The NC Outpatient Mental Health Zeitgeist

-----Original Message-----
From: Geoffrey Zeger
To: ncadvocacy
Sent: Sat, Feb 2, 2013 4:34 pm
Subject: The NC Outpatient Mental Health Zeitgeist

NOTE: The following is somewhat long but is a reflection of the recent topsy-turvy, sinusoidal, and duplicitous events in the NC Outpatient Mental Health setting.......

During the summer of 2012, while I was standing outside of a clinic where I contract waiting for my next client, a car rapidly pulled up and out jumped 4 stony faced people with briefcases and a purpose in their steps as they entered the clinic.

It was an unannounced Medicaid audit.

Many clinicians and agencies knew these were occurring so it was not completely unexpected. At this particular free-standing private clinic which accepted Medicaid there was some anxiety (as any audit would produce) but we were pretty confident about our work - electronic medical records had fail safes for compliance, supervision occurred regularly, and the Clinical Coverage Policies for Medicaid were followed.

Over the next few months as the audit progressed a surrealistic Russian style bureaucratic nightmare occurred. Medical records were requested by the auditors and submitted by the clinic. CCME (Carolina Center for Medicaid Excellence) who was doing the audit would say 'we didn't get the records' and be elusive and dodgy. Medical records were re-submitted - hand delivered. Feedback from CCME was that the Treatment Plans did not meet standards. The Treatment Plans were being developed in line with the posted Clinical Coverage Policy and they were also in line with the recommendations of one of the LME/MCO's right over the county border but after much back and forth CCME continued to say they were not in compliance. CCME did not provide a clear indication of what compliance was nor did they provide a clear template for the Treatment Plans. (NOTE: The LME/MCO from the nearby county said the clinic's Medical Records per their site review were at a 92.5% accuracy!!!).

Staff at the clinic worked diligently to cooperate with CCME but every attempt at cooperation was met with a shift of the carrot on the stick. Conference calls were scheduled, emails were written, repetitive requests for clarification were pursued without any success or resolve.

The clinic was then put on a "pre-payment review" meaning claims for services rendered were not paid until the records were reviewed and approved. 'Pre-payment review' is an unguided process that could take 30 days - the approval of records is based on unclear standards so any clinical services rendered were like the lottery - maybe they'll get reimbursed if someone somewhere says documents meet some kind of unknown standards....or maybe they won't get reimbursed at all.

Eventually, so much unproductive hoop jumping occurred and time was wasted that a deadline for acceptance by the local LME/MCO came due. Because of the delays by the CCME, the LME/MCO which went live on 2/1/13 said to the clinic 'we can't enroll you' due to the 'pre-payment' status.

With only 3 days of lead time, over 100 clients - some of which were children in foster care or with PTSD or within the Juvenile Justice System - had to suddenly be terminated from treatment and referred to other agencies. Fortunately, the clinic will continue - contracted with the other county LME/MCO and accepting private insurance.

Was this top-down inefficient State bureaucracy? Was this effective Public Mental Health policy? Was there any consideration for how this would impact service provision and the clients? Was this purposeful - intended sabotaging of a clinic in order to reduce the number of providers within a community and save Medicaid dollars? Is this the CCME's way of insuring 'Excellence?'

I, and my colleagues who provide Public Mental Health services and who have weathered many pressures and changes, are not naive about accountability - we are ready to stand accountable and provide appropriate services with appropriate billing and documentation. I understand there are economic pressures at hand here but the current zeitgeist of audits, regulations and site reviews seems like a witch hunt and feels like a displacement for the past sins of others (http://www.inthepublicinterest.org/article/reform-wastes-millions-fails-mentally-ill). With the laser beam aimed at service providers - purposely geared to finding the smallest of errors in an effort to go 'GOTCHA' the zeitgeist is a culture of fear in order to insure accountability to DMA, CCME, DHHS, CMS, EDS, and the LME/MCO. Well what about accountability to our clients? Have policy makers forgotten about the clients in an effort to weed out the service provider playing field?

As a side note, it was rumored - and it may just be urban legend - that Medicaid auditors were paid based upon how much money they generated from the audit. If anyone has more information on this I would love to hear it - but at the community level it is understood that the contracted auditors were paid based upon how much money they were able to save Medicaid - how many claim denials they could find and how much money they were able to claw-back.

