Strategies for Counties to Support Behavioral Health and IDD Services

As North Carolina continues its efforts to respond to the 2019 Coronavirus (COVID-19), there are actions that can be taken at the local level by partners like government agencies, community organizations, local management entity/managed care organizations (LME/MCOs), behavioral health providers, and others to assist in supporting behavioral health and Intellectual and Developmental Disability (IDD) services and mitigating the current health crisis.

Our Goals:

Maintain services now: To support the continuation of quality, medically-necessary services for consumers during the COVID-19 response, recognizing the need for providers and consumers to rapidly adapt to new methods of service delivery.
Sustain services over time: To stabilize, sustain and adapt provider networks to deliver services and supports tailored to the needs of North Carolinians, while also readying providers for the potential lasting impact of this pandemic.
Reduce burden on emergency departments and hospitals: To the greatest extent possible, reduce the need for any hospitalization, including facilitating discharge where appropriate and preventing avoidable readmissions.

The state has taken a wide range of actions to increase flexibilities and supports to both mitigate the current crisis and sustain behavioral health and IDD services.

North Carolina has applied and been approved for an 1135 waiver and an Appendix K waiver from the Centers for Medicare and Medicaid Services (CMS) to request flexibility of several Medicaid rules in order to be more flexible in responding to the needs of NC citizens.
The state has also rapidly modified telehealth policies for Medicaid and telehealth policies for state-funded services and quickly approved LME/MCO telehealth policies to allow for a broad array of behavioral services to be offered via telephone and video.
North Carolina has consolidated numerous other policy changes and financial flexibilities that have been provided to sustain services, as discussed in an open letter to LME/MCOs.
The state will approve an increase to the Medicaid-funded rate for private inpatient psychiatric hospital beds if the facility is experiencing an outbreak of patients with COVID-19.

If you have questions or suggestions for the state about providing or continuing access to behavioral health or IDD services, please email BHIDD.COVID.Qs@dhhs.nc.gov.

Local Actions to Support Behavioral Health and IDD Services During COVID-19

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Partner and leverage existing mobile crisis services through the local LME/MCO.
As currently approved, the federal 1135 waiver would allow for alternative treatment sites. This allows hospitals to convert existing spaces or use on or off campus spaces as treatment sites. The federal Centers for Medicare and Medicaid Services (CMS) has approved a 1135 Medicaid waiver for North Carolina as well as blanket waivers through Medicare that provide states and providers with short term flexibilities during an emergency.
Federal waivers allow ambulances to redirect patients without COVID symptoms and with behavioral health symptoms to an affiliated crisis center, on or off campus or from emergency departments to alternative sites of care including physician offices, FQHCs, and urgent care facilities. Sites would work together on payment reimbursements for redirected patients.
North Carolina is working to gain additional exemptions that could approve partnerships that involve additional non-emergent medical transportation.
For eventual off-campus possibilities, local providers could consider converting a local behavioral health facility into a current crisis and assessment center. Local partners could work with appropriate law enforcement and emergency responders to divert individuals with a suspected mental illness there. Individuals would have to be assessed for physical illness and diverted immediately to the emergency department, if necessary.
In consultation with legal counsel, facilities might consider adopting policies for emergency forced medication where this can be done pursuant to the relevant statute. (NC Gen. Stat. § 122C-57).
Consider allowing residents to fill out an online form if they believe they are experiencing symptoms, to target testing capacity.

Consider establishing stepdown units for stable patients that do not have other discharge opportunities, such as conversion of hotels or residence halls into semi-hospital level of care.
Purchase hotel rooms and collaborate with local Meals on Wheels programs or churches and other faith-based groups along with food pantries for individuals that need to be isolated or quarantined and do not have stable housing.

Encourage judges to hold Involuntary Commitment (IVC) hearings via teleconference.
Encourage law enforcement to bring people experiencing behavioral health crises to Facility-Based Crisis (FBC) Centers, Behavioral Health Urgent Cares (BHUCs) or temporary alternative care sites for first assessment.
Suspend jail visits and request inmates to allow attorneys to appear in court without physical appearance by the inmate.

Housing

Consistent with Chief Justice Beasley’s orders and Governor Cooper’s Executive Order 124, postpone evictions and foreclosures until after the COVID-19 outbreak subsides.
NCDHHS is working to waive various licensed residential facility requirements that will allow more flexibility for providers to continue care.
Other residential programs are strongly encouraged to adapt their program rules to be flexible in this moment, such as reconsidering zero-tolerance policies.

Transportation

To the extent possible, provide transportation, behavioral health and other required services to the maximum funding available. All resources should be maximized regardless of the lack of funding from other payer sources during the duration of the pandemic.

Food and Basic Needs

Supplement Meals on Wheels programs and other community-based or faith-based services with non-traditional resources such as Grub Hub and Door Dash.
Temporarily expand eligibility for in-home services such as Meals on Wheels to ensure the ability for suspected cases to remain in quarantine but still receive basic needs.
County-level Emergency Management operations have been asked to appoint a feeding coordinator for their county, and to the extent possible, coordinate resources such as food trucks, restaurants, cafeterias, adult day care centers providing meals, etc., with resources requiring additional food such as Meals on Wheels or other residential programs requiring additional supplies.

Services

Coordinate service providers such as day habilitation programs who have support workers that could be redirected to residences or other in-home services.
Develop systems for phone triage and telemedicine to reduce unnecessary healthcare visits.
LME/MCOs should take the lead on making sure that mental health, substance use disorder, and IDD providers are aware of the new federal and state flexibilities and reimbursement codes, including telehealth reimbursement codes. This includes disability specific changes, such as the U.S. Drug Enforcement Administration allowing prescribing one of the forms of substance use disorder treatment, buprenorphine, through telehealth without an in-person visit. It also includes guidance from the U.S. Department of Health and Human Services Office for Civil Rights regarding discretionary enforcement of HIPAA privacy and security rules in connection with the good faith delivery of telehealth services, and Substance Abuse and Mental Health Services Administration regarding the applicability of 42 CFR Part 2 limitations on use and disclosure of patient-identifying information.
With appropriate collaboration across relevant partners, allow facilities to provide services in alternative settings, such as a temporary shelter or through mobile units. This includes treatment and harm reduction programs.

The President approved North Carolina’s application for a disaster declaration. This makes available Category B funds which can be requested through the North Carolina Office of Emergency Management. Category B funds are emergency protective measures conducted before, during and after an incident are eligible if the measures: Eliminate or lessen immediate threats to lives, public health, or safety; OR Eliminate or lessen immediate threats of significant additional damage to improved public or private property in a cost-effective manner. This can include items associated with medical care, evacuation and sheltering, and shelter services.
NCDHHS is also working to identify additional federal and state funds to assist communities, providers, LME/MCOs, and other partners in continuing services and meeting individuals’ needs during the COVID-19 pandemic.
There also are public-facing resources on the NCDHHS website to connect people to care and build resilience.
Each LME/MCO is partnering with NCDHHS to coordinate these efforts, as well as developing initiatives and plans unique to their catchment. Maintain open lines of communication and refer directly to your LME/MCO for specific details in each county.

What are ways to minimize the flow of patients, particularly those with behavioral health and IDD needs, to emergency departments?

What can be done to help safely discharge a stabilized patient from a hospital if they don’t have an appropriate setting to placed into at the time of release?

How do I manage jail and justice-involved populations?

What are other actions counties can take to support community residents and reduce the burden on hospitals?

What resources are available to help support local actions to reduce the burden on hospitals?