(RNS) — ‘There are churches near, and people near, places where there are no internet carriers at all,’ said the Rev. Barbara Williams-Skinner.
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Between federal COVID relief funds and the $1.4 billion sign-on bonus North Carolina received for expanding Medicaid, state lawmakers were able to make significant investments in mental health services in the latest state budget.
Though state budget negotiations are done almost entirely behind the closed doors of the majority party in the General Assembly — currently the Republicans — health leaders in the House and Senate said they took care to listen to patients, families and providers while creating their mental health spending plan while also working closely with Department of Health and Human Services Secretary Kody Kinsley.
“Everybody saw that to make big changes was gonna take a lot of money,” Sen. Jim Burgin (R-Angier) said in an interview with NC Health News this week.
“And I think one of the attractions to Medicaid expansion for all of us was this once in a generation or maybe even once in a lifetime opportunity to say, ‘Mental health is a big deal,’” he said, explaining the significance of the federal sign-on bonus that came with Medicaid expansion, which lawmakers decided to use to invest in mental health services.
The result is pages of mental health policy and spending in this year’s budget document, where lawmakers committed to significant rate increases, bonuses and education for a variety of mental health workers. They set into motion big structural changes to the way behavioral health services are delivered to the most vulnerable populations across the state. And they directed hundreds of millions to support children in foster care and expand preventive mental health care and crisis care services.
Burgin said he has long been committed to improving the mental health system. He demonstrated that commitment when he embarked on a listening tour with Kinsley and other legislative guests to learn about the mental health needs across the state. After more than a dozen town halls, Burgin said he saw “a different face with the same heartbreaking stories about not being able to get services. We heard that at every meeting.”
“You don’t know how bad something is until you go see it yourself,” Burgin said. “You get a sense of urgency that we have to do something.”
Rep. Donny Lambeth (R-Winston-Salem) has been dedicated to improving health care through his six terms in the state House, and he said he’s never had a better working relationship with a DHHS secretary than he does now. Lambeth described Kinsley as being an open-minded problem-solver. Burgin was also quick to praise Kinsley for the time he’s invested in helping others understand the mental health needs of the state and forming the relationships necessary to move things forward.
“We’re actually getting a lot done, but we’re having a good time doing it because we enjoy talking about it and working on it,” Burgin said. “In the next 24 months, you’re going to see some fantastic things happen in North Carolina.”
Lambeth said that last summer he received three phone calls in one week from families with a child in a mental health crisis asking him what they should do to get help.
“Unfortunately, the only thing I could tell them is, ‘You need to go to the emergency room,’” he said. “We’ve got to get these individuals into a proper care site, not the emergency room.”
Going to the emergency room during a mental health crisis can be a traumatic experience for many, as emergency departments are not set up to treat mental health crises.
In recent years, ERs across the state have been overwhelmed by mental health patients, who often end up waiting days or weeks for an available inpatient psychiatric facility bed. Once that bed does open up, the patients are often transported under an involuntary commitment court order. They are handcuffed and driven by law enforcement officers in marked police vehicles.
Burgin said he gets similar phone calls from families with loved ones in distress. He also said the number is only increasing.
“What a shame that the entry point for mental health has become the door to the emergency room,” Burgin said. “And that’s what we’re trying to stop. There’s got to be a better entry point into mental health care.”
The expansion of Medicaid to about 600,000 low-income North Carolians who previously didn’t have health insurance is the first big step to get people into primary care offices instead of emergency rooms, Lambeth said.
“The foundation of expansion really is developing better access points, primary care — taking care of individuals who historically have not had good access,” he said.
Because of a lack of psychiatrists and child psychiatrists in the state, primary care providers often find themselves out of their depth with patients who come to their offices with mental health issues. To address this, the state spending plan also includes $2 million per year in recurring dollars for the Psychiatry Access Line (NC-PAL), a partnership between DHHS and the Department of Psychiatry & Behavioral Sciences at Duke University.
“Any health care provider, usually a primary care provider or pediatrician, can pick up the phone and speak to behavioral health experts,” Kinsley said.
The budget states that required annual reports be made to state lawmakers that include the number of consultations, counties using the services and the “estimated number of avoided emergency department visits resulting from the services provided through NC-PAL.”
State lawmakers provided $5 million to advance a collaborative care model — where common mental illnesses are treated in primary care settings, rather than sending patients to another provider, often after a wait. This model of care is something DHHS has been scaling up across the state.
