Crisis in PCS in NC, & How to Address It

From The Arc of North Carolina

Crisis in Personal Care Services in NC, and How to Address It

[ original post ]

Issue:

For thousands of North Carolina citizens with intellectual and developmental disabilities (I/DD), as well as people with mental illness, the Medicaid State plan service "Personal Care" (or PCS) has provided supplemental funding for housing supports in small licensed group homes.

Earlier this year, the General Assembly raised the level of disability needed to receive PCS. Now, individuals must require assistance with three activities of daily living [ADL’s]. This rule applies to both in-home and facility based services, to achieve legally required comparability. Unfortunately, most individuals living in licensed group homes will no longer qualify.

This change could reduce a group home’s budget by up to 30%, creating significant budget shortfalls- yet another hardship for an already struggling community-based option.

Not only does this reduction affect the provider’s ability to provide basic support services, in many cases it could lead to an inability to meet the group home’s debt obligations. Many of these homes were financed using US Dept. of Housing & Urban Development (HUD) funding streams, and a significant number are tied together through HUD approved refinancing methods. If vacancy rates rise due to lack of support services, well over 250 properties could be at risk of failing.

Recommendations:

For most people living in these types of homes, PCS was not their most needed service. Individuals living in these settings most often need support services to allow them to live successfully in communities. For people with I/DD, they are most likely support services that are habilitative and for people with mental illness they would be recovery based support services.

For both populations there are Medicaid options that, if designed correctly, could support people in these settings and other community based options that should not increase the state funds needed to provide these supports. Unfortunately, it is impossible to get these new service definitions designed and approved by the Center for Medicaid Services by December 31- the end date of the current PCS definition.

With this in mind, we would recommend the following course of action.

1. Extend the state funds available to people living in Adult Care Homes to licensed group homes. Thirty-nine million dollars is already set aside for adult care homes during this period of transition. This reserve should be extended to licensed group homes as well. People living in licensed group homes often have more significant disabilities than the individuals in adult care homes and deserve the same protection provided by the funds appropriated for adult care home residents.
2. For people with IDD- Immediately begin the work of creating a specific 1915i option for services[s] that would support individuals living in community settings- both licensed and non-licensed. The 1915i option is a near perfect fit for this type of service. Not only can it provide funding to offset the loss of PCS, it could be designed to offset the state services dollars that are used in group homes and provide another meaningful Medicaid service for people living in other community settings. The match money for these services could come from already appropriated community base state funds. Preliminary estimates by The Arc indicate that a carefully crafted 1915i option could support individuals in these homes and make a significant dent in the waiting list without any additional appropriations from the State.
3. For people with Mental Illness– It is possible that the same type of 1915i option services may make sense for people with Mental Illness. It may be more difficult to craft services definitions that assure cost neutrality, but this option should be explored immediately.

At the same time, the state should review the possibility of creating a recovery-based support service under Medicaid that could be used in non-licensed community settings as well as licensed settings. Since Mental Health services are recovery based, such a service could be created without the use of a 1915i. In both cases, 1915i or state plan service funds already used for community services for people with mental illness could be used for match.

These recommendations are straightforward solutions to what will become a significant crisis if we do not act. While there may be other options, we suggest the above actions because they have to potential to solve the problem short term and create a low cost solution for the long term that is consistent with best practice. If we are able to follow this path we not only stabilize the licensed community based options but create good options for individuals who choose to live in less restrictive settings.

NC-DHHS Settlement Agreement Dox w/ US DOJ

Settlement Documents (123KB pdf)

The above link will prompt a pdf download of the full settlement documents between the North Carolina Department of Health and Human Services and the United States Department of Justice, Civil Rights Division;

Documents to include:

• Complaint for Declaratory and Injunctive Relief 
• Joint Motion to Dismiss Without Prejudice and Retain Jurisdiction
• Proposed Order
• Settlement Agreement (Exhibit A)
• Memorandum in Support of the Joint Motion

See the Press Release from Disability Rights of NC

See the DHHS Press Release via The Arc of North Carolina

Hubert H. Humphrey said, "The moral test of government is how it treats those who are in the dawn of life . . . the children; those who are in the twilight of life . . . the elderly; and those who are in the shadow of life . . . the sick . . . the needy . . . and the disabled."

On behalf of so many, THANK YOU North Carolina!! 

Disability Rights NC Applauds North Carolina’s Settlement with U.S. DOJ

From Disability Rights of North Carolina

FOR IMMEDIATE RELEASE

Thursday, August 23, 2012

[ download pdf version ]

Disability Rights NC Applauds North Carolina’s Settlement with U.S. DOJ

Raleigh – Governor Beverly Perdue took a major step today toward resolving one of the greatest challenges facing our State’s mental health system by signing a settlement agreement with the U.S. DOJ. The agreement addresses findings made July 28, 2011, that the State violates the ADA by segregating North Carolinians with mental illness in Adult Care Homes rather than allowing people the choice to live and be supported in the community.

