The Strategic Alliances for Elders (S.A.F.E.) in Long-Term Care celebrated its 10^th anniversary on June 19. S.A.F.E. is a multidisciplinary taskforce dedicated to protecting residents from harm. 

Choices and options taken for granted by adults living in private homes in the community sometimes fail to extend to long-term care residents. Unfortunately, in many instances when a long-term care facility is robbed or property is stolen, law enforcement is not notified. The difference in response shows why concerned citizens should pay close attention to making sure every individual is given the same protection under the law. Victims may feel trapped in a situation and not want to get a person in trouble; they have few options to leave and may blame themselves for the situation.

If you see a crime or a resident tells you they have been mistreated and a reasonable explanation can’t be provided then facility administration and law enforcement need to become involved to resolve the concern.

The celebration was held in the Brown Building on the Dorothea Dix Campus. During the observance, Douglas Thoren, Assistant Attorney General, North Carolina Medicaid Fraud Investigation Unit, North Carolina Department of Justice; Sharon Wilder, State Long Term Care Ombudsman, North Carolina Division of Aging and Adult Services; Allison Jourdan, Chief of Program Services, North Carolina Department of Public Safety; Lorraine Snyder, Criminal Justice Training Coordinator, North Carolina Justice Academy; Marty Lamb, Retired Mental Health Professional, North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services; LeShana Baldwin, Adult Protective Services Consultant, North Carolina Division of Aging and Adult Services received recognition for their work.

(Note: This Tar Heel of the Week article was published in the June 23, 2013 editions of The News & Observer of Raleigh and offered here with permission from its author.)

By Marti Maguire

Regina Godette-Crawford had a newly minted business degree when she got a job inspecting ambulances in 1985. She didn’t expect to spend much time in the world of emergency medical services. “I thought of it as stepping stone,” Godette-Crawford says. “I told people, ‘I’m not going to stay here.’ ”

Three decades later, the Craven County native has risen through the ranks to the post of chief of the N.C. Office of Emergency Medical Services, overseeing nearly 40,000 men and women who respond to about 1 million medical emergencies across the state every year. Godette-Crawford, 50, has aided the office’s transformation from a loosely aligned collection of largely volunteer groups into a highly trained force of which roughly 70 percent are professionals. 

And now, she’s leading the state’s paramedics in another major movement, toward a focus on preventative care that will keep more patients out of emergency rooms, saving time and money at a time when many uninsured citizens rely on emergency care. It’s not the business career she imagined. But Godette-Crawford says she’s been driven by a passion to see people get the best help they can at their most vulnerable moments – and by a love for the dedicated paramedics across the state who share that passion.

“EMS is like a brotherhood,” she says. “You don’t do it for the salary. It’s a job that’s near and dear to your heart that comes from the compassion to help people.” Those who know her say her leadership style combines a relentless focus on making EMS more effective and efficient with a deft understanding of how to work with a wide variety of people.” She has such a passion to give patients all the best possible care,” says Kim Sides, a compliance officer with the state office, who has worked with Godette-Crawford for decades. “If there were an ambulance that needed to be inspected today, or a phone that needs to be answered, she would do it.” 

Joseph Zalkin, chief of professional development with Wake County EMS, says Godette-Crawford has supported a variety of innovative practices, in particular the preventative approach to EMS that Wake County is currently using. “Since she has taken the office, she has been sensitive to gathering stakeholders and looking beyond the box at issues affecting EMS systems,” says Zalkin.

Dedicated professionals, Godette-Crawford grew up in the coastal town of Havelock, the youngest of four children. Her father worked at the Marine Corps Air Station Cherry Point base repairing planes while her mother cared for their children on a farm with pigs and chickens.

She was a first-generation college student, and initially attended Winston-Salem State University. But she was so homesick and taken aback by city life that she quickly transferred to East Carolina University. While she didn’t plan to devote her life to EMS, she now lives and breathes it. Any conversation seems to veer back to a mix of acronyms, state statutes and credentialing procedures. It’s a field that has long struggled for recognition. There is still no federal EMS office, and the pay remains low. Yet its adherents are dedicated.

