DBHDS Update

Joint Subcommittee Studying Mental Health Services in the

Commonwealth in the 21st Century

PresentationSeptember 23, 2019

Mira SignerActing Commissioner

Department of Behavioral Health and Developmental Services

Slide 2

Presentation Overview

1. STEP-VA

2. Crisis Services

3. Hospital Census

4. Catawba State Hospital Beds

5. SB1488 Workgroup

Slide 3

STEP-VA Update

STEP-VA Service ImplementationRequirement Status Funds

Allocated

Same Day Access July 1, 2019 100% Implementation: March 2019

$10.8M

Primary Care Screening July 1, 2019 Launched: July 1, 2019$3.7M FY19$7.4M FY20

Crisis Services July 1, 2021

Detox ServicesLaunched: August

2019$2M FY20

Crisis ServicesLaunch: October 2019 $7.8M FY20

Outpatient Services July 1, 2021 Launched: July 1, 2019 $15M FY20

Psychiatric Rehabilitation July 1, 2021 Planning Began 4thQ FY19 –

Peer/Family Support Services July 1, 2021 Planning Began 4thQ FY19 –

Veterans July 1, 2021 Planning Began 4thQ FY19 –

Care Coordination July 1, 2021 Planning Began 4thQ FY19 –

Case Management (Adults and Children) July 1, 2021 Planning Began 4thQ FY19 –

Slide 4

STEP-VA Implementation Process

Milestones to Date:– Formulation of STEP-VA Advisory Committee (STAC)– Definitions, metrics and funding formula complete for Primary Care Screening (PCS)

and Outpatient Services– CSBs submitted Primary Care Screening AND Outpatient plans and distribute funds– Same Day Access has decreased wait times from above the national average to 50%

below– Investments made in training CSB staff to focus on building capacity for

interventions that are evidence-based and trauma-informed, inclusive of interventions for children and adults

Future Tasks: – September STAC: First round of feedback on Psychiatric (PS), Care Coordination (CC)

and Case Management (CM) steps– December STAC: Final definitions, metrics and funding formula presented for PS, CC

and CM steps. No plans till funding specified.– January 1st, 2020 planning COMPLETE for ALL steps. CSBs ready to work on plans

when funding appropriated.– Determine step initiation timeframe– Data collection, analysis and CSB performance assessment

Slide 5

Highlight: Same Day Access

• Has been initiated at all 40 CSBs

• CSBs worked with MTM to consider adoption of the following:– Same Day Access

– Collaborative Documentation

– No Show Management

– Productivity calculators

• Preliminary/process outcomes (30 CSBs reporting):– 20% decrease in staff time; 7% decrease in client time

– 26% more intakes being completed (on average)

– Wait time has decreased from above the national average to 50% below• National wait time is 49 days

Slide 6

Highlight: Outpatient Services

• Focus on building capacity for interventions that are evidence-based and trauma-informed, inclusive of interventions for children and adults

• Some examples of investments in training made by regions:

Trauma-focused Cognitive Behavioral

Therapy

Motivational Interviewing

Eye Movement Desensitization and

Reprocessing

Functional Family Therapy

EcosystemicStructural Family

Therapy

Shared subscription to web-based CEUs

Slide 7

Crisis System in Virginia

Current System

• Out of sync with national best practices

• Fragmented – by age and diagnosis

• MH emergency services and REACH (child & adult) programs operate in coordination, collaboration, but not integrated

• Access to mobile crisis 24/7 –dependent on where you live, age & disability

• Need for increased standardization, including assessments

Future System Key Elements

Crisis Hotline

Dispatch Infrastructure

Mobile Crisis Regionally deployed,

24/7 basis

Residential Crisis Intervention and

stabilization

Slide 8

Mobile Response and Stabilization Hallmarks

The crisis is defined by the caller

Available 24 hours a day, 7 days a week

Serve individuals in their natural

environments

Specialized trained staff

Build on natural support structures

Connect individuals to follow-up services and

supports

Best Practice Results – Other States’ Experiences

Reduce the burden on emergency departments and inpatient placements

Connecticut reported 666 inpatient diversions

in FY18

Seattle diverted 91-94% of hospital admissions

between 2013 and 2015

Create long-term cost savings on higher-cost

placements

Saved an estimated $7.5 million

Saved $6.6-10.3 million

Based on the experiences of other states, improving our system will:

Slide 10

2,1923,497 4,397 5,356 5,877

22,687 22,322 21,86120,323 19,328

24,889 25,798 25,852 25,679 25,205

0

5,000

10,000

15,000

20,000

25,000

30,000

FY15 FY16 FY17 FY18 FY19

Total TDOs Admitted to State Hospitals

Total TDOs Admitted to Private Hospitals

Total TDOs Issued

Statewide TDOs and Hospital Admission Trends

• 70% of admissions to state hospitals are civil TDOs.

