Alternatives to building a facility based crisis (FBC) center in Wilkes County and the risk of losing $1.4 million approved for Vaya Health to construct the 16-bed mental health facility were addressed in a meeting Thursday.
The two-hour work session of the Wilkes County commissioners ended with Vaya CEO Brian Ingraham saying, “Let us keep working on this…. I’m not going to over-promise, but there may be some hybrid approach that will meet requirements of the legislation” appropriating the $1.4 million.
The legislation allocated the $1.4 million to Asheville-based Vaya, which oversees behavioral health care in Wilkes and the 22 other westernmost counties as one of the state’s seven local management entity-managed care organizations (LME-MCOs).
Vaya does this through contracts with service providers like Daymark Recovery Services and Synergy Recovery Ltd., both with facilities in North Wilkesboro. Daymark replaced New River as primary provider of behavioral health care in Wilkes, Ashe, Alleghany, Watauga and Avery counties.
Legislation appropriating the $1.4 million said it would be used to construct an FBC center and Vaya proposed that it be built as an addition to the Daymark building at West Park. It would have 16 inpatient beds.
Ingraham said the problem is that Vaya doesn’t have enough money to fund the proposed FBC center’s estimated construction costs above and beyond the $1.4 million, as well as annual operations due to a $47 million cut in state funds for Vaya services to patients without Medicaid or private insurance since 2015, on top of a $31 million cut from 2009 to 2015.
Wilkes County government, Vaya and Daymark released a report this fall that proposed using the $1.4 million to expand Daymark’s current walk-in clinic to 24/7 as a more affordable and in some ways more effective alternative to an FBC center.
The possibility of using the $1.4 million to add two beds to Synergy’s 14-bed FBC center (16 is the most allowed), as well as making Daymark’s walk-in clinic a 24/7 service, was discussed Thursday. Ingraham said that appeared to be the optimal concept, which was his reference to a “hybrid approach.”
Commissioner Gary Blevins asked about using part of the $1.4 million to make Synergy a more comprehensive FBC center. When he asked if Synergy and Daymark could work together, Daymark Director Billy West said he and Synergy Director Carl Spake have known each other since 1998 and work together well.
Spake said Synergy has always been known as “the detox center” so few people realize it’s an FBC center. Although Synergy has inpatient beds, it doesn't offer the array of services available at other FBC centers.
“It looks like an opening that would fit with the legislation and really help Wilkes County,” said Blevins, who is on the Vaya board and executive committee.
Blevins also said that when he and Keith Elmore, chairman of the commissioners, learned about the 24/7 walk-in clinic proposal late last year, they were impressed with how well it would meet people’s needs and keep them out of hospital ERs and from being involuntarily committed. This proposal called for using the $1.4 million to expand the Daymark facility and fund two years of the 24/7 clinic’s operating costs.
The Daymark walk-in clinic, now currently open from 8 a.m. and 5 p.m. on weekdays, provided care for 1,111 people and diverted 331 people from the Wilkes Medical Center ER in 2017. The report said expanding the clinic to 24/7 would divert more people from inappropriate use of the hospital ER, provide more preventive care and allow stays of up to 24 hours.
West said a 24/7 walk-in clinic was launched at a facility in Winston-Salem as an alternative to an FBC center when funding was reduced.
West said he’d love to have an FBC center at West Park, but indicated uncertainty about it being sustainable. He said it’s hard to keep beds full at Daymark’s FBC centers elsewhere. “That’s not because there isn’t a need, it’s just the way people come and go, the way they decide to leave treatment and the way they get better when a better placement is available for them.
Within the Vaya system, there are 12 inpatient beds at FBC centers in Lenoir, 16 in Asheville and 10 in Banner Elk. Donald Reuss, Vaya provider network senior director, said all of these FBC centers had available beds Thursday.
Ingraham said another 44 inpatient beds are planned in Lenoir and Banner Elk combined and 35 are planned in Taylorsville at the old Alexander County Hospital. Daymark also operates an FBC center in Statesville under a contract with the Partners LME-MCO.
Reuss said the need is there, but most hospitals won’t discharge people to FBC centers because they view them as a lower level of care and prefer transferring people to another hospital. Transportation also is an issue.
“Our goal across the region is to divert kids and adults to our crisis centers before they get to the hospital," said Reuss, adding that a 24/7 walk-in center is effective because it can refer people to FBC centers.
West said FBC center beds often aren’t full because walk-in clinics work and not everyone needs to go to an inpatient facility. He said many people are accustomed to going to hospital ERs when behavioral health issues arise and when they do, Emergency Medical Treatment and Labor Act rules make it difficult to transfer them directly from a hospital to a FBC center.
Impact on hospital
Susan Bachmeier, Wilkes Medical Center’s chief nursing officer, said it’s imperative to the hospital that more behavioral health care beds be available.
Bachmeier said people coming to the hospital with behavioral health issues are held there “for days and weeks because we have no place that’s appropriate for their care. We keep them warm and safe and fed and bathed, but we’re not providing them mental health care, appropriate medication or counseling to their families, which is what they need to keep from coming back—and they do, every single time.”
