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This is the final installment of a six-part series about behavioral health care in North Carolina. Earlier pieces looked at how mental health care shortages intersect with substance abuse, law enforcement, hospitals, and schools in Columbus County. Today, The News Reporter and Scalawag will examine possible solutions.

Before the turn of the millennium, Columbus County had a public mental health agency that provided services to county residents. For some patients, that meant referral to outside, private entities. For others, that meant receiving mental health services—counseling, medication management, and the like—from the agency itself.

"The ideal of that era was the one-stop shop for people with complex needs," recalls Marvin Swartz, a psychiatrist at Duke University.

But that ideal was changing. That year, North Carolina's secretary of health and human services decided that mental health agencies' role as service provider and referrer was a conflict of interest. Reacting also in part to a wide-ranging auditor's report about efficiently funding mental health care, the state began to move toward a privatized model, with managed care organizations (known as LME/MCOs) disbursing state dollars to private providers.

The rest is the history examined throughout this series. State funding of mental health programs dropped, mental health care grew scattered and ragged, and those who fell through the cracks increasingly ended up where they did not belong: in jails and hospital emergency rooms, or at the bottom of a bottle of pills.

But at each juncture of the mental health care system, people in Columbus County and North Carolina as a whole are working toward improvements. Some hope to reimagine the state's system entirely, while others are working within the system to provide enhanced care in Columbus County. Many have their eyes trained on opioids, hoping to fight the most salient symptom of inadequate care. All offer reasons to hope that change may soon come.

Systems thinking

Most all of the long-timers that The News Reporter and Scalawag spoke with for this series agreed that the best option would be to return to the mental health agency, one-stop-shop model, with some amount of public funding and an obvious centralized location. But as it was only recently scrapped, that option is off the table for the time being.

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"One of the problems in North Carolina is that we change our behavioral health system every two to four years," says Nicholle Karim, interim executive director of the National Alliance of Mental Illness North Carolina. "The LME/MCO model, it's still so new! Is the LME/MCO model perfect? No. It is not. But let's give it time to work, and let's focus on the things that aren't working, and then come up with strategies and solutions and then see if that works."

The most common refrain from everyone involved in the system is that the state just needs to provide more funding.

This year's STOP Act did that a bit. Alongside legislation aiming to reduce opioid prescription lengths and total numbers of pills, the state also earmarked $10 million for community-based substance abuse treatment.

In general, funding increases are a difficult sell at the state legislature, which is trying to reduce government programs rather than expand them. Yet even within the model as it currently exists, there are tweaks that could be made.

State funding of mental health programs dropped, mental health care grew scattered and ragged, and those who fell through the cracks increasingly ended up where they did not belong: in jails and hospital emergency rooms, or at the bottom of a bottle of pills.

It begins with incentives, as Swartz explains. The current model of LME/MCOs is a "capitated" one, in which the organizations are given money based on the population in their areas of responsibility. The state gives the managed care organizations this money irrespective of the level of services they ultimately provide.

"It turns the whole incentive structure on its head," says Swartz.

"So you get paid for not doing things, instead of getting paid to do things."

These concerns are far from abstract. In May, State Auditor Beth Wood blasted Cardinal Innovations, the state's largest LME/MCO, for exorbitant executive pay and wasteful spending on holiday parties and charter flights. In November, Cardinal again came under fire after rewarding CEO Richard Topping with a $1.7 million severance package, and lavishing $2.1 million more on three other departing executives. By the end of the month, the state had decided to take over Cardinal's operations.

Cardinal ran like a business—wooing executives with high pay, and looking to cut costs wherever possible, which translated into cutting services. Eastpointe, the LME/MCO in charge of Columbus County, has also seen its share of executive misbehavior: This summer, former CFO William Robert Canupp was sentenced to more than three years in prison for embezzling nearly a million dollars in mental health funds.

Clear and well-enforced contracts with the LME/MCOs can prevent the sort of mismanagement that plagued Cardinal. These questions will soon transcend mental health, as the general assembly decided this year to transfer its successful Medicaid system for general health to the same LME/MCO model.

"Do we have the horsepower and the staffing and expertise to manage these emerging MCOs," asks Swartz, "or are we going to repeat the same problems we had with Cardinal?"

