental Health consumers, 74 Substance Use consumers, 28 Intellectual/Developmental Disabilities consumers, and 10 Traumatic Brain Injury consumers. Consumers were able to select more than one disability group.

Q1: Are you 18 years or older?

Response n Percentage Yes 205 91.9% No 18 8.1%

Q2: Within the last 12 months, have you received behavioral health services, such as mental health, substance use disorder, intellectual developmental disability (IDD), or traumatic brain injury (TBI), assessments, treatments, or referrals through Partners?

Response n Percentage Yes 173 76.2% No 39 17.2% I have never received services 15 6.6%

Population Yes No I have never received services Mental Health 83.2% 11.8% 5.0% Substance Use Disorder 75.7% 21.6% 2.7% Intellectual and Developmental Disabilities (IDD) 92.9% 7.1% 0.0% Traumatic Brain Injury (TBI) 66.7% 33.3% 0.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 108 Q3: Which group(s) best describes the services you get help for? (Select all that apply)

The table below shows the combination of disability groups. For example, 7 consumers said they for received services for both Mental Health and Intellectual and Developmental Disabilities (IDD).

Population n Percentage MH 107 49.8% SUD 30 14.0% IDD 18 8.4% TBI 3 1.4% MH/SUD 41 19.1% MH/IDD 7 3.3% MH/TBI 5 2.3% SUD/TBI 1 0.5% IDD/TBI 1 0.5% MH/SUD/IDD 2 0.9%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 109 Q4. Of the groups selected above, which do you receive services for the most? (Select only one)

Population n Percentage Mental Health 138 64.2% Substance Use Disorder 50 23.3% Intellectual and Developmental Disabilities (IDD) 22 10.2% Traumatic Brain Injury (TBI) 5 2.3%

Q5. In which county do you live?

County n Percentage Burke 41 18.7% Catawba 58 26.5% Cleveland 24 11.0% Gaston 17 7.8% Iredell 34 15.5% Lincoln 19 8.7% Surry 7 3.2% Yadkin 3 1.4% Other (please specify) 16 7.3% *Other counties specified were Caldwell (7), Rowan (3), Mecklenburg (2), Davie (2), McDowell (1), and Stokes (1)

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 110

Q6. Would you say that in general your physical health is:

Population Excellent Very good Good Fair Poor Mental Health 8.8% 17.0% 35.8% 28.9% 9.4% Substance Use Disorder 9.6% 19.2% 34.2% 27.4% 9.6% Intellectual and Developmental Disabilities (IDD) 7.1% 21.4% 42.9% 28.6% 0.0% Traumatic Brain Injury (TBI) 0.0% 33.3% 44.4% 22.2% 0.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 111 Q7a. Now thinking about your physical health, which includes physical illness and injury, how often during the past month was your physical health not good?

Population Always Often Sometimes Rarely Never Mental Health 8.1% 11.2% 33.1% 26.9% 20.6% Substance Use Disorder 9.7% 13.9% 33.3% 25.0% 18.1% Intellectual and Developmental Disabilities (IDD) 7.1% 7.1% 39.3% 21.4% 25.0% Traumatic Brain Injury (TBI) 0.0% 0.0% 62.5% 12.5% 25.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 112 Q7b. Now thinking about your mental health, which includes stress, depression, and problems with emotions, how often during the past month was your mental health not good?

Population Always Often Sometimes Rarely Never Mental Health 15.0% 25.6% 37.5% 12.5% 9.4% Substance Use Disorder 17.8% 26.0% 31.5% 13.7% 11.0% Intellectual and Developmental Disabilities (IDD) 10.7% 17.9% 42.9% 10.7% 17.9% Traumatic Brain Injury (TBI) 12.5% 0.0% 50.0% 37.5% 0.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 113 Q7c. During the past month, how often did substance use keep you from doing your usual activities, such as selfcare, work, family, or recreation?

Population Always Often Sometimes Rarely Never Mental Health 3.8% 5.0% 11.9% 8.8% 70.6% Substance Use Disorder 19.7% 15.5% 23.9% 8.5% 32.4% Intellectual and Developmental Disabilities (IDD) 0.0% 0.0% 0.0% 3.6% 96.4% Traumatic Brain Injury (TBI) 0.0% 0.0% 0.0% 12.5% 87.5%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 114 Q8. In the last 12 months, have you received medical care when you needed it?

Population Yes No Mental Health 86.2% 13.8% Substance Use Disorder 72.2% 27.8% Intellectual and Developmental Disabilities (IDD) 96.4% 3.6% Traumatic Brain Injury (TBI) 90.0% 10.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 115 Q9. Do you have someone you can depend on to listen to you, support you emotionally, or encourage you to get help for your problems?

Population Yes No Mental Health 85.6% 14.4% Substance Use Disorder 73.6% 26.4% Intellectual and Developmental Disabilities (IDD) 100.0% 0.0% Traumatic Brain Injury (TBI) 100.0% 0.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 116 Q10. Do you get the services and help you want?

Population Always Usually Sometimes Never Mental Health 39.6% 37.1% 22.0% 1.3% Substance Use Disorder 32.9% 28.8% 35.6% 2.7% Intellectual and Developmental Disabilities (IDD) 57.1% 42.9% 0.0% 0.0% Traumatic Brain Injury (TBI) 55.6% 22.2% 11.1% 11.1%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 117 Q11. Which group(s) best describes the services you would like to get, but currently do not? (Select all that apply)

*Many respondents chose to skip this question

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 118 Q12. Do you feel you can get help easily when needed in a mental health or substance use crisis or emergency?

Population Yes No Mental Health 87.4% 12.6% Substance Use Disorder 78.9% 21.1% Intellectual and Developmental Disabilities (IDD) 92.6% 7.4% Traumatic Brain Injury (TBI) 77.8% 22.2%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 119 Q13. In the past the 12 months, were you able to obtain information on the services offered and how to access them in a way you could understand?

Population Yes No Mental Health 88.2% 11.8% Substance Use Disorder 87.7% 12.3% Intellectual and Developmental Disabilities (IDD) 92.9% 7.1% Traumatic Brain Injury (TBI) 66.7% 33.3%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 120 Q14. Do you usually have to travel over 45 minutes to receive services?

Population Yes No I don’t travel to receive services Mental Health 12.4% 65.2% 22.4% Substance Use Disorder 16.2% 64.9% 18.9% Intellectual and Developmental Disabilities (IDD) 3.6% 82.1% 14.3% Traumatic Brain Injury (TBI) 11.1% 77.8% 11.1%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 121 Q15. Please check all the reasons below that may influence or have influenced your decision to stop seeking treatment:

Reason n Percentage Transportation 71 40.6% Other (please specify) 59 33.7% Money needed for monthly expenses 45 25.7% Didn’t feel treatment was working 33 18.9% Provider not available when needed 27 15.4% Medical problems 23 13.1% Family members/friends discouraged/made fun of me for attending appointments 11 6.3% Lack of childcare 9 5.1% Clinician doesn’t support my goals 9 5.1% *Themes specified by consumers who selected other (please specify) included, making bad decisions (including drugs), did not feel they needed treatment any longer, family support, group support, religion, jail, working hours conflicted with treatment, and did not receive treatment they needed.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 122 Q16. When you want to go somewhere, do you have a way to get there?

Population Always Usually Sometimes Never Mental Health 30.2% 32.1% 33.3% 4.4% Substance Use Disorder 25.0% 36.1% 30.6% 8.3% Intellectual and Developmental Disabilities (IDD) 50.0% 21.4% 28.6% 0.0% Traumatic Brain Injury (TBI) 30.0% 40.0% 30.0% 0.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 123 Q17. When you want to go somewhere, how do you usually get there? (Select all that apply)

Response n Percentage Rides from family or friends 95 43.6% Rides from staff in provider van or vehicle 72 33.0% By myself (e.g. vehicle, bike, walk) 71 32.6% Ride in staff’s car 45 20.6% Public transportation (e.g. bus, train) 34 15.6% Specialized transportation service (e.g. Medicaid Cab, etc.) 21 9.6% Other (please specify) 15 6.9% Taxi/Uber/Lyft 12 5.5% I am not able to get to the places I want to go 9 4.1% *Themes specified by consumers who selected other (please specify) included, ALF provider, company car, other family (foster parents, house mom, mom, treatment parent), how every they are able, their own vehicle, walking, sometimes unable to get transportation.

Q18a. Did you ever eat less than you felt you should because there wasn’t enough food?

Population Yes No Mental Health 27.7% 72.3% Substance Use Disorder 46.5% 53.5% Intellectual and Developmental Disabilities (IDD) 7.1% 92.9% Traumatic Brain Injury (TBI) 0.0% 100.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 124 Q18b. Has your utility company shut off your service for not paying your bills?

Population Yes No Mental Health 23.1% 76.9% Substance Use Disorder 34.7% 65.3% Intellectual and Developmental Disabilities (IDD) 7.1% 92.9% Traumatic Brain Injury (TBI) 11.1% 88.9%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 125 Q18c. Were you worried about having stable housing?

Population Yes No Mental Health 34.6% 65.4% Substance Use Disorder 52.1% 47.9% Intellectual and Developmental Disabilities (IDD) 10.7% 89.3% Traumatic Brain Injury (TBI) 12.5% 87.5%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 126 Q18d. Have you needed to see a doctor, but could not because of cost?

Population Yes No Mental Health 30.6% 69.4% Substance Use Disorder 43.1% 56.9% Intellectual and Developmental Disabilities (IDD) 0.0% 100.0% Traumatic Brain Injury (TBI) 12.5% 87.5%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 127 Q18e. Have you ever had to go without healthcare because you didn’t have a way to get there?

Population Yes No Mental Health 31.0% 69.0% Substance Use Disorder 45.1% 54.9% Intellectual and Developmental Disabilities (IDD) 11.1% 88.9% Traumatic Brain Injury (TBI) 12.5% 87.5%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 128 Q19. Read through the following list and select any you have experienced within the past year. These things may make it difficult to get the help you need. If none experienced, please select “None” at bottom of the list.

Response n Percentage Lack of reliable transportation 82 37.8% Homeless/housing issues 71 32.7% Lack of employment 65 30.0% Mental Health/Substance Use Issues 64 29.5% None 62 28.6% Medical/health issues 53 24.4% Lack of support from family/friends to seek out help 47 21.7% Cannot pay for services/medications 46 21.2% Feelings of fear or embarrassment 43 19.8% Physical disability/mobility issues 32 14.7% On a waiting list 26 12.0% Do not know what services are available 26 12.0% Frequency of services is not enough 24 11.1% Provider not close to my home (distance/time/cost) 20 9.2% Reading skill level/education level 19 8.8% Do not believe services will help 13 6.0% Other (please specify) 8 3.7% Lack of childcare 6 2.8% Cultural differences/Religious Beliefs 1 0.5% Language Barriers 0 0.0%

*Themes specified by consumers who selected other (please specify) included, duration of treatment for substance abuse is not enough, inconsistency of staff members (i.e. seeing a new person every time), and the hardships of addiction.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 129 Q20. Would any of the following improve the quality of life for you within your community? (Select all that apply)

Response n Percentage Housing 92 47.9% Dental care access 70 36.5% Public transportation 70 36.5% Mental health services 65 33.9% Community activities 63 32.8% Educational opportunities 60 31.2% Recreational opportunities 59 30.7% Employment opportunities 58 30.2% Health care access 57 29.7% Substance use support 53 27.6% Community Safety 45 23.4% Other (please specify) 23 12.0% After school programs 19 9.9%

*Themes specified by consumers who selected other (please specify) included, safe activities for children and teens to help parents stay in recovery, consistent staff, assistance obtaining disability, and more substance abuse supports.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 130 Q21. What would you change about the services you receive? When asked, “What would you change about services you receive?” One hundred and sixty-five (n = 165) of the clients who took the survey responded to the question. A large portion of respondents stated they would change “nothing” and that they liked the services they received, or the services received were “good” and “fine”. Individuals who wished to change something about the services they received mentioned they needed: help finding housing (including those for intensive outpatient) and transportation options, services available at different times (weekend and evening appointments), substance use programs, and community and group activities. Other consumers mentioned shorter waiting lists for services, housing with TCLI, the distance to the providers/doctors, a need for outpatient visits rather than home visits, longer duration of substance abuse programs, consistency of therapists and providers, funding, ACTT, and peer support.