“Behavioral health has been thought of as a specialty-level service. It’s not. It’s primary care. Everybody needs access to it,” Kinsley said in explaining the importance of expanding this model.
The budget allocates $80 million over two years for new mobile crisis teams and for crisis and respite facilities. These are alternatives to the emergency room for people who are experiencing mental health distress. The mobile crisis units consist of specialized teams of behavioral health providers that can meet someone where they are located. Respite facilities give people who are having emotional issues the opportunity to spend time in a therapeutic environment, receiving support from behavioral health workers or peer support specialists, people with lived experience of mental illness, all outside of a hospital setting.
Kinsley said he was happy to see $20 million over two years to fund a non-law enforcement pilot program for transporting patients for voluntary and involuntary psychiatric admissions. Putting distressed mental health patients in handcuffs in the back of a police vehicle is “not trauma-informed. That is not appropriate,” Kinsley said.
This spending plan offers “more access points. There’s more prevention. There’s better crisis services and more trauma-informed services if we need to go down that path,” Kinsley said.
The budget includes hundreds of millions in ongoing funding, which will increase reimbursement rates for several health care positions, including skilled nursing facility workers ($71 million in state dollars), personal care service providers ($50 million in state dollars), direct care workers for people on a state- and federally funded Medicaid program that serves people with intellectual and developmental disabilities ($55 million in state dollars).
Rates for mental health providers have not increased since 2012, and Lambeth and Burgin said they consistently hear about this issue. For years, health leaders have called for rate increases to attract and retain workers for these types of positions.
The budget includes, for example, increasing the hourly rate for direct care providers for people with disabilities who receive enhanced community services. Additionally, the budget provides $10 million in ongoing annual funding for 350 more people to receive services through the program, which makes it possible for people with disabilities to live in the community instead of a facility.
Due to the job’s time commitment and low wages, it’s become increasingly difficult for people with disabilities to keep their direct support providers who help them with simple everyday tasks — from bathing and dressing to going to appointments. Meanwhile, workforce shortages have also led to unstaffed inpatient psychiatric beds at the state’s psychiatric hospitals, thus reducing the overall number of beds available, even as people in need sit and wait in emergency departments for psychiatric beds.
“We can’t do this if we don’t have people to take care of the folks, and we’ve got hundreds of beds empty across the state because we don’t have workers,” Burgin said.
Kinsley said he applauded state lawmakers for committing continuing money to sustain these rates, instead of allocating one-time funding.
“It really unlocks a lot of potential,” he said.
The budget also includes one-time funding of $40 million over two years for sign-on and retention bonuses for employees of state mental health facilities. The spending plan includes $18 million over two years to “establish a workforce training center that would provide no-cost training to public sector behavioral health providers, and to administer grants to community colleges to enhance behavioral health workforce training programs.”
There is also a $2 million grant in the budget to pilot a “mental health in the workplace” program. Truusight Health Solutions will enter into a two-year public-private partnership in Cabarrus and Stanly counties aimed at helping employees access behavioral health services and supporting employers who are navigating the state’s complex behavioral health system.
Rural communities have long lacked medical care, particularly mental health care.
“We’re desperately short of people that are highly-trained, especially psychiatrists and family practice doctors. So we put dollars aside to pay them up to $100,000 to work in tier-one or tier-two counties,” Burgin said.
The state budget includes large expansions to the N.C. Loan Repayment program — to the tune of $50 million over two years. The North Carolina Area Health Education Center programs will develop and implement plans to recruit and enroll participants, and the state’s Office of Rural Health will track related data. The loan repayment programs are specifically aimed at recruiting and retaining primary care and behavioral health providers to rural or underserved areas of the states.
And with the expansion of Medicaid, more patients with health insurance will be able to walk through the doors. Having insured patients will help financially sustain these rural health practices.
The state spending plan also includes $20 million for grants over two years to rural health care providers for start-up equipment for telehealth, which will improve access for patients with transportation or other barriers to in-person medical care.
North Carolina’s foster care system has been struggling for years with high-profile failures that include children living in emergency rooms and sleeping on the floors of social services offices. The state health department has also had to take over some failing county operations.
“[The foster care system] is a high priority to us,” Burgin said. “We think that has got to be completely renovated, rejuvenated and reconstituted into a well-run statewide plan, where we can keep up with these kids.”
He said his goal is “limiting the number of times that they have to change places where they lay their little heads.”
The state budget includes the creation of a statewide specialty Medicaid plan for kids in foster care and their families that aims to streamline their physical and mental health care. The groups responsible for providing this care have pushed back on the statewide plan for a couple years, but state lawmakers and Kinsley have said the groups have not made enough progress toward improvement.
