Lots of help for mentally ill, if they can find it

July 30--"Alamance County is one of the best in the state of North Carolina," said Art Springer, president of the local chapter of the National Alliance on Mental Illness. "There are a lot of services available, but people don't know how to access the system."

Years ago there was a county mental hospital with a sign out front understandable to anyone, Springer said. Now there are a variety of agencies with names like Cardinal Innovations Healthcare and RHA Health Services, and those names seem to change every few years as state policy changes.

"It's very confusing," Springer said. "I can't keep up with it."

Emergency contacts for a mental-health crisis include:

--The NAMI North Carolina Helpline, 800-451-9682;

--Cardinal Innovations Referral and Crisis Line 800-939-5911; and

--RHA Behavioral Health Services walk-in Crisis Center at 2732 Anne Elizabeth Drive, Burlington, open Monday-Friday 8 a.m. to 8 p.m., or call 336-513-4200.

YEARS OF REFORM have left North Carolina, like a lot of states, with a mental healthcare system that is both public and private.

"We're a public entity that acts like a private entity for the public good," said Ric Bruton, senior community executive for Cardinal Innovations Central Territory.

Cardinal Innovations doesn't treat patients. It makes contracts with the organizations and individual practitioners that do, like RHA, and processes Medicaid and state funds, and works out what services patients qualify for, said Bob Byrd, a county commissioner who is on Cardinal's Community Board.

Providers offer treatment, from the walk-in crisis center at RHA, to substance-abuse and mental health counseling at Residential Treatment Services Agency of Alamance County, to care for the developmentally disabled at Carolina Child Psychology. When local psychiatrists bill for Medicaid patients, they bill Cardinal.

"So in a sense they're like an insurance company," Byrd said.

It's a big job and a big operation. In just three fiscal quarters, or nine months, from last July to March, Cardinal covered $27.7 million in services through Medicaid in Alamance County, and an additional $3.7 million in state dollars, according to Bruton.

Cardinal is the biggest of the seven Medicaid managed care plans in the state, according to Cardinal. It operates under contract with the state departments of Mental Health and Health and Human services to insure about 850,000 people with Medicaid or no health insurance in 20 North Carolina counties, including, since 2011, Alamance.

Cardinal had:

--$683 million in revenue in fiscal 2016, according to a Cardinal financial report;

--$587 million of which was Medicaid;

--$84 million was state money;

--$7 million came from counties;

--$4 million came from U.S. Housing and Urban Development and other agencies.

Cardinal in some ways sits on the fence between government -- local management entity -- and private -- managed care organization -- which has led to some controversy, like a report from the Office of the State Auditor in May slamming Cardinal for overpaying its executives and spending time and money looking for expansion opportunities "outside of its core mission."

THIS IS CALLED the community-based model. The state used to have four big mental hospitals. Dorothea Dix was the biggest. In the 1970s, people started to ask whether they were the best way to handle people with mental illnesses, or just a place to store them, getting vulnerable people out of sight and leaving them open to abuse.

They were also expensive.

"A lot of that, I think, was economically driven," Byrd said. "It was seen as a way to save money."

The idea was also to get people treatment closer to home and give them opportunities to live normal lives.

"This is a way to get people out of the state mental hospitals and into the community," Byrd said. "They can have productive lives out in the community -- if the services are available."

It hasn't always been a smooth transition.

Byrd remembers the transition when he heard the director of Piedmont Behavioral Health, which became Cardinal, speak, saying there would be better care at less cost, but it was a work in progress. He said medical professionals could tell how well it was working by how many crisis calls the emergency department got.

They got a lot at first, Byrd said.

The emergency department still gets a lot of mental-health calls. It served 417 Cardinal Innovations members in that same nine months from last July to March, according to Cardinal, at a cost of $407,607 in Medicaid dollars.

Byrd said the emergency department is a good and safe place for people to get stabilized, but it's about the least cost-effective way to deal with a crisis.

Springer blames that on the stigma associated with mental illness and the confusing system. People try to ignore the warning signs and don't know what to do when it turns into a crisis, so they dial 911.

"Cops have two options, jail and the emergency department," said Kirk Puckett, spokesman for the Alamance County Sheriff's Office. "Neither of which are good options because when they are released from either place, we've lost them. There's no follow-up plan."

There are on average about 40 people in the Alamance County Detention Center, or about 10 or 11 percent of the inmates, on some kind of treatment for mental illness, Puckett said.

Springer said NAMI -- using the Freedom of Information Act -- got statistics showing the average time nationwide people spend in emergency rooms before being involuntarily committed is more than three days.

"So someone is in restraints in the emergency department and not getting any help," Springer said.

They also have to be under guard, Puckett said, which takes a lot of police time.

THE NEXT STEP in getting the local mental-health system working better, Springer said, is the Stepping Up Initiative. Law enforcement, Cardinal and county government are all pushing this as a way to keep people with mental illnesses and substance abuse problems out of the jail and emergency room and into the right care for their conditions.

"Stepping Up is a tremendous improvement," Springer said. "They're all working together to solve a very difficult problem."

One part of this he sees working already is Crisis Intervention Training for police so they know how to recognize mental illness, defuse situations with people in crisis, and know where to send them.

"We've already noticed that we get calls on our helpline and say 'Who told you?' and they say 'Burlington Police,'" Springer said.

The other part of it is establishing a 24-hour, seven-day-a-week diversion center for police to take people in crisis and get them the right help more quickly, which Byrd said could take a year or more to get the money together to upfit a building and money to run it for the first couple of years.

Some of it will come from more than $1 million per year in county funds that had been going to Cardinal for mental-health services until this year. More could come from the institutions that would save money if fewer people are being sent to jails and hospitals.

"In other words," Byrd said, "the jails and hospitals."

Reporter Isaac Groves can be reached at [email protected] or 336-506-3045. Follow him on Twitter at @tnigroves.

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