Q22. Do you have any needs currently not being met you would like Partners to know about? When asked, “Do you have any needs currently not being met you would like Partners to know about?” One hundred and sixty-three (n = 163) of the clients who took the survey responded to the question. A large portion of respondents stated their needs were being met or they had “nothing” to tell Partners and like the services they receive. When needs were mentioned housing and transportation (including after hours) were the most frequently stated. Other needs included more substance use services, the need for more doctors and providers, affordable medication, funding for TBI services, dental services, TCLI program support, more mental health services, and faster access to appointments.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 131 Q23. Is there anything that would help make services better for you would like Partners to know about? When asked, “Is there anything that would help make services better for you would like Partners to know about?” One hundred and sixty-two (n = 162) of the clients who took the survey responded to the question. A large portion of respondents stated “no” or “nothing”. Those that did state there were things that would make their services better mentioned more housing opportunities and shorten the time it takes to receive housing, community activities and awareness, medication funding options including suboxone therapy, help with the referral process, more visits with the ACTT team, shorten the evaluation process, long term substance abuse care, transportation, and education funding options.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 132

Those receiving TBI services

Those who answered TBI for Q4 “Of the groups selected above, which do you receive services for the most? (Select only one)” were asked to answer additional questions. Three individuals responded TBI to Q4 and the questions and responses are below.

Q1: How difficult was it to find a service provider for treatment for TBI? All stated it was easy to find a service provider for TBI treatment. Q2: Do you have to travel more than 45 minutes to your TBI provider? One responded they do not travel to receive services, and two responded they do not travel more than 45 minutes to their TBI provider. Q3: How satisfied are you with your service provider for TBI? All stated that there were satisfied with their service provider for TBI. Q4: What services and/or supports do you need you find difficult to access or unavailable? Themes in the responses were appointments more often. Q5: Would you say that in general your physical health is: N/A Not Receiving Services Those who responded “I have never received services” to the question “Within the last 12 months, have you received behavioral health services, such as mental health, substance use disorder, intellectual developmental disability (IDD), or traumatic brain injury (TBI), assessments, treatments, or referrals through Partners?” were directed to answer the following set of questions. One individual answered the questions and for confidentiality reasons their responses are not displayed in this document.

Q1. In which county do you live?

Q2. Please check all the items from the list below you have experienced as a barrier to receiving services. If none experienced, please select "No barriers" at the bottom of the list.

Q3. Would any of the following improve the quality of life for you within your community? (Select all that apply)

Q4. Do you have any other needs you would like Partners to know about?

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 133 Family Members/Caregivers The total number of completed community assessment surveys for family members/caregivers was 118. Of these, 60 were family members/caregivers of individuals in Mental Health services, 13 were family members/caregivers of individuals in Substance Use services, 57 were family members/caregivers of individuals in Intellectual/ Developmental Disabilities services, and 6 were family members/caregivers of in Traumatic Brain Injury services.

Q1: Is the person receiving services 18 years or older?

Response n Percentage Yes 68 58.1% No 49 41.9%

Population Yes No Mental Health 28.8% 71.2% Substance Use Disorder 58.3% 41.7% Intellectual and Developmental Disabilities (IDD) 86.0% 14.0% Traumatic Brain Injury (TBI) 100.0% 0.0%

Q2: Within the last 12 months, has the person received behavioral health services, such as mental health, substance use disorder, intellectual developmental disability (IDD), or traumatic brain injury (TBI), assessments, treatments, or referrals through Partners?

Response n Percentage Yes 97 82.2% No 13 11.0%

They have never received Population Yes No services through Partners Mental Health 80.0% 11.7% 8.3% Substance Use Disorder 84.6% 15.4% 0.0% Intellectual and Developmental Disabilities (IDD) 93.0% 3.5% 3.5% Traumatic Brain Injury (TBI) 100.0% 0.0% 0.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 134 Q3: Which group(s) best describes the services the person gets help for? (Select all that apply)

The table below shows the combination of disability groups. For example, 5 families said their family member/individual they care for received services for both Mental Health and Intellectual and Developmental Disabilities (IDD).

Population n Percentage MH 44 38.3% SUD 3 2.6% IDD 49 42.6% MH/SUD 7 6.1% MH/IDD 5 4.3% MH/TBI 2 1.7% SUD/TBI 2 1.7% IDD/TBI 1 0.9% MH/SUD/IDD 1 0.9% MH/IDD/TBI 1 0.9%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 135 Q4: Of the groups selected above, which does the person receive services for the most? (Select only one)

Population n Percentage Mental Health 57 49.1% Substance Use Disorder 5 4.3% Intellectual and Developmental Disabilities (IDD) 53 45.7% Traumatic Brain Injury (TBI) 1 0.9%

Q5: In which county do they live?

County n Percentage Burke 23 19.8% Catawba 15 12.9% Cleveland 5 4.3% Gaston 16 13.8% Iredell 30 25.9% Lincoln 5 4.3% Surry 6 5.2% Yadkin 10 8.6% Other (please specify) 6 5.2% *Other counties specified were Mecklenburg (3), Caldwell (1), McDowell (1), and previously Yadkin (1)

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 136 Q6: Do they get the services and help they want?

Population Always Usually Sometimes Never Mental Health 50.0% 39.7% 5.2% 5.2% Substance Use Disorder 30.8% 46.2% 15.4% 7.7% Intellectual and Developmental Disabilities (IDD) 61.8% 23.6% 10.9% 3.6% Traumatic Brain Injury (TBI) 33.3% 33.3% 16.7% 16.7%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 137 Q7: Which group(s) best describes the services they would like to get help for, but currently do not? (Select all that apply)

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 138 Q8: Do you feel they can get help easily when needed in a mental health or substance use crisis or emergency?

Population Yes No I don't know Mental Health 77.6% 13.8% 8.6% Substance Use Disorder 58.3% 16.7% 25.0% Intellectual and Developmental Disabilities (IDD) 67.3% 10.9% 21.8% Traumatic Brain Injury (TBI) 66.7% 33.3% 0.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 139 Q9. In the past the 12 months, were they able to obtain information on the services offered and how to access them in a way they could understand?

Population Yes No I don’t know Mental Health 78.0% 11.9% 10.2% Substance Use Disorder 76.9% 7.7% 15.4% Intellectual and Developmental Disabilities (IDD) 83.0% 9.4% 7.5% Traumatic Brain Injury (TBI) 66.7% 33.3% 0.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 140 Q10. Do they usually have to travel over 45 minutes to receive services?

Population Yes No They don’t travel to receive services Mental Health 10.5% 78.9% 10.5% Substance Use Disorder 8.3% 75.0% 16.7% Intellectual and Developmental Disabilities (IDD) 5.4% 78.6% 16.1% Traumatic Brain Injury (TBI) 16.7% 83.3% 0.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 141 Q11. Please check all the reasons below that may influence or have influenced their decision to stop seeking treatment:

Reason n Percentage Other (please specify) 36 48.6% Transportation 22 29.7% Provider not available when needed 18 24.3% Money needed for monthly expenses 14 18.9% Didn’t feel treatment was working 13 17.6% Medical problems 9 12.2% Clinician doesn’t support their goals 6 8.1% Family members/friends discouraged/made fun of them for attending appointments 6 8.1% Lack of childcare 2 2.7% *Themes specified by family members/caregivers who selected other (please specify) included, being denied services, difficulty getting an appointment & appointment times (i.e. cannot take time off work to attend appointments), waitlist, loss of insurance, service location, and lack of treatment consistency.

Q12. When they want to go somewhere, do they have a way to get there?

Population Always Usually Sometimes Never Mental Health 54.4% 24.6% 17.5% 3.5% Substance Use Disorder 30.8% 23.1% 38.5% 7.7% Intellectual and Developmental Disabilities (IDD) 80.0% 14.5% 5.5% 0.0% Traumatic Brain Injury (TBI) 33.3% 0.0% 50.0% 16.7%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 142

Q13. When they want to go somewhere, how do they usually get there? (Check all that apply)

Response n Percentage Rides from family or friends 96 85.7% Rides from staff in provider van or vehicle 29 25.9% Ride in staff’s car 25 22.3% By them self (e.g. vehicle, bike, walk) 9 8.0% Public transportation (e.g. bus, train) 5 4.5% Specialized transportation service (e.g. Medicaid Cab, etc.) 5 4.5% Taxi/Uber/Lyft 0 0.0% They are not able to get to the places they want to go 0 0.0%

Q14. Read through the following list and select any the person receiving services has experienced within the past year. If none experienced, please select “None” at bottom of the list. Barriers n Percentage None 46 42.6% Medical/health issues 19 17.6% Frequency of services is not enough 18 16.7% Mental Health/Substance Use Issues 16 14.8% Feelings of fear or embarrassment 14 13.0% On a waiting list 13 12.0% Reading skill level/education level 9 8.3% Other (please specify) 9 8.3% Homeless/housing issues 8 7.4% Lack of reliable transportation 8 7.4% Physical disability/mobility issues 8 7.4% Lack of employment 6 5.6% Provider not close to their home 6 5.6% (distance/time/cost) Cannot pay for services/medications 6 5.6% Do not know what services are available 6 5.6% Do not believe services will help 5 4.6% Lack of support from family/friends to seek out help 4 3.7% Lack of childcare 1 0.9% Cultural differences/Religious Beliefs 0 0.0% Language Barriers 0 0.0% *Themes specified by family members/caregivers who selected other (please specify) included, lack of staff/staff inconsistencies, mental health issues, stigma, and being denied services.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 143 Q15. Would any of the following improve the quality of life for them within their community? (Select all that apply) Label n Percentage Recreational opportunities 45 51.1% Community activities 41 46.6% Educational opportunities 23 26.1% Mental health services 23 26.1% After school programs 19 21.6% Other (please specify) 15 17.0% Community Safety 14 15.9% Health care access 14 15.9% Employment opportunities 14 15.9% Housing 12 13.6% Dental care access 12 13.6% Public transportation 9 10.2% Substance use support 5 5.7% *Themes specified by family members/caregivers who selected other (please specify) included independent living skills training, IDD services, dual diagnosis services, additional long-term inpatient treatment/no waiting list, recreational services, and TFC and IAFT availability to help with placement.

Q16. What would you change about the services they receive? Of the family members/caregivers responded to the survey, seventy-nine (n=79) answered the open- ended question “What would you change about services they receive?” Most of the respondents said “nothing” needed to be changed, and thought services were working well or were great. For those who would change something many mentioned the following: more services outside the home, more approved hours, more housing options, employment, help accessing services including increased access to psychotherapy, community programs, more providers, long term care options for substance use, day treatment schools, services for families, funding, smaller/shorter waitlist, after hours help (nights/weekends).

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 144 Q17. Do they have any needs currently not being met you would like Partners to know about? Seventy-two (n=72) family members/caregivers responded to the survey answered the open-ended question “Do they have any needs currently not being met you would like Partners to know about?” Many of the respondents answered that there were no needs not being met or “nothing” for Partners to know about. For those who mentioned unmet needs they stated the following: difficulty getting services (e.g. repetitively denied services and long waitlists), community and recreational activities, supported employment, the need for more mental health services, timeliness of services and appointment time options, more provider options for DBT, autism/ABA therapy, housing (including IDD group homes), help with daily living and social skills.

Q18. Is there anything that would help make services better for them you would like Partners to know about? Seventy-two (n=72) family members/caregivers responded to the survey answered the open-ended question “Is there anything that would help make services better for them you would like Partners to know about?” Many of the respondents answered that there was “nothing” they wanted Partners to know about. For those who stated that there was something Partners could do they mentioned additional times for appointments (including times that do not interfere with their job/employment), education service denials, housing, long term treatment, staff/provider training, Day Supports/Programs, less paperwork, support with funding, community recreation, supportive employment, services for children, long term substance use treatment, and improved consistency of care.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 145 Those receiving TBI services For those that answered TBI for the question above “Of the groups selected above, which does the person receive services for the most? (Select only one)” were directed to answer the following additional questions. Two individuals responded to these questions.