The state budget directs DHHS to issue requests for proposals from agencies who wish to hold the contract for the statewide foster care plan, with the new services set to begin by December 2024.
State lawmakers also instructed DHHS to form a work group of child welfare experts and agencies to identify innovative Medicaid service options to address gaps in the care of children receiving foster care services.
Additionally, the state spending plan instructs DHHS to develop a proposal for federal approval to provide more Medicaid-paid mental health services to adults with serious mental illness and to children with serious emotional issues. The goal of this waiver would be to provide more community-based services for these populations while reducing psychiatric hospitalizations and emergency room visits.
The budget provides $80 million over two years “to support families and other caregivers of children with high behavioral health or other special needs by expanding intensive supports in the community and increasing structured options for meeting the needs of these children” and “to strengthen specialized treatment options for children with complex behavioral health or other special needs.”
The budget provides $99 million over two years for community-based, pre-arrest diversion programs and programs to help people reentering the community after incarceration. The money will fund local partnerships between law enforcement, counties and behavioral health providers, as well as community-based and detention center-based restoration programs for those with mental illness and substance use disorders.
Scattered across the budget are several provisions aimed at services for those with substance use disorders, using money from the nationwide opioid settlement funds coming into the state.
The General Assembly is given a small portion of those settlement dollars to distribute, while the majority flows directly to the counties to spend in their communities according to set guidelines. Many of those dollars are flowing to smaller organizations in lawmakers’ home districts, some which have thin track records.
The legislature also set aside nearly $11 million to make grants available on a competitive basis to each campus of the University of North Carolina system for opioid abatement research and development projects.
Meanwhile, at a time when people are dying at record numbers from drug overdoses, state lawmakers eliminated annual funding of $100,000 to the North Carolina Harm Reduction Coalition which was used to purchase overdose reversal medications.
One substance use allocation that pulls from funds outside of the opioid settlement funding is $2.3 million to DHHS for administration, about half of which to be used to create nine new positions to help administer substance use grants.
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Wilson Creek’s recreational areas are attracting an increasing number of visitors, particularly from the Latino community.
Unity in conservation, Part One: Embracing diversity and ecology at Wilson Creek is a story from Carolina Public Press, an award-winning independent newsroom. Our breakthrough journalism shines a light on the critical overlooked and under-reported issues facing North Carolina’s 10.4 million residents. Please consider making a contribution to support our journalism.
A North Carolina facility’s record of violations undercuts the dream of plastics recycling.
Garbage In, Toxics Out: They promised “advanced recycling” for plastics and delivered toxic waste is a story from Carolina Public Press, an award-winning independent newsroom. Our breakthrough journalism shines a light on the critical overlooked and under-reported issues facing North Carolina’s 10.4 million residents. Please consider making a contribution to support our journalism.
American Rescue Plan Act programs expired and the child poverty rate increased to 10%.
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Six months ago, Anthony “AJ” McKenzie, a 30-year-old cool vegetable crop and livestock farmer in North Carolina, stopped farming on his 40 acres. Last year, a drought killed at least 85% of his crop, which caused him to lose income. Usually, he’d grow his cabbage and turnip, mustard, and collard greens twice in the fall […]
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By Will Atwater
Last month, three people died as a result of infections from a category of bacteria you’ve likely never heard of: Vibrio. It is commonly present in coastal and brackish water, especially during warmer months.
“There are almost 80 described species of Vibrio that live in the water,” said UNC Chapel Hill Institute of Marine Sciences researcher Rachel Noble. But Noble also noted that as the seas warm through to climate change, there’s more Vibrio in North Carolina’s waterways.
According to a news release from the N.C. Department of Health and Human Services, there have been 47 recorded cases and eight deaths from infection caused by Vibrio microorganisms since 2019.
One way that people get infected with the bacteria is through eating undercooked seafood. Another way is the bacteria getting into a cut or scrape in the skin when exposed to water containing Vibrio. In people with weakened immune systems, a Vibrio skin infection can all too quickly lead to a systemic infection that can lead to loss of limbs or, left untreated, death.
Noble is among the experts who predict that in the future, Vibrio cases will pop up in places that previously had no issues, and they indicate that there will be more infections in December and January, for instance, since coastal waters are not cooling as much as in the past. .
Noble said that when she began testing the Neuse River estuary for Vibrio two decades ago in the winter, she found anywhere from three to ten microorganisms per 100 milliliters (a tenth of a liter) of water.
