Introduction For people who experience psychiatric symptoms, addiction problems, or developmental/intellectual disabilities in our state, the upcoming year may seem like a scary abyss as far as publicly funded services go.  But while the “anticipated unknown” causes anxiety, it can also offer us opportunities for growth and progress.  In fact, with regard to our public services, leadership at all levels will all face the future with the same angst or optimism.  Just like our readers must.   The choice is ours as service recipients, family members, friends, providers, administrators—and much depends, in our minds, on the kind of leadership we now have at the Department of Health and Human Services as well as decisions of North Carolina legislators.

With this in mind, NC CANSO has interviewed Dr. Beth Melcher, Assistant Secretary of the Department of Health and Human Services over Mental Health in North Carolina, so that readers can feel just a little more informed about the potential of the upcoming year.

Just among NC CANSO’s board members, we generated around thirty questions and realize that if there had been time, we could have had much input from others.  But to be practical, we selected the ten questions discussed in this article.

All Roads Lead Where? Beth Melcher started taking steps down paths that lead to this point shortly after finishing college.  It is our hope that along these paths, she has learned about the complexity of the needs of a given individual as well as the breadth of possibility within that person and how this should influence service system development.

After completing graduate school in 1986, Melcher began working as clinical director in Stokes County, part of the Forsyth-Stokes Mental Health (since merged in with CenterPoint Human Services).  She then worked for the Surry-Yadkin program with the “Willie M.” program, the result of a court ruling that had required the state to ensure more comprehensive services for children who might have mental health and who were aggressive and with significant behavior issues.   This work made her consider the breadth and depth of the family’s role and its needs; the community’s assets and the function of quality engagement at every level; and the results that all should have as the focus of community (including state-wide community) systems.  Melcher found herself realizing the importance of partnerships to promote good outcomes.  She learned, too, that social justice and civil rights were foundational to administering and providing effective services to citizens.  And she saw that without vigilance and effort, systems can minimize the integrity of its intended beneficiaries.

Dr. Melcher recognized the systemic barriers to ensuring these extremely important values.  She became very interested in the larger system issues that impact the lives of North Carolinians with psychiatric illness, addictive disorders, and cognitive/ developmental disorders.  So she took a bold step and became Director of a state affiliate advocacy organization, the National Alliance for the Mentally Ill (NAMI NC).  Between her administrative skill and her astute attention to leadership decisions in Raleigh which impacted the lives of citizens, this has been the role through which many North Carolinians have come to know Beth Melcher.

As North Carolina’s Mental Health Reform came in to being, Beth was concerned about the standards for care and which services would be offered in our state.  This would need attention as mental health centers were divesting services to multiple contracted providers.

With this in mind, she did an evaluation of North Carolina service objectives and helped to train providers to promote good outcomes with regard to several nationally recognized evidence based practices.  She resigned her advocacy position and managed a grant from the Substance Abuse and Mental Health Services Administration to offer the “Science to Service Project.”

It was the information in this report that led to her next position working with the Durham Center as Clinical Director.  Beth Melcher has years of experience understanding the LME and its potential as well as the barriers that impact LME activity and results.  Perhaps what distinguished her work at the Durham Center is the fact that the center director Ellen Holliman sought and supported the  effort toward developing a “system of care” approach that was not only specific to children’s services, but to adult services as well and incorporating evidence based practices and peer supports into that system.  A System of Care goes beyond developing a diagnosis-specific service plan for a person.  It develops a plan that engages multiple community partners to accomplish a wrap-around approach that supports a person toward stability and growth.  It also requires multi-stakeholder input into the actual system planning.  So Dr. Melcher set about developing focus groups with consumers and other stakeholders in Durham County to inform how the system should be developed.  Additionally, she had consumers directly involved in the development of the center’s quality improvement plan.  (After all, a good manager must hear directly from his/her customer!)   Advocates across the state watched with amazement as this LME struck out on its own to ensure quality of life outcomes in its planning very early in the reform effort!

A next step on Beth Melcher’s path was to understand the new paradigm for mental health services—the “recovery” approach!  In fact, before her appointment as Assistant Secretary, she worked for several years with a recovery-focused provider, “Recovery Innovations of North Carolina.”

So all roads, thus far, have led to this place.  The question readers must ask now is, where will this important next step in her leadership experience take us? I think that while so much is uncertain, it helps to know what is certain about Dr. Melcher:  she seems to have been down roads that have helped her to “get it,” as many consumer advocates say.

Beth Melcher Responds to our Questions While this discussion began as a live conversation, we sent Dr. Melcher home with the list so she could answer them for us to share.

