North Carolina State Advocacy Team Summary
In Phase II (2025), the NC team will be led by chapter lead Genevieve Skinner, Advocacy Director with the Bleeding Disorders Foundation of North Carolina, and HTC lead Lucia Opera, social worker at the University of North Carolina HTC. The team is supported by Melissa Cruz, family nurse practitioner with Meliora Medical Concierge and Physician Extender at Cherry Hospital NC Department of Health and Human Services; Dr. Rebecca Taylor, child and adolescent psychiatrist at Duke University Health System; Dr. Matt Pace, licensed marriage and family therapist, community member; as well as Gillian Schultz, and Aura Rosado from the Wake Forest HTC.
In Phase I (2023-2024), the NC state advocacy team was led by chapter led by chapter lead Gillian Schultz, Director of Programs, Bleeding Disorders Foundation of North Carolina; and HTC lead, Robin Gardner, social worker at St. Jude’s Affiliate Clinic at Novant Health Hemby Children’s Hospital. The team was also supported by members Genevieve Skinner, Advocacy Director with the Bleeding Disorders Foundation of North Carolina; Megan Stewart, social worker with the HTC at Atrium Health Levine Children’s Hospital; Melissa Cruz, family nurse practitioner with Meliora Medical Concierge and Physician Extender, Cherry Hospital NC Department of Health and Human Services; Dr. Rebecca Taylor, child and adolescent psychiatrist at Duke University Health System; Dr. Matt Pace, licensed marriage and family therapist, and Lucia Opera, social worker at the University of North Carolina HTC.
Phase I Summary of Achievements
In their first year, the BD SUMHAC NC team successfully:
Engaged with state officials and board members from the NC Department of Health and Human Services (NC DHHS); members of the Coalition, a multistakeholder collective of community members who support people living with addictive diseases, mental illness, and developmental disabilities; and NC state legislators.
Identified a state champion.
Mapped the regulatory landscape of SUD facilities and MH facilities, with particular attention to policies related to:
Self-administration of infusion and injection medications
Staff assisted administration of infusion and injection medications
External provider assisted administration of infusion and /injection medications
Patients’ ability to bring in their prescribed medications from home/outside of the facility (i.e., white and brown bagging)
Patient cherry-picking
Expanded by adding its newest member, Lucia Opara, LICSW, social worker at the University of North Carolina HTC.
Regulatory Landscape Mapping
Sorted by landscape area. All regulatory Information is as of July 2024.
SUD Facility Information
Self-infusions/ injections
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RESIDENTIAL TREATMENT/REHABILITATION FOR INDIVIDUALS WITH SUBSTANCE ABUSE DISORDERS
10a NCAC 27g .0209 MEDICATION REQUIREMENTS
(c) Medication administration:
(2) Medications shall be self-administered by clients only when authorized in writing by the client's physician.
(4) A Medication Administration Record (MAR) of all drugs administered to each client must be kept current. Medications administered shall be recorded immediately after administration. The MAR is to include the following:
(C) instructions for administering the drug;
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Self-administration of medications are permitted in SUD facilities if authorized in writing by the client’s physician. The regulations are silent on infusions (injections are specifically mentioned later in the section), they are not excluded from the section and therefore, should be permitted with physician permission.
Staff-assisted infusions/ injections
-
RESIDENTIAL TREATMENT/REHABILITATION FOR INDIVIDUALS WITH SUBSTANCE ABUSE DISORDERS
10a NCAC 27g .0209 MEDICATION REQUIREMENTS
(c) Medication administration:
(3) Medications, including injections, shall be administered only by licensed persons, or by unlicensed persons trained by a registered nurse, pharmacist or other legally qualified person and privileged to prepare and administer medications.
-
Staff assisted injections are permitted in SUD facilities. However, more clarity in the regulations would be helpful. There is no specific language in the current regulations that indicates infusions can be administered by SUD facility staff, but there is also no language excluding them either.
External provider-assisted infusions/injections
-
RESIDENTIAL TREATMENT/REHABILITATION FOR INDIVIDUALS WITH SUBSTANCE ABUSE DISORDERS
10a NCAC 27g .0209 MEDICATION REQUIREMENTS
(c) Medication administration:
(3) Medications, including injections, shall be administered only by licensed persons, or by unlicensed persons trained by a registered nurse, pharmacist or other legally qualified person and privileged to prepare and administer medications.
-
According to staff at the North Carolina Department of Health and Human Services, the SUD facility is ultimately responsible for ensuring that the person providing the medication administration is trained. There have been occasions in NC SUD facilities where contracts with outside nurses/medical staff have been signed to provide services that the facility staff were not trained to perform, including administration of infusion and injection medications. SUD facility staff are expected to receive basic training on medication side effects, even if they are not the ones actually providing the infusion/injection.
White bagging and brown bagging
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10A NCAC 27G .0209(b) Medication requirements.
(b) Medication packaging and labeling: (1) Non-prescription drug containers not dispensed by a pharmacist shall retain the manufacturer's label with expiration dates clearly visible;
(2) Prescription medications, whether purchased or obtained as samples, shall be dispensed in tamper resistant packaging that will minimize the risk of accidental ingestion by children. Such packaging includes plastic or glass bottles/vials with tamper-resistant caps, or in the case of unit-of-use packaged drugs, a zip-lock plastic bag may be adequate;
(3) The packaging label of each prescription drug dispensed must include the following:
(A) the client’s name;
(B) the prescriber's name;
(C) the current dispensing date;
(D) clear directions for self-administration;
(E) the name, strength, quantity, and expiration date of the prescribed drug; and
(F) the name, address, and phone number of the pharmacy or dispensing location (e.g., mh/dd/sa center), and the name of the dispensing practitioner.