She said Wilkes Medical Center provided over 22,000 patient holding hours last year, mostly in the ER but also in-patient unit. She said this reduced available ER or in-patient bed.
More than 600 patients came to the Wilkes Medical Center ER for behavioral health needs in 2018.
Bachmeier said two children who came to the hospital with behavioral health needs were held there most of last week.
Reuss said Vaya’s 16-bed FBC center for children in Asheville, one of only 2 facilities like it in the State ,was only half full Thursday. He said services at that facility are available to anyone in Vaya’s cachment catchment area meeting admission criteria.
The issue of local law enforcement officers having to stay with people with involuntary commitment orders for days at the hospital as they await placement in psychiatric facilities also was mentioned.
County Commissioner Eddie Settle asked Spake if using the $1.4 million at Synergy would alleviate problems.
Spake said adding two beds at Synergy would help to some extent, “but I’ll be honest with you. What is really needed is a 24-hour (walk-in) facility where people can come in and be assessed… and try to find placement” for them regardless of their condition.
“A lot of times these issues are resolved in less than 24 hours once a person gets someone to talk to. It varies, but I really feel like that’s what we need.” He said Daymark’s location across the street from Wilkes Medical Center was perfect for this.
Funds at risk of being lost
Rep. Jeffrey Elmore of North Wilkesboro, the only current legislator at the meeting, said developing and presenting a plan in April that calls for using the $1.4 million for operational purposes isn’t a viable option.
“Very few people in Raleigh would have the weight to make that change happen with the budget numbers that we are getting at this point—to turn something from non-recurring to recurring expenditure.” He agreed with Randleman that changing the language in the legislation would result in loss of the $1.4 million.
Ingraham said he was talking about a one-time use on something other than bricks and mortar for maximum benefit and agreeds with Elmore regarding the difficulty of changing the funding from recurring to non-recurring. “At the end of the day, that’s what we do - try to get the maximum benefit for all of the residents of our catchment area” with the funds Vaya receives. “We look for clinically and financially viable solutions to community need” he stated
Reflecting ongoing legislative pressure on LME-MCOs to spend more of their reserve funds, Elmore said the big question for Vaya officials is how much of their 30-day cash supply they’re willing to use.
He said Vaya could afford to use part of its 30-day fund balance on operating costs of the FBC center proposed in Wilkes.
Ingraham said it would be fiscally irresponsible for Vaya to spend down its fund balance any lower, contrary to a recent N.C. Division of Health and Human Services recommendation to the General Assembly. Vaya currently has $28.6 million in spendable cash, which Ingraham said represents about 25 days of cash flow.
He said Vaya couldn’t touch its additional $40.6 million in reserve funds because by state statute, the use of that money is only allowed in cases of insolvency to pay provider claims.
Shirley Randleman of Wilkesboro, credited with securing the $1.4 million last year during her last Senate term, said in the meeting that the legislation specifically said it was non-recurring funding and only for building an FBC center in Wilkes. She said any other plans would cause loss of the funds.
Randleman said Vaya must submit a status report on construction of the FBC center in Wilkes by April 1 to the N.C. Department of Health and Human Services, which must report this to the Joint Legislative Oversight Committee on Health and Human Services by May 1.
She spoke against using the money for anything besides an FBC center, which primarily would be for residents of Wilkes, Ashe, Alleghany, Watauga and Avery. She said it would accept people with involuntary commitment orders.
“I think the people in Wilkes and this part of the state deserve the services that people elsewhere in the state get,” said Randleman.
Randleman said she didn’t know if Synergy was ever considered in the discussion of the $1.4 million and added, “If that is an option, I think it needs to be discussed.”
More on finances
Vaya estimates annual operating costs of the FBC center proposed in Wilkes at $2.5 million, of which only about $378,892 would be funded with Medicaid since most FBC center patients aren’t eligible for Medicaid and lack private insurance.
Vaya also estimate $5.5 million in total first year costs of the proposed FBC center, including $2.74 million for constructing the 14,000-square-foot addition to the Daymark building, $254,830 for program start-up and the $2.5 million for annual operations. Other Vaya FBC centers had additional startup funding sources.
West said spokesmen for LME-MCOs across the state he has spoken all say they don’t know if they can sustain their current levels of services. He said increasingly the issue is where to make cuts.
He added, “I hear it from every single one—what we’ve got is more indigent but not enough indigent money.” West said people can talk about addressing this by expanding Medicaid eligibility, but it’s meaningless until it happens.
“People can talk about going to the legislature and asking for more money. I’ve been doing that since 1996 and got it once, but it was a whole lot less than the amount ($1.4 million) we’re talking about now,” he added.
Spake said that when national accreditation became a requirement for having involuntary commitment patients, Synergy stopped accepting them because this accreditation cost $10,000 to $20,000 every three years. “I’m not sitting on $10,000 to $20,000,” he added. Synergy also doesn’t have nurses.
Spake said Synergy has difficulty maintaining cash flow and he has worried about competing with other FBC centers, but he added that Synergy gets clients from Caldwell County even though Lenoir has an FBC center.