MINUTES

STATE OF NORTH CAROLINA BOARD OF COMMISSIONERS

COUNTY OF HENDERSON SEPTEMBER 25, 2000

The Henderson County Board of Commissioners met for a special‑called meeting at 3:00 p.m. in the Commissioners' Conference Room of the Henderson County Office Building at 100 North King Street, Hendersonville, North Carolina. It was a joint meeting with the Social Services Board to discuss mental health needs of children.

Those present were: Chairman Grady Hawkins, Vice‑Chair Bill Moyer, Commissioner Renee Kumor, Commissioner Don Ward, Commissioner Marilyn Gordon, County Manager David E. Nicholson, Assistant to the Manager Selena D. Coffey, County Attorney Angela S. Beeker, and Acting Clerk to the Board Avalina B. Merrill.

Absent was Clerk to the Board, Elizabeth W. Corn.

DSS Board members present were: Chairman William L. Lapsley, Jack Drill, Wanda Mitchell, and Grace Poli. DSS staff present were Director Liston B. Smith, Human Services Attorney Charles Russell Burrell and Volunteer Coordinator Carole Kitchen.

In the audience were: Dottie Effinger, Diane Weaver, and Jane Lindsey, advocates for children's mental health needs.

CALL TO ORDER/WELCOME

Chairman Hawkins called the meeting to order and welcomed those in attendance.

Chairman Hawkins thanked the DSS Board for meeting with the Commissioners to engage in discussions about mental health needs for children. He asked DSS Board Chair Bill Lapsley to speak on behalf of the DSS Board.

Mr. Lapsley: "We thank you as well Mr. Hawkins and members of the Commission for having us. I think my assignment first here on the agenda is to refresh everybody's memory about how this group got started, what its charter was, and a little bit of a time schedule. Then I would like to turn it over to Liston to go through the recommendations that were in the report some of which are still current, some of which will probably need to be updated because some time has elapsed since this report was put together. Bear with me as I kinda go through a little time schedule here to refresh everyone's memory. In September of 1998, the Board of Commissioners as we understand, it received some concerns from members of the public about mental health services for children in general and in particular those that are in the custody of DSS and the foster care program. A special concern was raised for those children that were being covered under the Medicaid program. That was in September of 1998. As a result of those concerns, the Commissioners approached, then Chairman Eklund, approached then Chairman of the DSS Board Frank Blazey about the matter and asked the DSS Board to consider setting up a task force to look into this situation. Some of you may recall that it was about that time September 1998 that the DSS Board had just finished a very successful task force study on the permanence of children in foster care. Subsequent to that, the County received some special recognition for that program. So we had just finished a successful job, the task force, on another matter, and I think that was what prompted consideration to look at this one in the same format. So in October of 1998, about a month later, then Chairman Blazey submitted an outline of a proposed task force back to then Chairman of the Board Eklund and in that outline it was recommended that there be a task force of joint chairs, one from DSS and one from Trend, as well as eleven other members of specific agencies and non‑profit interest groups in the community. That was again in October of 1998. In November of 1998, the next month, the Commission reviewed the outline and proposed membership and approved of that outline. Then a month later in December of 1998, a new Chairman Hawkins asked to discuss this matter further with the Chairman of the DSS Board Blazey and requested that DSS consider expanding the membership from eleven to eighteen and to expand on the effort if we could and get on with the program. So then Chairman of the DSS Board Blazey revised the outline and met with Trend Chairman and got the program started in March of 1999. That was the first of what was to be eight meetings of the task force or steering committee, depending on which term you prefer to use. The co‑chairs of the committee were Grace Poli and Phil Jackson from Trend. I must say at that time, the DSS Board and the Trend Board felt very strongly about the final product that was put together by the two chairmen and I think we still feel that way. They did the study in a very professional manner and did a very thorough job as far as we know. In October of 1999, about a year ago, Grace and Phil completed the report with the help of the DSS staff and Trend staff and presented their recommendations in the form of the report, some of you may remember this yellow booklet that was submitted to the Board of Commissioners in November 1999. In October the month before, the task force presented their recommendations to both the DSS Board and the Trend Board at a joint meeting and both of those boards reviewed it and each passed their resolution of recommending its transmittal to the Board of Commissioners and recommending to you that you strongly consider adopting the recommendations in the report. That was done in November 1999. You may recall that when the report was submitted to the Board at the regular Commissioners meeting, there were some members of the public who raised concern about some of the recommendations that were in the report, questioned whether maybe this was as thorough as it needed to be. I think based on what the Commissioners heard from us on the report and some comments from the public, Chairman Hawkins at the time requested that we have a joint meeting work shop and discuss the recommendations and maybe answer some questions that the Board might have. So that leads us to today. Our DSS Board is here at your request and it was a joint effort between the Trend Board and the DSS Board, but since DSS was charged with the responsibility to the Commissioners to take this on, we're here to help you and to answer your questions. At this stage, unless you have some questions of me, I'd like for Liston to go ahead and go through the report recommendations and maybe give you some insight on what things have changed in the last twelve months and maybe what is applicable and maybe not applicable today."

Liston B. Smith, DSS Director, highlighted the report prepared by the task force. Mr. Smith distributed copies of the task force recommendations entitled ?Revisiting The Henderson County Task Force on Mental Health Needs for Children, September, 2000, Board of Social Services.

Mr. Smith gave an overview of the key current influences which were listed as:

1. Study of State Psychiatric Hospitals and Area Mental Health Programs

Office of State Auditor/Public Consulting Group Inc. April 2000

� Broad reform/major changes in public mental health system.

� Alignment of funding/spending patterns to current public need.

� Shift responsibility for management/governance of mental health as well as accountability to counties. Area Program to County Program.

� Restructure, unify and expand Medicaid (DMA) policy and operations in line with (DMHDDSAS) policy, operations and service provision.

� Deinstitutionalization/increased community social services.

� Reduction(s) in State Hospital System.

� Separate Developmental Disabilities Division.

� Increased and expanded service delivery on county level through a 'matching process'.

� Establishment of Blue Ribbon Legislative Implementation Commission (GA established Mental Health Oversight Commission summer of 2000 session) multi‑year rollout.

