Medicaid enforcement could push out thousands of mentally ill

by Josh Lanier

As many as 1,200 mentally ill adults could be forced out of assisted-living facilities as the state tries to enforce a Medicaid rule concerning mental health care centers.

The rule requires assisted-living facilities with more than 16 beds have no more than half of their residents diagnosed with a mental illness. The rule is decades old, but the state is now asking the homes to comply or fall under the designation of “institution of mental disease.” Mentally ill residents in those facilities cannot receive Medicaid funding.

To comply with the state’s new initiative, officials say assisted-living facilities will have to kick out mentally ill residents into an already overstretched mental health system that is not prepared to handle the deluge.

“It’s a disaster in the making,” said Deby Dihoff, state executive director of the National Alliance of Mental Illness, “because we’re catching up with decades of neglect in the housing options for the mentally ill at a time when there are few beds and no money to increase those options.”

The Medicaid law, passed in 1965, had the provision regarding assisted-living facilities. North Carolina, however, looked the other way and allowed the mentally ill to fill those beds because it eased waiting lists and opened up beds in its psychiatric hospitals across the state, said Amy Hart, owner and administrator of Hunter Village assisted-living center and Crown Colony.

Officials with the state’s Medicaid and Health and Human Services offices were not immediately available for comment, but a spokesman said details of enforcement are “fluid” at the moment.

Lanier Cansler, secretary of the N.C. Department of Heath and Human Services, told South Charlotte Weekly’s news partner WBTV last month that the state is taking the issue of housing seriously.

“Issue number one is the residents themselves and the fact we’re trying to make sure they’re not going to lose their Medicaid coverage and have a place to live,” he said. “Issue number two is the stability of the adult-care homes.”

The current target date to remove those adults with mental illness from assisted-living facilities is Sept. 1. But delays in assessments of how officials will define mental illness could push that date into 2012.

“That’s our hope,” Hart said. “I don’t think the state is ready to dump these residents out of assisted-living facilities and onto the streets. There are just too many questions to answer right now.”

The answers are as complex as they are many.

Will those residents who cannot find permanent, protective housing still be able to receive Medicaid? Where will they get treatment? Will they have access to medication? Who will be diagnosed as mentally ill?

The assessments, conducted by state appointed Critical Access Behavioral Health Agencies, better known as CABHAs, will ask assisted-living facility residents questions about their mental status and whether they feel they can live on their own without around-the-clock supervision. This is the preferred method, but assisted-living officials are worried the assessment will not be thorough enough and some could fall through the cracks.

Hart fears Medicaid officials will use the codes generated by hospitals to receive payment as the method of determination. As an example, someone suffering from a serious medical ailment that also receives medication for depression could be diagnosed as mentally ill because the reimbursement code for the medication falls into the mental health category, Hart said.

“If I was a young person who had to live in an assisted-living facility because I could not care for myself, I think I would be depressed,” Hart said.

Assisted-living facilities were originally intended to care for those who could not care for themselves and was assumed to be an option more for the elderly or retired. They take the residents to medical appointments, hand out medications and make sure residents follow doctors’ orders. But over the years, the scope of their care has widened greatly, Dihoff said, and they’ve begun to take in residents diagnosed with more complex disorders, like bi-polar and schizoaffective, who had nowhere to go other than hospital waiting rooms. Dihoff hopes current discussions happening at the state level will go into more substantive talks about better housing options in the future.

Pat Townsend’s son was diagnosed with a mental illness, and after years of trying to find care for him, she decided to place him permanently at Hunter Village. She asked the South Charlotte Weekly not to report her son’s name or disorder.

“I’m terrified,” she said. “I don’t know where he’ll go if he’s asked to leave Hunter Village” because of the rule enforcement. “I don’t think it’s fair because they wouldn’t take away treatment from someone with cancer. Why my son? Why these people?”

Hunter Village, a 68-bed facility, and Crown Colony, which has 60 beds, could lose as many as 64 patients combined. Losing that many patients would mean Hart would have to cut back services for remaining residents, lay off employees and most likely shut down both facilities, she said.

“My biggest fear is for my residents,” she said. “These people need real care … If they’re put out on the street, they’re going to end up in one of three places: homeless, filling our hospital waiting rooms or jail.”

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