Many families have responded to emergency calls for generations, and Godette-Crawford says the average paramedic has a career of 35 years. Her own long career has included nearly every aspect of EMS other than actually responding to calls. She started as a regional coordinator, and has spent entire weekends grading paramedics as they performed CPR and splinting. She’s conducted disaster response exercises and fielded calls from grieving parents.

Her field was transformed after the terrorist attacks of Sept. 11. The profile of paramedics was raised, and local offices were infused with grant money to boost their ability to respond to attacks.

In 2003, Godette-Crawford was tapped to lead the state’s effort to strengthen its emergency preparedness infrastructure using a $13-million federal grant, including the creation of a mobile disaster hospital. “It was fast-paced work,” she says. “And it helped broaden our scope. We’ve always had a role in response and recovery, but this enhanced the profession and paved the way to introduce other things.” By 2005, she had come to the state office as assistant chief. She became interim chief in 2010 and chief in 2011.

The state doesn’t dictate policy to local EMS offices, but creates standards and helps disseminate new ways of doing things. In that sense, Godette-Crawford’s job is a mix of helping local offices correct mistakes and urging them to adapt practices to be more efficient. She says her job is all about maintaining relationships, not only with local EMS groups but also with hospitals, local governments, national groups, lawmakers and more. “It’s about a good business plan and my love of people,” she says.

Instituting better practices, since taking over as chief, she has sought out new methods and ideas, from using vending machines to replace equipment quickly to creating local teams to evacuate hospitals in an emergency.

One ongoing initiative is a program to treat EMS workers with substance abuse problems – an issue that often crops up when they become addicted to pain medication after work-related injuries. “It can happen to anybody,” Godette-Crawford says. “We saw this as an opportunity to return them to the workforce as quickly as possible.”

This year, her main focus is preventative care, expanding the role of EMS units to care for patients on site or to connect them with resources other than hospitals – often the most expensive treatment option. The idea is to make ambulances more like traveling clinics than just transportation that has the equipment needed to get a patient to the hospital. Paramedics can also talk to patients about how to treat chronic conditions such as diabetes, and perform routine checks on blood sugar or blood pressure.

“Some of these ‘frequent flyers’ don’t have the intention of abusing the system, but they need the care,” she says. “Part of health care reform is to make sure we educate people on what’s available to them and how they can use other measures and not tax the system.”

Wake County has diverted more than 200 patients from emergency rooms under its program, saving more than 3,000 emergency room bed hours. Godette-Crawford says some systems nationally have reduced call volume by as much as 30 percent. In addition to saving money, she says, the change will forge a crucial role for EMS in a health-care landscape that is rapidly changing as the Affordable Health Care Act is implemented.

She unveiled the program to local agencies at a meeting in February. “An evolution is happening to be more proactive than reactive,” Godette-Crawford says. “Some people saw the health care act as a monster or something you need to be threatened by. I say, ‘Why not identify the gaps and use that as an opportunity to expand our role?’ ”

Traditionally, North Carolinians with mental health support needs have had limited choice in where they receive their services. That is changing with the Transitions to Community Living Initiative. This initiative is the result of a settlement agreement between the North Carolina Department of Health and Human Services (DHHS) and the U.S. Department of Justice (DOJ). The agreement outlines the steps that DHHS will take to ensure that people living with serious mental illnesses or severe and persistent mental illness can choose where they live.

“Over the next eight years, the Transitions to Community Living Initiative will move at least 3,000 individuals in North Carolina from a state psychiatric hospital or Adult Care Home to an apartment in their community,” says Jessica Keith, DHHS special advisor on the Americans with Disabilities Act (ADA). “These transitions into the community will provide long-term housing stability and reduced hospitalizations.”

The initiative is based upon the following guiding principles set by the ADA of 1990 and the Olmstead v. L.C. decision of the U. S. Supreme Court:

• Individual choice is valued and supported;
• Services should be in the least restrictive and most integrated setting appropriate for the individual;
• Services should be built on resiliency and be recovery oriented;
• Housing setting should enable individuals with disabilities to interact with individuals without disabilities to the fullest extent possible; and,
• Housing setting should not limit an individual’s ability to access community activities at times, frequencies and with people of their choosing.