Mr. Smith: "I started out with current influences prior to the ending recommendations largely because I think you need to hear the current influences in order to do discussion about recommendations. There has been a State study. It was done by the State Auditor, a private group, a public consultant group released in April of 2000. It was a state‑wide study of the entire mental health system including state hospitals and that type. They're calling for role reform and major changes in the public mental health system. They're also looking at the alignment of funding and spending patterns relative to the current need. What that basically means is the way priorities were made and funding streams were set up ten years ago are not necessarily applicable to the needs of today and those funding streams need to be adjusted. They talked about a major shift of responsibility for management and government's mental health and accountability to the counties. They also talked about restructuring, unifying and standardizing the Medicaid policy operations and particularly doing this in line with the mental health policies at the state level. One of the things that came out very strongly in the study added to the recommendations was the disparity and any congruence between the rules that DMA had on the state level and the rules for mental health subsidies themselves which basically made it rather difficult for local mental health providers to really know what to do. They called for de‑institutionalization, increased community social services, mental health services, reduction in the state hospital system, separating the developmental disabilities section out of mental health. I think they've done that already. Increased and expanded service delivery on the County level for a matching process. What that basically means, they're talking about funding mental health the same way they've done Social Services where the County Commissioners have to come up with a certain amount of county money for certain amount of state and federal money. The status of the blue ribbon legislative implementation commission and the General Assembly established a mental health oversight commission in the summer of 2000 session saying that this major study roll out change would be a multi‑year type process."

2. Child Residential Treatment

House Bill 1840, Section 11.19(a)‑(d). General Assembly summer session 2000.

� Purpose. To provide appropriate and medically necessary residential treatment alternatives for children at risk of institutionalization or other out‑of‑home placement due to mental/developmental disability/substance abuse problems.

g Memorandums of understanding/coordination between MH, DSS, AOC.

g Behavioral health screening/assessment.

g Multi‑disciplinary case management.

g Residential treatment placements.

g Mechanisms to insure children are not placed in DSS custody for the purpose of obtaining/funding MH residential treatment services.

g Mechanisms to maximize current funding streams and expand use of Medicaid as a funding stream.

Mr. Smith: "The child residential improvement. This one is more specific to the recommendations that's coming up later but it's very important. House Bill 1840 the General Assembly passed in the summer session 2000. The purpose of the bill was to provide appropriate medically necessary residential treatment, alternatives for children at risk for institutionalization or other out‑of‑home placement due to mental health development disabilities. What you'll see, General Assembly two years later from our recommendation has put a recommendation in place statewide pretty much to gear us to our recommendation number two and three that's in our report. That's basically calling for ways to maximize funds on the local level and ways for maximizing state and federal funds that are used by our local providers in collaborative case management and other things like that for your high‑risk children that need out‑of‑home placements."

3. Elimination of Willi‑M and Thomas S.

General Assembly summer session 2000.

� Left funds in overall MH budget.

� Eliminated administrative, infrastructure, categorical funding.

� Contradictory to Study of State Psychiatric Hospitals and Area Mental Health Programs Report recommendations.

� Treat all children the same.

Mr. Smith: "The third term influence, this is most specific to mental health, was the elimination of the Willi‑M. and Thomas S. categorical funding streams by the General Assembly of this session 2000. They eliminated the administrative infrastructure categorical funding which basically if you have a special kid with a special type need here's this funding source for you. They left the funds in the budget and as I understand it, local mental health basically ended up with a hundred thousand dollars less money for children than when the General Assembly started. Another interesting thing about the elimination of the Willi‑M. and Thomas S. funds is they eliminated the appeal process and it is in direct contradiction of the State study that was done. Clear amount of criticism of the General Assembly's actions in that this action was taken in contradiction of the State study prior to the General Assembly's own commission that they appointed to make those recommendations. To make a long story short, it makes funding issues on a local level for difficult to serve kids even more difficult."

4. Olmstead

� June 1999 US Supreme Court ruling

� Opinion based on American Disabilities Act (ADA)

� Requires community based (integrated) rather than institutional services (segregated)

g When integration can be reasonably accommodated

g When beneficiary does not oppose integration

g When medical professionals have determined integration appropriate

� Segregation of disable discriminatory

� Applies to Medicaid and all other government funded beneficiaries

� Applies to persons already in institutional setting and persons being assessed/potentially eligible for institutionalization

� Applies to all disabled, physical or mental, who otherwise would be entitled to institutional services. Such as the following groups:

g Long term stay patients in State Hospitals or State Developmental Centers

g Children in residential treatment centers

g Residents in nursing/rest/adult care homes

g Individuals who cycle in and out of hospitals due to lack of community resources

Mr. Smith: "Olmstead. It has the same fateful ruling in June of 1999. This is based on the American Disabilities Act. It requires community‑based, a term you'll see frequently as this iceberg emerges and floats around, is integrated rather than institutional services which is segregated. So basically it's supposed to look at community‑based services when you can reasonably be accommodating which is ADA language, when the person wants to be independent. So if the person wants to stay in the institution or wants to go to one, then they're allowed to go. You just can't force a person to be in an institution. They basically see putting someone in an institution with a disability as discriminatory under the Civil Rights Act and the ADA. That applies to Medicaid and all other government funded beneficiaries. There's some bit of confusion right now that this is going to affect mental health and this is only going to affect Medicaid funded programs. This is going to affect the school systems, Social Services, mental health, any entity that works with disabled people and use any government funds. It applies to folks who are already in an institutional setting as well as persons being assessed and potentially eligible for institutionalization. It applies to disabled, physical or mental, who otherwise would be entitled to institutionalized services. It would include any long term stay patients at state hospitals or state governmental centers, children in residential treatment centers, residents in nursing, rest or adult care homes, any individuals who cycle in and out of hospitals due to a lack of resources. So the bottom line is because it is attached to ADA it applies to any person on disability. That can be and will be an enormous undertaking. The other key influence when you look at funding, and this is the one that I think will be an iceberg that the Commissioners continually have in front of them, is an on‑going phenomena of Medicaid and looking at the disparity between Medicaid children, mental health children who are served through Medicaid funding versus children who are served by mental health without Medicaid. Medicaid is the fastest growing mental health program revenue. There is a hundred forty‑seven percent increase, it grew from sixty‑seven billion to a hundred and sixty three billion between 1995 and 1999. The average Medicaid funded child that receives mental health services gets a reimbursement around two thousand one hundred seventy three dollars compared to a child without Medicaid at two hundred dollars. If you don't remember anything else that I say today, remember that you've got a regular child out there that's not on Medicaid, two hundred dollars, Medicaid two thousand one hundred seventy three. That force is a major drive, it's a major influence on what a mental health can do on a local level, how priorities are made, how decisions are made, how people get in trouble using Medicaid. I mean that figure alone tells you a lot about what has happened in the past, what's currently happening and what will happen in the future. For example, the state says they're going to give county accountability for mental health programs. So what are you going to do for those children that are not Medicaid. Fifty nine percent of the children served by Trend are funded by Medicaid, forty one percent of the children seen by Trend are funded. So those key influences I felt like I needed to throw out there on the table as folks were making decisions and thinking about things in the future."

