Specific Recommendations Recommendation 7

DMHDDSAS should convene a steering committee to develop, implement, and oversee a work plan to most efficiently facilitate the diversion of primary substance abuse admissions from state hospitals to the revamped ADATCs. This recommendation to divert primary substance abuse admissions from state hospitals to the revamped ADATCs will efficiently and effectively address a well-known flaw in the utilization of state hospital resources. To succeed, this plan (or any variation of this plan) must meet the following criteria:

! Alternative secure detoxification settings have to be created that can provide safe management of difficult-to-mange and/or combative patients.

! Efficient administration and client management mechanisms must be in place to ensure good access to these settings (e.g., 24/7/365 admissions, no waiting lists, geographic access, efficient admissions procedures).

! Efficient system capacity is necessary to perform rapid step-down to less secure and more clinically appropriate settings (e.g., continued detoxification, postdetoxification rehabilitation, available and accessible step-down services; and transportation to those services, if needed).

Recommendation 7.2

Ensure that the Mental Health Trust established in this year’s budget is used to provide substantial funding for diverting inappropriate state hospital admissions of individuals with primary substance abuse problems.

The Mental Health Trust should be a primary funding agent for implementing the reforms demanded by Olmstead and addressing the thus far intractable problem of inappropriate primary substance abuse admissions to the state hospitals. Such an investment will reduce state hospital expenses significantly, improve the quality and appropriateness of services provided, and likely create far more positive outcomes for those affected. The appropriate diversion of these individuals, typically over 3,000 a year, could be done

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quickly and efficiently and represent a meaningful system improvement early in the reform process. It greatly benefits both the mental health system and the substance abuse system and is a win/win move for all concerned.

Recommendation 7.3

Transfer any savings or staff positions related to the diversion of primary substance abuse admissions from state hospitals to adapted ADATCs to the Substance Abuse Services Section to support the additional costs of expanding ADATC capabilities.

The costs of expanding ADATC capabilities will be measured in the millions of dollars and will probably come out of the SAS section budget. The savings resulting from these diversions will be deducted from the state hospital budgets. Fairness would suggest that any savings resulting from the diversions should support the cost of developing the services that will take those diversions.

4.2.4 Suggested Time Frame

Substance Abuse Services Section Report to Oversight Committee January 2002

Implementation July 2002

4.3

Recommendation 8

Develop complete continuums of locally and regionally accessible substance abuse services.

4.3.1 Goal

Ensure consistent access to a comprehensive continuum of substance abuse services to North Carolinians in all counties in order to dramatically reduce the impact of substance abuse problems on health care costs, crime, and the overall quality of community life.4

4.3.2 Findings

Even though the North Carolina SAS Section is one of the most respected and forward-looking in the country, the system has substantial weaknesses in terms of

Research cited by the National Association of State Legislatures strongly suggests that the current level of untreated substance abuse in North Carolina is costing the state tens of millions of dollars annually in terms of increased criminal justice costs, increased health care costs, lost productivity, and so forth.

Substance Abuse System Recommendations

access, accountability, and quality across the state due to insufficient funding, a highly decentralized system, and longstanding systemic problems. Many area/county programs fall short in terms of ensuring availability of and access to the needed continuum of services, and access to services varies greatly depending on what county you live in or what area/county program serves you. Overall, the most essential and basic substance abuse services (e.g., specialized outpatient substance abuse services, detoxification and treatment programs, day/evening treatment programs, halfway houses, and other residential and hospital based services) that form the foundation of a complete substance abuse service system are unavailable in many regions across the state. North Carolinians seeking or requiring substance abuse services will often find that the services they need are not available or they must wait several weeks for a first appointment.

We also noted that North Carolina has suffered a substantial loss of psychiatric and substance abuse beds in the past few years due to a wide range of factors (See Exhibit 4-9: Community Psychiatric and Substance Abuse Bed Closures). However, most beds were lost due to the changing and more challenging health care market. Their loss has significantly weakened North Carolina’s ability to provide necessary substance abuse (and mental health) services to its population. Current political and economic pressures have led many area/county programs to restrict or terminate contracts with outside agencies they view as competitors and to provide the services themselves (often to detriment of the consumer). The actions of the area/county programs have been a major factor in the downfall of several well-respected substance abuse programs in the state.

The American Society of Addiction Medicine (ASAM) has made a major contribution to the substance abuse field over the past decade by developing and publishing the ASAM Patient Placement Criteria. This document, now in its third edition, has served to standardize definitions across the country regarding the different levels of

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EXHIBIT 4-9

COMMUNITY PSYCHIATRIC AND SUBSTANCE ABUSE BED CLOSURES1

Facility2 County Date Closed Child/ Adoles. Psych Beds Adult Psych Beds Total Psych Beds Child/ Adoles. SA Beds Adult SA Beds Total SA Beds Total Psych and SA Beds

Charter Asheville Buncombe 1999 42 65 107 20 20 127

Park Ridge Henderson 1999 12 12 12

Transylvania Com. Hosp Transylvania 2000 40 40 40

Amethyst/BHC Mecklenburg 2000 30 14 44 40 60 100 144

Charter Pines Mecklenburg 1999 20 40 60 1 1 2 62

Rowan Regional Med Cntr

Rowan 2000 15 15 15

Piedmont Area SS Detox Cabarrus 1999 8 8 8

NC Baptist Forsyth 1999 5 5 5

CenterPoint Forsyth 2000 16 16 16

Charter Winston-Salem Forsyth 2000 24 51 75 75

Charter Greensboro Guilford 2000 32 68 100 100

Oakleigh Durham 2001 27 27 27

Cumberland Cumberland 2000 16 16 32 32

Pitt County Memorial Pitt 1999 10 10 10

Brunswick Brunswick 2001 12 12 12

Totals 191 282 473 41 189 230 703

Source: SAS Section, DMHDDSAS.

1

Bed counts based on number of licensed beds closed.

2

Substance Abuse System Recommendations

care within a full continuum of substance abuse services. It also provides baseline criteria for when a client should be admitted to, maintained in, and discharged from those levels of care. If one is involved in any aspect of substance abuse system development, the understanding of the “ASAM continuum” of substance abuse services is helpful. It describes four general levels of care (Levels I, II, III, and IV) and specific or specialized services within those levels of care (e.g., Level III.7). A variety of ancillary services can be offered at many or all of those levels of care (e.g., detoxification can be provided at all levels). Exhibit 4-10 briefly describes the ASAM continuum.

EXHIBIT 4-10