Q1. How difficult was it to find a service provider for treatment for TBI? One individual stated that it was easy to receive services for treatment and one individual stated that it was difficult. Q2. Do they have to travel more than 45 minutes to their TBI provider? Both individuals stated that they do not need to travel more than 45 minutes to their TBI provider. Q3. How satisfied are they with their TBI service provider? Both individuals were satisfied with services. Q4. How could TBI services be improved in their community? Two family members or care givers responded to the question. Both education and additional group homes were mentioned. Q5. What services and/or supports do they need that are difficult to access or unavailable? No family members or caregivers responded to the question above.

Not Receiving Services

Those who answered not receiving services to the question “Within the last 12 months, has the person received behavioral health services, such as mental health, substance use disorder, intellectual developmental disability (IDD), or traumatic brain injury (TBI), assessments, treatments, or referrals through Partners?” were directed to answer the following additional questions. One individual answered the questions and for confidentiality reasons their responses are not displayed in this document.

Q1. In which county do they live?

Q2. Please check all the items from the list below they have experienced as a barrier to receiving services. If none experienced, please select "No barriers" at the bottom of the list.

Q3. Would any of the following improve the quality of life for them within their community? (Check all that apply)

Q4. Are there any other needs you would like Partners to know about?

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 146 Providers of Services The total number of completed community assessment surveys for providers was 281. Of these, 236 were Mental Health providers, 120 Substance Use Disorder providers, 114 Intellectual/ Developmental Disabilities providers, and 56 Traumatic Brain Injury providers. Providers were able to select more than one disability group.

Q1: What disability groups do you serve? (Check all that apply)

The table below shows the combination of disability groups served by providers and the number of providers serving those disability groups. Population n Percentage MH 77 27.6% SUD 10 3.6% IDD 30 10.8% TBI 1 0.4% MH/SUD 65 23.3% MH/IDD 25 9.0% MH/TBI 2 0.7% IDD/TBI 2 0.7% MH/SUD/IDD 16 5.7% MH/SUD/TBI 10 3.6% MH/IDD/TBI 22 7.9% MH/SUD/IDD/TBI 19 6.8%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 147

Q2: Which counties do you deliver services? (Check all that apply) County n Percentage Burke 122 45.2% Catawba 143 53.0% Cleveland 112 41.5% Gaston 125 46.3% Iredell 100 37.0% Lincoln 115 42.6% Rutherford 57 21.1% Surry 73 27.0% Yadkin 75 27.8%

Q3: In your opinion, do consumers receive treatment or services as soon as they want?

Population Always Usually Sometimes Never Mental Health 7.3% 57.1% 33.8% 1.8% Substance Use Disorder 8.1% 58.6% 31.5% 1.8% Intellectual and Developmental Disabilities (IDD) 6.7% 50.0% 41.3% 1.9% Traumatic Brain Injury (TBI) 9.8% 39.2% 49.0% 2.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 148 Q4: In your opinion, are consumers informed about the different services available to them and how to access to them?

Population Yes No I don’t know Mental Health 67.7% 24.4% 7.8% Substance Use Disorder 75.2% 15.6% 9.2% Intellectual and Developmental Disabilities (IDD) 68.0% 23.3% 8.7% Traumatic Brain Injury (TBI) 68.6% 25.5% 5.9%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 149 Q5: In your opinion, is the accessibility to any of the following services reported as a barrier by your clients? (Check all that apply)

Services n Percentage Residential Treatment Levels 1 - 4 64 28.1% Facility Based Crisis 51 22.4% Child and Adolescent Day Treatment 49 21.5% Partial Hospitalization 45 19.7% Detoxification (non-hospital) 43 18.9% Opioid Treatment 41 18.0% IDD Out of home respite 41 18.0% No accessibility gaps 40 17.5% SU Intensive Outpatient Program 38 16.7% IDD Supported Employment 38 16.7% Mobile Crisis 34 14.9% Other (please specify) 64 28.1% *Other services specified by providers who selected other (please specify) included, but are not limited to, additional psychiatric services/psychiatrists, adolescent services (psychiatric, outpatient, schooling, and IDD), psychological services/evaluations, respite, biofeedback, case management, day supports, housing, transportation, service referrals, other supports for those waiting for innovations waivers, outpatient services, and substance abuse programs including residential services.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 150 Q6: Select any of the following you perceive as a barrier to people receiving services. If you feel no barriers are experienced, please select “No barriers” at the bottom of the list.

Barriers n Percentage Lack of reliable transportation 174 70.7% Homeless/housing issues 128 52.0% Lack of support from family/friends to seek out help 118 48.0% Paying their bills (i.e. utility bills, rent/mortgage payments, phone, etc.) 107 43.5% Cannot pay for services/medications 102 41.5% Mental Health/Substance Use Issues 101 41.1% Do not know what services are available 95 38.6% Lack of employment 93 37.8% On a waiting list 92 37.4% Provider not close to their home (distance/time/cost) 91 37.0% Medical/health issues 89 36.2% Do not believe services will help 72 29.3% Feelings of fear or embarrassment 68 27.6% Lack of childcare 66 26.8% Cost of services 58 23.6% Reading skill level/education level 57 23.2% Frequency of services is not enough 55 22.4% Food Insecurity 51 20.7% Physical disability/mobility issues 47 19.1% Language Barriers 45 18.3% Cultural differences/Religious Beliefs 29 11.8% No Barriers 29 11.8% Other (please specify) 20 8.1% *Themes specified by providers as additional barriers to services included, but are not limited to, lack of funding and insurance, lack of providers, lack of children services, and lack of follow-up and referrals.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 151 Q7: If you identified barriers for those you serve, does your agency assist in overcoming these barriers? If yes, please provide an example.

Population Yes No Mental Health 89.5% 10.5% Substance Use Disorder 92.8% 7.2% Intellectual and Developmental Disabilities (IDD) 87.8% 12.2% Traumatic Brain Injury (TBI) 91.5% 8.5%

If yes, provide an example: Examples of how agencies assist in overcoming barriers include, but are not limited to, education on services available to both consumers and family members/caregivers, covering cost gaps, sliding scale fee, providing transportation, providing referrals, employment and educational services, assisting in applications for Medicaid and other funding sources, peer support, translators and interpreters , flexible appointment times, home visits, case management, hiring additional staff to reduce waitlists, and advocating for the consumer.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 152 Q8: Please check all the reasons that may influence a person to not continue to stay engaged in treatment. Response n Percentage Transportation 165 69.0% Money/monthly expenses 110 46.0% Doesn’t believe interventions/treatment are successful 95 39.7% Wait list for services 86 36.0% Stigma 83 34.7% Not engaged with clinician 81 33.9% Lack of childcare 71 29.7% No evening or weekend appts available 65 27.2% Medical 63 26.4% Availability of appointments 60 25.1% Other (please specify) 32 13.4% *Themes specified by providers as reasons a person may choose to not continue treatment included, but are not limited to, timeliness of services including scheduling, lack of providers, staff turnover/inconsistency, lack of funds/underinsured, no long-term treatment options, and addiction.

Q9a: I am sensitive to the consumer’s cultural background (race, religion, language, etc.).

Population Strongly Agree Agree Disagree Strongly Disagree Mental Health 71.3% 22.0% 0.5% 6.2% Substance Use Disorder 70.2% 26.0% 0.0% 3.8% Intellectual and Developmental Disabilities (IDD) 73.0% 21.0% 1.0% 5.0% Traumatic Brain Injury (TBI) 74.0% 20.0% 2.0% 4.0%

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Q9b: I help the consumer obtain the information needed so that he/she could take charge of managing his/her illness.

Population Strongly Agree Agree Disagree Strongly Disagree Mental Health 67.1% 27.6% 0.0% 5.2% Substance Use Disorder 71.2% 26.0% 0.0% 2.9% Intellectual and Developmental Disabilities (IDD) 66.0% 30.0% 0.0% 4.0% Traumatic Brain Injury (TBI) 68.0% 30.0% 0.0% 2.0%

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 154 Q9c: Consumers are encouraged to use consumer run programs (support groups, drop-in centers, crisis phone line, etc.).

Population Strongly Agree Agree Disagree Strongly Disagree Mental Health 46.4% 41.1% 5.8% 6.8% Substance Use Disorder 57.3% 34.0% 3.9% 4.9% Intellectual and Developmental Disabilities (IDD) 41.2% 46.4% 6.2% 6.2% Traumatic Brain Injury (TBI) 60.0% 34.0% 4.0% 2.0%

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The following questions were analyzed using a word cloud. A word cloud graphically depicts responses to open ended questions. The color of the word changes and the font size increases as the word appears more frequently throughout responses.

Q10. What other needs in your community are not being met for the clients you serve? One hundred and fifty-nine (n=159) providers who responded to the survey answered the open-ended question “What other needs in your community are not being met for the clients you serve?” Most of the responses had to do with the accessibility and affordability of services. These services included, day services (treatment, supports, and programs), crisis, substance use, outpatient, psychiatric (adults and children), autism, I/DD, and services for children. It was also discussed that services in general were difficult to find and easily denied. Transportation was also mentioned frequently. Providers brought up transportation being the main issue for many individuals and their ability to attend appointments. It was also brought up that there is a lack of transportation for “after hours” and is needed for many consumers. Housing was also mentioned often with emphasis on safe, affordable, and transitional opportunities within the catchment area. Providers also brought up a lack of/need for more preventative services, child psychiatrics, psychological evaluators, translators, and parental training.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 156 Q11. What needs are not being met for your agency? One hundred and forty-nine (n=149) providers who responded to the survey answered the open-ended question “What needs are not being met for your agency?” Many of the responses were that all their needs were being met or “none”. Those who felt not all of their agencies needs were being met said they had needs related to trainings, transportation, services for children, lack of pay and reimbursement, lack of funding for services, lack of staff, difficulty with the referral process, and the lack of finding resources such as housing, office space, higher levels of care, and testing.

Q12. Do you feel your agency is provided the support it needs from Partners BHM to serve your clients? One hundred and ninety-four (n=194) providers who responded to the survey answered the open-ended question “Do you feel your agency is provided the support it needs from Partners BHM to serve your clients?” Most responses were “yes,” their agency is provided the support it needs and when needed. Providers stated Partners is helpful to their organization and continues to work them to provide necessary services. The areas where providers felt they could use more support from Partners included helping clients access services, services for children, funding, referrals, the need for new staff (including clinicians, providers and therapists), and a reduction of paperwork.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 157 Q13. What additional training needs do you have that Partners BHM could assist with? One hundred and twenty-eight (n=128) providers who responded to the survey answered the open-ended question “What additional training needs do you have for your staff that Partners BHM could assist with?” Many providers stated “none” or there were no additional training needs Partners could assist with. For those that stated they would like to see additional/more trainings offered the following were mentioned: evidence based practices, SNAP, new staff trainings, CBT/DBT, IDD services, trauma informed care, substance use, primary insurance agencies, Medicaid (Transformation, Wavier, provider arrangements, and documentation), and billing. Other trainings included, cultural sensitivity, referrals, care coordination, CPR, SOAR, WRAP, PCP, and autism. Providers also wanted education on which trainings were available to them, as well as online trainings.

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Community Stakeholders The total number of completed community assessment surveys for community members/stakeholders was 74. The majority of those who responded came from the Department of Social Services and the School System.

Q1: Are you a collaborative member?

Response n Percentage No 38 51.35% Yes 36 48.65%

Q2: Which collaborative are you a member of?

Collaborative Member n Percentage Child and Family Collaborative 14 43.8% Crisis Collaborative 4 12.5% Juvenile Justice Collaborative 3 9.4% Residential Collaborative 1 3.1% Other (please specify) 10 31.2% *Individuals who selected other stated they were collaborative member of the following: MCO, MCO CC, Transition Coordinator, Care Coordinator, DSS SW, Public Health, Adult Collaborative, L.A.S.T., and Mental Health.