Mr. Smith then discussed the six recommendations of the Task Force.

TASK FORCE RECOMMENDATION

Is it current priority

State Study

Olmstead

Current Recommendations

1. Study of local group home options for children

gYes gDe‑institutionalization Olmstead New Juvenile Court Laws gLack of local resources gA lot of money going outside of county g90% of children jointly served by MH, Social Services, Court in residential treatment placed outside of County

gDe‑institutionalization

gApplies

JCPC (or commensurate level group) study gTarget children gResources/ funding gCosts gGroup home policy/ program gOutcome measures

2. Study and implement TREND, Social Services, AOC collaborative for children served by all three (3) agencies requiring out‑of‑home placement. 3. Establish subcommittee accountable to TREND, Social Services Boards to hear, resolve, advocate for resolution of obstacles to service provision.

gYes gCost shifting gRoles unclear gInefficient use of multiple of funding streams gInappropriate placements in Social Services custody gElimination of Willi‑M categorical funding gIneffective assessment/ initial placements. 80% of children served jointly by TREND, Social Services, AOC have had 3 or more placement disruptions g100% of children served jointly by TREND, Social Services, AOC have been out‑of‑home over a year g22% increase statewide in children entering Social Services custody for MH reasons (compared to 5% decrease in children entering Social Services custody overall).

g@Joint total responsibility" gInteragency partnerships gDevelopment of alternatives to hospitalization and long term residential placement

Applies

gRequest TREND, Social Services, AOC formally study and implement HB Child Residential Treatment Services Program gRequest periodic report to inform Commissioners of study, implementation, routine evaluation, outcomes, cost. gInclude Recommendation Three as part of collaborative model implemented by TREND, Social Services, AOC

TASK FORCE RECOMMENDATION

IT IS CURRENT PRIORITY?

CURRENT RECCOMENDATIONS

4. Study of respite care options 5. Development of a comprehensive children's services database, centralized Information and Referral System 6. Study school based mental health services.

gNo gNo gNo

None Similar initiatives are being developed by the Child and Family Resource Center None. Study and/or initiative should generate from School Board to be viable.

Mr. Smith: "When it comes to recommendations from the task force, I felt like the only proper thing for me to do was to deal with six recommendations we made then and revisit those. I have one more that I'm going to throw out there that is really not a mental health recommendation. When you look at recommendation number one, the recommendation was to study local group home options for children. Is it a current priority? Yes. I didn't make these decisions by myself. I talked with the mental health director. Why is it a priority? Because of de‑institutionalization and the State study, because of Olmstead, because of the new juvenile court laws, all of which are placing an emphasis on local resources and programs for children versus sending a delinquent child to training school, sending a child with mental health problems to Charlotte. All of these are saying do it in your own county, do it with you own resources. Lack of local resources, and by that I mean placement facilities and other programs to prevent placements. A lot of money going outside the County. If we look at the amount of money that we're expending on out of home placements, one way to look at it is what could we do with that amount of money if we were putting it back into our county versus putting it outside the county. Ninety percent of the children jointly served by the mental health social services for in residential treatment are placed outside the county. I mentioned the State study to see if there is any correlation between what we came up with, what the State's recommending and de‑institutionalization is a major emphasis in the State study. Olmstead, it also applies to any child that's being considered for residential treatment. What that is, institutionalization if that child is removed from their home and they are placed in a residential facility too. My current recommendation would be that we look at what types of placement resources do we have in Henderson County and regionally and we look at what are the target children, where we're going, our priorities, what type of resources and funding are available, what are the costs, what are the policies and other things that govern whether children can enter a group home or not and come up with outcome measures. What do we want to accomplish with this money for the children. So that's recommendation number one.

Recommendation two in the original task force was study implementing Trend, Social Services and Juvenile Court collaboratively with children who are served by all three agencies requiring out of home placement. Is it a current priority? Yes. Why? Cost shifting, which basically means with the confusion over the last two or three years, if there is any way to dump it on the County Commissioners or the taxpayers to fund this thing and it has been done and is being done. Roles are very unclear. One of the things that was brought out in this study also was brought out in our local task force, there's a lot of confusion between a case manager at Trend, and a case manager at Social Services and the Juvenile Court counselor about who's responsible for what when all three are working with the child. We're doing better with that but there's still a great deal of ambiguity. Inefficient use and multi funding streams. That's still an issue. We'll do a whole lot better if we work collaboratively.

Inappropriate placements in Social Services custody. That's one of the things that came out in the new bill that the General Assembly passed which basically said there needs to be an effort for children not to go into Social Services custody just for mental health treatment services just because the parents are unable to afford the programs. What that means is if you put a child in my custody, they're automatically eligible for Medicaid. Bingo, the parents don't have to pay. That's what we may want to talk about later. That's a large ethical issue. They eliminated the Willi‑M. categorical funding which basically means the most difficult children to serve we have lost the funding stream for those children.