-
According to staff at the North Carolina Department of Health and Human Services, medications can be brought into SUD facilities from outside if they are provided by a pharmacy and have the correct labeling information.
SUD facility pharmacies are permitted to review and verify medication labels for patients.
Policies to prevent cherry-picking
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There are no current regulations that prevent facilities from admitting or denying patients based on perceived medical complexity.
-
State regulations do not have protections against cherry-picking. However, facilities that receive federal assistance, are required to abide by the requirements of Section 504 that prohibit discrimination on the basis of disability and require an individualized assessment as part of the admissions process.
MH Facility Information
Self-infusions/ injections
-
10A NCAC 27G .1900 Psychiatric Residential Treatment Facilities (PRTF)
(2) Medications shall be self-administered by clients only when authorized in writing by the client's physician.
10A NCAC 27G .1901 SECTION .1900
Psychiatric Residential Treatment for Children and Adolescents\
There is no language in these regulations on self-administration/ infusions/or injections.
-
Self-administration of medications are permitted in adult MH facilities with physician authorization. While the language is silent on self-infusions and self-injections, they are also not specifically excluded from this requirement and therefore, it can be assumed that they are included with the same requirement that they are authorized in writing by the client’s physician.
In child and adolescent facilities, the regulations are silent on self-administration of medications altogether.
More clarity in the regulations would be helpful.
Staff assisted infusions/ injections
-
10A NCAC 27G .1900 Psychiatric Residential Treatment Facilities (PRTF)
(c) Medication administration:
(3) Medications, including injections, shall be administered only by licensed persons, or by unlicensed persons trained by a registered nurse, pharmacist or other legally qualified person and privileged to prepare and administer medications.
10A NCAC 27G .1901 SECTION .1900
Psychiatric Residential Treatment for Children and Adolescents
There is no language in these regulations on staff assisted administration of medications.
-
Medications can be administered by trained staff in MH facilities. While the regulations specifically include injections, they are silent on administration of infusions.
It can be assumed that staff-administered infusions are permitted with the same requirements as for injections but more clarity in the regulations on this point would be helpful.
In child and adolescent facilities, the regulations are silent on administration medications altogether.
External provider assisted infusions/ injections
-
10A NCAC 27G .1900 Psychiatric Residential Treatment Facilities (PRTF)
(c) Medication administration:
(3) Medications, including injections, shall be administered only by licensed persons, or by unlicensed persons trained by a registered nurse, pharmacist or other legally qualified person and privileged to prepare and administer medications.
-
According to staff at the North Carolina Department of Health and Human Services, the MH facility is ultimately responsible for ensuring that the person providing the medication administration is trained. There have been occasions in NC MH facilities where contracts with outside nurses/medical staff have been signed to provide services in instances where the facility staff were not trained to perform those services, including administration of infusion and injection medications. MH facility staff are expected to receive basic training on medication side effects, even if they are not the ones actually providing the infusion/injection.
White bagging and brown bagging
-
10A NCAC 27G .0209(b) Medication requirements.
(b) Medication packaging and labeling: (1) Non-prescription drug containers not dispensed by a pharmacist shall retain the manufacturer's label with expiration dates clearly visible;
(2) Prescription medications, whether purchased or obtained as samples, shall be dispensed in tamper resistant packaging that will minimize the risk of accidental ingestion by children. Such packaging includes plastic or glass bottles/vials with tamper-resistant caps, or in the case of unit-of-use packaged drugs, a zip-lock plastic bag may be adequate;
(3) The packaging label of each prescription drug dispensed must include the following:
(A) the client’s name;
(B) the prescriber's name;
(C) the current dispensing date;
(D) clear directions for self-administration;
(E) the name, strength, quantity, and expiration date of the prescribed drug; and
(F) the name, address, and phone number of the pharmacy or dispensing location (e.g., mh/dd/sa center), and the name of the dispensing practitioner.
-
According to staff at the North Carolina Department of Health and Human Services, medications can be brought into MH facilities from home (brown bagging) if they are provided by a pharmacy and have the correct labeling information. MH facility pharmacies are permitted to review and verify medication labels for patients. Otherwise, bringing in medications from home is not permitted.
White bagging where an outside pharmacy submits directly to the facility is permitted.
Policies to prevent cherry picking
-
There are no current regulations that prevent facilities from admitting or denying patients based on perceived medical complexity.
-
State regulations do not have protections against cherry-picking. However, facilities that receive federal assistance, are required to abide by the requirements of Section 504 that prohibit discrimination on the basis of disability and require an individualized assessment as part of the admissions process.
Next Steps for Advocacy
The NC team has determined the following goals for Phase 2:
Educate MH/SUD providers on BDs, infusion and injection medications, and related topics to support staff development across the state.
Determine another champion to help facilitate patient access to private MH/SUD facilities in the event of a denial.
Identify language to propose to DHHS for incorporation into Medicaid contracts to minimize patient cherry-picking within MH/SUD facilities.
Continue to engage with NC legislators to share more about BD SUMHAC’s local advocacy and ways they can get involved in facilitating access to MH/SUD facilities for people with BDs across the state.
Meet with major insurance providers to share more about the healthcare access needs experienced by the BDs community. When seeking inpatient or residential MH/SUD treatment, individuals with BDs often get stuck in an emergency department for days or weeks without access to appropriate care. This is a very expensive burden to the healthcare system, as emergency departments are the most expensive setting of care.
Create a step-by-step plan for the BD community in NC in the event of a denial to a MH/SUD facility.