Community Services Board

March 20, 2012

Proposed FY 2013 Budget – WorkSession | 2

Community Services Board Members

Mr. Bill Tracey, Chairman - Neabsco Magisterial District

Mr. Charles Rigby, Vice-Chairman - Gainesville Magisterial District

Mr. Obediah Baker, Secretary - Occoquan Magisterial District

Mr. Carman Cellucci - Manassas City Representative

Mr. Dean Sprague - Manassas Park City Representative

Mr. Roy Coffey - Potomac Magisterial District

Ms. Kelly Matthews - Woodbridge Magisterial District

Mr. Tony Grimm - Member-At-Large

Ms. Anne Sale - Coles Magisterial District

Vacant - Brentsville Magisterial District

Proposed FY 2013 Budget – WorkSession | 3

What you will hear today

Dividends - 3 examples of the dollar value of return on invested tax dollarsEfficiencies - Consistent efforts of staff to reduce and contain local expendituresBudget Additions Changes made by the staff and CSB to balance access to services with available revenue streamsCritical needs reflected in waiting lists for services, measured by risk to individuals and communitySummary of the State’s agreement with Department of Justice (DOJ Settlement)

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Who are our Clients?

Early Intervention for Infants and Toddlers with DisabilitiesInfants & Toddlers (0-3 years) with Serious Developmental Delays FY 2010 - 852*FY 2011 - 1,004*

Intellectual Disability (ID) Case Management ServicesID Adults with Behavioral & Medically Complex ProblemsFY 2010 - 656* FY 2011 - 693*

Emergency ServicesPsychiatric Crisis - those who contact us or are brought to our attention by Police or Hospital staff as being a danger to themselves or othersFY 2010 - 2,780*FY 2011 - 3,237*

*Actual Unduplicated Cases

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Who are our Clients?

Mental Health: Outpatient, Residential, Day Support and Vocational and Medical Services

Seriously Mental Ill AdultsFY 2010 - 2,486*FY 2011 - 2,401*

Youth Substance Abuse and Mental Health ServicesEmotionally Disturbed AdolescentsFY 2010 - 1,487*FY 2011 - 1,478*

Adult Outpatient Substance Abuse and Drug Offender Recovery Services

FY 2010 - 2,016*FY 2011 - 1,750*

*Actual Unduplicated Cases

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County Investment Pays Dividends

Intensive Community Treatment (ICT)*- last 3 years - paid for by County 57%; Medicaid 43%

47 ClientsPre-program Hospital Days 3,663ICT Hospital Days 571

Reduced Hospital Days 3,092Costs/Bed Day $600/dayHospital Cost Reduction $1,855,200**

Mental Health Day Support & Employment Services140 Clients119 (85%) secured competitive employment97 (69%) maintained employment greater than 6 months21 hours is the average work week per employee$10.68 is the average hourly rate

*FY 10 - 11 PACT/ICT Program Outcome Report; 1/20/12 DBHDS

**Savings to Commonwealth

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County Investment Pays Dividends

Early Intervention for Infants and Toddlers with Disabilities

FY 2011 ActualChildren Served 1,004Children Completing Services 219Moving to Public/Private Education 132 (60%)Moving to Special Education 87 (40%)

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Efficiencies and Process Improvements

Pharmaceutical Assistance Program - (Free or Reduced Prescription Drugs)

Utilized County’s Continuous Quality Improvement Process443 Enrollees in FY 2011Based on the Wholesale Price an average client saves $5,683 per yearCost Avoidance $2.5 million

Medicaid Appointment Reminder (Daily Email)

Medicaid Summit Group - Quality Improvement ProcessSame day transactions previously: 1 of 4 lateSame day transactions currently: 1 of 9 lateResulting in additional billable Medicaid revenue of $33,328

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Budget Additions

Medical Services 1 Nurse Manager $134,029 Total Costs

Medicaid Revenue Support $ 15,000Local General Funds $ 119,029

Service ImpactsProvide 130 additional assessment & treatment hours1,000 Urgent Case Screenings per yearProvide Supervision and Training to 4 Licensed Practical Nurses

Residential Support Services2 Therapist IIs $148,194 Total Costs

Medicaid Revenue Support $ 31,510Local General Funds $ 116,684

Service ImpactsMove 16 clients into permanent housing12 unlikely to be re-hospitalized3 will find employment

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Budget Additions

Community Support/Jail Diversion 1 Therapist II $ 34,782 Partial Year Total Cost

Cities of Manassas & Manassas Park Funding $ 34,782Local Funds $ 0

Service Impacts for FY 1180 people screened for diversion from Adult Detention Center 1,433 bed days opened at ADC13 people enrolled in ICTReduce hospitalization of the 13 by 283 days

Mental Health Outpatient Services (Recap Item)1 Therapist III $ 80,002 Total Cost

Local General Funds $ 80,002

Service Impacts Treat 75 of 200 from waiting listPrevent 15 hospitalizationsIncrease clinical supervision to 3 Therapist IIs

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Critical Needs

Emergency Services30% Increase in 3 yearsFY 2009 - 2,499 FY 2010 - 2,780 FY 2011 - 3,23748% of people receiving Emergency Services are totally new to CSB

Mental Health Programs - Serve only Seriously Mentally Ill (SMI)People with the diagnosis of schizophrenia, bi-polar or major depression and who have been hospitalized Provide therapy for families and adolescents at risk of residential treatmentNo longer provide therapy to people with moderate depression or anxiety disordersNo longer provide family and marriage counseling or bereavement counselingPeople with commercial insurance are referred to private practitioners

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Critical Needs

Mental Health Programs continued…Outpatient - consistent waiting list of 200 (9 months from intake to treatment)Residential Support

Mental Health Residential Support Services - Waiting List 50 SMIIntensive Community Treatment Team - additional 35 SMI - indefinite waiting period - need a new teamMental Health Day Services - 50 SMI - intake to admission (part of 85)

Intellectual Disabilities (ID - formerly Mental Retardation)Case Management - now there are 194 people who receive only limited (telephone) support, but no active case management or day supportDay Support for Special Ed graduates and those waiting for urgent ID Waivers-dropped out of 5 year plan in FY 2007

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What Does the Future Hold?

