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HIGH POINT — Six years into North Carolina's effort to remake its mental health safety net, the system still struggles to fix the problems that came with the overhaul.

The eventual result may well be the more cost-effective, nimble and comprehensive mental health network envisioned by legislation passed in 2001, providers, advocates and analysts say.

But we're far from that goal.

Today's public mental health system cannot always provide the service a client needs or the quality of care one might expect from an agency dealing with vulnerable people. A critique of the state system recently completed for the N.C. Division of Mental Health found that too much change undertaken too quickly had shifted the focus away from patients, something that even top mental health officials say is a fair criticism.

Occasionally, the results grab headlines. In 2004, a mentally ill man killed an elderly neighbor at an assisted living center in Guilford County; a similar tragedy occurred in Alamance County the next year.

But the vast majority of cases are less dramatic. The people in these predicaments are not likely to hurt themselves or others, but their recoveries can be stymied, and the costs — personal and public — can mount.

One woman's story

"When my mother passed away, I just went downhill," said Lisa Magdaraog, 43, who in 2004 was the picture of an ambitious working mother of three boys. A certified nursing assistant, she made the honors list at GTCC and hoped to become a registered nurse.

When Magdaraog's illness began to assert itself, there was crying. Then, she began to do things out of character: She became less attentive at work. She had an affair.

Finally, she found herself spinning out of control.

"I had told my doctor that I wanted to die and I wanted to take my children with me," Magdaraog said. That admission would lead social services to take her children away for a time, something she said "just about killed me."

Eventually, doctors would diagnose major depression and borderline personality disorder, a disease that makes moods hard to regulate and can disrupt a person's sense of self-identity.

It took three trips to the hospital to stave off the worst of her disease, Magdaraog said, struggling to weed through the jumble of memories from that confusing time.

She lost her job and the private insurance that went with it.

Magdaraog's then-doctor referred her to the Guilford Center, the public mental health agency in Guilford County, which in turn referred her to Destiny House, a rehabilitation program run by the Mental Health Association in High Point. Workers at both programs have told her she would benefit from continued one-on-one psychiatric counseling.

But that's not going to happen. Magdaraog's family doesn't qualify for Medicaid because of her husband's retirement income. And no state or local funding is available to pay for that sort of ongoing treatment.

At Destiny House, a day treatment program, she talks with others who have dealt with mental illness. She works two or three times a week at the nonprofit's market-sample store. She lives at home and is there for her children when they return from school each day.

And she has a little ambition again.

"I'd like to have a better job and have some insurance and," she said, pausing on the thought, "I guess I'd live a normal life like I did before."

That's Magdaraog's bottom line. She's better now, but by no means is she her old self. Fear lurks behind even simple tasks.

What's she afraid of?

"That I'm going to mess up, that I'm going to do the wrong thing, I'm going to say the wrong thing," she said. "When I was a CNA before, I didn't worry about that sort of thing."

Psychotherapy might help overcome that doubt and allow her to get back to work, if not in nursing, then perhaps in retail. But until she can land some private insurance through a job, she can't get psychotherapy.

Magdaraog finds herself in a Catch-22. And she has plenty of company, say those on the front lines of providing mental health care.

"They're in that category of prevention ...," said Blair Benson, executive director of the Mental Health Association in Greensboro. "There are some service providers to send them to, but it's difficult to find them. That provider might be full; it might be two months for them to get an appointment."

Looking for gaps

Gaps in the mental health system are nothing new. They were one reason for reform and have become a fact of life in the safety net as it now exists.

Officials with the Guilford Center looked for local gaps earlier this year. They found, for example, that only two providers in the entire county offer outpatient therapy for clients without Medicaid or other insurance.

In some cases, no agencies, private or public, provide a particular service. As of August, for example, no one provided short-term crisis beds in Guilford County, a safe haven for clients to get treatment away from home. The Guilford Center has since contracted with a group called Recovery Innovations to begin that service.

But other gaps remain unfilled.

What happens to those clients?

"Our staff who do screening triage and referral make every effort to connect consumers up with something," Guilford Center Director Billie Martin Pierce said. "It may be a volunteer organization, it may be another private not-for-profit organization, but we really strive not to say the words, 'We have nothing for you.'

"We believe it is not acceptable or appropriate to have nothing."

On other occasions, only a limited number of agencies fulfill a certain need. Only two, for example, provide Assertive Community Treatment services, which are used by the most severely ill clients who can live outside a hospital.

