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TO: Secretary Carmen Hooker Buell FROM: Dan Coughlin Secretary Buell: Congratulations on your recent appointment Your reputation precedes you and the public MH/DD/SA sector, comers, & advocates are heartened and excited to have you at the helm. By way of introduction, I am Dan Cough/in, Area Director of the Piedmoat Behavioral Healthcare, the largest multi-county and third largest overall Area Program in the state. I am new to the system baying come here in July from New York State where I worked in the public MH/DD/SA system for over 25 years in roles ranging from direct clinical care and supecvision to public - administration and policy making. I also spent time as the chief administrator of the behavioral health division of a large hospital system in central New York and as an executive with ValueOpt/ons, a mt/omi behavioral health managed care company (that you may know from your days in Massachusetts). My perspectives herein, therefore, come more from my experiences outside of North Carolina than from inside. Regarding the PCG Report, System Reform, and the Legislative Oversight Committee: Division of Mll/DD/SA · The Division of MIt/DD/SA sorely needs a strong, visionary leader with national standing who can manage and who is an expert in the field, knowing both national clinical and systems trends as well as health care policy and financing o The discussion around mb-directors for each disability should be deferred until well after a new DivisiOn Director is in place and the Division has been strengthened and stabilized · Aligning the state Medicaid Plan with the Division of MH/DD/SA Plan is critical & consideration should be given to "carving out" the MHIDD/SA Medicaid piece · The state MH/DD/SA Medicaid plan, as it exists, is a Byzantine fee-for-service system that lacks flexibility and falls to well support "special" populations such as SPMI adults & SED cinldren. The Medicaid plan should take advantage of the "Rehab Option" and/or Medicaid waivers. Local Area Programs should be supported and encouraged to write 1915B waivers that provide flexibility and ereative service provision · The current structure of the system is designed on an acute care model which cannot adequately address modem community based models incorporating psychiatric rehabilitation, consumer empowerment, self-help and peer initiatives · At the policy level, the slate needs to develop an overall vision and direction for the system that clearly and concretely defines populations to be served, concomitant benefits plans, and the financial structures to support both. There are particular needs surrounding "indigent care", SPMI, Homeless MI, MUSA (co morbidity), Forensic, & SED populations. Local Services and Restructuring Governance · First off, until the system is reformed at the state level (as above), to address changing governance at the local level is a case of putting the can before the horse · Next, the existing governance model (Public Authorities) is probably the strongest model in existence clue to: o its hybrid character that weds public accountability with the independence and flexibility of a private organization. It's a tried and true model all over the counu*y (airports, hospitals, transportation, etc) its having a policy making, citizen board comprised of a mix of consumers, advocates, and public officials (County Commissioners) · Critics of the existing Area Programs believe they are too many and too small; that, especially small, single county programs should consolidate. I agree