Department of Justice Settlement (DOJ) with the State of Virginia SummaryWhy:

1999 Supreme Court Case: Olmstead (State of Georgia vs. L.C. & E.W. (ID/MH mental hospital patients)

Ruling related to requirements of Americans with Disabilities Act (1990)Original Ruling: that people with mental disabilities who live in, are at risk of living in, or are eligible for placement in facilities and institutions, have the right to live in the community if:

They and their treatment team agree they can live successfully in communityThey choose to live in communityThere are available resources to help them live in community

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What Does the Future Hold?

Courts did not rule:Institutions had to closeLack of resources alone is not an acceptable excuse for failure to move people into the communityState responsibilities are limitless

Since original decision many additional Federal Court decisions and DOJ State Settlements

In 2008 concerned Virginia citizens filed a formal complaint to the Justice Department

Central State Virginia Training Center in violation of OlmsteadAs the investigation progressed it expanded to include all 5 Training Centers

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What Does the Future Hold?

Fiscal Problem for Virginia 2000 - 1,600 Residents in Training Centers Statewide

2012 - 1,000 Residents in Training Centers Statewide

Training Center costs are 63.8% of the appropriation for individuals with ID and supports only 15.6% of the ID population Virginia serves

Cost per Resident - Now averages $216,000/year

Cost per Resident will continue to increase as operating & maintenance increases and occupancy decreases

30 Discharges and 7 admissions per year

State estimates average statewide annual cost for community based care for comparable Training Center resident is $138,000

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What Does the Future Hold?

What is in the DOJ Settlement:Covers people with Intellectual and Developmental Disabilities in Institutions or meets ID/DD Waiver criteria living in community

Closing 4 of 5 Training CentersClosing Northern Virginia Training Center (NVTC) end of 2015

153 people live there today

25 are Prince William County citizens

Very challenging because of complex needs: medical, immobility and co-occurring major mental health diagnosis - schizophrenia and bi-polar

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What Does the Future Hold?

In many cases no adequate services currently exist4 bed group homes24 hour skilled nursing homesUniversal access designed group homes

Some providers we currently work with are capable but need start up funding and increased Waiver reimbursement

Additional Case Management ResponsibilitiesIncrease face to face contact from once every 90 days to once a month for all 366 current Waiver cases

Estimate 4 to 5 days of new workload (appointment, travel, documentation) per month for each Case Manager

Increased monitoring of vendors reporting to Licensing and Human Rights

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What Does the Future Hold?

4,170 New Waiver slots over 10 years805 for Training Center discharges2,915 for Urgent ID Waiver Waiting List statewide

Currently 3,316 statewide on Urgent Waiting List97 in Greater Prince William County on Urgent Waiver Waiting List

450 for Developmental Disability Waivers (autistic, cerebral palsy & others)

Medicaid is funded State 50% and Federal 50%

Virginia ranks 47th out of 50 states in spending on Medicaid and is ranked as the 6th wealthiest State in the U.S.

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What Does the Future Hold?

Crisis Stabilization Teams and Centers2 for Northern Virginia

Employment First (targeting people living in Community)

4 Additional Monitoring and Quality Improvement Activities to Assure Progress

Independent Reviewer

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Next Steps

First Step:

Assigned 2 Case Managers to work intensively with 25 NVTC residents, families and potential providers

To absorb those cases we are requesting you and the County Executive consider funding 3 Therapist IIs and 1 Therapist III at Budget RECAP

These 4 positions can generate sufficient Targeted Case Management Medicaid Revenue to cover their salaries and fringes within approximately 18 months

The start up costs for FY 13 would be $91,156

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Next Steps

Using Medicaid revenue CSB can absorb the DOJ changes and eliminate the current waiting list of 194 in 5 years beginning FY 13 with modest County revenue support.

Intellectual Disability Case Management Services

5 YearFY12 FY13 FY14 FY15 FY16 FY17 Total

CASE MGMT WAITING LIST 194 174 141 78 29 0NVTC / CVTC DISCHARGES 0 25 0 4 0 0ADDITIONAL STAFF 4 5 3 4 3 19ADDITIONAL EXPENSE 299,300 693,400 912,700 1,212,000 1,431,300 4,548,700NEW MEDICAID REVENUE 208,144 515,903 772,728 1,068,732 1,325,557 3,891,064COUNTY GENERAL FUNDS 91,156 177,497 139,972 143,268 105,743 657,636 Revenue as Percentage of Expenses 69.5% 74.4% 84.7% 88.2% 92.6% 85.5%

CSB plans to request a case management staffing plan as part of the FY 14 proposed budget process.

Proposed FY 2013 Budget – WorkSession | 22

Questions