Wouldn't this contractual arrangement be considered a kickback?....'the more money you save or make us the more you will get from us?' Aren't kickbacks considered illegal within the Medicaid and Medicare system?

Clinicians, Clinics and Agencies believe that there has been an INTENDED consequence with the tightening of regulations (such as CABHA and Medicaid Waiver) - the intention is the eventual reduction of the number of private agencies that provide outpatient Mental Healthcare. Both, agencies that do enhanced services as well as core services, are being purposely circuitously and indirectly liquidated. When looking at lists of agencies that accept Medicaid over time, there was a 50% reduction of agencies after CABHA. With the implementation of the Medicaid Waiver the list has dwindled even further. Initially LME/MCO's have been accepting virtually all agencies that apply but it is anticipated that over the next year the bonsai tree will be trimmed even further with reviews of 'outcome measures.' More and more agencies will not be able to sustain. It is presumed that the final goal is to have a few large agencies contracted across the state.

Now, be advised that I have seen with my own eyes heinous service and billing improprieties in 2005 and 2006 and received backlash from profiteers when I called out inappropriate activities....so, I agree that it is necessary to set clear standards and hold providers accountable... HOWEVER, the zeitgeist is an over-rotation.

Let's see how the pendulum swing, tightening of the noose and reduction of reimbursements is working....

One of the larger agencies that has satellite offices in 15 counties in the central NC area just closed two of it's offices in 2 counties. In a different county where this large agency still has an office the pay for clinicians was cut, then cut again, then cut again, and a colleague of mine who works at this agency said that there were sweeping layoffis in her office. What is interesting is that many community clinicians believed this big multi county agency was one of the golden children that would sustain and still be standing while all the other 'mom and pop' or 'pop up' agencies were dissolved. Well, it seems like no one is immune anymore.

Another colleague of mine described how his multi county agency had radical re-structuring recently, specific Medicaid services were cut and the providers of those services were laid off, and there were across the board pay cuts.

Clinicians have no recourse either - 'if you don't like the pay cut then you can always try to find another job...wait...there are no other jobs since everyone else is closing so I guess you are stuck.'

On another side note, I recently head about a survey of private Psychologists who had been accepting Medicaid. The survey showed that over 40% of them intended to stop taking Medicaid clients due to the increase of regulations and requirements and reduction of reimbursements (all of which makes service provision cost and time prohibitive). Many of these surveyed Psychologists had over 8 years of experience - the intended consequence of reducing providers ALSO reduces your qualified and experienced professional base - these are the providers who know the clients and know the community and know the collateral resources.

I am aware of several private multi-county/multi-provider agencies that used to accept Medicaid clients but have stopped due to the cuts in rates and arduous regulations. What is interesting is that these private non-CABHA agencies provide excellent care, are preferred by clients, and ironically they bill a FRACTION of what CABHA agencies bill.

On February 1st a therapist from NC had an 'opinion' published in the Washington Post called:
"The risk of skimping on mental health funding"
Below is the link to this article which describes his frustrations with the Medicaid cuts in Southern Pines:

http://www.washingtonpost.com/opinions/the-risk-of-skimping-on-mental-health-funding/2013/02/01/5cdf8ad4-6ba6-11e2-ada0-5ca5fa7ebe79_story.html

Since you may have to do a free 'Register' with the Washington Post online to see the article, here is an excerpt:

For mental health providers in North Carolina, 2013 marks another year of cuts to Medicaid reimbursement rates, which have declined steadily since 2008. States are responsible for a larger portion of mental health services than they are for physical services, which means mental health is hit hard by state budget negotiations. More than $4.3 billionhas been slashed from state mental health budgets nationwide since 2009, according to the National Association of State Mental Health Program Directors. South Carolina, Alabama, Alaska, Illinois and Nevada are among the states that have had the deepest cuts.

The director of our clinic in Southern Pines, N.C., in the center of the state, has told me that this year’s cuts are likely to force us to close. Our facility offers mental-health and substance-abuse counseling to 75 to 100 clients a week, half of whom are 18 years old or younger. Typically, they are referred to us from child protective services, doctor’s offices or the local domestic violence/sexual assault agency.

