The first few years of the Formerly Incarcerated Transitions (FIT) Wellness program were limited to helping people in Wake County with mental illness who had recently been released from state prison.
Evan Ashkin, a family physician from UNC Health who helped found the program in 2017, said that FIT Wellness was able to serve 45 to 50 people a year in this “very vulnerable population.” That meant helping them get connected to psychiatric services, housing and employment — in short, services that would enable them to succeed.
But the program’s footprint was small. Nearly 20,000 people are released from incarceration each year in North Carolina.
Now, thanks to new funding from last year’s state budget, FIT Wellness is poised to expand into Durham, Orange and New Hanover counties. Ashkin estimates the program will be able to help about 200 people annually.
The expansion was announced in January by Gov. Roy Cooper as part of a “whole-of-government approach” to help people re-enter society from the carceral system. The goal is to reduce overall state costs by reducing recidivism and connecting these folks to mental health care and other basic services.
“This is a really significant effort by the governor, setting aside $99 million for people with [severe mental illness] impacted by the prisons and the carceral system in general,” Ashkin said.
With the $5.5 million that’s coming from that stream to FIT Wellness, Ashkin hopes to show how its approach not only makes the lives of the people in their care better, but also saves the state money that it’s now spending to keep people locked up.
The funding going to FIT Wellness is just a small part of the $835 million appropriated by the legislature in 2023 to be spent on behavioral health over two years.
Those funds are starting to be distributed, and over the coming weeks, officials at the state Department of Health and Human Services plan to make a series of announcements about how some of the millions will be used.
Getting started
Kelly Crosbie, the head of the Division of Mental Health, Developmental Disabilities and Substance Use Services, gave lawmakers a preview at a legislative committee hearing Tuesday morning of how her department plans to spend some of the allocated dollars.
Some of the funds will expand existing programs. Others will retrofit existing facilities for new purposes. Plans are still being finalized to help the department get a bigger bang for its buck in North Carolina, which is still wrestling with a slew of behavioral health needs that have been underfunded for a decade — and became more pronounced during the pandemic.
One goal for the first year of the two-year funding stream is to get money into the system quickly.
“‘Shovel ready’ is not quite the right word, but we looked at facilities that were already available that needed up-fitting, projects that were already near to completion, places that had room to expand, maybe we could add some beds to a facility,” Crosbie told the Joint Legislative Oversight Committee on Health and Human Services.
“We're trying to think of really cost-effective, efficient infrastructure investments — things that we can start using right away.”
Crosbie compared the current behavioral health system to the emergency management system. For example, when someone calls 9-1-1 for a heart attack, they know the number to call, they know that EMTs in an ambulance will come and get them, and they know they’ll end up at a hospital.
The state’s behavioral health crisis services are lacking in comparison, Crosbie said. People looking for behavioral health services may know a number to call, but they don’t know who will come to help and they don’t know where they’ll end up after someone arrives.
“We have sort of the bones of this system in North Carolina,” she said. “It's just fragmented and not consistent and certainly not well funded.”
Things are slowly changing, though, she said. With the scale-up of the 9-8-8 crisis line, more people know where to call. About 7,500 callers and texters a month are reaching out to the crisis responders each month now.
The next step in getting help can be more challenging than punching in 9-8-8, Crosbie said.
“When I ask people, ‘Do you know where the behavioral health urgent care is in your community?’ most people have no idea,” she said. ”When I say, ‘Do you know where the crisis center is — not the emergency room, but the psychiatric crisis center?’ Nobody knows where that is.”
Even if someone knows that behavioral health urgent care centers exist, Crosbie said, there are other hurdles. Some are staffed 24/7, but others are open only during business hours. Some provide detox services; others don’t. Some are set up to care for children; others cater to adults only. Many of the facilities tend to be in large counties, leaving a void in smaller, more rural areas. Mobile crisis teams that come to a person’s home to help defuse mental health crises are becoming more common, but many counties haven’t yet created such a workforce.
There’s no consistency, Crosbie said. Furthermore, she added, many people don’t trust the facilities that are there.
One of the projects that will help put the state on a road to more stability is the conversion of some facilities in Butner , N.C., into a crisis care center for children and adolescents. Once that center is fully operational, some of the other state facilities that have been feeling the squeeze will have more breathing room.
“We are adding 44 new beds for kids, 64 new beds for adults, nine new behavioral health, urgent cares, and one new co-response team,” she said. “That's mobile crisis — mental health and law enforcement — going together to respond.”
Looking down the road
In the second year of funding, Crosbie said DHHS will be looking harder at the personnel challenges throughout the system, such as the 20,000-person shortfall in direct support workers to assist people with mental health and developmental and intellectual disabilities.
”We have an untapped resource. We have something called ‘peer support specialists,’” she said. “These are people with lived experience. They are being certified, but they're not necessarily getting and maintaining employment in our system. And that's a real loss.”
Crosbie and her boss, Mark Benton, the undersecretary of DHHS, talked about raising salaries for nurses and others working in psychiatric hospitals. Currently, Benton said, 296 of the state’s 894 psychiatric beds (34 percent) cannot be used because of lack of staffing.
“These are not easy jobs, but they're terribly meaningful. So we need good rates,” Crosbie said. “And we need to give employers tools to keep people employed.”
Lawmakers pushed back. Rep. Hugh Blackwell (R-Valdese) whose district also includes Morganton, home to Broughton Hospital, a state psychiatric facility, acknowledged the importance of providing an attractive wage. But he cautioned that it might not be a cure-all when other providers are raising salaries too.
“Everybody's chasing after too few people, and it seems to me that … what we need from the department is some fresh thinking … what specifically do we need to do about these regulations that prevent you from hiring when the need is there and you've got the person standing there in front of you?” Blackwell said. “How do we deal with this salary issue that is ongoing? How do we use the dollars that we're paying temps now to maybe solve some of the salary needs?”
There is some evidence that the $220 million in salary increases approved by the General Assembly last year are alleviating some shortages, said Robyn Whalen, Central Regional Hospital CEO. She told lawmakers that before the salary boosts, it was difficult to hire mental health techs — staffers who need to be in the facility around the clock.
“The labor market adjustment rates were wonderful for us this year. They just went into effect, and I've already seen for our health care technicians — we went from an average of maybe hiring two a month last year in 2023 to over 20 in the past two months,” she said. “It’s had that big of an effect.”
Workforce challenges remain, though. State health officials have not mastered the recruitment and retention of registered nurses on state salaries when Central Regional and other facilities are in the shadows of larger health care systems that pay better such as Duke and UNC Health. RNs can make around $64,000 to start at a state-run facility, while they can make more than $100,000 in the large academic hospitals or a staffing agency, Whalen told them.
Short-term spending, long-term benefits
Crosbie told NC Health News after the meeting that her division would be making announcements about additional investments from the appropriations in the coming weeks. She said she’s excited about how, if the state keeps its eye on the ball, spending on mental health services could translate into money saved over the long run.
For example, it costs, on average, about $48,700 to keep someone locked up in a state prison for a year. In a best-case scenario, if the UNC FIT Wellness program serves as few as 200 people in a year, it could save the state as much as $9.7 million in prison costs annually — rapidly outstripping what it takes to finance the program.
Ashkin pointed out that FIT Wellness will also help train psychiatric residents studying at the medical schools at UNC Chapel Hill and Duke, and some residents training in New Hanover County. He pointed out that medical residents tend to put down roots where they did their training, and that could be a side benefit to the program in a state with a dearth of psychiatric professionals.
“And that's the thing, if you give people exposure, they can see how gratifying it can be,” he said.
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.