Ineffective assessment, additional placements. Eighty percent of the children served jointly by Trend, Social Services and Juvenile Court have greater or more placement disruptions. A hundred percent of the children served jointly by Trend, Social Services and then offices of the Juvenile Court have been out‑of‑home placement for over a year. There has been a twenty two percent increase in children entering Social Services custody for mental health reasons compared with five percent overall increase in number of children entering Social Services custody. What that means is the number of children coming into custody has gone down five percent when all factors are considered in all children, but if you look at the ones that did come into custody there has been a twenty two percent increase in the number of children entering custody because of mental health residential treatments. That's state‑wide, that's not specific to Henderson County. The state study does call for joint total responsibility, I put quotes on that because I don't know what joint total responsibility means. It definitely means that there should be collaboration and shared responsibility from the providers .

Inter‑agency partnerships alternatives to hospitalization and long‑term residential placement. The Olmstead applies. My current recommendation for this one is real easy because I know that my Board and the Trend Board, I certainly know that Jeff Grimm, the Trend director, and I are ready to do this. We've been talking and I know our Boards will be. It's just a matter of Trend Board and Social Services, if we get Juvenile Court folks involved, then we get together and study ourselves locally how we're going to implement the child residential treatment program. I think that it should be done in such a way that County Commissioners, certainly the Social Services Board and the Trend Board, but County Commissioners are aware of the implementation. Give periodic reports and sort of know what's going on because this is definitely a biggy. So my recommendation on that is tell the Social Services Board and the Trend Board to get with it.

The task force recommendations four, five and six, the study of respite care centers. I want to emphasize this when I say use of the current priority. I didn't say is it a current need. I said is it a current priority. I do not think that it is a priority. It continues to be a need but I would not consider it a priority. So do I have a recommendation on that one? No.

Development of a comprehensive children's services data base centralized informational referral system. Is it a need? Yes. Is it a priority? No. There are also some similar type activities and initiatives being done by child and family resources center. If there is interest in this, I would encourage use of that group because they're certainly active.

Recommendation number six study school based mental health services. Is it a need? Yes. Is it a priority? No. I have no recommendation on that one other than enter a study and if there's attitude it should be initiated by the school board.

I have one more. I wouldn't call it a recommendation but those of us who have been active in the Community Child Protection Team and are around this whole issue, some of us recognize that when we did the original mental health task study that we did not include children with disabilities. I also know that my Board was real interested in children in Social Services custody with developmental disabilities and for various reasons that one sort of sat there on the back burner. But at our last meeting of the Community Child Protection Team, we as a child protection team have agreed we would do a study on Social Services and services to children with developmental disabilities that are in the custody of the Department of Social Services. That is not a study on mental health. You may say that's not in the context of this meeting but since we are the custodian and you study what we're doing or not doing with any child in our custody with developmental disabilities, this sort of makes us branch out in a much broader territory and what's going on.

Suggested actions for the Boards. I would basically say that the original document is really no longer a working document in that priorities have shifted. A lot of the information that generated the report is at least two years old. Recommendations one, two, three are still very much priorities and need to be dealt with and so I think we should put energy and time into those. I think recommendation two and three can both get accommodated by the Trend and Social Services Board taking that on in a very formal study and implementation. It is my recommendation to keep the Commissioners informed of this implementation. Recommendation number one is probably the hardest one to get a hold of. I think the ranking of the priorities on our community with private providers, public providers and multi agencies, there would need to be some type of committee put together that is endorsed or appointed by the Board of Commissioners. I think the JCPC, Juvenile Crime Prevention Council, that would be an excellent group for that or a community group that could study and present our report to the Commissioners on residential facilities aided by community based services. That's all I have."

Chairman Hawkins: "Thank you for that kind of succinct report. There's a lot of information there. I might just ask you a couple of questions. I'm not very familiar with the improved plan. What is the Thomas S? It was mentioned in there and I'm not familiar with that."

Mr. Smith: "My understanding of the Thomas S. is it is similar to Willi‑M in that the lawsuit brought about creation of a funding stream and rules and structure on a state level for adults who have significant emotional disability type problems. Similar to Willi‑M in that they were very costly to serve these folks, high risk folks both to themselves and to people that they are around. So Willi‑M and Thomas S were created by the General Assembly. Special funds set up, special programs set up."

Mr. Hawkins: "So neither of those programs of the particular funding stream for the Willi‑M and Thomas S was repealed with this House Bill 1840?"

Mr. Smith: "The significance of that is one of the things about the task force recommendations in looking at the priorities, you have both adults throughout who mental health serves and children who are very high risk, very needy and very costly because of insufficient funding and program structure lawsuits occurred in North Carolina which created both of these national funding streams for these very difficult special children and adults. That's the sunset bill being repealed so we're back where we were in the beginning where you have the same problems and children, you just no longer have the special funding structure. I suspect that you can make an argument OK we're just going to make the whole pie to be equal access for all children. The problem with that is the needs of all children are not equal. If you understand what I'm saying, in other words, that did not help the mental health system in North Carolina to undo those."

Ms. Kumor: "Well, let me ask you a question. With Willi‑M, they had a whole canopy of services that you were able to get from this program, so with it sunsetting, all of the services have disappeared or just your money?"

Mr. Smith: "Just the money and that is no longer categorically there for Willi‑M children which is usually violent children either to themselves or to others at very high risk as far as emotional problems."

Ms. Kumor: "So what are the real concrete options that you have for Willi‑M children in your custody?"

Mr. Smith: "Still take a bigger piece out of the pie or more local money to pay for their needs. They will still be eligible for mental health services. Mental health just will not have a special funding stream for them."

Ms. Kumor: "What I'm saying is there was whole legal action that said they had a special way to do some special treatment whether the money went away or not didn't change or did it?"

Mr. Smith: "Yes, the special treatment was based on the lawsuit and the lawsuit expired, the requirements for special treatment expired."

Human Services Attorney Russ Burrell: "They reached an agreement where the State agreed to provide the same services for those children who in the past were past members of either Willi‑M or Thomas S and they would be able to do away with the special classification of the lawsuit. They don't segregate that money out so that it must be provided just for these children. They just took the amount in Willi‑M and put it in all the children's services."

Mr. Smith: "What it sets in motion is a competition so the more pressure there is on mental health to serve four or five different target groups, then you've still got to serve the Willi‑M child and it's still going to cost us much more money but there is more pressure for more funds for other children."