When the events at the service delivery level are brought to policy makers' attention, I deeply resent their disregarding platitude of "oh well....we know change is hard." Well, it has been change (2001 divestiture and privatization), and change (2005 slashing community support), and change (2006 ValueOptions authorization policy changes) and change (2010 CABHA), and change (2012 Medicaid Waiver) and change (2013 Medicaid rates rates slashed 40% effective 1/1/13 then returned to prior rate on 1/23/13 with delays of payment for 1/13) and change (2013 CPT code changes and Medicaid rate and service time reductions). You don't know how many times I have had to say to clients "....I am sorry but there are NEW Medicaid regulations which will effect you in the following way..." You don't know how many of my colleagues have said to me "....the agency where I was working closed....do you know who is hiring...."). 

Furthermore, I resent the proverbial 'pot calling the kettle black' when Community Agencies, Individual Clinicians, and Private Practices accepting Medicaid are being scrutinized and audited to the point of being inoperable ALL THE WHILE there is waste and mismanagement at the top - DMA mismanagement (http://pulse.ncpolicywatch.org/2013/02/01/problems-identified-by-medicaid-audit-largely-result-of-nc-republicans-own-budget/), cost over runs with Computer Sciences Corporation (http://www.newsobserver.com/2012/06/17/2142627/state-contract-for-updating-computer.html), "structural flaws," and more (http://www.wral.com/audit-mismanagement-costs-nc-medicaid-system-millions/12048026/).

I hope McCrory means what he says ( “We want to make sure that the money that’s supposed to help people is going to them, not to the administrative cost.”) and that 'Medicaid Reform' will have a positive result. I hate to be a 'Negative Nick,' but my fear (based on experience) is that if you squeeze on one side of the tube of toothpaste it gets smooshed (yes...a real word) to the other side....in other words, the ATTEMPT to reduce administrative waste may actually make its way down to the community level in the form of service and provider cuts. We shall see.....

I continue to provide services to Medicaid clients and IPRS clients through contracts with agencies, but it is unclear how much longer I will be able to provide Medicaid services through my own private practice. More to be revealed.

Please forgive the long ramble. I haven't written for a while and a lot has happened. Feel free to write back with your experiences, thoughts, and or comments.

Geoffrey Zeger, ACSW, LCSW
(919) 286-[ redacted ]
[ email address redacted ]

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DMA 8M Public Comment on CAP-I/DD 292

Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared save the removal of the submitter's personal contact information and abbreviation of last name.

[ More on DMA Public Comments. ]

Comment 292

To: Webmedpolicy, Dma
Cc: Bradshaw, Tammie
Subject: 8M policy
Sent: Thursday, August 11, 2011 9:59 PM

DMA,

I am writing in response to the proposed policy recommendations. I own my own Case Management Company, and serve individuals in Mecklenburg, and Pathways LME. I am deeply concerned over the policy recommendations as well as recent increased activity at the State level of changes or proposed changes that will effect folks I serve. I was very involved with advocating against the recently accepted HB 916, and am now seeing my concerns being played out with this proposal, and previous proposals within the last several months. I warned lawmakers (Rep. Earle, and Insko) of the dangers of the HB, and am seeing my predictions being played out even before implementation of HB 916. I have served folks with disabilities for over 25 years, and am disappointed in DMA/DHHS (divisions that are set up to assist folks with disabilities) put out policy that actually hurts the folks they are supposed to support. I have done an analysis of some of my cases (about 5) with the proposed changes in the 8M policy from current services in their cost summary to proposed changes under the 8M policy recommendations. The outcome has been a reduction in cost/services of about 25% per client (good job state!!) without any medical justification for a reduction other than a policy change as recommended by the State. I plan on laying out my issues in this e-mail from my careful review of the 8M policy so you will better understand my concerns as well as the people I support. In an attempt to save money I believe you all have lost sight in the people that are being served. Your attempt at trying to save money by reducing or eliminating services will backfire and create more cost to the state as Families will be forced to place their disabled family members in placements that will cost the State much more money. My issues will be laid out in the following order with reference to the page number in the 8m policy so as to easily follow my point.