The Department of Health and Human Services, which oversees the state's Medicaid spending, must be empowered to write clear contracts and enforce them, says Swartz. "It's a matter of contracting. Whoever the successful bidder is, how do you write the contract for them so it says how much you are going to spend on care versus administration. What are the outcomes that we expect you to achieve? What are the data that we expect you to generate? All those things need to be spelled out and enforced."

Making the most of it

The Columbus County Community Collaborative, or CoCo Collaborative to those who know it best, hopes to streamline the disparate services that do exist in the county. The group, which focuses especially on services for young people, is made up of many of the area's mental health providers, as well as representatives of intersecting institutions like the juvenile justice system, the county health department, and faith-based organizations.

The idea is to share information with one another and get a better sense of the landscape of care. "If there's something here that can help, let's get that recognized and get it out into the community. If there's not, let's figure out how we can get it here to the community," says Erin Warlick, chair of the CoCo Collaborative.

The group's work is ongoing. Ultimately, emulating the old mental health agencies, the CoCo Collaborative hopes to centralize behavioral health information and facilitate communication among groups that do not always speak together.

It cannot, however, centralize services. There are ways to build the one-stop shop model back into the LME/MCOs' constellation of care without reverting to public facilities. Under Beverly Perdue, the state tried to implement Critical Access Behavioral Health Agencies, which were designed to provide a wide range of services under one roof. In exchange for seeing to many needs for a community, these agencies were to be preferred providers, Swartz recalls, and paid a premium for their services.

That program was never fully implemented and has mostly fizzled. It does, however, offer a model of wraparound care that could be recreated.

"If there's something here that can help, let's get that recognized and get it out into the community. If there's not, let's figure out how we can get it here to the community," says Erin Warlick, chair of the CoCo Collaborative.

Alternatively, Swartz suggests a mandate that, within the services that they contract out, LME/MCOs must guarantee basic services and operate a facility to house those services. That would mean essentially recreating the county mental health agencies within the LME/MCO system, while leaving them still in charge of coordinating more specialized care.

Other programs take aim specifically at the shortage of practitioners able to prescribe medications in rural areas.
"It's almost impossible to hire psychiatrists anywhere, if you want to do inpatient work," says Carla Hollis, CEO of Columbus Regional Healthcare System. That's especially true in rural areas—Columbus Regional, the county's only hospital, has no psychiatrist on staff, while Swartz is one of Duke Hospital's more than two dozen psychiatrists in Durham.

One solution is training and licensing non-psychiatrists to prescribe psychiatric medications. University of North Carolina has a program for nurse practitioners from rural and remote areas in the state, granting them prescribing authority. "They're really successful in training people. It's hard to set up a program like that and make it successful," says Alan Ellis, a professor of social work at North Carolina State University.

The "psychiatric mental health nurses" are then able to fulfill some of the functions of the psychiatrists missing from areas like Columbus County.

"We need that in a lot of the mental health professions. I think social work is the largest one," Ellis says. "And we don't have anything like that in social work in North Carolina."

Such programs, specifically targeting rural populations, are some of the most effective at getting practitioners into rural areas. Even putting training centers in rural areas is less effective, Ellis cautions, because people so often move on from where they train.

Another promising program is telepsychiatry, which allows for psychiatrists elsewhere to see patients in Columbus County by videoconference. It is already being implemented in Columbus Regional's emergency department. Ellis lauds this service model, and expects it to expand coverage in rural areas in the coming years.

Hollis, the Columbus County hospital's CEO, believes in telepsychiatry. The hospital has seen a surge in recent years of patients in mental health crisis with nowhere to go, and telepsychiatry consultations allow patients to begin treatment in the emergency room before being transported to an appropriate psychiatric facility.

But there is still a big hurdle to its wider implementation, says Hollis: "We don't get paid for that today. There's not a mechanism for payment. We pick up that tab. It's a big thing on our state legislators' plate right now."

The opioid connection

Without adequate services, Columbus countians have turned in droves to opioids to self-medicate. The county's opioid prescription rates lead the state, which is what initially brought Dr. Godfrey Fondinka to the area.