DHHS, in partnership with the Local Management Entity-Managed Care Organizations (LME-MCOs), will administer the initiative and an independent reviewer will evaluate the entire process.

“This initiative is designed to be very individualized,” says Keith. “The services and supports are to be wrapped around the individual and help sustain them wherever they choose to live.”

The following services and supports are provided by the Transition to Community Living Initiative:

• In-reach (information sharing)
• Diversion (screening process)
• Transition planning
• Housing slots with rental assistance and transition supports
• Fidelity to the assertive community treatment team model
• Supported employment
• Quality assurance and performance improvement
• Crisis resources

In-reach is a series of conversations with the individual, their families, and professionals to help everyone fully understand what options may exist so that an informed choice can be made. These conversations will be coordinated by the LME-MCOs and conducted by certified peer specialists. In-reach will begin with residents in adult care homes that have high percentages of individuals with a diagnosis of serious mental illness and will recur at regular intervals to determine if an individual’s needs or desires have changed.

Diversion is a screening process intended to identify individuals with potential mental health needs. Individuals who are seeking admission to an adult care home will be evaluated using the pre-admission screening and resident review. Those individuals with mental health needs will then be informed of all options available to them. Individuals who choose a community placement rather than an adult care home will be directed to community-based services and will work with their LME-MCO to develop their transition plan.

Transition planning assists the individual in developing an effective written plan that will enable them to live independently in an integrated community setting.  Transition planning is a person-centered planning process in which the individual has a primary role and is based on the principle of self-determination.  The planning is overseen by the LME-MCO’s transition coordinator and should include the individual and the individual’s family or guardian.  

The planning process will ensure that the individual has the necessary services and supports needed for successful community living, including but not limited to:

• Medical services
• Housing supports
• Educational supports
• Employment supports
• Behavioral health services
• Financial management services
• Other community supports

Transition planning will also ensure that benefits transfer, provide person-specific risk mitigation strategies and crisis planning, along with any necessary adaptive equipment.

“Transition coordination is a critical element of the process,” says Trish Farnham, project director for the N. C. Money Follows the Person Demonstration Project. “The transition coordinator works with the participant to make sure that numerous details related to their move into the community are effectively identified and addressed.”

The LME-MCOs will assume the responsibility for assisting on moving day by having a moving company do the heavy lifting if necessary and having someone on-site to assist such as a peer specialist, housing specialist or transition coordinator.

Housing slots are a state-supported package of subsidies that include rental assistance, one-time transition supports, and community services. The Transitions to Community Living Initiative will create more than 3,000 housing slots during the life of the program on a first-come, first-served basis and will be based upon geographic availability and individual preferences.

Housing slots include tenancy support services to assist in overcoming the barriers to obtaining and maintaining housing. The housing slots will be at scattered site locations with no more than 20 percent of the units occupied by a person with a disability.

“This will enable individuals with disabilities to interact with non-disabled people to the fullest extent possible,” says Martha Are, director of housing and homelessness with the Department of Health and Human Service’s Division of Aging and Adult Services. “The preference for housing slots is in a non-licensed, single occupancy apartment-style setting. This type of location will allow for choice in everyday activities.”

Assertive Community Treatment Team is a service-delivery model that provides comprehensive, locally-based treatment to people with a serious mental illness or a severe and persistent mental illness. Assertive Community Treatment Team recipients receive the around the clock availability of multidisciplinary, behavioral health staffing within the comfort of their own home and community. There will be 33 teams serving 3,225 individuals by July 2013 and by July 2019 there will be 50 teams serving 5,000 individuals.

Supported employment is a service to assist individuals with job training, job coaching and finding employment opportunities. This service will be based upon the Dartmouth Individual Placement and Support Model. The initial target for supported employment services is 100 individuals by July 2013 and increasing to 2,500 individuals by 2019. Supported employment does not mean sheltered workshops, employment in segregated settings, group employment models or sub-minimum wages.