Ms. Kumor: "Then let me ask you this. If the money is drying up as we've seen when the money dried up for residential places, is that what's going to happen with Willi‑M? Are the services that used to be funded, pretty much because they were guaranteed some State funding, are those services going to start to disappear?"

Mr. Smith: "I think that's a big concern of some of the mental health provider people who are supporting those programs."

Mr. Hawkins: "Let me ask you this question. The difference between House Bill 1840 which is already on the statutes and directly based with this out of the state consultant group which the committee, the legislature charged, are you saying that included in the State consultant report is the same things that were passed in House Bill 1840? You've got House Bill 1840 that you said that the first two recommendations that were previously appropriated in that. The request, was that also in the State auditor's report?"

Mr. Smith: "Just in similar language it talked about local agencies sharing responsibility, local agencies working on developing community based services. Our recommendation two years ago was very similar to child residential treatment plans in House Bill 1840. One of the messages in that study is with the difficult to serve children. It can't be just mental health, it can't be just Social Services, and it can't be just the court system. The three are going to have to partner to figure out, one, how to pay for it and two, how to give them more effective services. If you leave out any one of the three, it's like a three leg stool, if you pull one of them out then the stool falls over."

Mr. Hawkins: "The other question, it talked about families that were unable to afford mental health programs and it sounded like in lieu of not being able to afford these programs that they basically didn't get the mental health services they needed. That would be a terrible decision to make."

Mr. Smith: "If you're a judge and you're sitting there and a family needs something, remember we're talking about kids with significant needs, this is not just a regular mental health issue, and he's forced to say I can't do anything so just go ahead and put the child in DSS custody so that treatment can be funded."

Ms. Kumor: "So it's not the parents choice, it's the judge's?"

Mr. Smith: "It can work either way."

Comment from an individual in the audience: "It can be the parents choice especially if there's siblings in the home and if the care will totally bankrupt the family and they still have income that will disqualify them from Medicaid. So that's a heart wrenching decision for parents all across the United States, it's not just North Carolina. That's because the treatment is just not available at prices an average family can afford. Some of these families even have health insurance but the health insurance doesn't cover mental health."

Mr. Smith: "I would hope that when this Trend Board and the Social Services Board gathers this group together, we've got to do this, and put this all together that we will have some specific criteria to try to avoid that. I would rather try to find the money for someone. Taking custody away from the parent just because of the money gives you a disheartening feeling. If there is some way to avoid that, we would be making greater progress."

Mr. Moyer: "I think you touched on this but I'm still troubled. In your chart, you say is it a current priority? On one, two, three you have answered yes. And then four, five and six you answered no. Now I'm trying to get to the basis of who established this. You said you talked to people, you listened, and you made this determination?"

Mr. Smith: "We didn't get this task force back together and they decided there were three yes's and three nos. This is largely me synthesizing this information, looking at what the current priorities are, talking to the mental health director."

Mr. Moyer: "So that's fine. Then going back over these, you looked at each of these based on what's happening and what you hear and you then said whether it's still a current priority or not without input from Partnership for Health or any Board or Trend or anybody else?"

Mr. Smith: "That would be the case."

Mr. Moyer: "I just wanted to be sure that I understand. I think this is a discussion that you and I had about nine years ago, but number five on here, is I think our priority which you and I said a long, long time ago, and I'm amazed to see this no longer a priority. I thought having this data base was so the agencies knew what was happening."

Mr. Smith: "I saw this as being done by someone other than Department of Social Services, Trend or Commissioners having to say we needed to find someone to do it."

Mr. Hawkins: "Let me move to action under recommendation number one. The recommendation deals with having someone to look at all the ramifications of the group home. When I looked at that as I looked through the report, it seemed to me that particular aspect of whatever this huge re‑overhaul, the group home was one aspect. As I looked at that as far as how to go about getting a feel for which way to go on that or what we're going to do, it seemed that would be a part of this bigger report or whatever charter we get or don't get from the State. Does that make sense at all?"

Ms. Kumor: "Well, because there are different kinds of children, you have to determine what our residential facility is doing and all the other kinds of residential needs that children have."

Mr. Hawkins: "But isn't that all going to be a part of this report here?"

Ms. Kumor: "No, because it's our residential treatment facility."

Mr. Hawkins: "But I mean our mental health program. We're going to have a huge overhaul, is the way that I understand it, is not the group home going to be a part of that overhaul? It's going to be separate?"

Ms. Kumor: "The group home is out. Our Youth Programs comes under Henderson County and it deals with a number of children who don't necessarily fit into having mental health needs but the children are there for their safety, and children are there for a variety of reasons for a level of emergency shelter that doesn't come under mental health or its reform."

Mr. Smith: I don't know if this is in context, I want to be real clear, when I say group homes. I'm not talking about the County group home, I'm talking about what was at Park Ridge, Trend facilities, I'm talking about all types of group home settings in our County."

Ms. Kumor: "What happened was when all the money dried up for residential treatment, all these people shut their doors and the only recourse people have is to put their children in treatment now out of County. We're kind of first level entrance for things that aren't necessarily falling in line with mental health treatment. We don't do treatment at our facility. We do emergency sheltering. That's all we do and it has nothing to do with mental health."

Mr. Smith: "The succinct way of putting that, Grady, is that if you took the current group home and turned it into a high‑need residential mental health facility, then all of a sudden we'd be paying for the emergency shelter care children that currently gets services there. You've got a continual level of needs. I want to be real clear about saying let's look at the group home and turn it into a high risk treatment facility. That's not what I was saying."

Mr. Hawkins: "Your last recommendation is to ask this Board to look for some group or groups of people who look at that particular aspect of the mental health program."

Mr. Smith: "Yes, get a separate group from DSS or Trend to study group home availability in the County and to see if they would meet this mental health need. Social Services uses group homes, Trend Mental Health uses group homes, it's one of these where we all use these facilities."

Ms. Kumor: "But you're sending a lot of money out of county and when you send those children depending on how far they go, they may not see their families or their case worker or anybody else that has an interest in them for long periods of time."

Mr. Hawkins: "If we're going to do that would we better off maybe to correspond with the court system, Trend, DSS, to see what's involved?"