Q3: As a community member/stakeholder, what best describes your department, agency, role, etc...?

Department/Agency/Role n Percentage Department of Social Services 9 19.6% School System 6 13.0% Division of Juvenile Justice 4 8.7% Hospital 3 6.5% Public Health 3 6.5% Department of Justice 2 4.3% Department of Social Services, Child Protective Services 2 4.3% Other (please specify) 17 37.0% *Individuals who selected other described their roles in the community as follows: Mental Health, MCO, System of Care, Advocate, Child and Family Agency (Non-Profit), Therapist, Housing Provider and Program Assistance Administrator, Non-Profit Volunteer Organization, Partnership for Children, Community Collaborator, Partners Employee, LPC, Judicial System, Non-Profit Opioid Coalition, Early Childhood, and Psycho-social Rehabilitation. Q4: Which county you serve? (Check all that apply)

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 159 County n Percentage Burke 10 20.0% Catawba 14 28.0% Cleveland 12 24.0% Gaston 24 48.0% Iredell 7 14.0% Lincoln 15 30.0% Rutherford 4 8.0% Surry 5 10.0% Yadkin 4 8.0%

Q5: In your opinion, do consumers receive treatment or services as soon as they want?

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 160 Q6a: In your opinion, do consumers receive treatment or services that they need?

If not, what services could enhance your community? Housing/Residential Services – specifically mentioned were Level 3 residential providers for transitional teen housing ages 17 to 21, I/DD leveled housing, and group homes. Other service needs included day treatment facilities, allowing children to receive a higher level of care without multiple placements, increased number of TFC and IAFT, transportation support, more trauma informed care providers, substance use services, interim services for those on Innovations wait list, services for those with sexual abuse history, and 24-hour crisis center. Other enhancements related to services mentioned were improving staff consistency, affordability of treatment, and faster access to services.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 161 Q7: In your opinion, are consumers informed about the different services available to them and how to access to them?

Q8: In your opinion, is the accessibility to any of the following services reported as a barrier by your clients? (Check all that apply)

Services n Percentage Residential Treatment Levels 1 - 4 22 46.8% Child and Adolescent Day Treatment 13 27.7% Mobile Crisis 13 27.7% Opioid Treatment 11 23.4% Detoxification (non-hospital) 11 23.4% Facility Based Crisis 9 19.1% Partial Hospitalization 9 19.1% IDD Out of home respite 9 19.1% SU Intensive Outpatient Program 8 17.0% IDD Supported Employment 8 17.0% No accessibility gaps 4 8.5% Other (please specify) 10 21.3% *Themes specified by individuals who selected other included, but are not limited to, outpatient services, group care, level II services, higher level of care options, applied behavioral analysis and services for children with autism, access to resources, family exploitations, and TFC and IAFT.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 162 Q9: Select any of the following you perceive as a barrier to people receiving services. If you feel no barriers are experienced, please select "No barriers" at the bottom of the list.

Barriers n Percentage Lack of reliable transportation 39 76.5% Mental Health/Substance Use Issues 32 62.7% Lack of support from family/friends to seek out help 30 58.8% Cannot pay for services/medications 29 56.9% Homeless/housing issues 28 54.9% On a waiting list 27 52.9% Paying their bills (i.e. utility bills, rent/mortgage payments, phone, etc.) 25 49.0% Do not know what services are available 23 45.1% Lack of employment 22 43.1% Provider not close to their home (distance/time/cost) 22 43.1% Reading skill level/education level 20 39.2% Do not believe services will help 19 37.3% Feelings of fear or embarrassment 18 35.3% Cost of services 16 31.4% Frequency of services is not enough 15 29.4% Lack of childcare 15 29.4% Medical/health issues 14 27.5% Language Barriers 13 25.5% Food Insecurity 13 25.5% Cultural differences/Religious Beliefs 11 21.6% Physical disability/mobility issues 8 15.7% No Barriers 3 5.9% Other (please specify) 2 3.9% *Those selecting other (please specify) mentioned co-occurring issues.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 163 The following questions were analyzed using a word cloud. A word cloud graphically depicts responses to open ended questions. The color of the word changes and the font size increases as the word appears more frequently throughout responses.

Q10. What other needs are not being met for the clients you serve? Twenty-one (n=21) stakeholders who responded to the survey answered the open-ended question “What other needs are not being met for the clients you serve?” Those who stated there were needs not be met mentioned outpatient therapy, case management, additional services for children/families, additional support with food insecurity, help while on the waitlist, information on what services are available, access to resources, immediate assistance for families in crisis, and transportation.

Q11. What needs are not being met for your agency or department? Twenty-one (n=21) family stakeholders who responded to the survey answered the open-ended question “What other needs are not being met for your agency or department?”. Needs mentioned by those who responded included help additional help finding placements, access to services for children and teens, training, trauma informed providers, evidence-based practices, supports for working parents, communication from providers after discharge, and informing parents on services available. It was also mentioned a need for a better referral process or more training on the current process, and quicker access to treatment.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix E1: Community Assessment Survey Response Index 164 Juvenile Justice Those who answered “Juvenile Justice” to Q2, “As a community member/stakeholder, what best describes your department, agency, role, etc...?” were directed to answer the following additional questions. Three individuals responded to these questions.

Q1: How satisfied are you with the interaction between Partners and the Juvenile Justice collaborative? All were satisfied with the interaction between Partners and the Juvenile Justice Collaborative.

Q2: For the juveniles that have been in contact with the legal system, what specific areas can Partners BHM be of assistance? (Check all that apply) Response n Percentage Treatment needs 3 100% Residential 3 100% Referral for services 3 100% Transportation needs 2 67% Education with providers 2 67% Education with family 2 67% Other (please specify) 0 0%

Q3: How easy is it for juvenile offenders to access mental health and substance use services? All stated it was easy for juvenile offenders to access mental health and substance use services.

Q4: How could services for juvenile offenders be improved in your community? Responses included: more education on the referral process, more psychiatric evaluations, and more placements for sexual based offenders; specifically, those needing post release supervision from Youth Development Centers.

Q5: What services and/or supports do you find the most difficult for juvenile offenders to access or obtain? Responses included: Difficulty in finding support for youth to return to the community and placements for step down services from YDC or other therapies; substance abuse treatment is difficult for juvenile offenders to obtain.

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Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 192 Appendix F: Network Access Plan Section 5.1 Executive Summary I) Provide a summary of the 2019 Network Adequacy and Accessibility Analysis Report and the areas of focus that will be addressed in the upcoming year. Summary of the 2019 Network Adequacy and Accessibility Analysis The Partners Behavioral Health Management 2019 Community Mental Health, Substance Use and Developmental Disabilities Services Network Adequacy and Accessibility Analysis was conducted in compliance with the 2019 Community Mental Health, Substance Use and Developmental Disabilities Services Network Adequacy and Accessibility Analysis Requirement for the North Carolina LME/MCOs and as part of the Partners Behavioral Health Management (Partners) ongoing quality improvement initiatives. The intent of this analysis is to determine service gaps and identify service needs within the Partners catchment area and assess the adequacy and accessibility of Partners provider network. The analysis utilizes several methods of evaluation which include encounter data analysis, demographic data analysis, survey administration and analysis, Partners team meetings, stakeholder meetings, and other sources of information including NC TOPPS data, dashboards, and quality assurance/quality improvement reports.

Throughout the four report sections similar themes emerged. These themes are categorized as Service Accessibility & Availability; Perceptions, Social Support, and Stigma; Special Populations; Substance Use System of Care; Integrated Care; and Social Determinants. All the categories are connected to one another and affect each other.

Service Accessibility & Availability: The access and choice standards were met for all services except SA Comprehensive Outpatient Treatment (SACOT). However, there has been improvement in closing the service gap. For SACOT Medicaid, the percentage of consumers with access to 2 providers within 30/45 miles of their residence was 77% last year (2018) and this year is 99% (2019). For SACOT Non- Medicaid, the percentage of consumers with access to 1 provider within 30/45 miles of their residence was 88% last year (2018) and this year is 90%.

For those calling the access center, the percentage of emergent calls that received timely services was 100%; above the standard of 97%. The percentage of urgent and routine service requests that received timely follow-up continues to be below the standard. Partners continues to identify additional barriers to attending appointments after the root cause analysis identified scheduling appointments to not be the issue but attending appointments to be the issue. The availability of timely services was also identified by consumers as an area to strengthen.

Special populations: There was an increased focus on the special populations this year. Information requested was for population level data, supports available, and the numbers served. While information on some of the populations of interest is easy to obtain, methods to capture better data and information is still required (e.g., TBI, pregnant women with substance use disorders). Substantial efforts have been made to increase the supports available to the special populations. Partners has been able to increase jail/prison services via a diversion grant and participates annually in the Veteran Stand Down. Additionally, an internal task force has been developed to analysis the language and interpretive service needs for our catchment area.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 193 Perceptions, Social Support, and Stigma: The feeling or belief that treatment does not work was a top influencer in a decision to stop seeking treatment reported by consumers and providers. Providers and community stakeholder holders also perceived consumers belief ‘services will not help’ as a barrier to receiving services. Lack of support from family/friends was reported as a top service barrier by consumers, providers, and community stakeholders. Additionally, a perception gap was identified on whether consumers are informed about the different services available to them between consumers and providers & community stakeholders.

Substance use system of care: Those in the northern counties of the catchment area are still experiencing obstacles and barriers to receiving substance use services, but progress has and continues to be made. Affordability of services and the stigma surrounding substance use is a concern. Mental health services for substance use consumers are needed. When asked what would improve quality of life in their community 41% of SUD consumers said mental health services; 43% of SUD consumers reported their mental health was always or often not good in the past month.

Integrated Care: 5,373 individuals engaged in a Comprehensive Clinical Assessment in the 2017-2018 fiscal year. Over 650 individuals made one of these sites their medical home. Development of the Whole Person Integrated Care model is facilitating the process of individuals being introduced to behavioral health clinicians through an initial contact with primary care physicians. 30% of MH consumers and 43% of SUD consumers had needed to see a doctor but could not because of cost in the past 12 months. Not being able to pay for services/medications was a top 5 perceived barrier to receiving services reported by providers and community stakeholders. Partners was awarded a multi- year grant from SAMHSA to expand the System of Care in four counties. This grant allows the opportunity for individuals to link to services through presentation at their primary care facility. Social Determinants of Health: Social determinants continue to be a barrier to receiving services. The magnitude of social determinant factors varied substantially by population and this year substance use consumers seemed to be the most affected. Transportation, housing, and costs were the most experienced and influential social determinants.

Focus for next year Rutherford County: With the addition of Rutherford County as of July 1, 2019, Partners will be assessing the strength of the provider network in Rutherford County and assessing gaps within the community. This will include the credentialing and enrollment of new providers, as well as partnerships with new community stakeholders.

Medicaid Transformation: The upcoming NC Medicaid Transformation is a mindful piece of all future plans, as Partners prepares to become a Tailored Plan PHP. This has involved discussions with physical health providers as well as internal restructuring of resources to accommodate the needs of tailored plan members within the Partners communities. Additional information can be found in Appendix G.

Substance use disorder services: Partners will continue to work on increasing capacity for substance use disorder services across our catchment area. To ensure a comprehensive continuum of care in all areas we will continue to fill the gaps for Substance Abuse Comprehensive Outpatient Treatment (SACOT) and increase capacity for Opioid Treatment. With the award of two new contracts to SU providers, this should close the previous gap in the northern counties.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 194 Services & Social Determinants: Another primary focus will be increased capacity for residential treatment services for special populations such as females, children with complex needs, children and adults with dual diagnosis, adolescents experiencing problem sexual behavior, and adolescents experiencing substance use disorders. This was a need identified during the 2018 Community Access and Accessibility Analysis and will continue to be expanded during the 2019-20 year. Partners will continue to promote services for whole person integrated care, crisis services and social determinants of health such as housing and transportation. With transportation being a top barrier to treatment completion and engagement, this will be a top priority on the new Network Development (ND) Plan. We will also address barriers identified around transportation for follow up to urgent and routine appointments. Community awareness and education opportunities will focus on access to services and member perception of treatment efficacy.