Using Quality Assurance and Performance Improvement, North Carolina will ensure that services provided by the state are of good quality and are sufficient to help individuals achieve increased independence, gain greater integration into the community, obtain and maintain stable housing, avoid harms, and decrease the incidence of hospital contacts and institutionalization.  

This will be done by tracking length of stay, readmissions and tenure in the community.  Personal outcomes will also be tracked, including:

• Incidents of harm;
• Repeat admissions;
• Use of crisis beds and community hospital admissions;
• Repeat Emergency Department visits;
• Time spent in congregate day programming; and,
• Number employed, attending school, maintaining living arrangement, engaged in community life.

Quality Assurance and Performance Improvements will also conduct Quality of Life Surveys with the individuals that are part of the initiative and will evaluate the in-reach and discharge activities for the program. An External Quality Review will also help ensure that the state is meeting its responsibilities under the agreement.

The agreement creates an eight-year timeline for the Transitions to Community Living Initiative, during which at least 3,000 individuals across North Carolina will begin living in their community instead of in an institution. Transition efforts are being supported during the first year with an allocation of $10.3 million in the state budget. 

                                                              - Chris Pfitzer, DMH/DD/SAS

For additional information regarding the Transitions to Community Living Initiative, please visit the program website at www.ncdhhs.gov/mhddsas/providers/dojsettlement/.

Severe weather events already this month are a good reminder of the need for North Carolina residents to be prepared for natural and man-made disasters. The N.C. Department of Health and Human Services (DHHS), along with our public safety partners, encourages individuals to stock up on basic necessities such as food and water, but just as important, to consider preparing now for recovery after the storm is over.

We need only look at recent disasters such as the tornadoes in Oklahoma, the terrorist bombings during the Boston Marathon, and the devastation caused by Hurricane Sandy to understand the importance of developing resilience within a community.  Studies show that the more prepared the community, the faster and more robust its recovery will be.  After the attacks on 9/11, our state established a Public Health Preparedness and Response program in the DHHS Division of Public Health to help develop local resources and the knowledge necessary for communities to help themselves during and after emergencies. Four regional offices work with local health departments and emergency responders across the state to enhance community resilience through better communication and coordination. Public health collaborates with other agencies within DHHS to oversee resources and staff that are prepared to respond to emergencies through local departments of social services, area agencies on aging and mental health providers to ensure that our citizens get the support they need in their own communities during recovery.

Our primary mission at DHHS is to ensure the health, safety and well-being of all North Carolinians. To that end, we strongly encourage and support individual preparedness for emergencies. To identify the resources you and your family will need during and after a hurricane or other catastrophic event, you should make a plan. Our public health preparedness team has put together a Family Disaster Plan that is available to download and complete at http://epi.publichealth.nc.gov/phpr/individuals.html.

As part of your planning, it is important for each person to know what their medical conditions are and what medicines they take and keep an amount packed in a ready-go bag in case they need to evacuate or supplies are delayed.  You need to know what durable medical goods you use regularly and what alternative power sources might be needed if the electricity goes out. You should have an evacuation plan and know who to call if an evacuation is ordered.  If you or a family member has a health condition, it is critical to know how to reach a health care provider if you are sheltered or displaced.  Anyone who is not sure how to address their specific concerns should make a point of discussing them with their health care provider.

Most importantly, people with medical issues or disabilities need to have access to information.  DHHS provides specially-adapted weather radios to ensure that individuals with documented hearing loss are alerted to severe weather events and other emergencies. If you are a senior citizen, ask your local agency on aging what services, like door to door notification, may be available to you. 

Recent events across the country and here at home reinforce that it is the community that provides the essential early links to resources and assistance.  Neighbors reach out to neighbors, communities reach out to communities. There are many ways that individuals, churches and civic groups can become involved to help others in your community.  One very good approach would be to contact your local health department or emergency management office and ask to speak with those involved in preparedness planning.  By being involved in preparation, you can have more of a sense of control if disaster strikes in your community. 

                                                  - Dr. Laura Gerald, State Health Director

The N.C. Office of Rural Health and Community Care (ORHCC) is coordinating the efforts of 40 agencies planning “Appalachian Care,” a special medical mission event in June 2014 to deliver free medical services for more than 18,000 people from 14 counties in western North Carolina and northern Georgia that are designated as medically underserved and health professional shortage areas. 