“Disability Rights NC applauds the Governor and the Secretary Delia for their leadership. This agreement will protect the rights of people with disabilities and help the State avoid costly litigation,” said Vicki Smith, Executive Director.

The agreement provides for the creation of appropriate community mental health care, employment services and housing options for people with mental illness in our State. “This agreement will improve the lives of N.C. families – our brothers and sisters, mothers and fathers. Disability Rights NC pledges to remain vigilant, ensuring the agreement’s promise is permanent,” said Smith. “North Carolina has seized an opportunity to cultivate a robust system of care for people with mental illness which all of us can be proud of.”

Background on North Carolinians with Mental Illness Housed in Adult Care Homes

In July 2010, Disability Rights NC filed a complaint with the US DOJ alleging that the State of North Carolina is in violation of the Americans with Disabilities Act (ADA) because the State has a bias towards placing people with mental illness in Adult Care Homes (ACHs) rather than supporting them in more integrated settings in their home communities. ACHs are institutional settings that do not provide appropriate services to support recovery and meaningful community integration. Disability Rights NC alleged that the State, in relying on placements in these types of Adult Care Homes, is violating the ADA. Please see the Report: Trapped in a Fractured System - People with Mental Illness in Adult Care Homes on the website (www.disabilityrightsnc.org). Under the ADA the unjustified segregation of persons with disabilities is an illegal form of discrimination. The integration mandate allows individuals to interact with non-disabled persons to the fullest extent possible so people with disabilities are not isolated from their communities.

The US DOJ, Civil Rights Division, issued a letter of findings on July 28, 2011, concluding that North Carolina "fails to provide services to individuals with mental illness in the most integrated setting appropriate to their needs in violation of the ADA," and that "[r]eliance on unnecessary institutional settings violates the civil rights of people with disabilities." The central finding of the US DOJ is that North Carolina lacks an adequate community support system for people with mental illness. As a result, individuals are institutionalized in more expensive and more restrictive settings in Adult Care Homes. "Most people with mental illness receiving services in adult care homes could be served in more integrated settings, but are relegated indefinitely and unnecessarily to adult care homes because of systemic State actions and policies," wrote U.S. Assistant Attorney General Thomas Perez. "Reliance on unnecessary institutional settings violates the civil rights of people with disabilities.”

###

NC DHHS, US DOJ Reach Agreement on Community Based Care for Only Citizens with Serious Mental Illness

From The Arc of North Carolina

Breaking: NC DHHS, US DOJ Reach Agreement on Community Based Care for Only Citizens with Serious Mental Illness

[ view release at arcnc.org ]

Press Release from NC Dept. of Health & Human Services:

Raleigh — The North Carolina Department of Health and Human Services and the United States Department of Justice today reached an agreement on the state’s plan to offer more choices of where and how citizens with serious mental illness receive care and supportive services.

The plan, which was announced last month, will create housing slots in the community to offer the choice of community-based care for many adults with serious mental illness. It will also invest in job training and employment assistance for those citizens and will set up a comprehensive, 24/7 crisis care program for people with a serious mental illness.

This agreement will modernize our mental health system and ensure that North Carolina is providing the best possible treatment for adults diagnosed with severe mental illness. It will also provide the opportunity for many of these individuals to live in community settings if they choose to do so, and ensure that North Carolina is fully complying with the Americans with Disabilities Act and other federal laws.

This agreement is similar to ones signed by governors of a number of other states including, among others, the governors of Virginia and Georgia.

DHHS Secretary Al Delia agrees that more should be done to ensure access to community-based treatment for those with mental illness. “North Carolinians who have a serious mental illness have a right to choose the very best care environment to meet their personal needs,” he said. “That choice – whether they live in the community or in an adult care home – will be supported with access to mental health and other support services that will be available in part due to this agreement. Moving forward with a solution to help them identify and access those choices is the right thing to do,” he said.

“Disability Rights NC applauds the Governor and Secretary Delia for their leadership on this matter. They have not only done the right thing to protect the rights of people with disabilities, they have helped the state avoid costly litigation and destabilizing uncertainty,” said Vicki Smith, executive director of Disability Rights NC.

The agreement outlines DHHS’s plan of action to provide community-based services to people with mental illness. The budget the General Assembly passed in July expressly contemplated a settlement and appropriated funding to make this agreement possible. The timeline for completing the plan is eight years; this transition period will enable people who want to move to community-based settings to do so on a workable timetable and will allow sufficient time for North Carolina’s mental health infrastructure to implement this agreement.

# # #

NC Fails at DOJ Settlement, but has a Plan!

