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NC Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
 
 

For Those We Serve

US Public Policy Update: North Carolina Systemic, Therapeutic, Assessment, Respite and Treatment: NC-START

Jill Hinton, William R. Rollo McCuller, Joan B. Beasley, Diana Antonacci, Steven Baker, Jarret Barnhill, Michelle Klutz, Vivian Leon, Jarret Stone, Lisa Wolfe

 

As with many populations that require the use of multiple services and systems of care, there exist gaps in the service system that undermine the ability to provide successful support to individuals with intellectual/developmental disabilities and co-occurring severe mental illness or significant behavioral needs. The need for close collaboration between general mental health services and specialized services is a necessary component of community support for this population. Other gaps in the community system have been found to include lack of community based crisis supports, need for specialized training for support staff, and lack of collaboration between systems of care at the community level. Traditional mental health services in the community have been too fragmented, inaccessible, and ineffective as a treatment option for individuals with intellectual/developmental disabilities. The complexity of this population mandates a highly coordinated, multimodal approach to assessment and treatment that is coordinated by a team member who is able to understand and integrate different strands of information. There seems to be a consensus that specialized mental health teams are necessary to assist with coordination of community treatment for individuals with intellectual/developmental disabilities.

Recognizing the reality that this gap in the community system exists in their state, North Carolina has implemented a statewide system of crisis prevention and intervention for individuals with IDD and MI or significant behavioral needs. The North Carolina DD Practice Improvement Collaborative brings together professionals in the field of IDD who research, evaluate, and propose adoption of best practices for people with IDD in the state. This group recommended to the state and the legislature that a system of crisis support based on the START model be funded and implemented in North Carolina. The legislature of North Carolina funded the implementation of the NC START program statewide beginning in 2009. In North Carolina, NC START has been implemented across the state through three regionally based START teams: NC START West, NC START Central, and NC START East. Each team is responsible for implementation of START services for their region. The three regions work together to develop consistent policies and processes. Collection of data has is also been standardized. The Division of MH/DD/SA has been intimately involved through all stages of implementation and will continue to monitor this new model through collection of data and on-going contact with the regional teams.

What Have We Learned So Far?
Clinical Issues

NC START is Needed and Works: First and foremost, NC START has positively impacted the lives of many individuals and families. Between January and December 2009, 332 persons were referred to and served by NC START with 43% having experienced a psychiatric hospitalization during the previous year. These individuals received a variety of services and supports based on their needs including intake/assessment, crisis plan development, crisis and planned respite, and consultation visits to provide support and education to the family/natural supports/provider in the home environment. There were also 225 admissions to NC START respite during this period. In over 68% of the crisis referral cases, the individual was able to remain in their community setting and avoid hospitalization. This represents significant cost savings along with reduction of restrictive interventions.


Polypharmacy is Prevalent: The majority of individuals referred were on multiple psychotropic medications. Review of medication history often revealed the addition of medications with minimal discontinuation of previous medications and very little in the way of positive behavioral supports. Through START involvement, a significant number of individuals were able to have medications reviewed and modified and multimodal supports provided. As we move into the second year, this will be an area of increased data collection and analysis.


Clinical Needs are Diverse: The target population is extremely diverse ranging from individuals with mild ID and depression to those with moderate/severe ID and extreme behavioral issues. This requires clinically strong and experienced staff. Individuals who present with additional concerns such as substance use/abuse and sexual deviancy have been challenging and have required additional referral and supports.  These additional issues as they required expertise beyond the scope of the teams, and limited community resources available are limited. 

Systemic Issues
Geography Matters: The original START model was implemented in a more contained region (Northeast, MA). Statewide implementation in North Carolina has presented challenges. Each of the regions is vast and contains at least two fairly large urban regions but also include large rural areas as well. This has resulted in significant travel time for teams, which then limits clinical contact.
Relationships Take Time: Building effective relationships and collaborations require attention and time. Covering large geographic areas that include several regional systems requires team members to communicate effectively and work efficiently.
Systematic Feedback from Stakeholders and Data Analysis is Essential:
In order to be effective, objective outcomes measures have are necessary. These need to be continually evaluated on an on-going basis. Collaboration between mental health department representatives, experienced experts, services users, families, and local service providers has been necessary in order to maintain quality services. Advice and counsel of experts who have effectively provided similar services, along with service users and partners in service delivery, is also needed in order maintain quality services.

Although NC START has only been in place for a little more than a year, the value in a systemic linkage approach to collaboration and clinical support has been demonstrated. Crisis intervention begins with a strategy to prevent a problem from becoming a crisis, and this requires a thoughtful and flexible approach to service delivery. As we go forward with NC START, evaluation of the service needs of individuals with co-occurring disorders and outcomes associated with this effort will continue.

Contact: Jill Hinton, Ph.D.
Clinical Director NC START Central
Jill.Hinton@nc.eastersealsucp.com

References

Beasley, JB (2001); “Collaborative services in Massachusetts: The START/Sovner Center Program.” Impact 14 (1)16-17.

Beasley, J.B. (2002)Trends in coordinated emergency and planned mental health service use by people with dual diagnosis. In J.Jacobson, S. Holburn, & J. Mulick (Eds.), Contemporary Dual Diagnosis MH/MR Service Models Volume II: Partial and Supportive Services (pp. 51-67). Kingston, N.Y.: NADD

 

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