Early in 2012, North Carolina’s Appalachian Regional Commission (ARC) staff approached the ORHCC about a partnering opportunity that could potentially benefit many NC communities.  Anne Braswell, manager for Integrated Healthcare Delivery Systems at ORHCC, and her staff worked closely with the NC ARC and “safety net” provider organizations as well as the Georgia State Office of Rural Health and the GA ARC program to assess needs and resources throughout the region and apply for assistance from the Department of Defense’s Civil-Military Innovative Readiness Training (IRT) Program. Under the IRT Program, medical care is provided free of charge for community members by local volunteers alongside military personnel, while also providing training opportunities for military reservists.   

The primary service location planned for the Appalachian Care Medical Mission is Andrews, N.C., with satellite sites at Bryson City, N.C., and Clayton, Ga.  The 14 targeted counties include Cherokee, Clay, Graham, Haywood, Jackson, Macon, Swain and Transylvania in North Carolina.

During a two-week period in June 2014, the three communities will host dozens of volunteer medical providers donating services along with more than 100 military medical personnel. The three sites will offer primary care, dental care, optometry, behavioral health care, and veterinary services.

Murphy Medical Center, local health departments, community free clinics, rural health centers, departments of social services, local emergency medical services, and law enforcement are among the participating agencies. The 172^nd Multi-Functional Medical Battalion (U.S. Army Reserve) based in Ogden, Utah will lead the participating detachments of military medical personnel. Continuity of care will be coordinated by care managers who will connect patients needing follow-up care with local resources.

“We are fortunate to have the Appalachian Care Medical Mission on the calendar,” Braswell said. “Collaborating with so many organizations and dedicated individuals will not only help to improve community health in the region, but also promises opportunities to partner around other challenges for years to come.”

According to Lt. Col. Russell Reiter, the 172nd MMB commander, the group conducting the Appalachian Care Medical Mission will be composed of service members from across the United States.  Reiter said, “The 172nd is honored to have been selected by the Department of Defense to lead this mission. Our Soldiers are proud to use their medical knowledge to benefit a deserving American community like the Appalachian Region and look forward to repaying a small portion of the support we have received from our fellow Americans since 9-11.“

As part of this effort, ORHCC provided two future healthcare leaders from the University of North Carolina at Chapel Hill Gillings School of Global Public Health with a unique opportunity to experience community health in action while planning the Appalachian Care Medical Mission.  ORHCC intern Peter Lyu drafted the application for IRT support in 2012. Currently, ORHCC intern Spencer Brady is helping coordinate planning and logistical arrangements among the more than 40 agencies partnering in the mission. 

DHHS Secretary Aldona Wos visited Opportunities Industrialization Center in Rocky Mount last month, touring facilities and checking out the Mobile Health Clinic, used to serve hard-to-reach people who cannot access services due to severe illness, disability, lack of transportation and financial hardship.

She also met with staff from the Wilson County Department of Social Services where she had the opportunity to discuss the improvements that NC Fast will bring to operations in Wilson County. And she learned how local DSS efforts have greatly improved high school graduation rates for teen mothers.

DHHS Secretary Aldona Wos was taking no chances as she prepared providers, stakeholders, citizens, legislators and news media for the launch of NCTracks, the state’s new Medicaid claims processing system.

Television interviews, news releases and op-ed pieces in newspapers were all part of efforts to keep the information streaming from DHHS to citizens, and providers in particular. Meetings with providers of health care services and even a trip to the NCTracks Call Center were all gauged to build awareness and to educate anyone who would read, watch and listen to news reports about the change that is coming to Medicaid billing as well as the longer-term need to reform a costly system.

She also took time to offer thanks and gratitude to Joe Cooper, DHHS Chief Information Officer, and to teams of employees that have worked extra hours over the past months to push the switchover to NCTracks over the goal line on time. 

The call center has added staff who will be working expanded hours to help with an anticipated influx of calls in the first several weeks as providers get used to using the new system. DHHS will be monitoring the system’s performance on a real-time basis and will be making adjustments to stay ahead of the claims processing load.