22 Years Ago Today...

Thu, Jul 26, 2012 at 7:59 AM
From: Vicki Smith, Executive Director of Disability Rights North Carolina
Re: State fails to settle with DOJ but announces 8 year plan



FOR IMMEDIATE RELEASE


[ view the DRNC Press Release ]

DOJ Update

NC Secretary of Health and Human Services, Al Delia, will announce the details of an 8 year plan to develop services for 3,000 individuals with mental illness in living in Adult Care Homes to more integrated setting appropriate to their needs later today. 

The plan is an attempt to address a July 28, 2011 Letter of Finding issued by the US Department of Justice. The letter was issued in response to a complaint filed July 26, 2010 by Disability Rights NC alleging North Carolina’s practice of warehousing people with mental illness in adult care homes violated the ADA’s integration mandate. 

The State and USDOJ have been in confidential negotiations for the last year. At the table were representatives from the Governor’s Office, Department of Health & Human Services, and the Attorney General’s Office. Little information was shared about discussions until today’s announcement that the parties have failed to reach agreement but the state is moving forward with a plan. However, the General Assembly’s inclusion of $10.3 million in the 2012 - 2013 Budget to begin implementation of any settlement was seen as a sign that resolution was near. The announcement will also include acknowledgment by the State that it was unable to reach a settlement agreement with USDOJ, largely because of disagreement regarding an enforcement mechanism.

Our Response

“We are disappointed that the State was unable to come to an agreement to resolve our complaint with USDOJ,” said Vicki Smith, Executive Director of Disability Rights NC. “It is reassuring to have the State acknowledge the enormity of the unmet needs of people with mental illness and their plan to increase supported housing, supported employment and other services. However, the plan outlined by the State lacks a binding agreement, one which once and for all commits the state to fulfill the promises we’ve heard today. “ 

The Department of Justice may still pursue legal action against the state. Whatever steps the USDOJ takes next, Disability Rights NC will continue to address this situation. 

North Carolina has failed to:

Develop a meaningful Community Integration Plan as required by the 1999 Supreme Court’s Olmstead Decision including policies that provide incentives for community based services and placements;

Adequately fund the state’s Mental Health Trust Fund;

Develop community based services as hospital beds were closed, instead it relied on an industry that was neither designed nor competent to promote the recovery and inclusion of people with mental illness in the community; and

Most importantly, the State failed to focus first and foremost on the interests and needs of people with mental illness. It lost sight of its purpose - protecting the health and safety of all its citizens while providing essential human services.

What a way to celebrate the 22 anniversary of the signing of the ADA into law.

Take a look at this short video:  http://youtu.be/6ieH8FE9Dhw

“Let the shameful wall of exclusion finally come tumbling down.”

More information as it develops!

Vicki Smith

Executive Director

Disability Rights NC

2626 Glenwood Avenue, Suite 550

Raleigh, NC 27608

Phone: 919-856-2195

TTY: 1-888-268-5535

Fax: 919-856-2244

vicki.smith@disabilityrightsnc.org

http://www.disabilityrightsnc.org

Disability Rights NC is the state's protection and advocacy system. 

Disability Rights NC is a 501 (c)(3) organization. Donations support our efforts to promote a clear and independent voice for North Carolinians with disabilities. If you are a state government employee, you can support Disability Rights NC through the State Employees Combined Campaign (SECC). Please use code # 1544.

This transmission is intended for the sole use of the individual or entity to whom it is addressed, and may contain information that is privileged, confidential and exempt from disclosure under applicable law. Any dissemination, distribution or duplication of this transmission by someone other than the intended addressee or its designated agent is prohibited. If your receipt of this transmission is in error, please notify us by telephone (919) 856-2195 or return e-mail to the sender. Please delete all copies of this message and any attachments.

N&O article re TRO Issues Against DHHS

Judge halts effort to assign adult care homes special status
Published Fri, Jun 15, 2012
By Lynn Bonner - lbonner@newsobserver.com
Published in: Health/Science

[ Original News and Observer article here ]

An administrative law judge on Friday put a temporary stop to the state assigning adult care homes a special status that cuts off their federal Medicaid payments.

A group of adult care homes went to court this week to ask that the state Department of Health and Human Services no longer be allowed to designate certain adult care homes “institutes of mental disease.”

To comply with federal rules, the state is surveying adult care homes to determine how many of their residents are mentally ill. Adult care homes have long offered housing for mentally ill people, but the practice conflicts with federal policy.

Senior Administrative Law Judge Fred G. Morrison Jr. granted a temporary restraining order Friday telling the DHHS it could continue its surveys but that it could not take the final step to stop the flow of Medicaid money from adult care homes they find to be violating federal rules before June 28.

The federal Medicaid program won’t reimburse adult care homes where more than half the residents have mental illness as a primary diagnosis. The adult care homes said losing the federal money would create a financial hardship because the government health insurance program pays more than 40 percent of each eligible patient’s yearly costs.

Bonner: 919-829-4821