II) Describe progress of activities, projects, and initiatives developed and/or implemented to address service gaps and service exceptions identified in last year’s gaps analysis report. For areas in which continued gaps exist and service exceptions are still needed what barriers have been identified and addressed? During the 2018-19 fiscal year, Partners developed Provider Network goals to meet the service needs identified in the 2018 Needs Assessment and Gaps Analysis. Goals continue to focus on six areas of need including Children and Families, Housing and Employment, Integrated Care, Intervention and Treatment, Prevention and Education and Quality Management and Monitoring. Goals were completed at 89%. The Network Development Cross Function Team comprised of Partners cross departmental staff, Consumer and Family Advisory Committee (CFAC) representatives and provider representatives, were responsible for initiation and development of the identified goals. The focus was on the development of new services, expansion of existing services and implementing strategies to improve services.

The following was accomplished by the Children and Families workgroup: • Expanded residential treatment services to include a residential group home for Problem Sexual Behavior. • Collaborating with stakeholders to establish a residential setting for youth with Substance Use needs.

The Housing and Employment workgroup met goals through the following activities: • Submitted a plan to develop several small homes in Gaston county with community partners • Expand inventory of affordable homes in the catchment: 10 units were added in Iredell Co, 3 pending in Gaston County. • Streamlined the process of notification process for vacancies of units within the targeted complexes eliminating the underutilization of units. • Hosted a Workforce Summit to educate employers about hiring members with MH/IDD/SU • Engaged at least 3 providers through the Provider Council on participation on the homeless COC committee.

Goals accomplished through the Integrated Care workgroup included: • Surveyed 85 providers Goal 1: Access-Collaborate with 60 In Network Providers to adopt protocols to obtain preventive physical care and annual physical data for behavioral health consumers. • Analyzed barriers to access psychological assessment for members, working to establish a

Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 195 new rate for providers. • Analyzed options to expand behavioral health crisis urgent care.

The Intervention and Treatment Workgroup met goals with the following activities: • Initiated implementation of High-Fidelity Wraparound and Mobile Outreach Response and Stabilization services. • Expanding High Fidelity Wraparound to Burke and Iredell Counties. • Initiated a Request for Proposal for Comprehensive SU services for Surry and Yadkin counties, awarding the RFP to two providers. • Dual Diagnosis-Develop and implement one dual diagnosis (IDD/MH/SU [ASD]) 1-person placement (IAFT) serving ages 12-17. • Developed a plan and promoted the need for bilingual therapists in the catchment area • Fully implement 2 previously approved in lieu of service definitions: Young Adults in Transition and Long-Term Community Supports. • Develop an alternative definition/payment for at least two new services. • Implement an enhanced rate for two Evidenced Based Practices.

Activities designed to meet goals of the Prevention and Education workgroup included: • To promote community awareness of behavioral health services and criteria for service eligibility, four articles will be written and published in the Behavioral Health Focus (BHF). • To promote awareness of behavioral health stigma, in our catchment area, Public Relations' campaigns will include 4 community speaking engagements/presentations.

Quality Monitoring and Management achieved the following: • Develop or obtain software with capability to provide the data analytics and predictive modeling to meet Partners identified needs. • Identify barriers and develop plan to reduce barriers to consumers missing follow up appointments. • Monitor member episode completion rates for 25% of consumers. • Treatment effectiveness/consumer satisfaction increased to 55%. • Increase consumer support group presence within Partners catchment area by three new groups.

Partners was able to close gaps in the provider network for Opioid Treatment services during the last fiscal year. This was done through the recruitment of Office Based Opioid Treatment Providers, expansion of existing Opioid Treatment providers, and distribution of CURES funding. There is a choice of at least one State Funded provider and two Medicaid providers within the required minute/mile range throughout the catchment area. Due to the need for Opioid Treatment we continue to work on expanding capacity.

Gaps continue to exist for Medicaid and State Funded Substance Abuse Comprehensive Outpatient Treatment (SACOT) services. A service exception will continue to be needed for SACOT. We have recruited 2 new providers and worked with existing providers to expand this service but continue to have barriers, particularly in the northern region of our catchment area. We have one other existing network provider that has shown interest in providing Medication Assisted Treatment and a continuum of substance use disorder services, including SACOT, in the northern region. We are in the process of working with these providers.

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Section 5.2 Access Plan I) Describe the actions that are underway or will be taking place over the next fiscal year to address the identified service gaps in Section One: Network Availability and Accessibility.

In order to close the Accessibility and Availability gap that exists in the northern counties of Surry and Yadkin, efforts continue to progress with providers to expand Comprehensive Substance Use Services, specifically SACOT to members in those counites. Contracts were awarded to two providers, and implementation of the SACOT programs are currently underway. This will give members a choice of two providers for comprehensive substance use services, which has not been an option in the past.

Partners internal Network Cross Function Team is working to identify social determinant barriers during access and treatment planning. A task force/workgroup will be created to provide treatment solutions that solve treatment barriers. This work is done to address the issues identified with Urgent and Routine follow up visits, as well as member engagement and episode completion.

II) Describe the actions that are underway or will be taking place over the next fiscal year to address geographic, cultural or special populations needs identified in Section Two: Accommodation.

Partners will work to build methods to capture better data and information on the State emphasized special populations. An Internal Workgroup within the Network Cross Function Team is working on identifying the complex needs of the deaf and hard of hearing as well as the needs of the bilingual members within the community. Goals include identifying financial supports needed for interpretive services as well as the bilingual providers in the most be beneficial geographic areas. The Integrated Care Team is also working to establish supports for the LGBTQ community. These internal groups will expand to include TBI and pregnant SU women supports. Efforts will be explored to assist providers in developing culturally sensitive cultural competence plans and consideration is being given to link these efforts to value based contracting.

III) Describe the actions that are underway or will be taking place over the next fiscal year to improve consumer and stakeholder experience as identified in Section Three: Acceptability.

The Network Cross Function Team will be focusing on aligning perceptions of availability and accessibility of services for consumers and community stakeholders & providers. The team works with Marketing and Communication to provide education to members and training to providers that target service availability and accessibility and promote communication, engagement and cultural acceptance. The Partners System of Care Team (SOC) is an integral part of community training and awareness. SOC provides ongoing CIT training for local law enforcement, anti-stigma campaigns, promote access to Partners resources and provide support for juvenile justice collaboratives to establish resources for at risk youth.

A copy of the Network Development Plan can be found in Appendix H.

Section 5.3 In Lieu of and Alternative Services North Carolina ranks high across multiple child and adult health measures, scoring in the top third for children’s access to primary care, well child visits and immunizations. In adult health measures, North

Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 197 Carolina scored in the top tier of states for managing adults on persistent medications and monitoring individuals on antipsychotic medications. North Carolina still has work to do to improve other key health performance indicators, including timeliness of prenatal and postpartum care, low birth weight, preventive health measures for women, and timely access and follow-up to mental health services. To that end, some of the In lieu of service definitions and Alternative Service definitions assist with Partners in attaining timely follow up benchmarks.

I. For Medicaid-funded “In Lieu of” Services, using the list from the following pages of approved Medicaid “in lieu of” service definitions for the LME/MCO, address the following: A. Geographic area covered by each approved “in lieu of” service B. Service capacity of each “in lieu of” service C. Demonstrate how each “in lieu of” service filled the gap it was intended to address, including the number and characteristics of members served and how they accessed the service D. Barriers encountered or challenges experienced during implementation

Family Centered Treatment (H2022 Z1; H2022 HE): Family Centered Treatment® (FCT) is a comprehensive evidence-based model of intensive in-home treatment for at risk children and adolescents and their families. Designed to promote permanency goals, FCT treats the youth and his/her family through individualized therapeutic interventions. Geographic area: 5 providers; 13 sites in counties of Catawba, Cleveland, Gaston, Iredell, Lincoln, Mecklenburg, Forsyth and Wake. Service capacity: 358 Service gap identified/filled: Some providers had adopted Family Centered Treatment as a model and were trying to implement it within the Intensive In-Home (IIH) Service Definition. They approached Partners about the difficulties using FCT with IIH. Based on the Needs Assessment current at that time, evidenced based practices had been identified as a need within our provider network. Based on the expressed concerns of the providers, Partners staff worked with the providers and the FCT Foundation to develop and submit the in lieu of definition for FCT. FCT filled the gap it was intended to address by providing an alternative to out-of-home placements or, when it is in the youth’s best interest to be placed out of the home, minimizes the length of stay and reduces the risk of recidivism. Number & characteristics of members served: children who are at risk 358 at risk children ages 3 to 18 were served in FY18. How services are accessed: Care Coordination, DSS, Access to Care Barriers/Challenges encountered during implementation: The largest barrier was trying to develop an FCT service definition that would meet requirements within Clinical Coverage Policy (CCP). The group working on the definition had to develop accountability measures and requirements that would hold true for multiple providers across the network. We have built in incentives to the payment methodology.

CTI (H0032 U5): Critical Time Intervention (CTI) is a time-limited intensive case management model designed to assist adults age 18 years and older with mental illness who are going through critical transitions, and who have functional impairments which preclude them from managing their transitional need adequately. CTI promotes a focus on recovery, psychiatric & physical rehabilitation, and full community inclusion. Geographic area covered: 4 providers; 4 sites in counties of Burke, Iredell and Gaston. Service capacity: 91 individuals served in FY18 How the service filled the gap it was intended to address: Partners Behavioral Health Management (BHM) proposed a Critical Time Intervention Program for individuals who have a serious mental illness,

Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 198 who are homeless/risk of homelessness, and have had a psychiatric inpatient admission, an arrest, or high use of emergency rooms. Partners believes that CTI is a valuable service in our catchment area and fills the gap it was intended to address by reducing inpatient psychiatric admissions, arrests, and homelessness. Number and characteristics of members served: 91 adults ages 18 years and older with mental illness who are going through critical transitions, and who have functional impairments which preclude them from managing their transitional need adequately. How those served accessed the service: Access to Care, Care Coordination, DSS, Mobile Crisis Barriers encountered or challenges experienced during implementation: Barriers included limited amount of housing resources and options, limited space for staff to be housed, individuals without benefits, limited or absent family and natural supports, lack of meaningful day activities, and homeless agencies without clinical staff. Homeless providers only offer shelter, which is prescribed by HUD, who funds their services. Any clinical support should be provided by Partners contracted providers for continuity of care.

Outpatient Plus (90873 U5): Not implemented yet: sent back to DMA due to changes in the service definition in 2018, Approved definition and updated rate received back at Partners in late January, early March. The service will be released to providers by 7/1/19.

Rapid Response Crisis Services for Children and Youth (S5145 U5): Rapid Response Homes are licensed therapeutic foster homes with a North Carolina Licensed Child Placing Agency that provides emergency treatment, structure, stabilization, and supervision to children and youth who are experiencing a behavioral health crisis and who have Medicaid originating from the designated LME/MCO catchment area. This emergency service is intended to support family stability, prevent abuse and neglect, provide short term treatment and prevent or minimize the need for out-of-home placements. This service was implemented 3/1/18 in the Partners catchment area. Geographic area covered: 2 sites currently utilized, Iredell County and Mecklenburg County Service capacity: 5 providers contracted to serve all 8 counties; 2 active providers who served 35 children. How the service filled the gap it was intended to address: We created this service due to lack of crisis situations with placement, either the next level of care identified didn’t have an open bed and there’s a wait and the provider needs to discharge the consumer from their agency/facility due to authorizations denied. Other times, due to unmanageable behaviors in a residential facility, the child gets an eviction notice to leave the facility, no placement identified, hence RR bed is next option. Number and characteristics of members served: 21 consumers served in FY18; children with primary MH diagnosis who are in crisis. How those served accessed the service: Stakeholders (providers, DSS, DJJ, Care Coordination, school) need to contact ACCESS for openings. Barriers encountered or challenges experienced during implementation: The barriers with Rapid Response (RR) continue as other RR providers are still recruiting families in all our catchment areas, it’s challenging to develop homes that meet the criteria, some providers are still denying some challenging consumers, lack of specialized families to handle complex needs or IDD children as well as a need for a more refined referral process.

