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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%
7-J
an
14
-Jan
21
-Jan
28
-Jan
4-F
eb
11
-Feb
18
-Feb
25
-Feb
4-M
ar
11
-Mar
18
-Mar
25
-Mar
1-A
pr
8-A
pr
15
-Ap
r
22
-Ap
r
29
-Ap
r
6-M
ay
13-
May
20-
May
27-
May
3-J
un
10
-Ju
n
17
-Ju
n
24
-Ju
n
1-J
ul
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