“Twenty years later, those numbers are closer to 100 to 200 per 100 milliliters in January.”
“There has definitely been not only an extending of the summer infection season,” she said, “but there’s also been a trend that it’s no longer true that our estuaries go down to almost zero in concentration in the winter months. They don’t. The Vibrios [bacteria] are still very much there.”
Climate change and Vibrio
Vibrio bacteria thrive in warmer, brackish waters where blue crabs live, especially when they’re molting and losing their hard outer shell. And one of the prime ways people get infected is when the bacteria gets into small cuts and scrapes.
Those small nicks in the skin have the potential to be a big issue for people like commercial fisherman Keith Bruno.
Bruno migrated to North Carolina from Long Island, where he once fished for lobster. After an outbreak of West Nile virus in New York in the 1990s, the regions around Long Island Sound aggressively sprayed for mosquitoes that carry the virus. Bruno is among those who blame the spraying for the collapse of the lobster fishery there. But around the same time, the waters in Long Island Sound began to warm, likely delivering the lobsters a fatal blow.
Now, the waters off the North Carolina coast, where Bruno harvests blue crab, are warming. The Vibrio bacteria threaten commercial fishers and those who work and play in or near coastal estuaries and marshes. In the wake of Hurricane Florence in 2018, there were a number of Vibrio incidents.
And with that warming water comes more risk to Bruno and other fishers, who often get cuts and scrapes over the course of their work day.
Because of a medical condition, Bruno leaves most of the handling of crab pots to his son these days. But, he said, the risk of infection is part of the job.
“We are constantly getting scratched and cut and bit and jammed and poked,” said Bruno, who recounted being scratched from handling crab pots and fishing gear and being poked by bones protruding from buckets of bait.
“If anybody gets a wound in the water, they need to get medical attention right away,” said Dr. Michael Somers, an emergency medical physician at Carolina East Medical in New Bern. “We can … treat the infections, but better than that we can give medication to prevent the infection.”
If people who may have been exposed to Vibrio seek immediate medical attention, they can be prescribed an antibiotic such as doxycycline to protect themselves against developing the infection, Somers said.
Bruno said to save time, he and other fishers rely on bleach to prevent infection while out on the water.
“The down and dirty is ‘throw some bleach on it and get back to work,’” he said. “We live to work and work to live … We’re not going up to the walk-in clinic for antibiotics every time we get scratched — we’d live there and never make any money.”
There’s something in the water
A research article published in March 2023 supports the idea that Vibrio is spreading northward along the Atlantic Coast. That study bolsters a growing body of research showing that warming seas are driving more bacterial infections in more northern climes.
To better track the bacteria, the CDC partnered in 1989 with the Food and Drug Administration and four Gulf Coast states — Texas, Louisiana, Alabama and Florida — to develop the Cholera and Other Vibrio Illness Surveillance. The surveillance has now expanded and includes Vibrio data for the Atlantic Coast states.
Noble said that two forms of Vibrio are of particular interest to researchers and public health officials in the state: Vibrio vulnificus and Vibrio parahaemolyticus. V. vulnificus infections usually occur from exposure to brackish water, and V. parahaemolyticus is associated with eating undercooked shellfish.
The Centers for Disease Control reported in an email that in 2019, there were 158 Vibrio vulnificus infections. Twenty-one percent of the infections resulted in deaths — roughly one-half of V. vulnificus infections occurred in Gulf Coast states, and about one-third were in Atlantic Coast states.
When it comes to V. parahaemolyticus, the agency estimates about 52,000 people contract it annually from shellfish. While it will make a person miserable, with vomiting and stomach cramps, it has a very low death rate.
One of the three North Carolina deaths was someone who both ate seafood and waded in brackish water, so it’s unclear whether food or water exposure killed them.
Typically, healthy individuals infected with Vibrio have mild reactions. However, the CDC reports that individuals with underlying health conditions “are more likely to develop V. vulnificus or severe complications such as septicemia,” according to the email.
Protective measures
Sheila Davies, director of public health with the Dare County Department of Health & Human Services, understands the challenges faced by crabbers and fishers, but she strongly advises anyone to seek medical attention as soon as possible if they have scratches or cuts that have been exposed to brackish water.
“If you’re getting cut on a fishing hook, or crab pot or barnacles hanging … it increases your risk of infection,” she said. “So [I’m] strongly promoting how important it is to seek medical attention.”
