Agency to add state-funded staff for care coordination

As state officials proceed with a plan to move people with mental illness out of adult care homes, the governing board of Asheville-based Western Highlands Network recently approved its first step to comply by increasing staff for care coordination of individuals who require mental health services.

The change is prompted by an Aug. 23, 2012, settlement agreement between North Carolina and the U.S. Department of Justice reached after an investigation begun in 2010. The advocacy group Disability Rights North Carolina filed complaints alleging that the state was violating the Americans with Disabilities Act by placing individuals with mental health problems in adult care homes, co-mingled with elderly men and women, and without a proper plan for care. The purpose of the settlement agreement is to assure that persons with mental illness are allowed to reside in their communities in the least restrictive settings of their choice.

In the 18 westernmost counties of the state, there are nearly 300 of these homes, according to the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services. Western Highlands Network provides mental health, substance abuse, and developmental disability services for residents of Buncombe, Henderson, Madison, Mitchell, Polk, Rutherford, Transylvania and Yancey counties. Smoky Mountain Center provides those services for residents of 15 counties, including Avery, Cherokee, Clay, Graham, Haywood, Jackson, Macon, McDowell, Swain and Watauga counties.

Peggy Manning/Carolina Public Press
Peggy Manning/Carolina Public Press

Local managed care organizations, including Western Highlands and Smoky Mountain Center, are charged with screening and assessing the needs of individuals with disabilities or behavioral health issues. They are also charged with developing a plan to provide the appropriate services to each individual. That often includes transitioning those individuals from a hospital or other care facility into community housing. People move into adult- or family-care homes either from their own home or the home of a family member, directly from a hospital or psychiatric unit, or after being released from prison or jail. An adult-care home can house seven or more residents, while a family-care home houses two to six residents.

Under the settlement agreement, North Carolina’s system will, within the next eight years, expand community-based services and supported housing that promotes inclusion and independence, according to a U.S. Department of Justice news release. The N.C. General Assembly set aside money in this year’s budget to begin the transition.

The N.C. Department of Health and Human Services has funded all managed care organizations with four positions to help transition individuals into appropriate care and 5.64 positions for peer support specialists. Peer support specialists have been through the mental health system and, after being trained and certified, provide support to others who can benefit from their experiences.

That means, Charlie Schoenheit, Western Highlands’ interim chief executive officer, explained during a recent personnel committee meeting, that Western Highlands Network will receive 9.64 additional positions as a result of the settlement. Western Highlands Network currently employs 55 care coordinators. The additional positions that are being provided by the state will bring that number to nearly 65.

Schoenheit said the department will continue to fund these positions after they are hired. The annual cost of the 9.64 positions is estimated at $490,095, he said.

“If not, we simply can’t do it,” he told the Western Highlands personnel committee.

The committee also heard whether the agency is able to meet benchmarks for monitoring patient care.

“The current case load for intellectual and developmental disability care coordination staff is 47.5 cases per worker per month, versus a case load of 30 to 35 per worker in other managed care organizations,” Schoenheit told the committee. “Internal monitoring shows that approximately 60 percent of the total cases are monitored monthly.”

The N.C. Division of Medical Assistance requires 100 percent of the cases to be monitored monthly. Schoenheit said Western Highlands simply does not have enough staff to do that and suggested that 13 new positions be hired to primarily address care coordination. That is in addition to the 9.64 positions being provided by the state. Funding is available within the agency’s budget for seven of the 13, which could include transfers within the organization, he said.

After deliberating whether to add six unfunded positions and the impact it would have on financial projections for the remainder of the year and going forward, the committee decided on a plan to transition seven people through Western Highlands’ reorganization. The governing board approved the recommendation on Feb. 8.

“With these positions, we may be able to handle 38 to 39 caseloads per worker per month and may be able to monitor 80 percent of the total cases,” Schoenheit said. “That is still not 100 percent, as required.”

Settlement outlines statewide changes

The settlement agreement between North Carolina and the U.S. Department of Justice requires the state to provide access to 3,000 housing slots, with at least 100 housing slots for a maximum of 300 individuals by July 1. In order to qualify for one of the slots, an individual must be Medicaid-eligible, have an income equal to or less than the federal poverty level or be eligible for special assistance funding.

The state must also have 33 Assertive Community Treatment teams to serve 3,225 individuals by July 1. That ratio will increase to 50 teams serving 5,000 individuals by July 1, 2019. Supported employment services must also be provided to at least 100 people by July, with that number increasing to 2,500 by 2019.

This settlement also comes following questions about Western Highlands’ leadership and financial management, which resulted in the firing of the agency’s CEO and state legislators’ questions about the financial health of the organization. The agency is still working through a hiring process for a new CEO as a part of its reorganization.

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Peggy Manning is a contributing reporter for Carolina Public Press. Contact her at

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