Mr. Smith: "I don't think you want us, Grady, leading and I guess for lack of the word bias. Trend's going to want a place for residential mental health, DSS is probably going to want something similar and like Renee said you got a whole group of kids that aren't that needy, they just need emergency care or that type of service. To me it would be critical to have leadership on this committee to be as unbiased or be as broad a base of dysfunctional issues that you can get."

Mr. Hawkins: "So you want that mix of requirements?"

Mr. Smith: "Yes, because Liston would just take the group home over tomorrow night and make a residential treatment type that DSS is because Liston has these very difficult to serve kids that the community may not want, in a broader respect."

Mr. Hawkins: "So we probably, I guess, your suggestion probably is to find a group of people, all of those various areas, that have interest in it to look at that aspect."

Mr. Smith: "We need to very deliberately and formally study all these different options. Look at cost effectiveness, cost efficiency, look at outcomes for children. If a child has problems particularly mental health problems, the first thing you do is take them out of the home and put them in a facility 200 hundred miles away from their school, from their neighbors, from their parents, but what have you done other than back set them another year as far as making treatment progress. It's got to be all kinds of considerations."

Bill Lapsley: "Another point that I'd like to make, if we could get a jump start on this group, we're going to be hearing more in the future, if we as the County can get a better handle on what our needs are accomplishes two things. One, it puts us in a position to respond to potential changes in regulations and maybe we can have some input in what comes to us from Raleigh, and second, whatever is implemented we should be able to react quicker and respond and get up and going faster than other counties. So it seems to me that it would be in our best interest to get going."

Mr. Hawkins: "You're talking about group homes?"

Bill Lapsley: "Yes, to know what the potential attendance is, where are these people going, what the cost is so we can tell you, or this group can tell you, the Commissioners whether it's a good idea or not. Right now we think we may know but we don't have anything to show you."

Mr. Moyer: "Liston, how'd you answer this? The State basically says we want to move away from de‑institutionalization. To me a group home is simply moving where the institutionalization is. It's exactly what the State is saying to get away from and we're saying we're going to all these new homes and the State is saying this is the wrong way to go and I'm really scratching my head at why we're even thinking about that."

Mr. Smith: "Let's see if I can succinctly answer that one. I'll use this analogy. It's like nursing home care for elderly folks. You have heard me say we need to put more and more money into in‑home services, community services so folks don't have to be out of their home and go live in a nursing home. But the reality is, you're going to have a certain percentage, and it will still be a growing number just because of the demographics, of folks who have to be in nursing homes. It will be the same thing with group home care, residential care. There will be children who will have to be in residential treatment facilities and stuff like that. What they're trying to say is you should not put them in a residential treatment facility if you can have community resources that are equal to what they would get in a residential treatment facility."

Mr. Moyer: "I'll buy that. You answered that just what I wanted. So we'll be studying what the problem is and how we deal with it rather than studying having more group homes?"

Ms. Kumor: "That's why you're having us doing a strategic fund for children. That was your whole point."

Mr. Moyer: "But here we saying we're going to study establishing group homes, and I think what the study is saying is what the problem is and how we deal with it."

Mr. Smith: "Remember, Bill, I said recommendations one through six I'm going to confine myself to those. If I was going to do recommendation number seven, it would be to look at community based services and starting to really get a handle on what Chairman Lapsley was saying on what are our community based services, what does Olmstead mean, what does de‑institutionalization mean."

Mr. Moyer: "Maybe that's where we should be starting rather than with number one."

Ms. Gordon: "Let me throw something else out here too because there's another way to look at what the state is saying about de‑institutionalization. They're talking about reducing, the way I understood it, the big state run institutions. There's a difference between a big state run institution in Raleigh and group homes that are located in communities that are smaller and more accessible. It's still technically an institution but I took it, too, that they were saying let's get away from the big buildings in Raleigh and spread it throughout the whole state locally. So that's another thing about the State doing away with the concept of having these with more supervision and more care you can give them."

Mr. Smith: "You're exactly right. They may not go to Raleigh but they go to some type of center other than Henderson County. The other is Olmstead which is not just the state facilities and that type stuff. It applies to any disability need child. I didn't bring any easy information or easy extras or anything. When I think in terms of taxpayers funding and priorities and what's going to be enacted over the next two, three, four years, I think it's an enormous challenge for our Board of Commissioners, Board of Social Services, Trend Board and others in meeting these needs."

Chair Lapsley: "Seems to me, Bill, that the answer to your question is that if we can get a group appointed that deals with these placements of people out of the county and get a handle on how many of those we have and what their problems are, what their services needs are, we're accomplishing the idea of getting a quantity and getting a handle on that. And then while they're studying that, they may be able to evaluate how many of those may be candidates for a lesser level of in‑home treatment so we can accomplish both things at once and be prepared to respond to what comes out of Raleigh better, faster and more effective."

Mr. Moyer: "I just don't see how you can do an effective job on the first part without going ahead."

Mr. Smith: "You're right, Bill, it's just enormous. For example, going on Marilyn's point, under the Olmstead Act we could be sued if a child's in our custody and I place it in a facility in Buncombe County in a group home. Assuming they say you failed to integrate this child because you took him out of his local school system and or you took him out of his neighborhood or you caused his parents to run off. It's a real interesting thing because then you are asking the question of what community services and local plans did we have in place and use prior to making the decision before sending the child to Buncombe or to go to Gaston or some other place. It is both sides of the coin."

Ms. Kumor: "And that becomes a piece of what the JCPC's facing. Did we get $180,000? We're supposed to look at what the needs are in the community with regard to children in the court counsels, what programs should we fund with that $180,000 to serve that population of children because their point is that we don't want these youngsters going to trade school, we want them to stay in our town. So we're running out of money that we could use because the court counsels keeping telling us the programs that are functioning in the County that we've paid for over the last decade haven't been doing the job that they're supposed to do. But our money hasn't increased and the amount of children they're trying to serve has increased. And we're now trying to do for less money but more children. We've been doing that for the last decade. And you've not been allowed to be creative because we can't go beyond what we're doing because what we're already doing is serving certain needs and meeting the priorities that we've set for our community, but there's no extra money to go beyond that and create more programs in either more intensive services or more preventive services that will address some of the needs that are highlighted in this study."