1) Respite for Residential Support folks (can they get Respite or not? if so why not on the same day?)
2) Elimination of Home Supports
3) Elimination of Enhanced services
4) change from "guidelines" to "Criteria" in the proposal
5) limitation of Habilitative hours to 129 H/M (30 H/W) for adults/children when out of school
6) Limitation of Habilitative hours to 86 H/M (20 H/W) for school age children
7) Limitation on hours a month for Guardians and family members to 40 H/W or 5.8 H/D

I want to start out this analysis by looking at what was written into the policy. On page 4 of the 8M policy this statement was made "The waiver, Community Alternatives Program for Individuals with Intellectual/Developmental Disabilities (CAP-I/DD) is designed to give persons with intellectual and developmental disabilities, a cost-effective alternative to care in an intermediate care facility for persons with mental retardation (ICF-MR). The goal of this funding source is to enable individuals to have a choice of living in the community instead of in an institutional setting and to have effective support in creating a preferred lifestyle that challenges each individual to live to his or her fullest potential." This I imagine is the driving force behind the waiver. If so, the 8M policy and DMA seems to forget the mission as outlined here. This statement was found on page 5 of the 8M policy that is also significant. "Person-centered planning is a process of determining real-life outcomes with individuals and developing strategies and goals to achieve those outcomes. The participant, the legally responsible person, or both direct the process and share authority and responsibility with system professionals about decisions made" (page 5). These decisions made in this policy were not made by the people that matter (the clients or their team members, but by politicians or people who are not concerned about what is best for the individual served). Another qoute I want to use from the 8M policy is from page 39 under amount and duration of service. "The amount and duration of services provided are determined through the person-centered planning process with the participant’s planning team. Services are based on the needs and priorities of the participant, the availability of other formal and informal supports, and rules of the funding source. The planning team shall ensure that medical necessity criteria are met for Medicaid reimbursement as cited in 10A NCAC 22O .0301.
Authority G.S. 108A-25(b); 42 CFR 440.230(d). In and throughout the policy you put limits on services that are in direct conflict with what is written in the policy. Amount and duration of services is determined by the participants planning team, not DMA.

Point # 1: The 8M policy is unclear on its stand as to Respite for folks recieving Residential supports. On page 11 of the 8M policy it seems to indicate that Respite would not be allowed for RS clients, but on page 94 of the policy it states that it can not be billed on the same day as RS, and then later states that it cannot be billed on the same time time as day as RS. Either way it presents problems. If totally eliminated then staff would have to pay out of pocket for Respite, and then the State would find themselves in a sticky situation because they could not mandate Staff requirements for non Medicaid payment opening themselves for a huge liablity issues and potential lawsuit if the staff have a friend do respite that may potentially abuse the client, and the staff/provider would have to say they had to do that because of state policy requirements. The other matter regards to not doing RS and Respite on the same day presents another issues. If staff provide RS for anytime during the day, and bill for it, and then have someone provide Respite the Respite will be paid out of pocket as illustrated in previous statement (huge state liability). If RS staff do services during the day, and don't bill because they want to use Respite and Respite is billed, then it becomes a labor law issue because the State is mandated staff work free if they provide RS services, and respite on the same day. This once again opens up the State for lawsuit due to policy changes.

Point #2: In the 8M policy it recommends elimination of Home Supports for individuals who live in their own home and recieve services from their Guardian or Family Member with replacement of HCS and personal care services. This is the biggest issues I have with this policy, and where most of the cuts are effected. Many individuals who recieve Home Supports do so because their Family Members have decided to quit their fulltime job to care for their loved one with a disability. Now the State wants to put an additional burden on these families because they consider them natural supports, and it is "their duty to care for their loved one" and so they decide to cut services. This puts an undue burden on the Families to provide the same quality of care with less support. Many of these Families provide this service because of past abuse by staff or because they live in an area that is hard to staff, or the individual has such intense needs no one would work with them. I will cover this in another area, but when the 8M policy limits the habilitative hours to 129 H/M, and the person recieves Day Supports (typically utilized at 30 H/W) then their is no more habilitation to be used even though the consumer needs it so Families are left to use PC, and only 40 H/W or 5.8 H/D of services. Many of these consumer require 12-20 H/D of services so this policy forces Families to care for their family members much more than they are compensated. The end result will be that Families will have to utilize other options such as institutionalization to care for their family member as they will not be able to take on the additional stress of caring for their loved one and meeting the daily responsibilites of paying their bills. This will result in cost increases at the state level.