1. CANSO:  Do you foresee that in the future consumers will be involved in decision-making before changes go into affect?

Melcher: Decision making is not exactly a point in time, and it can be impacted through the process of decision development.  It relates to how a conversation is generated . . . it starts with research about an issue of concern or a potential solution that has been raised.  There are many ways in which consumers can impact such discussions, even including contributing their own research or ideas about structures and processes.  The Division is taking steps to insure more inclusion of the consumer voice on work groups, etc.  (look for DMH web site upgrades for more)   Sometimes, though, decisions are driven by time frames imposed by the legislature or funders.

2.  CANSO: Why are the rates for psychosocial rehabilitation and recovery-focused services so much lower than those for services that reflect a more “medical model” approach?

Melcher: We are exploring whether it is possible to create a different type of rate for the psycho-social rehabilitative club house model.  We have not been able to increase the current rate for psycho-social rehabilitation due to the current budget situation.

3.  CANSO: With the housing prices falling as they have, is there any way the state could foster placement of homeless individuals with disabilities in supported housing, as with a Housing First approach?

Melcher: We have had some very successful efforts at developing supported housing in this state, for example the housing 400 and Key programs. These programs ensure that we not only finding housing, but that we supply the supports that help people become stable tenants.  This, again, requires continued funding and new funds to expand This is also a place where specific advocacy could be helpful to support funds that could be targeted toward housing and supports.

4.  CANSO: What, in your opinion, has been the largest factor in our high number of hospitalizations?  What kind of system enhancements would reduce these numbers, promoting alternative responses to personal crisis as an opportunity for personal growth?

MELCHER: I think it really is coming from cumulative factors, including a statewide reduction in the number of inpatient beds across the state at the same time being slow to build community capacity for crisis alternatives. We’ve made good progress with the expansion of mobile crisis teams and walk-in clinics across the state, as well as the three-way contracts for community hospital beds. We also are expecting CABHAs to fulfill their role as first responders. Part of being an effective first responder is working closely with service recipients to develop effective plans to first prevent crisis but also to identify ways to respond to a crisis so that the need for hospitalization does not occur

5.  CANSO: Mental health clients in the public system die 25 years ahead of the general population.   Does North Carolina have a real plan for integrating physical and mental health care, including dental care (this applies across disabilities).

Melcher: There are significant efforts to support integration efforts through the LMEs and the CCNC (Community Care of North Carolina) network. There have been a number of successful collaborative efforts and the learnings are now being shared across LMEs. National Health Care reform is emphasizing integrative care, not only MH services at primary care settings but also health care provided in mental health settings (so called “reverse” co-location). We have a few of the larger CABHAs that are interested in piloting this type of integration.

6.   NC CANSO: Does the Division have a plan to ensure that consumers have service choice in large rural areas?  What incentives might be used to encourage more providers to serve in those areas?

Melcher: We are closely tracking not only where CABHAs are located but what types of services are available through the CABHAs across the state so that we can identify gaps. The expectation is that consumers will have choice of providers across the state. There are challenges in our rural areas but LMEs have been working hard to fill gaps by reaching out to existing CABHAs and encouraging them to expand into new areas, using RFPs to identify new providers, and using state and county funding to assist with start-up efforts.

7.  NC CANSO: Where do peer support specialists and associate professionals fit into the new CABHA system?  This questioner is only allowed to work four hours per week and knows an Associate Professional whose hours were recently cut in half.

Melcher: Peer support as a billable service can only be provided through a CABHA. We know that there are CABHAs who already employ peers support specialists, even prior to the service definition being implemented. Associate Professionals can work as allowed in the service definitions. How many hours an AP receives to work is really a business decision on the part of the agency.

8.  NC CANSO: Can you help us understand what case management will look like for persons with developmental disabilities or with psychiatric issues?

Melcher: Case management is intended to help individuals connect to services and supports, including natural supports. So likely that activity will be more frequent when individuals start services or when they need to revise/renew a service plan. Case management should empower and encourage service participants. It is not meant to be a long term service but accessed when needed.

9.  NC CANSO: What do you think the most effective role for consumer organizations is?

Melcher: As service participants/recipients consumer organizations provide critical information on what is working and what is not; advise us on service and policy initiatives, and participate in various workgroups to help us develop solutions.

10.  Do you have any comments you could share regarding the investigation of our use of adult care facilities by the U.S. Department of Justice?

Melcher: The Department (HHS) is dedicating itself to gathering and providing information requested by investigators.  

We thank Dr. Melcher for her time and interest in hearing our questions and sharing her ideas.  We wish her well in this upcoming year.  Her leadership will have impact on many North Carolinians.