Mr. Hawkins: "We're expecting some significant changes in legislation in mental health that this committee's getting out in front of that along with this piece of the pie, we may need a committee charged with this specific mission that includes the schools, DSS, the Trend, the court system, JCPC."

Ms. Kumor: "If you're talking about the auditor's report, that's something that all the area mental health agencies are going to be having to start to design. That's a real global discussion that's going to happen going on over the next five years and some of that's going to depend on what the State says counties may have to do. We want to look at just children's issues. That is a little more specific. And part of it is the County Commission has already instigated a strategic planning for process for children that's going to be on going and forever. We'll be coming back at the mid‑October meeting with an interim report about what's been found so far and what we're going to do. One of the issues was the resource assessment. We're starting that on Tuesday with a look at some of the resources but we certainly won't get into all the residential issues but that's a big piece of this that you're going to start looking at those things. That's already started so I don't know if you want to look at this specific issue that is critically becoming a need. But don't get into a strategic plan because you're already doing that."

Mr. Hawkins: "I think that aspect of it that there is some things already going on obviously and we definitely could put together a committee to look at a broad spectrum of what's going on."

Ms. Kumor: "But I don't understand what it's going to look at."

Mr. Hawkins: "Well, to me it's like the difference between Thomas S. and Willi‑M. One is kind of an adulting of the mental health program and the other is down at the other end yet we have to look at both of them and certainly in areas that we're already working on. There's obviously going to be ramification to this when it comes on board for everybody. The juvenile court system of course will be focused on those programs but there's going to be other parameters that we're going to have to deal with. I think what Bill is saying is that there are lot of other agencies that's going to be involved in this. Those that come out of the school are going to have the school to play with. If they're part of the funding source would be another a big charge for group of people who has independent sources. You have some out of the JCPC, DSS has some, the school has some, Trend has some, the County has some. I don't know how all of those are going to come together when the legislature decides on how we're really going to run mental health in that context and how does that impact DSS. I don't think any of us here know that."

Grace Poli: "We're talking about funding but initially when this all started, the center was the child. What I heard Liston say was that the various entities should come together and look at how it can work as a team in helping this child. Liston, am I correct?"

Liston: "Yes, on recommendation two."

Ms. Poli: "I think that needs to go forward. How do we work so that we can bring this child into a level that meets his need."

Mr. Hawkins: "I guess that's on recommendation one because I think recommendation two talks about implementation of House Bill 1840 between Trend and Social Services, I think deals specifically with that issue. That's kind of the way that I read it. I don't how much of 1840, I've not read the whole bill, includes anything out of JCPC."

Mr. Smith: "The link between the three with this bill is that the child needs mental health residential services. So you have a delinquent child that likes to set everything on fire that he can see. Well, he's a fire setter and committing a crime but he's also obviously got a mental health problem. So I mean the link is the mental health treatment services. There's a lot of delinquent children that are perfectly sane or don't have mental health problems and there's DSS children that don't have mental health problems."

Mr. Hawkins: "I think you were looking for two things from the Board of Commissioners. One was on recommendation two and three and asking the Board of Commissioners to request Trend, Social Services and OAC study and implement House Bill 1840. I think the Board is comfortable with that. So I'll be happy to generate that correspondence on behalf of the Board to these entities and ask that which will set those wheels in motion. The next one got into the broader scope of how the whole overhaul of the mental health program is going to impact both DSS and Trend and any priorities the JCPC puts out. According to Renee's thinking, some of those aspects are well underway to be looking at some strategic needs for children etc. I don't see it as conflicting with what the overall charter to some of these organizations, DSS, Trend, the court system with impeding any of that. The thing that Bill's looking at as far as are we going to be ready with our best anticipated action on the part of what the legislature is going to do or are we going to access what resources we have, but from the county perspective will have to do both of them. I think that's what I'm hearing from the Board to include part of the things that is being dealt with already."

Ms. Kumor: "I'm wondering, does this Board want, the Board of Commissioners want, them to initiate a letter to Trend saying that you have this mental health report, anticipate things that will happen and we'd like you to start pulling things together, people in the community, because we would like for you to have an assessment of our needs and resources before we move forward with the plan. I think that's where some of the study is going to have to start with Trend and probably what they're doing is waiting to hear exactly what they have to do. But if that was your request, I think it is very appropriate because it starts to position the Trend Board, the DSS Board, the Board of Commissioners, and everybody else who has a piece of this, to at least get the preliminary assessment work done so that when these changes start to happen and when Mr. Nicholson is down there being a participant in instigating changes that he knows and we all know how we would like some of these outcomes to be and how we would like legislation to put a hold on other things."

Mr. Moyer: "I think that we should have a separately appointed group by the Commissioners to study this report and understand it and say what is right for our county. I definitely don't think it should be headed by Trend."

Ms. Kumor: "I think the Commissioners should take the lead but the question that we're asking I think goes beyond what we came here to meet about today."

Mr. Moyer: "I think it does but we're merging the two together and when you said send them a recommendation to get ready for this, I think that's the wrong thing to be done. Recommendations coming out of this group may put Trend out of business."

Ms. Kumor: "I think as a courtesy they should be brought in as a resource."

Mr. Moyer: "We keep merging this recommendation one which is far more than mental health and talking about studying that particular document and whether we support it or that we recommend trashing it. We'll have to take a position on legislation if we add it as a separate thing beyond the scope of what we're here to meet about today, but I think strongly that we need to get going on that and get a group to study that."

Ms. Gordon: "I think we're talking about two different things. Liston's recommendation one that DSS form a task force to look at this is going back to the report that was given to us a year ago but we still haven't done it or even started it or even initiated. It was studying specifically where this falls. Just that one thing. I think if we do attach the task force, that we go after one part, one piece of the pie, and they should be able to come up with some specific recommendations hopefully that we would be able to implement. If we try to make it too broad in scope, then we're just going to get another package of generics that really won't give us any directions and I'd much rather at this point and time get that, because this is a part of that other study that you're talking about. We could already have this done and concluded if we'd done it a year ago but we didn't, so let's get that going. And then this other report, it is my understanding this report has not been passed by our legislature so if we wait for that committee to meet out there and tell us how we're going to implement something that hasn't passed. You're talking about something extremely complex and very comprehensive. I guess I'm wondering how much time are they going to need to be able to get the study done before this is all implemented, or how much time are we talking about, what level the committee is taking on the whole package, or we're going to have to divide these pieces up to be handled."