Policy #3: In regards to elimination of enhanced services I believe that once again the State has failed to take in consideration the individual served and has decided to look at the cost savings. People recieve enhanced services primarily due to behavioral or medical issues that warrant intense need. By eliminating the enhanced services staff and/or Family will have to care for the the needs of the individual without appropriate commpensation due to the additional training required or additonial liability they take on. The long term effect will be an inabilty of providers or Family to provide well trained staff to provide services once again forcing alternative placement that will increase state costs

Policy #4: I am not clear on the differientiation between "Guidelines" and "criteria" when it pertains to limits on services. My understanding is that Guidelines are recommendations, and criteria is limits. Just need clarification

Policy #5: I have concerns that the limitation on Habilitation hours to 129 H/M conflicts with the concept of Person centeredness, and seriously effects folks recieving Home supports. 129 H/M limits folks to 4.2 H/D of habilitation of services if they recieve services 7 days a week. If folks get Day supports (typically done at 30 H/W) it would eliminate any habilitation being done at the home, only PC. This would force families, and staff in providing uncompensated work beyond what is needed to the individual. This has potential labor law issues, and rights violation issues for the State. This will directly effect adult consumers who live at home who reieve additional servcies, and will result in a cut in services. This policy recommendation also appears to comflict with other things in the policy that states that adults may recieve up to 12 H/D of Habilitative services in one day. Many of these individuals served have a treating physician stating they need more services beyond 129 H/M, and yet the State wants to limit services regardless of what the treating Physician states.

Policy #6: Regards to the Policy recommendation on Limitation of Habilitative hours to 86 H/M (20 H/W or 3 H/D) for school age children. I have concerns because it seems to conflict with other things in the policy that states kids can recieve up to 6 H/D of habilitation services (129 H/M) or other places that says they can recieve up to 12 H/D on non school days.

Policy #7: Regards to the policy Limitation on hours a month for Guardians and family members to 40 H/W or 5.8 H/D. As stated earlier this puts an undue burden on Families who have quit their jobs to care for their adult child, and are now looking at a huge reduction in services, and are expected to continue to provide supports, but under the heading of natural supports (because that is what Families should do). This Policy recommendation will seriously effect Families who provide home supports. Many of those adult individuals also recieve Day Supports, and because of the other limitation recommendation of 129 H/M these families will only be able to provide PC which in many case is not sustainable given what they gave up to care for their child forcing many members to rethink caring for their loved one in their which will result in an increased cost at the State level. I have many Family members who provide well over 10 H/D of services due to intense needs of their family members who will now be forced to resign their day jobs or place their Family members in a group home/AFL/Institution due to service limitations put forth in this policy.

I hope I have been clear in my deliberation on my concerns and issues, and my desire to support the individuals, and Families I represent. If you have any questions or need to speak to any of my families on how these policy changes will directly effect tehm please call me at 704-249-7418.

Sincerely,

Paul Peters
Owner
Covenant Case Management Services, LLC

Legislative Correspondence from a Provider

In my research, and most especially my conversations and dialogues with members and representatives of the General Assembly - and yes, event PBH Consumer Affairs  folks, throughout this controversial DD managed care overhaul, there seems to be a common theme regarding the poor quality of dishonest providers abusing the system as an argument for reform. --While I know they are out there, I personally have not had such experiences and find the habit of tossing all the apples in one basket offensive... The various agencies and professionals I have had the pleasure of working with in over 10 years have always proved exemplary, going above and beyond to assist families such as mine and assure our needs were met.

Were it not for my agency QP, I would have lost my job years ago when we had to fire both my staff for unethical conduct. Every day this woman picked up my child from school and cared for her personally for 3 weeks or more while I worked at the time as a contractor (with no benefits) at FPG Child Development Institute at UNC-CH and searched for new care-givers. I was a single parent then; I could not have done it without her nor without the peace of mind that Isabel was well taken care of.

Below is an email (posted with permission) from an agency Qualified Professional from A Small Miracle here in Raleigh. Though ASM isn't the agency I referenced, I can attest they are among the best in the field; their reputation is one of compassion and love for what they do and are they are well loved by their families because of it.

Just one example of the many non-family small business stakeholders who will be greatly impacted by changes to come.


Wendy is a constituent of NC Senate District 17 and House district 37. 

Legislative Correspondence 

from a Provider Perspective

From: Wendy Singleton
Date: Fri, 25 May 2012 10:46:23 -0400
Conversation: Imploring you to FIX HB 916!
Subject: Imploring you to FIX HB 916!