Dialectical Behavioral Therapy (H2019 U5): RFP posted 3/14, deadline 4/18. No responses were received. Barriers encountered, or challenges experienced during implementation: DBT is currently available as an EBP on the benefit plan- at a special rate. Previously when put out to providers, the response was minimal to nothing because the certification was extensive, and the rate was not promising from what

Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 199 has been shared. The plan moving forward is that the Network Cross Function workgroup has been looking at a couple different options for certification that will both meet the best practice expectation AND the network need at a rate that is workable. Training options and certification requirements are being explored. After addressing training/certification and a rate (the general framework), meeting with providers would be the next step for their feedback and then re-RFP.

Behavioral Health Crisis Assessment and Intervention (T2016): A designated service that is designed to provide triage, crisis risk assessment, evaluation and intervention within a Behavioral Health Urgent Care (BHUC) setting. A BHUC setting is an alternative, but not a replacement, to a community hospital Emergency Department. Individuals receiving this service have primary behavioral health needs and an urgency determination of urgent or emergent. Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care. The BH-CAI service is utilized within a Tier III or Tier IV BHUC setting. A Tier III BHUC is operated during business or extended hours, while a Tier IV BHUC operates 24/7/365. Both Tier III and Tier IV BHUC settings must be able to provide the following: • Involuntary Commitment First Evaluations (IVC) as an IVC designated setting • Medical Screenings • Clinical Evaluation • Psychiatric services • Referrals and case management • Disposition & discharge planning • Inclusion of family or natural supports (as available). Typically, within a BHUC setting, law enforcement is available on site to maintain custody and facilitate drop off by community first responders or other law enforcement in instances where a petition has been filed or an IVC has been initiated. Geographic area covered: Cleveland – 1 site location Service capacity: 1 provider using this service: Phoenix Counseling – 232 individuals served in FY18. Service capacity to provide crisis triage and assessment in the urgent care area for both voluntary and involuntary consumers continues to be a primary concern due to limited space. Partners has two providers interested in adding this service in Catawba and Lincoln Counties. Options are being explored. How the service filled the gap it was intended to address: Increases use of BHUC versus ED for individuals in behavioral health crisis and overall decrease in recurrent crisis episodes. Increases knowledge of BHUC program and service delivery model as evidenced by increase in consumer and stakeholder awareness of the availability and function of the BHUC in addressing behavioral health crisis. Decreasing the number of individuals that go to local EDs for behavioral health crises. Quickly and safely serve individuals triaged as Emergent and Urgent. Expedited processes for Law Enforcement to “drop off” individuals in need of BHUC services and return to regular duties. Number and characteristics of members served: 232 Served in FY18; All MH or SUD, and co-occurring BH/IDD consumers 4 and older. They are consumers experiencing a behavioral health crisis meeting Emergent or Urgent triage standards. How those served accessed the service: Referral by mobile crisis, drop off by local law enforcement, walk in. Barriers encountered, or challenges experienced during implementation: (1) Only one provider is currently using this service limiting the geographic area it can be accessed. In December 2018, Partners, built a secure area for Law Enforcement in the urgent care area, which further limited space available for consumers waiting for either initial triage and assessment, admission or transfer to a more acute setting. (2) For Phoenix Counseling Center/Cleveland Crisis and Recovery Center to meet the States’ Crisis Services Initiative to divert behavioral health consumers from local emergency departments and to continue to be

Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 200 the designated 24-hour facility where law enforcement can bring respondents for a 1st Examinations, Partners must seriously undertake expansion of the urgent care area of Cleveland Crisis and Recovery Center. (3) Financial Sustainability of this service is difficult to maintain. It is a costly service to sustain and fund.

High-Fidelity Wraparound (H0019 U5): Services began September 2018. Still in process. Should be implemented within the next couple of months. The piloted providers are in the process of being trained now and services will begin by the end of August. The providers will not start billing Medicaid until October 1, 2019 but will begin to submit service authorization requests (SARS) 30 days prior. Grant money was provided to start up and build the programs. Geographic area covered: Gaston, Lincoln, Burke and Iredell are the counties to be served. (1st 2 years Gaston/Lincoln; 3ys 3-4 of grant Burke and Iredell). Service capacity: The grant projected to serve 142 families (we anticipate serving more). How the service filled the gap it was intended to address: This service is still in process and has not yet been implemented. Number and characteristics of members served: 25 families are currently enrolled in the HFW program. The characteristics of the members are youth and young adults with Serious Emotional disturbances and/or at risk for a First Episode of Psychosis (FEP). They will also be involved in multiple systems. How those served accessed the service: Participants will access the service through community referrals and pediatric clinic referrals. They must live in the counties mentioned above and be between birth- 21. Participants must meet criteria based on a screening tool for the High-Fidelity Wrapround services. Barriers encountered, or challenges experienced during implementation: Barriers encountered were educating providers, referral sources and families about the new service and its benefits. Provider agencies referring families that meet criteria for the service. Working with the pediatric clinic to access and screen all patients in the pediatric clinic. Contracting with physical health providers in Lincoln County to provide integrated care. The last identified barrier is the rate in which providers can enter a family into the service. There are specific rules around the timing a team can bring new families into the service for fidelity reasons.

Young Adults in Transition (H2022-U5): Geographic area covered: Burke and Catawba Service capacity: 40 in the first year How the service filled the gap it was intended to address: Number and characteristics of members served: Service has not yet started How those served accessed the service: Service has not yet started Barriers encountered, or challenges experienced during implementation: NCtracks credentialing took a very long time for the provider identified to pilot this service—therefore, the service has not yet started

II. For approved non-Medicaid-funded alternative services, using the list from the following pages of non-Medicaid Alternative service definitions for LME/MCO, address the following: A. Geographic area covered by each approved alternative service definition B. Service capacity of each non-Medicaid-funded definition C. Demonstrate how each non-Medicaid-funded definition filled the gap it was intended to address, including the number and characteristics of members served and how they accessed the service D. Barriers encountered or challenges experienced during implementation

Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 201 Crisis Evaluation & Observation (YA324): Not implemented at Partners

Peer Support (YA308): Not implemented at Partners

Peer Support Group B3 (YA309): Not implemented at Partners

Assertive engagement (YA341): This service is a way of working with adults and/or children who have severe mental illness and/or substance use disorder and have difficulty engaging in treatment services. Additionally, these consumers also have a history of non-compliance with medication resulting in symptom manifestation and/or relapse or have a history of frequent hospitalizations, jail/detention/involvement with law enforcement or utilization of crisis services. Assertive engagement is a critical element of the rehabilitation and recovery model as it allows flexibility to meet the consumers’ needs in their own environment or current location (i.e., hospitals, shelters, streets, etc.). It is designed as a short-term engagement service targeted to populations or specific consumer circumstances that prevent the individual from fully participating in needed care for mental health or substance use issues. Geographic area covered: 6 providers; 15 sites in Burke, Catawba, Gaston, Iredell, Surry, Yadkin, and Rowan. Service capacity: 148 were served in FY18 How the service filled the gap it was intended to address: This service was implemented in 2014 to meet the need to increase timely follow up from hospitalization, increase consumer engagement with community-based services, and to reduce frequent readmissions to Emergency Departments for non- emergent/urgent care. This service has been in place for over two years now and continues to fill the gap it was intended to address by assisting community providers to meet consumers in a timely manner while still in Inpatient Psychiatric units and emergency departments. Number and characteristics of members served: 148 served in FY18 adults and/or children who have severe mental illness and/or substance use disorder and have difficulty engaging in treatment services. How those served accessed the services: Care Coordination, Hospital liaison, Access Barriers encountered or challenges experienced during implementation: Barriers included limited access for community providers to meet with consumers on the Inpatient units and community providers indicating challenge to hiring peer support staff to perform assertive engagement.

Peer Support Hospital Discharge & Diversion – Individual (YA343): *The name of this changed slightly but the procedure code is still the same Peer Support Aftercare & Diversion service (PSAD) facilitates consumer engagement in treatment following an episode of hospitalization or incarceration (includes ADATCs, detox facilities, jails) and bridges the service gap when timely aftercare appointments are not available. The service may also be used as part of crisis response and diversion when individuals in crisis access walk-in crisis facilities. It is available for adults aged eighteen and older with a MH and/or SA disability. PSAD is not intended to be an ongoing or long-term service. This service is provided by Peer Support Specialists to consumers individually or in groups following discharge from state and local hospitals and ADATCs or release from jail/prison. The service is designed to improve aftercare and diversion rates, facilitate engagement and retention in outpatient treatment, promote consumer recovery and empowerment and provide additional support during transition to the community. PSAD services emphasize the acquisition, development and expansion of rehabilitative skills needed for recovery. Geographic area covered: 5 providers; 15 sites in Burke, Catawba, Gaston, Iredell, Surry, Yadkin, Rowan Counties

Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 202 Service capacity: 1,256 served How the service filled the gap it was intended to address: Consumers being discharged from hospitals were being given appointments but often were not following up. This service fills the gap it was intended to address by certified peers providing outreach, engaging consumers, mitigating barriers, and increasing timely follow up and engagement in community-based services and supports. Number and characteristics of members served: 1,256 consumers individually or in groups following discharge from state and local hospitals and ADATCs or release from jail/prison in FY18. How those served accessed the service: Care Coordination, Hospital, Access, or direct referral from providers Barriers encountered or challenges experienced during implementation: Identifying providers with strong certified peers and a commitment to outreach. Helping promote collaboration with hospitals to ensure rapid referrals and good information about how to connect with these consumers. Long wait times for some open access models & transportation barriers were two factors that deterred some consumers from making it to aftercare services that the peers have been able to help mitigate. Over the past fiscal year and to date, Partners facilitated three Certified Peer Support Training courses and has trained forty- nine Peer Support Specialists.

Hospital Discharge Transition Service (YA346): This service includes face to face attendance at state and community psychiatric hospitals, facility-based crisis centers, detox centers and other 24-hour facilities for the purposes of discharge planning with assigned and unassigned consumers. Services are inclusive of face to face contacts with consumers and staff, attendance at treatment/discharge meetings, and contact/linkage with community resources identified in discharge plan. The objective is to facilitate discharge planning and when applicable, complete all documentation required to transfer consumers to another appropriate service with an MCO network provider. The Hospital/Inpatient Discharge Planning & Transition (DPT) service should be used briefly and only until consumers are connected to a provider for ongoing services. Geographic area covered: 6 providers; 16 sites in Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Surry, Yadkin, Rowan, Stanly, Anson Counties Service capacity: 529 served How the service filled the gap it was intended to address: Implemented in 2014, the hospital discharge transition service fills the gap it was intended to address by increasing timely follow up from hospitalization, increases consumer engagement with community-based services, and reduces frequent readmissions to Emergency Departments for non-emergent/urgent care. Number and characteristics of members served: 529 behavioral health consumers with a behavioral health admission and discharge diagnosis served in FY18. How those served accessed the service: Care Coordination, Hospital staff, Hospital Liaison staff, Access Barriers encountered or challenges experienced during implementation: Barriers included hospitals frequently not making the referrals or letting MCO staff know who was admitted and discharged and needed connections to a community provider. Sometimes this occurs because individuals are discharged in the evenings or weekends and there is a disconnect between the staff at the hospital and letting Access to Care know the individual needs to be connected to community provider. Additional barriers include limited access for community providers to meet with consumers on the Inpatient units and community Providers indicating challenge to hiring peer support staff to perform assertive engagement.