"Really and truly, most of the people that think they need a chemical to be happy have got a mental problem," Fondinka says. "They have got issues that they aren't able to deal with. So then they take this thing that puts them in a different world, and experience happiness temporarily. But when the thing is gone, they need it again, because that condition is still there."

"Most of those people who either do self-medication, or substance abuse, have been identified and stigmatized and classified as people that are abusing drugs in a very negative way. Just normal human beings that have mental issues that have never been addressed."

Fondinka, like others in the county, provides suboxone treatment, one method of "medication-assisted therapy" for those with substance use disorder. Suboxone, which includes a drug that reverses the effects of opioid overdose, offers a way to taper off the drugs without quitting cold turkey, which is rarely effective and can invite relapse. Especially for those who relapse using heroin, a more powerful stand-in for its medical opioid cousins, that can be a fatal proposition.

Drug courts offer one option to divert those with substance use issues from ending up in jail…. The programs have been shown to reduce recidivism and court costs.

Methadone treatment offers a similar option to suboxone, but without requiring a patient to go through withdrawal beforehand. There is currently no methadone clinic in the county, but Fondinka hopes to get approval to operate one soon.

Both methadone and suboxone are prescribed in short courses that require a patient to return frequently to the prescribing clinic—methadone clinics typically ask for daily visits—to discourage their sale on the black market. Both have been shown to greatly reduce the risk of death by overdose in those addicted to opioids.

Swartz, the Duke psychiatrist, is currently studying the efficacy of including these medication-assisted treatments in "drug court" proceedings. Drug courts offer one option to divert those with substance use issues from ending up in jail. Instead of being dealt with by the judicial system, non-violent drug offenders are given counseling and probation.

The programs have been shown to reduce recidivism and court costs. Columbus County does not have a drug court, unlike neighboring Robeson and Brunswick counties.

Drug courts are part of what Aaron Cox, who teaches criminal studies at Southeastern Community College, calls "community policing." Community policing looks holistically at a person's behavior to understand not only criminal activity but also the social context in which it occurs. By getting to know community members beyond their legal infractions, proponents of community policing suggest, lawmen are able to act more empathetically toward those they are serving, and perhaps head off desperate behavior before it results in crime.

In an earlier installment of this series, Cox posited that "policing is really a part of social work." Such policing both furthers and depends on seeing substance users as whole people. Improved mental healthcare will depend on the same attitude toward those with mental illness.

Access denied

In the meantime, the stigma remains. "Talking about it is really important," says Karim of NAMI-NC. "Having these public dialogues about the problem. People with mental illness are actually more likely to be the victim of a crime than the perpetrator of a crime."

"When you start having those public dialogues that link mental illness to violence, that freaks people out more. Why, hypothetically, would I come forward and talk about my experience with bipolar disorder when the media keeps telling me that I'm dangerous, and that they need to be watching out for people like myself?"

Compounding the shortage of services in Columbus County—the lack of psychiatrists, the lack of a methadone clinic—is the question of distance. It is a huge county—954 square miles, the third largest in the state. Even practitioners within county lines can be nearly an hour away.

The services that people end up using are often outside county lines, and access can be tricky—especially for those without cars. For detox facilities, people must travel the forty-some minutes to Lumberton or Wilmington. For a lucky few, inpatient psychiatric beds can be found there as well, but otherwise patients are taken to public beds in Goldsboro, Charlotte, Butner, or even farther afield.

"Why, hypothetically, would I come forward and talk about my experience with bipolar disorder when the media keeps telling me that I'm dangerous, and that they need to be watching out for people like myself?"

A detox facility in Columbus County could transform the services that its residents receive, especially if the facility had medication-assisted treatment clinics connected. While it would not offer the same remove from the social circumstances of substance use as more distant detox centers, a local detox facility would be much easier for patients to access. Treatment that is easier to access is, of course, more likely to be used.

Inpatient psychiatric beds in the county could be similarly transformative. That is a tall ask—the beds are rare statewide—but multiple people interviewed wondered if Columbus Regional could open up their empty wing to provide such services.

Hollis, Columbus Regional's CEO, worries that financing inpatient beds would be difficult, noting the wing would require a psychiatrist on hand at all hours. But she says she is open to exploring the possibility.