Good Morning Representatives:

I am contacting each of you today appealing for further review and overhaul of proposed HB 916, with extra plea Representatives Mr. Barnhart, Mr. Dollar, Mr. Burr, Ms. Insko, Mr. Ingle, Mr. Moffit, and Mr. H. Warren. As a community member, constituent, taxpayer and proud advocate for individuals with special needs I am deeply troubled by the proposed statewide expansion of the 1915 (b)/(c) waiver.

If the The 1915 (b)/(c) Waiver goal is “for implementation improvements in the Medicaid program designed to increase cost effectiveness, efficiency, consumer access, consumer choice and provider quality. . .” as a qualified professional, NCI instructor and therapist working in the field with the IDD population I can say from first hand experience this proposed waiver is not meeting goals.

-The overhead costs of new vs. refurbished buildings does not save money, nor does elimination of targeted case management with two new jobs of Care Coordination and Community Guide as well as Qualified Professionals writing individual’s short term goals. Purported savings with the 5 county model are now being refuted, with legal cases surrounding “satisfaction rates” and “Savings” from this waiver model.

-Efficiency is no longer a word most families, staff, QP’s and current case managers would use to describe the process of the CAP system. With lessened oversight and elimination of third party case manager the proposed waiver will likely become as efficient as the now defunct Value Options authorizing entity. As targeted case managers are being told their jobs will be eliminated on January 1st, 2013 many highly qualified, gifted and talented advocates are leaving their jobs to provide for their families. This has left many of our families without a case manager or plans not being authorized in a timely manner requiring provider agencies in some cases footing the bill until they can be paid—Many smaller agencies have closed their doors because they simply can’t afford to provide services on “good faith” of being paid. Individuals who have waited for CAP services for 5 or more years in some cases are being told by Wake County they may lose their CAP slot if services are not provided in 15 days, and their CAP slot is eliminated after 30 days without services—This should NEVER happen because of a lack of efficiency in a system purported to be created for the well being, consumer access, and consumer choice of individuals served!

-Individuals and their families once had a voice to advocate for what targeted case manager / agency they wished to have to provide best services for their loved ones. Today they have laryngitis. No longer are there several agencies to choose from, nor are there case managers available due to the overwhelming caseloads given to them at 45-80 individuals per case manager!!!! Families served feel ‘lucky’ to have a case manager, even if they don’t see them for 6 months or more due to overwhelming work load required of case managers in the field. The reason for this is that most people, when faced with certain job loss, will seek a different job. With the 1915 (b)/(c) model having no oversight with model due to authorizing body having decision in type/scope of service as well as no reputable process for mediation there are major concerns with families having ability to challenge decisions when one player holds all cards in the deck. The “Right Sizing” of the network poses even bigger questions for provider agencies in that there is no known parameters of criteria for elimination of a provider agency in the network.

-With the current freeze on new CAP recipients (formerly slots) access is simply not available. With the proposed waiver utilizing last month’s numbers as a benchmark for current need this will further increase lack of access due to some families not having staff available to them due to the 10% rate cuts already imposed on a burdened system, or family / individual situations such as hospitalization, accident or death. If an individual goes out of town for two weeks to travel out of state for a funeral / service, it is impossible and irresponsible to make a correlative relationship that the next month the person ‘survived’ with only two weeks therefore that is what they should receive in services. 

Care Coordinators are not required to have advanced degrees, nor is the reimbursement rate adequate to entice providers to enroll to participate in this service, further eliminating access to services.

-Most provider agencies strive to provide the highest caliber and quality of services, and wish to continue to do so in a timely, organized, cost effective manner. I ask that you reconsider this waiver model until issues of oversight and alleged ‘budgetary savings’ can be addressed. Many families if given the opportunity would manage the money allocated to them very wisely, and if the model moves forward with more oversight and known system with third party entity to appeal decisions made by authorizing body for scope and amount of services provided for their loved ones would be more comfortable with restructure of the CAP system which is integral, imperative, and is cost effective in decreasing rates of institutionalization for the people we proudly serve.

As NAMI stated in a letter to Representative Barnhart last year on 1915 (b)/(c) waiver “We no longer have the resiliency to endure more failures”.

Thank you,

Wendy Singleton, QP
A Small Miracle Inc.
Raleigh, NC 27607
(919) 900-4422
(919) 900-4466 (fax)

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*As special parents, our perspectives, interests, and priorities in various issues surrounding NC's new 1915(b)(c) Innovations Waivers and the changes they bring to our families differ according to the unique needs of each of our children.

If you have something to share, email: no2nchb916@gmail.com