Jail Support (YA349): Not implemented at Partners

Assertive Engagement (YA368): Provided under the Assertive Engagement YA341

Partners 2019 Network Adequacy and Accessibility Analysis Appendix F: Network Access Plan 203

Crisis Evaluation & Observation (YA369): A service for individuals experiencing a behavioral health crisis. Available 24 hours a day, seven days a week. Will assess, stabilize and refer persons to the least restrictive setting or service. Geographic area covered: One provider currently providing this service, Phoenix Counseling. The Phoenix Counseling Center-Cleveland BHUCC is a Tier IV Center which is open 24/7, 365, and serves all counties in the Partners Behavioral Health catchment area but with a primary service focus of Cleveland, Lincoln and Gaston Counties. Service capacity: The Cleveland BHUCC has a service capacity of no more than six members at one time (please see Barriers and Challenges for a better explanation). During the FY18, 239 individuals were served at the BHUC. How the service filled the gap it was intended to address: For Phoenix Counseling Center/Cleveland Crisis and Recovery Center met the States’ Crisis Services Initiative to divert behavioral health consumers from local emergency departments and to continue to be the designated 24-hour facility where law enforcement can bring respondents for a 1st Examinations. How those served accessed the service: Referred by self/family or friends, Law Enforcement or Outpatient Community MHDDSA Services or supports. Barriers encountered or challenges experienced during implementation: Financial sustainability of a BHUCC center have proved to be the primary barrier for this and the BHUCC service.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix G: Impact of NC 1115 Medicaid Waiver 204

Appendix G: Impact of NC 1115 Medicaid Waiver Partners Needs and Gaps Analysis--Impact of Transition under the NC 1115 Medicaid Waiver The upcoming transition to the 1115 Medicaid Waiver presents exciting opportunities for Partners to build on its existing strengths and expand our capacity to “Improve Lives and Strengthen Communities”.

Beginning in July 2020, a significant portion of the Medicaid population currently managed by Partners will have the opportunity to enroll in its choice of statewide health plans known as “Standard Plans”. These plans will be responsible for ensuring that the entire healthcare needs of members are addressed…behavioral, as well as physical. This is referred to as an “integrated care” approach. It is increasingly established by medical science that the all healthcare needs of NC citizens are interrelated. In other words, the best outcomes are achieved when a physical health concern is addressed with consideration to the behavioral health needs of the individual…and vice versa. The Standard Plans will not cover the most acutely ill members of Partners…only those with “mild to moderate” conditions will be eligible. This group of members represents a significant majority of the current Partners Medicaid enrollees. Of the approximately 160,000 Medicaid lives currently enrolled in Partners’ service area, around 130,000 will ultimately transition to Standard Plans.

In July of 2021, Partners intends to become responsible for managing the physical (including pharmaceutical) and behavioral needs of its remaining 30,000 Medicaid enrollees. This group represents those who have the most complex behavioral and physical health needs and are most likely to access higher levels of healthcare, as well as tax supported human services (e.g., law enforcement, health departments, social services, etc.). In order to accomplish this, Partners will be required to meet the requirements of a formal “readiness review” in order to be approved by NC DHHS as a “Tailored Plan”. The expansion of Partners’ Medicaid coverage to encompass the physical and pharmaceutical needs of these highly vulnerable, and high needs members will require several initiatives to achieve the best outcomes for those we will have responsibility for supporting. Some of these will include the following:

• Robust expansion of our provider network to include medical practices (especially primary care for adults and children) • Comprehensive assessment and care planning to integrate physical, behavioral, and “social determinant” (housing, transportation, nutrition, employment, etc.) issues • Development of comprehensive expertise in intensive case management and care coordination for whole person care (physical, behavioral, social) • New administrative capabilities to handle claims administration for all Medicaid claims (medical/pharmacy/behavioral) • Expansion of our Access to Care system to support all callers with any physical or behavioral issues • New Information Technology infrastructure and software that will enable real time electronic access to health information by providers, as well as generate data that will measure outcomes and ensure accountability for quality services • Expanded medical and clinical leadership in utilization management that will enable members to get the “right care in the right amount at the right time in the right setting” • Compliance with new regulatory requirements including accreditation by the National Committee for Quality Assurance (NCQA)

As always, the needs of members will be determined on an ongoing basis and in annual surveys to keep abreast of any service gaps that arise as Partners enters this new era of opportunity to support those who are dependent on a wholistic and coordinated approach to achieving optimal outcomes while ensuring the most efficient utilization of resources.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix H: Network Development Plan 205 Appendix H: Network Development Plan A – Social Determinants of Health

Timeline ID Work Group and Team Lead: Projected Projected Actual Start Activity Lead Responsible Parties Start Date Duration Date How long (# of Who (individuals/ departments) are What date is days) do you What date did Who is working to accomplish this activity Social Determinants of Health Jerry this activity estimate this the activity coordinating and what is their responsibility? What projected to Campbell activity will take actually start? project activity? other Workgroup Leads/ members start? to accomplish? need to be involved? Goal 1: Facilitate 12 Community Based Activities developed from department provided data sources by 6/30/20. Outcomes: Reduce Member Barriers to Treatment 1a Review Department provided data 7/1/2019 30 Jerry Campbell IC Team MR and SOC 1b Discuss findings and determine priorities 8/1/2019 14 Jerry Campbell IC Team MR and SOC 1c Identify Target locations and Activities 8/15/2019 16 Jerry Campbell IC Team MR and SOC 1d Delegate activity related responsibilities 8/15/2016 16 Jerry Campbell IC Team MR and SOC 1e Facilitate activities 9/1/2019 300 Jerry Campbell IC Team MR and SOC 1f Produce Summary Reports 6/15/2020 15 Jerry Campbell IC Team MR and SOC Goal 2: Increase member engagement by implementing 3 identified strategies for improving transportation solutions by 6/30/19 Outcomes: increase member appt follow up 2a Brainstorm strategies for improving 7/1/2019 5 7/1/2019 Jerry Campbell Integrated Care Team and transportation solutions Member Relations Research brainstormed strategies 7/6/2019 30 Jerry Campbell IC SOC MR 2b Identify Strategies to implement 8/15/2019 30 Jerry Campbell SDOH Workgroup team, PN 2c Implement activities 10/1/2019 270 Jerry Campbell SDOH Workgroup team 2d troubleshoot issues 11/1/2019 270 Jerry Campbell SDOH Workgroup team 2e 2f summary report 6/1/2020 30 Jerry Campbell SDOH Workgroup team

Partners 2019 Network Adequacy and Accessibility Analysis Appendix H: Network Development Plan 206

B – Member Experience

Timeline ID Work Group and Team Lead: Projected Start Actual Start Activity Lead Responsible Parties Projected Duration Date Date Who (individuals/ departments) are What date is this How long (# of days) What date did Who is working to accomplish this activity and activity do you estimate this Member Experience the activity coordinating what is their responsibility? What projected to activity will take to Liza Go Harris actually start? project activity? other Workgroup Leads/ members start? accomplish? need to be involved? Goal 1: Develop Transportation options in Surry and Yadkin Counties by identifying 3 transportation resources available to members by 6/30/20 Outcomes: transportation resources will be identified and distributed to members in the northern region 1a Explore available resources/services offered 8/1/2019 90 days Liza Go-Harris ME workgroup by PART public transportation 1b Meet with network providers to discuss 10/1/2019 60 days Liza Go-Harris ME workgroup transportation needs, challenges and possible solutions Goal 2: Increase IAFT providers treating the specialty population (sexually trafficked youth) to serve all 9 counties by 6/30/20. Outcomes: increase provider network of trained IAFT providers that are able to serve youth who have been sexually trafficked 2a Schedule 1-3 collaborative meetings with 9/30/2019 60 Liza Go-Harris ME workgroup IAFT providers to discuss need for specialty population 2b Identify challenges, barriers and/or training 12/30/19 needed for IAFT providers dealing with specialty population Goal 3. Increase availability and capacity of residential level II for youths (both male and female) Outcomes: Increased availability and capacity of residential level 2 3a Assess need for both male and female Level 8/1/2019 30 days Liza Go-Harris ME workgroup II

Partners 2019 Network Adequacy and Accessibility Analysis Appendix H: Network Development Plan 207 Timeline ID Work Group and Team Lead: Projected Start Actual Start Activity Lead Responsible Parties Projected Duration Date Date 3b approach existing providers with service 9/1/2019 60 days Liza Go-Harris ME workgroup expansion options or recruit new providers Goal 4: Increase access to Psychologists to provide mobile evaluations Outcomes: Increased mobile evaluations completed by network Psychologists 4a Assess current provider network providing 8/1/19 30 days Liza Go-Harris ME workgroup mobile evaluations 4b Meet with psychologist providers to discuss 9/1/19 60 days Liza Go-Harris ME workgroup the network needs, challenges, barriers and explore possible solutions 4c Explore need for value-based contracts 11/1/19 60 days Liza Go-Harris ME workgroup and/or incentives for mobile evaluations

C – Member Outcomes

Timeline Activity ID Work Group and Team Lead: Projected Actual Start Responsible Parties Projected Duration Lead Start Date Date What date is How long (# of days) Who is Who (individuals/ departments) are working What date did Member Outcomes this activity do you estimate this coordinating to accomplish this activity and what is their ID the activity projected to activity will take to project responsibility? What other Workgroup Doug Gallion actually start? start? accomplish? activity? Leads/ members need to be involved? Goal 1: Decrease percentage of SUD consumers who report their MH as always or often not good to 33% or less by 6/30/20. Outcomes: percentage of SUD consumers who report their MH as always or often not good will be 33% or less by 6/30/20 1a Document baseline percentages from 2019 IDD and MH CC, WPIC, SOC, PN, 8/1/2019 60 days Doug survey data. Member Services 1b Survey SUD providers on who is integrating 10/1/2019 60 days Doug SUD and MH services.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix H: Network Development Plan 208 Timeline Activity ID Work Group and Team Lead: Projected Actual Start Responsible Parties Projected Duration Lead Start Date Date 1c Develop a plan for SUD providers to 1/15/2020 90 days Doug increase integration with MH services. Goal 2: Develop 1 Dual Diagnosis IDD/MH/SU/ASD 3-4 bed residential group home that serve adults ages 18-35 by 6/30/20 Outcomes: increase availability of residential options for members dually diagnosed 2a Provider will obtain initial licensure for carried over 10/1/2019 Doug IDD and MH CC, WPIC, SOC, PN, .5600C group home. from 2019 Member Services 2b Provider will submit proposed budget for carried over 11/1/2019 Doug approval. from 2019 Goal 3: Develop one Dual Diagnosis IDD/MH/SU/ASD Level III residential treatment facility serving females ages 12-17 by 6/30/20 Outcome: Increase availability of residential options for members dually diagnosed (MH/IDD/ASD). 3a MCO will develop new In-Lieu of service, get 9/1/2019 90 days Doug IDD and MH CC, WPIC, SOC, PN, approval from DMA. Member Services 3b Develop RFI new service. 2/1/2020 90 days Doug Goal 4: Develop one TFC home, specializing in IAFT, (with no other children in the home), serving children ages 9-12 by 6/30/20 Outcome: Increase availability of residential options for members dually diagnosed (MH/IDD/ASD). 4a Provider will obtain initial licensure and carried over 10/1/2019 Doug IDD and MH CC, WPIC, SOC, PN, certify TFC in IAFT model. from 2019 Member Services 4b Provider will submit budget for approval. carried over 11/1/2019 Doug from 2019

Partners 2019 Network Adequacy and Accessibility Analysis Appendix H: Network Development Plan 209

D – Tailored Plan Timeline Activity ID Work Group and Team Lead: Projected Start Actual Start Responsible Parties Projected Duration Lead Date Date How long (# of days) Who (individuals/ departments) are working What date is this What date did Who is Tailored Plan do you estimate this to accomplish this activity and what is their activity projected the activity coordinating activity will take to responsibility? What other Workgroup Jeanne Patterson to start? actually start? project activity? accomplish? Leads/ members need to be involved? Goal 1: Increase percentage (to meet state average) of youth perception of care for access and general satisfaction by 6/30/20. Outcomes: percentage of youth perception of access and general satisfaction will increase to meet state average 1a Educate youth providers on perception 7/1/2019 Ongoing Jeanne Jeanne, SOC Expansion Grant staff, of care Youth Move 1b Ensure youth and families understand 7/1/2019 Ongoing Jeanne Jeanne and family partner right and participate in treatment 1c offer opportunities for family and youth 7/1/2019 Ongoing Jeanne Jeanne and family partners to participate in child and family team training 1d Support the development of Youth 7/1/2019 Ongoing Casey Pruitt Casey, Jeanne and County Move and other identified youth Collaboratives empowerment programs. Goal 2: Identify a cultural competence assessment tool to be used with providers that will enable Partners to identify areas in need of improvement. Outcomes: perception of provider cultural competence will increase as reported from member surveys 2a Gather information from NCQA and 7/1/2019 90 days 7/1/2019 Jeanne Jeanne, Janet Noblitt, Tailored Plan other sources about available tools to team assess cultural competency.