• 800 to 1,000 additional individuals admitted each year to state hospitals.

• Use 30 more beds each year.

• Funded bed use = 97%

• Staffed bed use = 127%.

Slide 11

Calendar Year 2019 State Hospitals Census Trends

91.20%

95.40%

91.20%

95.40% 95.70%96.40% 96.50%

95.00%

96.50%

98.00% 99.80%

100.30%

98.00%

86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

102.00%

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14

-Jan

21

-Jan

28

-Jan

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11

-Feb

18

-Feb

25

-Feb

4-M

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11

-Mar

18

-Mar

25

-Mar

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8-A

pr

15

-Ap

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22

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29

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6-M

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13-

May

20-

May

27-

May

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Percent of Adult and Geriatric Beds Filled in State Hospitals

As of September 16, 2019, the state hospitals were operating at 101% capacity

Slide 12

Temporary Beds at Catawba

6-8 beds

3 Months

15 bed unit

6 Months

all 28

beds

9 Months

• This summer DBHDS initiated action to add temporary beds to Catawba Hospital’s current operating capacity in order to continue to meet its legal obligations under 37.2-809 “Bed of Last Resort” and 19.2-169.2

• 56 beds will be added; 28 in FY 2020 and 28 beds in FY 2021

• DBHDS using $4.15M of special funds in FY20

• DBHDS will request additional general funds of $9.3 million in FY 21 and $10.3 million in FY 22 to operate these beds

• Timeline (following approval/funding and as staff are hired, trained and deployed):

Slide 13

Temporary Beds at Catawba

• Adding beds at Catawba is a temporary and emergent necessity

• These beds would be in place until the rate of state hospital census growth plateaus or decreases

Slide 14

Addressing Census Pressures

• Building community capacity - STEP VA and other critical initiatives

• Collaborating with CSBs to consider/expand temporary use of crisis stabilization units and other alternatives

• Exploring crisis capacity, including crisis intervention teams assessment centers and mobile crisis

• Anticipated completion of the Western State Hospital expansion (end of FY 2021)

• Encouraging private hospitals to use their estimated 25% capacity to alleviate census burden

• Holiday weekends from May – September: special “call to action” from Commissioner to CSBs and private hospitals

• TDO Work Group (SB 1488): short and long-term recommendations around right-sizing, evaluation process, emergency custody order period

Slide 15

Virginia’s Utilization of Behavioral Health Dollars

FY 2020 in VirginiaHospital = 50.4% /$352.8MCommunity = 49.6%/347.5M

National State Beds per 100k = 11.7 / Virginia State Beds =18.2

General Fund Dollars Invested in Community Services Relative to State Hospitals

Slide 16

SB1488 Workgroup

• Goal: Develop short and long-term recommendations for reducing the census in state hospitals

• Topics covered:– Role of the Virginia’s state hospitals compared to other states

– Emergency Custody Order (ECO) timeframe

– Custody and role of Law Enforcement

– Individuals with complex medical conditions

– Individuals who are intoxicated at the time of assessment

– Most appropriate setting for care

– Efficiency of evaluation process

– Diverting admissions from state hospitals

– Increasing community services

• Last meeting will be in October 2019

Slide 17

Overview of Workgroup Meetings

Meeting Date Discussion

April 2019 Understanding the census crisis from all perspectives

May 2019Overview of the civil commitment processNational Perspective

June 2019Overview of alternative sites for TDO assessmentDiscussion of ECO time frame extension

July 2019Overview of civil commitment process for medically complex and intoxicated individuals

August 2019Presentation and discussion of policy recommendations for children

October 2019 pt. IReview workgroup recommendations and discuss policy options

October 2019 pt. II Workgroup feedback on report – Due to GA on 11/1

DBHDS Update

Joint Subcommittee Studying Mental Health Services in the

Commonwealth in the 21st Century

PresentationSeptember 23, 2019

Mira SignerActing Commissioner

Department of Behavioral Health and Developmental Services