Mr. Moyer: "Just getting a group of the key people together that can understand the report and start kicking it around and have discussion of what's really in there, what does it mean, what are the implications for our county. If something does occur six months out, we'll be ready to deal with that or at least ask them to consider that. They're not going to take that report and be able to get up to speed in a week. It's going to take them quite a while and that's why I think we need to get started on it."

Mr. Hawkins: "Who all would be on this Board organization wise that you can think of beside the school, DSS, Trend and somebody out of the court system.?"

Mr. Moyer: "Which committee are we talking about? Are we talking about number one or we talking about mental health?"

Mr. Hawkins: "I'm talking about this report."

Ms. Kumor: "I think that needs some thought and should be on a board agenda."

Mr. Smith: "The recommendation one for a study on the group is a much more sail in, immediate, time limited, get in there do something and we can make a lot of progress in our county and get a lot of clarity and actually implement something rather than having another recommendation. And it may or may not have anything to do with the larger mental health study when it comes down to it, if I know the state. Everybody says we're coming down with a plan in two years saying the same thing they've already said which is you guys develop local things. I think we should dive right into that with the larger mental thing. I know this is none of my business but I will give you an observation is that the Trend Board right now is as strong and energetic and involved as it has even been. I think Jeff has dived in there and is doing a really good job. I recognize that a big committee for the county doesn't need to be run just by Trend. It needs to be run by the Commissioners but I certainly would encourage a very active participation in the leadership from the Trend Board because this is very complicated stuff."

Mr. Hawkins: "With that thought, let's go back and focus just on the group home question. The short term thing, besides DSS and Trend, who needs to be looking at that? Who's going to have some involvement?"

Chair Lapsley: "Chairman Hawkins, if it would be appropriate to pass that baton over to the DSS Board, we'll get back to you with a suggestion for the makeup of a committee to bring back one specific recommendation. Then we can gather the information in phases. That way you'll have a recommendation faster."

Mr. Moyer: "I'll tell you right in advance unless the bigger issue is to study the study that we talked about before, I don't think it's going to have that much creditability. If you're asking me to vote on establishing a bunch of group homes based on this, it's not going to hold up with me. I'm telling you right in advance."

Chair Lapsley: "If the Board wants to sit and continue to discuss where we're going, then my suggestion is to take no action on that recommendation. I think that's clear, we will continue to do what we're doing now and that is shipping folks out. My only suggestion is based on the recommendation of the report, not to necessarily come back to you and say whether we establish a group home or not, but at least get a better handle on where are all these children going and how much is it costing us and have that data ready for the Board of Commissioners to use whenever you want to make that decision. That's my only suggestion. If you don't feel that is necessary, then leave the recommendation, let it sit and it'll be tabled and we'll continue on."

Ms. Gordon: "I agree with Bill, we asked for a report from the task force, we got it a year ago. The first recommendation they made was that there be a study of the group home situation. Now a year later they come back, the first recommendation we get is that there be a study of the group home situation. Because we study it doesn't mean there is a commitment to do anything with it. But I need the information. I couldn't make a decision now if something came before me intelligently because I don't have the information. And I don't see what you're losing by saying going ahead at this point and get the report going."

Mr. Hawkins: "What exact information are you looking for out of this study for mental health?"

Ms. Gordon: "We need to know what's out there that's available and at what cost, what the rate of use is, how much is going out of county and then get into the part that Bill was talking about where you tie into the report what we've projected needing."

Mr. Moyer: "But the problem we always get into, Marilyn, every time we do this we sort of indicate to the groups that if we get a recommendation saying you need this home, we're going to do it. And I will be straight forward in saying when all this data comes back, I do not know because I've not seen the bigger picture yet but it doesn't set in my mind the fact that you need another group home for nine people for another million dollars doesn't mean that I'm going to go for it."

Ms. Gordon: "But if we get an objective board that does what they're asked to do and evaluate, they can also come back with an evaluation that says no at this point in time we cannot justify it. And so that's what we're asking for is a honest study based on facts. I don't think that we should assume because we're asking for a report that we've already made up our mind that we're going to do something. That's not the idea."

Mr. Hawkins: "Let me look at another way of putting this. Bill, I think what you're looking for is the capability of at least making an assessment of what currently is happening."

Chair Lapsley: "My suggestion is that to help you that the DSS Board in consultation with David and Liston come up with a recommended make up of this group, not that it necessarily be charged to DSS to do because it's all these folks. We can come up with a list of participants that we think you should consider. If you appoint them, then the group can get together, analyze the data, pull it all together and report back to you. We may have most of the data very quickly."

Mr. Nicholson: "A group home is a long‑term facility that we had kids from four to five years at the group home. Our goal right now is get them in there, find what their needs are and get them out to a web of services that are in our community, which are vast. That's what our goal is. We've got ninety days to make those recommendations sometimes to place that child in Morganton or Charlotte or Gastonia. That's a problem for staff. They're struggling with that."

Mr. Hawkins: "I guess that it is the consensus of the Board, we'll ask you to take a look at that, give us a recommendation for the make up of a task force that will study this. I think it is also the consensus from the Board for your first request to issue correspondence to these various agencies to ask for their assistance in this study."

Mr. Moyer: "Let's go back to number one again. You're asking the Board to forward their recommendation. Are we going to ask them to just pull together all the information with respect to status or are we asking them for the Board's recommendation again?"

Mr. Hawkins: "They were going to make a recommendation on the make up of the task force."

Mr. Moyer: "I'm fine with that."

Chair Hawkins adjourned the meeting at approximately 5:00 pm.

APPROVED BY:

Grady Hawkins, Chairman

Henderson County Board of Commissioners

ATTEST:

Avalina B. Merrill, Acting Clerk

DATE APPROVED:

Note: In the quasi verbatim portions of the transcription, the punctuation is at the discretion of the preparer of these minutes to enhance clarity and understanding.