The state as a whole could provide more inpatient psychiatric beds—especially for children, whose shortage is yet more acute. The lack of non-crisis options for mental health care begets more psychiatric crises, which land patients in the emergency room, either voluntarily or involuntarily. The reason they stay there so long is the exceeding difficulty of finding them a bed. North Carolinians waited for public beds for an average of 2.5 days in 2016, a time in which their condition is likely to deteriorate. Donna Hill, chief emergency nurse in Columbus Regional, estimates that patients tend to stay in her emergency room for two to four days on average, lying in wait.

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"If I were the king of North Carolina, and I was rebuilding this system, I would probably want to hire at least two psychiatrists full time for Columbus County," says Dr. John Hodgson, a primary care physician in Whiteville. "Their team would consist of two psychiatrists and several counselors, one or two social workers—a mental health team. They would have some kind of outpatient facility or office."

"And I would want our hospital, like every hospital in every county, to have at least a small inpatient psychiatric ward where these doctors could take care of these patients on an inpatient basis," says Hodgson. "I think that certainly could be done. But it all comes down to: What would that cost?"

"It looks like this whole opioid crisis comes down to a mental health crisis," says Dr. Hodgson. "And it looks like our whole mental health crisis comes down to a lack of financial support for mental health."

In thinking about mental health care in North Carolina, the question of cost hangs over everything. The service shortages are worst for the state's poor. Affording care is significantly more difficult without insurance. "Being uninsured can be a big barrier to obtaining care," says Marisa Domino, professor at UNC's Gillings School of Public Health. "And we know that people who have behavioral health conditions—mental health or substance abuse disorders—are definitely overrepresented among people who are uninsured."

The state's decision not to expand Medicaid in 2013, after the passage of the Affordable Care Act, now leaves an estimated 300,000 to 500,000 North Carolinians uncovered who might have the insurance. Most of the funding for the program—90 percent—is federal. If North Carolina were to expand Medicaid, those uninsured people would be able to access the care now unavailable to them, and might be diverted from ending up in emergency rooms or jails, where they are costing the public money anyway.

"We decided as a state that we would not expand Medicaid because it's a political issue," laments Andy Anderson, a service provider for patients with intellectual disabilities at Community Innovations in Columbus County.

Traditionally, many working adults have gotten insurance through their employers, but the lack of quality work in Columbus County leaves that option less available. In the last 30 years, the local economy has been battered by the decline of North Carolina tobacco and textiles. Columbus County is now one of the poorest in the state—the U.S. Census Bureau estimates median household income at $35,847, less than three-quarters of the statewide figure.

Joblessness can also contribute to the sort of despair and lack of purpose that can nudge a person toward opioid use.

A Gallup poll in 2014 found unemployed respondents more than twice as likely to have depression than those with full-time jobs, with that number rising as unemployment lasts longer. Finding a way to jumpstart the local economy would help to ameliorate the worst of the area's behavioral health crisis. The second part of this series examined the sort of purpose that faith-based organizations provide, as they help to battle opioid use. Quality employment can have a similar, if perhaps less soulful, effect.

Darren Mills, who struggled in his younger years with drug use, notices that the deadening of the county's economic life ripened conditions for opioids. "It's bad choices," he says. "I can be in Myrtle Beach in 50 minutes. I can be in Wilmington in 50 minutes. I can be in Fayetteville. So I can get anything, any of the culture I want. But what am I gone do Monday through Friday, and the kids are bored, and there isn't a movie theater here anymore, there isn't even a bowling alley anymore, it's closed?"

An economic downturn in Columbus County, and the state's cutback on the services it provided struggling citizens, laid the ground for the county's struggles with opioids and mental illness.

"It looks like this whole opioid crisis comes down to a mental health crisis," says Dr. Hodgson. "And it looks like our whole mental health crisis comes down to a lack of financial support for mental health."

An economic recovery, one that came with jobs, would certainly help; so would expanded services in the meantime for those individuals experiencing behavioral health issues. The county is resilient, and its residents soldier on together. But they cannot go it alone.

"We're not a poor country," says Anderson. "It's an economic decision, or a human decision. What are we going to value?"

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Sammy Feldblum

Sammy Feldblum studies geography at UCLA and reports across the southern half of the United States.