- Lawmakers and experts say gaps in North Carolina’s outpatient commitment system limit oversight and follow-through, raising questions about how the state manages care for people with severe mental illness and protects the public.
A House Select Committee on Involuntary Commitment and Public Safety meeting on Wednesday focused on the mental health system in North Carolina, specifically, outpatient commitment vs. inpatient commitment, both involuntary and voluntary, and what can be done to improve outcomes.
The meeting comes as questions about the system are at the forefront of many people’s minds after the murder of Zoe Welsh, Raleigh, earlier this month, allegedly at the hands of Ryan Camacho, who has a lengthy rap sheet and a history of mental illness.
It has been reported that Camacho became delusional in 2016, had schizophrenia, and that his mother had him involuntarily committed. She would also try to get him declared incompetent several times over the years and was reportedly granted guardianship over him multiple times.
A Wake County Assistant DA tried to have Camacho involuntarily committed for an August crime last month, but Wake County District Court Judge Louis Meyer III denied the request, and the charges and case were dismissed, leaving Camacho to walk free.
Committee Co-Chair Rep. Hugh Blackwell, R-Burke, acknowledged at the beginning of the meeting that the committee received a letter from Wake County Republican Reps. Mike Schietzelt and Erin Pare requesting that the facts of the Welsh case be incorporated into their work, but that the circumstances would be discussed at a later date to determine how the committee may choose to make recommendations.
The consensus among all of the guests, including Dr. Marvin Swartz, a professor at Duke University School of Medicine Department of Psychiatry and Behavioral Sciences and the lead of the Behavioral Research Team at the Wilson Center for Science and Justice at Duke Law, was that continuing care is needed for those who have mental health issues.
While not directly referring to Camacho, he said recent occurrences of violent behavior from someone with mental illness are rare.
Swartz discussed the outpatient version of involuntary commitment to a psychiatric hospital, called Assisted Outpatient Treatment (AOT), in which law enforcement transports the person to a mental health facility for reevaluation that could result in involuntary commitment if the person meets the criteria, but noncompliance doesn’t necessarily trigger involuntary inpatient commitment, and there isn’t any forced medication permitted under outpatient commitment.
At one point, he said North Carolina was a role model for other states, like New York, for assisted outpatient treatment. That all changed with mental health reform in 2001, when the shift away from area programs made the responsibility and accountability for outpatient commitment by Local Management Entities/Managed Care Organizations (LME/MCOs) ambiguous and fell into disuse, adding that monitoring by these has been severely lacking. Many of the patients who are treated are also in the Medicaid system.
Swartz said that long-term outpatient commitment, usually six months or more, can reduce hospital readmissions, shorten hospital stays, and lower rates of minor violence, and is safer for the patient than being committed because they would be less likely to be victimized or assaulted by someone else.
He also gave an example of how New York State passed an AOT statute, “Kendra’s Law,” named for Kendra Webdale, who was killed by a schizophrenic in 1999 when he picked her up and threw her in front of a subway train in New York City.
The state law has strict oversight, detailed court-ordered treatment plans, and receives millions of dollars in annual funding from state lawmakers.
While she thanked Swartz for his presentation, Rep. Donna McDowell White, R-Johnston, said not everyone with a severe mental illness can live outside of an institution. She noted that a psychiatric patient was placed on the cardiac floor of her local hospital for over six months because there weren’t any beds at any
“It is not the responsibility of our law enforcement, our hospitals, our acute care hospitals,” she stated. “It is the responsibility of our long-term operating psychiatric hospitals…. We need to have qualified people in those hospitals that were designed to keep people in a safe environment where they are much happier, and they’re not out there wreaking havoc among the general population.”
Carrie Brown, Chief Psychiatrist, North Carolina Department of Health and Human Services (NCDHHS) that some individuals with serious mental illness are caught in a pattern of cycling through hospitals, jails, and emergency departments due to their non-compliance, and with limited resources to encourage them back into treatment, they deteriorate and only reenter the system when they’re in the midst of a crisis.
She did stress that outpatient commitment is not appropriate for the vast majority of individuals with mental illness, and that it is for a select group of individuals who have severe psychotic disorders with no insight that they have an illness and as a result, decline all treatments, including medication and they also have a documented history of engaging in repeated violence or criminal acts that result in repeat hospitalizations and incarcerations.
Brown noted that outpatient orders that do not dictate what specific treatments, limited accountability and enforcement mechanisms to ensure treatment compliance, complex orders that are difficult for the patient to understand, and a shortage of specialized providers are among the current problems with outpatient commitment.
Some options that she said could improve outpatient commitment include ensuring that every individual has a navigator with ongoing care management and monitoring, extending maximum commitment from 90 to 180 days to allow adequate time for stabilization, and expanding capacity and accountability with more programs that provide individualized, wraparound care and stronger treatment compliance while diverting people from the criminal justice system.
Brown said that thanks to funding by the General Assembly last year, NCDHHS has added a significant number of facility-based crisis beds across the state, as well as behavioral health urgent care beds, and alternatives to emergency departments. In addition, they are looking at developing alternative locations for capacity restoration so that they can offload state psychiatric hospitals and have three pilot programs in Mecklenburg, Wake, and Pitt counties.
Senitria Goodman, General Counsel and Chief Compliance Officer at Trillium Health Resources, a specialty care manager, said the missing puzzle piece is mobile crisis services, which deliver an immediate response directly to the person, 24 hours a day, 7 days a week, by licensed mental health professionals, thereby easing the burden on the system.
She said LME/MCOs have the capacity to make it work, but funding is needed from lawmakers to make mobile crisis services available for magistrates in all 100 counties and make it the default
Make Mobile Crisis the default front door for involuntary commitment (IVC) determinations, assessment, and treatment planning.
Stephen Eide, Senior Fellow, Manhattan Institute, told lawmakers that outpatient commitment was the “gold standard” for hospital discharge for people with untreated serious mental illness. He urged lawmakers to increase psychiatric bed capacity, increase the length of stay, focus any community-based investment on serious mental illness, and use AOT to make community mental health systems more accountable.
Blackwell noted that the state has 300 hospital beds in mental psychiatric hospitals that are closed because there aren’t enough staff.
Eider added that a provision in Medicaid, known as the IMD Exclusion, which prevents Medicaid from being used for standalone psychiatric hospital care, such as in state hospitals for adults between the ages of 18 and 64, has been in Medicaid since the 1960s. The provision restricts states from receiving reimbursement for that type of care. He said ultimately Congress will need to address it to help states with funding.
“I think one of the questions is, are there enough nurses that are out there just waiting for us to pay enough and then they’ll come to work, or do the numbers we need not exist?” Blackwell asked. “So the question for me is what do we do while we’re waiting on Washington, while we’re waiting on the pipeline, to try to get into beds people who need it and treat them as best we can.”
The committee’s next meeting is scheduled for Feb. 11.