And in some cases, plenty of agencies provide a particular service — at least on paper — but some can't deliver on clients' needs.

More than 110 agencies, for example, say they offer Community Support Services for adults in Guilford County. This program is a linchpin of the evolving mental health system, with workers doing varied tasks such as making sure clients get and take their medications and live in a safe, clean place and helping them find treatment.

But not all are created equal. The state Division of Mental Health reacted this summer to findings of widespread billing fraud by these providers by slashing the rates they were paid.

"I've heard other stories of community support providers that are doing the service and they shut their doors and nobody is notified," said Ellen Jones, executive director of the Mental Health Association in High Point. "The consumer just doesn't hear from them again."

Other problems

In some cases, the system's own rules can limit treatment options.

Changes imposed in the spring lengthened the time it takes to enroll people in treatment programs, said Jodi Lorenzo-Schibley, executive director of Sanctuary House in Greensboro, which helps rehabilitate those with severe mental illnesses.

"It takes six to seven weeks at times just to get someone in the door due to the paperwork requirements and various other requirements by the state," she said.

Nonprofits such as hers spend a great deal of time sorting through regulations to make sure they don't run afoul of one or another, Schibley said. And the changes keep coming, including new Medicaid rules being drafted by the federal government that could make many of the services her group offers ineligible for public funding.

There are other problems. Common themes brought up by Guilford County providers and advocates include:

*Too many people with substance abuse and mental health problems wind up in the court system rather than in treatment.

*Housing for the mentally ill can be scarce and expensive.

*Medications are expensive. Many on publicly funded programs such as Medicaid fear that going back to work would make them ineligible for the service before they can afford medications on their own.

A statewide view

A broad analysis of the state's mental health reform, commissioned by the Division of Mental Health and completed this fall, found that providers and government agencies alike had been hurt by the rapid and constant changes undertaken during the process.

"The most serious shortcoming of the implementation is that in the rush to complete structural changes, the public partners have jointly lost sight of the most important beneficiary of the reform: the consumers," wrote Alice Lin, the author of the study.

Leza Wainwright, deputy director of the state Division of Mental Health, called that a "valid criticism."

"For 85 percent of consumers, things have gone well," Wainwright said. Still, the remaining 15 percent represent "slippages" in the system that need to be corrected.

State and local agencies are working to develop needed services, she said, but filling the gaps will take time and patience.

"Let's not keep tweaking this and that and making more and more change," Wainwright said. "Let's give the system time to acclimate to the change that's already in place."

Lacking direction

Many of those interviewed say they are unsure what the mental health system should look like when reform is finished because the state failed to give clear goals and directions.

"I don't know if they know where they're going, and they really threw the baby out with the bath water," said Melissa Floyd Taylor, a professor at UNCG's School of Social Work who has studied the mental health care system.

Officials pushed too hard to move services from government providers to nonprofits, she said, and the result is a fragmented system in which some providers are not always up to the task at hand.

Guilford County resisted some of that push, Martin-Pierce said. For example, the county never got rid of its crisis centers in Greensboro and High Point despite regulatory pressure to do so. And the county will soon open a new central substance abuse center on Wendover Avenue, paid for with county tax money.

As for how to close the gaps where mental health services don't exist, the process may never stop, said Anthony Ward, who conducted the Guilford Center's gap analysis. Plans already are in the works for another round of surveys starting in January.

"I'm not certain we'll reach an end point that will be our destination and we'll close up shop and go home," Ward said. "I think it's a continual quality-improvement process."

To be fair, the state has a strategic plan, complete with specific actions to fill in the gaps that cause the most concern, such as the need for more short-term crisis beds and housing for the mentally ill. But it has taken longer than expected, said Michael Moseley, director of the N.C. Division of Mental Health.

Part of the problem, he said, was that the legislature mandated reform overnight, without providing time for the old and new systems to overlap.

"If we had a rational approach and enough time, we would have done more things differently on the front end," Moseley said.

Wherever the system is heading, providers and government officials seem confident — to varying degrees — that it will eventually begin to work better, if not as envisioned by the architects of reform earlier this decade. The concern is not so much for the future as it is for the here and now.

What happens to those who fall through the gaps in the meantime?

"I haven't gotten anybody five years into this thing to tell me what it's supposed to look like in the end," said Jones, of the Mental Health Association in High Point.

"I've posed the question, you can be sure. It's going to take years. It's going to take time. My concern is what happens to our clients in the meantime."

Contact Mark Binker at (919) 832-5549 or mbinker@news-record.com