Echoing Davies’ concern, NCDHHS included the following suggestions designed to help people avoid a Vibrio infection:
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Two organizations that manage behavioral health services for people with Medicaid and for some uninsured people in different areas of North Carolina have agreed to merge into a single entity that will serve more than 100,000 people across 21 counties.
Eastpointe, an organization that coordinates care for low-income residents in 10 eastern counties, on Thursday said it intends to consolidate with the Sandhills Center, which operates in 11 southwestern counties. The consolidated entity is expected to be the second-largest of its kind in the state “based on population,” according to a news release from Eastpointe.
Sandhills Center and Eastpointe are part of a network that currently consists of six state-supported managed care agencies, commonly called LME-MCOs, that serve people with mental health needs, substance use disorders and intellectual or developmental disabilities. These people tend to require more extensive care and support than the average Medicaid participant.
The LME-MCOs play a critical role in the N.C. Department of Health and Human Services’ vision for the future of Medicaid, which includes moving many of the residents served by the agencies onto specialized health care plans that are tailored to their complex needs. DHHS had originally hoped to launch the tailored plans in December 2022. After multiple delays, the department announced last month that the rollout would be postponed indefinitely to give the LME-MCOs more time to prepare for the transition.
In a statement to NC Health News on Friday, DHHS said the decision to delay the launch of tailored plans was “influenced in part by the need to ensure LME/MCOs readiness and focus on providing services to populations they are best positioned to manage successfully.”
“Ensuring that all North Carolinians have access to quality whole-person health care is central to the Department’s mission,” a DHHS spokeswoman said in an email. “This is especially true when it comes to management of the Medicaid Tailored Plans that will serve people with complex behavioral health conditions, Intellectual/Developmental Disabilities and traumatic brain injury.”
The spokeswoman added that DHHS will “evaluate the intent to consolidate” Sandhills Center with Eastpointe, and “work with the entities on a path forward that best serves improving outcomes for the people of our state.”
The department has said about 150,000 people, or 5 percent of the state’s Medicaid participants, will eventually be moved to tailored plans. The LME-MCOs will be responsible for coordinating care for tailored-plan enrollees by acting as intermediaries between patients and providers, who will work under contract with the agencies.
In the news release announcing the consolidation agreement, Sarah Stroud, CEO of Eastpointe, said combining with Sandhills Center will “give us an unmatched ability to deliver quality benefits and support our provider partners while also meeting the objectives of the state’s policymakers.” Stroud will also serve as CEO of the consolidated entity, which has not yet been named.
Anthony Ward, who earlier this year became CEO of Sandhills Center, added that consolidation “offers the best opportunity to preserve local management of services for individuals in our communities.” In an email to NC Health News, Ward said he will serve as executive vice president of the consolidated organization.
No layoffs are expected in connection with the consolidation. The new entity will employ nearly 900 people and oversee a budget of about $1.4 billion, according to the news release. It will be based out of Sandhills Center’s facility in the Moore County town of West End.
In addition to Moore, the Sandhills Center covers Anson, Davidson, Guilford, Harnett, Hoke, Lee, Montgomery, Randolph, Richmond and Rockingham counties. Eastpointe covers Duplin, Edgecombe, Greene, Lenoir, Robeson, Sampson, Scotland, Warren, Wayne and Wilson counties.
The boards of Eastpointe and Sandhills Center, which are made up of 19 commissioners from the agencies’ respective counties, will be condensed into a single board. The consolidated organization will “draw about half of its board members from each LME-MCO,” according to the news release.
Harry Southerland, a Hoke County commissioner who chairs the Sandhills Center board, said the agreement “presents a tremendous opportunity to promote superior services to our members and meet the goals of the Department of Health and Human Services and our legislature.”
His comments were echoed by Jerry Jones, a Greene County commissioner who chairs the Eastpointe board. Consolidation, Jones said, “ensures our approach to service delivery reaches more members at exactly the right time as North Carolina looks to expand its Medicaid program.”
The proposed consolidation must still be approved by DHHS. In its statement to NC Health News, the department said it does not know how long that will take.
“Without having seen the specific proposal at this time, it is hard for NCDHHS to comment on the consolidation,” the department said.
The last consolidation of an LME-MCO occurred after the demise of Charlotte-based Cardinal Innovations in 2021, after a series of spending scandals and dissatisfaction with the organization’s services expressed by commissioners in multiple member counties.
If approved, the new consolidation will reduce the number of LME-MCOs in North Carolina to five. The other agencies are Alliance Health, Partners Health Management, Trillium Health Resources and Vaya Health.
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