2b Present information to providers and 10/1/2019 Ongoing Jeanne Jeanne, Stacey Bryant, local others about cultural competence as a collaboratives, Provider Network meaningful practice.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix H: Network Development Plan 210 Timeline Activity ID Work Group and Team Lead: Projected Start Actual Start Responsible Parties Projected Duration Lead Date Date 2c Provide information to providers, 7/1/2019 90 Jeanne Jeanne Patterson, Stacy Bryant, Jeff stakeholders and members about Brucato cultural competency surveys and self- assessments. 2d Provide ongoing information and 8/1/2019 Ongoing Jeanne Jeanne Patterson, Stacy Bryant, Jeff trainings on full cultural competency Patterson Brucato through Provider Bulletin, provider meetings, county collaboratives.

E – Value Based Contracting Timeline Activity ID Work Group and Team Lead: Projected Actual Start Responsible Parties Projected Duration Lead Start Date Date What date is How long (# of days) Who is Who (individuals/ departments) are working What date did Value Based Contracting this activity do you estimate this coordinating to accomplish this activity and what is their the activity projected to activity will take to project responsibility? What other Workgroup Jennifer Moore actually start? start? accomplish? activity? Leads/ members need to be involved? Goal 1: Develop at least 1 transitional housing program for adults diagnosed with substance use disorders in Partners Northern Region 6/30/20. Outcomes: The Northern Region will have at least one SUD transitional housing program for Adults by 6/30/20 1a Identify and recruit a workgroup of subject 7/1/2019 30 J. Moore matter experts to oversee implementation 1b Identify provider of SUD transitional housing Develop value-based contract with provider 1c Identify location for housing program 1d 1e Begin operations Goal 2: Develop an alternative payment/definition for at least two services by 6/30/20. Outcomes: 2 new or existing services will be approved for alternative payment.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix H: Network Development Plan 211 Timeline Activity ID Work Group and Team Lead: Projected Actual Start Responsible Parties Projected Duration Lead Start Date Date 2a Identify and recruit a workgroup of subject J. Moore matter experts, to include provider representatives, to assist with examining 7/1/2019 30 existing services/funding/data. 2b Identify the 2 (two) services for development of alternative payment/definition 2c Engage Partners' Financial Analysts to determine cost-neutrality 2d Determine whether to engage in a pilot project with a specific provider or to initiate the RFP process 2e If RFP is the chosen route, develop RFP, host Bidders Conference, review bids, select providers 2f Execute contracts with selected providers either through Pilot Project or RFP process Goal 3. Increase number of SACOT services providers in the northern counties (Surry & Yadkin Counties) by 6/30/20. Outcomes: Add at least 1 SACOT provider to close service needs gap in Surry and Yadkin County 3a Review results of Gaps/Needs Analysis on 7/1/19 J. Moore SUD and SACOT 3b Run Monthly SUD/SACOT service capacity based on claims via reports manager 3c Develop and release RFP on SACOT 3d Meet with interested providers for education/discussion 3e Create an RFP Review Team 3f Finalize SACOT providers from RFP

Partners 2019 Network Adequacy and Accessibility Analysis Appendix H: Network Development Plan 212 Timeline Activity ID Work Group and Team Lead: Projected Actual Start Responsible Parties Projected Duration Lead Start Date Date 3g Submit SACOT providers list to Network Management 3h Start credentialing/contracts process Goal 4. Increase value-based provider contracts by 10% for FY ending 6/30/20. Outcomes: Increase positive member health outcomes and decrease overall FY expenditures per standard reporting measures. 4a Identify the member population and/or 8/1/19 J. Moore service area to target from claim data and previous FY expenditures. 4b Document baseline existing VBC info per available data sources 4c Review current value/performance/incentive models to determine best options to use for VBC 4d Review current community providers and/or new providers for target population/service area. Engage those providers/partners 4e Engage Partners' Financial Analysts to determine predictive financial analysis 4f Execute contracts with selected providers with quantifiable monitoring and follow-up.

Partners 2019 Network Adequacy and Accessibility Analysis Appendix I: Request for Exception 213 Appendix I: Request for Exception

LME/MCO Request for Exception(s) from Provider Access and Choice Standards

LME/MCO ____Partners BHM______Date submitted _____6/27/19______

LME/MCO Contact person ______Beth Lackey______Title ___Director of Provider Network

Phone ______828-323-8058____ Email [email protected]______

Instructions: Complete this form to request exceptions for services that do not meet access and choice standards. Submit the form and any accompanying materials by email to the LME/MCO’s DMA Contract Manager and DMH/DD/SAS LME/MCO Liaison.

Put a check mark in the box to indicate the funding source(s) for services in this request. All services should be put on the same form.

Services and Access and Choice Standards for Medicaid (DMA) and State- State-Funded (DMH/DD/SAS) Services Medicaid Funded Outpatient Services. Medicaid & State-funded standard: 100% have a choice of two providers within 30/45 miles of their residences. Location-Based Services. Medicaid standard: 100% have a choice of two providers for each service within 30/45 miles of residence. State-funded standard: 100% have access to one provider for each service within 30/45 miles of residence. Psychosocial Rehabilitation Child and Adolescent Day Treatment SA Comprehensive Outpatient Treatment Program X X SA Intensive Outpatient Program Opioid Treatment Day Supports Community/Mobile Services Medicaid standard: 100% have a choice of two providers for each service within catchment area. State-funded standard: 100% have access to one provider for each service within the catchment area. Assertive Community Treatment Team Community Support Team Intensive In-Home Mobile Crisis Multi-Systemic Therapy (b)(3) MH Supported Employment Services (b)(3) I/DD Supported Employment Services (b)(3) Wavier Community Guide (b)(3) Waiver Individual Support (Personal Care) (b)(3) Waiver Peer Support

Partners 2019 Network Adequacy and Accessibility Analysis Appendix I: Request for Exception 214 Services and Access and Choice Standards for Medicaid (DMA) and State- State-Funded (DMH/DD/SAS) Services Medicaid Funded (b)(3) Wavier Respite I/DD Supported Employment Services (non-Medicaid-funded) Long-term Vocational Supports (non-Medicaid-funded) I/DD Non-Medicaid-funded Personal Care Services I/DD Non-Medicaid-funded Respite Hourly Services not in a licensed facility Developmental Therapies (Non-Medicaid) MH/SA Supported Employment Services (IPS-SE) (State-funded) Developmental Services (State-funded) Crisis Services – Medicaid and State-funded standards: 100% have access to at least one provider for each crisis service within the catchment area. Facility-Based Crisis - adults Facility-Based Respite Detoxification (non-hospital) Inpatient Services – Medicaid and State-funded standards: 100% have access to at least one provider for each service within the catchment area Inpatient Hospital- Adult Inpatient Hospital-Adolescent/ Child Specialized Services Medicaid and State-funded standards: 100% have access to at least one provider for each service. Partial Hospitalization MH Group Homes Psychiatric Residential Treatment Facility Residential Treatment Level 1 Residential Treatment Level 2: Therapeutic Foster Care Residential Treatment Level 2: other than Therapeutic Foster Care Residential Treatment Level 3 Residential Treatment Level 4 Child MH Out-of-home respite SA Non-Medical Community Residential Treatment SA Medically Monitored Community Residential Treatment SA Halfway Houses I/DD Out-of-home respite (non-Medicaid-funded) I/DD Facility-based respite (non-Medicaid-funded) I/DD Supported Living (non-Medicaid-funded) (b)(3) I/DD Out-of-home respite (b)(3) I/DD Facility-based respite (b)(3) I/DD Residential supports Intermediate Care Facility/IDD C-Waiver Services – Medicaid choice of two providers Community Living and Supports Community Navigator Community Navigator Training for Employer of Record Community Networking

Partners 2019 Network Adequacy and Accessibility Analysis Appendix I: Request for Exception 215 Services and Access and Choice Standards for Medicaid (DMA) and State- State-Funded (DMH/DD/SAS) Services Medicaid Funded Crisis Behavioral Consultation In Home Intensive In Home Skill Building Personal Care Crisis Consultation Crisis Intervention & Stabilization Supports Residential Supports 1 Residential Supports 2 Residential Supports 3 Residential Supports 4 Respite Care - Community Respite Care Nursing – LPN & RN Supported Employment Supported Employment – Long Term Follow-up Supported Living C-Waiver Services – Medicaid access to at least one provider Day Supports Out of Home Crisis Respite Care - Community Facility Financial Supports Specialized Consultative Services (at least one provider of one of multiple services)

Complete the following items for each service in the request: 1. Name of service requested. SACOT 2. As of the date of this request, the number of providers of the service under contract to LME/MCO for this service. 16 3. As of the date of this request, the number of individuals receiving the service. 171,405 4. As of the date of this request, the number of individuals in need of the service. For Medicaid funded – 1,248 without a choice of 2 providers; many of these have access to at least one. Non-Medicaid funded – 450 5. Reason(s) why the access and choice standard(s) cannot be met. Those in the northern counties are still experiencing obstacles and barriers to receiving substance use services. Some of the new and existing barriers include: (1) The notion of “Narcan Parties” continues to be a difficult perception to dispel and replace with the tenants of harm reduction. Syringe exchange is another harm reduction strategy that the county does not want to pursue at this time; (2) the District Attorney is not supportive of Law Enforcement Assisted Diversion; (3) physical plant issues that have hampered Daymark’s ability to expand and introduce SACOT; (4) providers providing Suboxone without the counseling components thus making it difficult for other providers to attract these potential clients; (5) there are also affordability issues that create barriers. Clients can pay cash and sell a portion of their prescriptions to recoup their expenses. The

Partners 2019 Network Adequacy and Accessibility Analysis Appendix I: Request for Exception 216 Opioid Response Director has been notified of this issue; (6) challenges within the certain communities to have SUD treatment in/near the city limits; (7) lack of public transportation options for individuals needing to access SUD services; and (8) stigma.

6. Is this a new request or have you previously requested an exception for this service? If applicable, give the date of the previous request. 10/1/18 7. For a service that does not meet its access standard, describe plans for how the LME/MCO will meet an individual’s need for access to the service. Positive gains have been made: (1) Northern Hospital of Surry reached out for assistance with acquiring an expedited OON (out of network) agreement to convert acute care beds to gero- psychiatric beds and we are assisting them with this process. They hope to hire a psychiatrist that will be able to serve this population and provide consultation to other departments (ED) at the hospital; (2) Northern Hospital is coordinating a meeting with the new Sheriff to discuss the IVC issues in Surry and wants to include Partners staff members. (3) Pinnacle Therapeutic Services reached out and is experiencing an increase in indigent referrals for SUD services and are seeking State dollars. They have been supplied with the funding request form and we are maintaining communication with them. 8. For a service that does not meet its provider choice standard, describe plans for how the LME/MCO will offer choice of providers to an individual who needs the service. Partners recently published a Request for Proposal (RFP) for Comprehensive SU services in Surry and Yadkin counties. Two providers were awarded contracts and have begun the implementation process. A contracted provider within the network, has expressed interest in expanding to the norther counties as well. With these three providers, and expansion efforts of the existing provider in that region, we anticipate this closing the gap. 9. What is the expected ending date of this exception? (Exceptions may not exceed one year.) 7/1/20