Historically in our state, each public service agency has been granted segregated powers, duties, and funding to provide services independent of each other through state mandates. Though these state agencies — Department of Corrections, Department of Juvenile Justice, Division of Social Services, Department of Public Instruction, etc. — worked independently with clients, many served the same clients at any given time. With no evident organizational multi-agency leadership by the state, there was created costly overlapping services for clients and gaps in services for clients falling through the cracks.
This costly, inefficient, and ineffective system was apparently of no concern when taxpayer money was “plentiful.” However, there was suddenly a need for “reform” when the state budget crisis occurred. Though the state created this segregated/ fractured service industry, the powers that be decided it was time for the agencies to collaborate to serve more clients with less money; it would come to pass that there would indeed be more clients as well as less money.
Agencies in the seven counties of Western North Carolina historically did collaborate within their own agencies in order to survive the inattentiveness of Raleigh for this part of the state. However, with sovereignty and local control intact, there would be limited collaboration between agencies as territory and turf were established and they competed for state funds. Though the state public service system was not created to be collaboratively friendly, the powers in Raleigh set the multi-agency collaboration process in motion. The problem was that state leadership put the cart before the horse by not legislatively removing roadblocks to collaboration that were originally created.
The Division of Health and Human Services (DHHS) was commissioned by the General Assembly in October 2001 through H.B. 381 to facilitate reform within mental health, developmental disability, and substance abuse services (mh/dd/sas), which had become administratively bloated, financially out of control and ineffective in service provision. The principles of reform were creative, but the implementation was negligent. DHHS created a state plan as a blueprint for local mh/dd/sas area programs to follow in the creation of a local business plan designed to address the needs of the community (or maybe more accurately, to address the state budget crisis).
With the ingrained history of local control, DHHS was not legislatively given the power/tools to do much more than create some guidelines in the creation of local business plans. DHHS did, however, have the power to approve or deny the local business plan and withhold state funding. This paved the way for Area Programs to get “creative” in the development of the local business plan to be submitted to the state for approval to become a Local Management Entity (LME) worthy of state funding to supervise the private providers of the privatization/reform process. The state plan did set guidelines in calling for a local multi-agency collaborative process that also was to include consumer advocates. There was a multi-million dollar attempt for a regional collaborative spearheaded by the local Smoky Mountain Center (SMC) LME, but that initiative was dismantled when the federal grant money supporting it ran out. This was also the case with the WestCare transportation grant that had relieved the burden of client transportation by county sheriffs’ departments, as reported in the SMN. It does not seem “best practice” to rely on temporary grants to provide stable services.
It only stands to reason that an agency is going to dig its heels into its turf and circle the wagons when its livelihood becomes threatened. This does not create a favorable environment to enhance collaboration. Factor in local control and you know that the local business plan is going to look good on paper. In addition, the entire process can become more of an exercise in public relations than actual substance of any kind. Even the “required” State Plan Consumer and Family Advisory Council (CFAC) could succumb to a rubber-stamp function and for the possibility of a staff-dominated LME committee.
So it appears that we got where we are today in mental health because state leadership was asleep at the wheel when the budget was good and because of historical philosophy of local control that created division where cooperation was needed.
However, closed-door politics probably was the biggest culprit in the failures of reform. As a member of the State Mental Health Planning Advisory Council — as well as the SMC Regional Collaborative, CFAC, and Client Rights Committee — I have met a lot of genuinely caring/devoted professionals committed to service. Despite the creative ideas and promising plans of those people, as well as some state legislators, and university minds, it was meaningless without appropriate funding.
It became apparent that reform was about budget cuts rather than service, when funding was cut that was needed to work the plan that so much effort went into the plan turned out to be a contest to see which of the 29 local LMEs in the state could come up with the best plan to serve the most clients with the least funding. In this “eat or be eaten process,” the “winners” would take over the losers in the LME survival scenario in a process of consolidation. The surviving LMEs would then have larger territories and more clients to serve with even less resources. This, along with the DHHS hands-off policy that evolved out of the local control era, meant that the clients were the guinea pigs in the process. There never really was a master plan in reform; it was an elusive moving target that “evolved.” Reform was too much, too soon, and too fast. The premise of mh/dd/sas reform arose out of the landmark U.S. Supreme Court decision on a Georgia case — Olmstead vs. L.C. (June 22, 1999) — which decreed that a client has the right to be served in their own community rather than being confined to a state facility. As our state leaders created the “plan” to close state facilities, it did not make available the time or the funds needed to create community care supports.
So, the answer to the question “how did we get this bad?” is somewhat elementary; though the issue itself is complex, it will take a different kind of leadership and a higher level of commitment as a whole to answer the question — where do we go from here? Now that the wild horse of mental health has been “broken,” maybe with the right leadership and resources an arena of a multi-agency collaborative process will develop out of necessity in this crisis.
Evidence of this has been seen in the recent gathering of our region’s sheriffs in Macon County, where they — along with congressional representatives, mh/dd/sas staff, service providers, etc. — realized just how dire this fractured system has become.