Last month two leading newspapers published op-ed articles written by DHHS leadership.. The Winston-Salem Journal published an op-ed from Secretary Wos focusing on Medicaid reform. The Fayetteville Observer published an op-ed from Medicaid Director Carol Steckel that focused on comments made June 19 by Gov. Pat McCrory to Medicaid employees. The Governor emphasized the importance to the state budget of their accurately projecting Medicaid claims and working collaboratively to reduce errors and share knowledge.

NCTracks, the state’s new Medicaid billing system, launched successfully July 1 with customer service representatives standing by to assist providers. Built and operated by Computer Sciences Corp. (CSC), NCTracks replaces North Carolina’s 35-year-old Medicaid Management Information System with the nation’s first Medicaid-based multi-payer system.

“This very complex system has been 10 years in the making, but seeing it through to today’s launch is an example of our commitment to enhancing technology to improve efficiencies in the department,” Secretary Aldona Wos said on launch day. “We anticipate that NCTracks will save the state $35 million each year in operating costs while making it easier for providers to submit claims and receive more accurate reimbursements.”

With NCTracks, Medicaid providers can submit claims using an online portal.

“Based on conversations with other states that made similar, successful system conversions, we anticipate two primary sources of disruption during the first 60 to 90 days: expected technical issues and a learning curve for users,” said Joe Cooper, DHHS Chief Information Officer. “We have established a call center with expanded hours and staff to manage the expected increase in call volume, as well as a centralized command structure with a 24/7 response team that is resolving technical difficulties as swiftly as possible.”

Providers who call DHHS staff for assistance are to be redirected to the Call Center at 1-800-688-6696 for the most accurate answers to their questions.

“The best way to avoid potential issues and delayed payments is to undergo training in the new system,” added Cooper. “We continue to urge providers to take advantage of online and instructor-led training opportunities to understand how to use the new system features and enhancements.”

Gov. Pat McCrory joined Secretary Wos and DHHS CIO Joe Cooper July 9 to visit the NCTracks call center and command center. McCrory congratulated DHHS, and its vendor CSC, on NCTracks’ successes that include processing more than 4 million claims since July 1 and paying many Medicaid claims a full week ahead of schedule. McCrory also thanked the teams for their work in helping North Carolina providers through this transition period.

Each year, NCTracks will process 88 million claims from more than 70,000 healthcare providers totaling $12 billion that cover the services provided to more than 1.5 million Medicaid beneficiaries. The system will also promote information sharing and efficiencies by consolidating several other aging computer systems in Public Health, Mental Health and Rural Health, which will:

• Decrease the likelihood of fraud and abuse by making available more provider, recipient and claims data.
• Improve operations for the state, providers and recipients by switching providers from a paper to a digital submission process. (At least 57 forms have been eliminated.)
• Accelerate processing/adjudication times.
• Improve cash flow. (Providers will be paid 50 times a year, almost weekly; up from 42.)
• Provide for electronic submissions for claims, prior authorization, enrollment, inquiry options, and attachments - saving money and time.

RALEIGH — Regina Godette-Crawford had a newly minted business degree when she got a job inspecting ambulances in 1985.She didn’t expect to spend much time in the world of emergency medical services. “I thought of it as stepping stone,” Godette-Crawford says. “I told people, ‘I’m not going to stay here.’ ”

Three decades later, the Craven County native has risen through the ranks to the post of chief of the N.C. Office of Emergency Medical Services, overseeing nearly 40,000 men and women who respond to about 1 million medical emergencies across the state every year. Godette-Crawford, 50, has aided the office’s transformation from a loosely aligned collection of largely volunteer groups into a highly trained force of which roughly 70 percent are professionals.

And now, she’s leading the state’s paramedics in another major movement, toward a focus on preventative care that will keep more patients out of emergency rooms, saving time and money at a time when many uninsured citizens rely on emergency care. It’s not the business career she imagined. But Godette-Crawford says she’s been driven by a passion to see people get the best help they can at their most vulnerable moments – and by a love for the dedicated paramedics across the state who share that passion.

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