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SJ 47 Joint Subcommittee update: A vision for public mental health services in Virginia takes shape.

At the October 26, 2016 meeting of the SJ 47 Joint Subcommittee to Study Mental Health Services in the Commonwealth in the 21st Century, the Subcommittee's Work Groups and members appeared to move closer to adopting a shared vision of a future statewide system of mental health services, while acknowledging the significant obstacles to realizing that vision. The Joint Subcommittee's Work Groups also recommended more immediate action on reforms within the current system to help to move it toward that future vision. The Division of Legislative Services (DLS) report on the October 26 meeting can be found here, and a more detailed description of each Work Group's activities and decisions from the summer of 2016 to the October 2016 meeting follows the summary below.

The Vision for the Public Mental Health Services System

Adoption of the STEP-VA (System Transformation, Excellence and Performance in Virginia) program model

Senator Hanger, the chair of the System Structure and Finance Work Group (Work Group #1), noted the Work Group's endorsement of the Department of Behavioral Health and Developmental Services' (DBHDS) STEP-VA plan for the Commonwealth's public mental health system. That plan is built upon the concept of providing access across the state to 10 "core" services that would ensure access to needed services for all individuals with mental illness. Those services are: (1) same day access to mental health screening and timely access to assessment, diagnostic, and treatment services; (2) outpatient primary care screening and monitoring services; (3) crisis services; (4) person-centered mental health service treatment planning services; (5) outpatient mental health and substance abuse services; (6) targeted mental health case management; (7) psychiatric rehabilitation services; (8) peer support and family support services; (9) mental health services for members of the armed forces and veterans; and (10) care coordination services.

Funding priority for "same day access" and outpatient primary care

Work Group #1 also endorsed the DBHDS proposal that full funding for these "core" services be implemented over a period of years, with such funding being sought first for the statewide implementation of two services: (1) same day access to mental health screening and timely access to assessment, diagnostic, and treatment services (estimated cost: $1.5 million in FY 2017, $12.3 million in FY 2018, and $17.3 million annually thereafter); and (2) outpatient primary care screening and monitoring services (estimated cost: $3.72 million in FY 2019 and $7.44 million annually thereafter).

Availability of Psychiatric Emergency Services (PES) units to persons in crisis

Delegate Garrett, chair of Work Group #3 (Mental Health Crisis Response and Emergency Services) described to the Joint Subcommittee the Work Group's endorsement of PES units, which, he explained, are an alternative to hospital emergency departments, and to psychiatric hospitalization, in providing treatment for individuals experiencing mental health crisis. Delegate Garrett noted that such units may reduce the costs associated with psychiatric boarding, but that the Work Group and its Advisory Panel are still attempting to determine the costs associated with psychiatric boarding in the Commonwealth and the potential cost benefits that may result from the establishment of psychiatric emergency services units.

Adoption of a model for criminal justice diversion

Delegate Bell, the chair of the Work Group #2 (Criminal Justice Diversion), reported that in 2017 the work group will focus on specific models for diverting persons with mental illness from the criminal justice system.

Permanent Supportive Housing

Senator Howell, chair of Work Group #4 (Housing), reported that an estimated 5,000 individuals in Virginia are in need of permanent supportive housing. Permanent supportive housing is a support for persons with serious mental illness that has been proven to be effective in both enabling people to stabilize their lives and reducing the costs of providing services to these individuals (who, without the housing and related services, experience more frequent hospitalizations, criminal justice system involvement, and crises requiring higher cost care). Full implementation of permanent supportive housing in Virginia would, according to Senator Howell, cost $100 million.

Enabling ongoing review and reform

Senator Deeds and other Joint Subcommittee members discussed a key dilemma: that prior studies of the state's mental health system had seldom resulted in more than piecemeal reforms, focused primarily on Virginia's mental health emergency response system. Meaningful change would require substantive improvements to the community-based care available throughout the state, and a state body that could continue the Joint Subcommittee's work after the expiration of its four-year charge. Senator Deeds expressed his preference that the Joint Commission on Health Care (JCHC) be given sufficient resources to continue this work on an ongoing basis.

Specific reform proposals for 2017

The Work Group chairs set out the following specific reform proposals:

Telemental Health

From Work Group #1: Request the Joint Commission on Health Care (JCHC) to review the work group report on telemental health services (described later in this article) and develop recommendations for increasing the use of telemental health services.

From Work Group #3: Amend Virginia's laws to facilitate the use of telemental health services, and in particular the prescribing of medications via telemental health, to the extent allowable under federal law. (More details on the specific proposed amendments to the Virginia Code are set out later in this article.)

Information sharing

From Work Group #1: Amend Va. Code [section] 37.2-818 to allow DBHDS access to records relating to involuntary commitments to enable DBHDS to maintain statistical archives and conduct research on the consequences and characteristics of those proceedings.

State psychiatric hospital utilization

From Work Group #1: Reduce and stabilize the current census at the state psychiatric hospitals through multiple strategies, including (1) implement census reduction initiatives adopted by DBHDS and the CSBs (described more below); (2) develop budget requests to support needed initiatives; (3) study the "statutory, policy, financing, and administrative elements of the current mental health system" that are not "aligned" with the vision of system reform; (4) direct DBHDS and DMAS to study the potential use of the Involuntary Mental Commitment Fund for both involuntary and voluntary temporary detention.

Alternative (non-law enforcement) transportation services for people in mental health crisis

From Work Group #3: Require DBHDS and other relevant stakeholders to develop a model for the use of alternative transportation providers, including the criteria for the certification of such providers and the costs and benefits associated with the implementation of the model.

Mental Health Services in the Criminal Justice System

From Work Group #2:

Provide authority to an appropriate entity, possibly the Virginia Board of Corrections (BOC), to investigate in-custody deaths in jails.

Require the use of a standardized instrument upon intake of persons into jails to screen for mental illness.

Require DBHDS to develop a plan for the provision of discharge planning services for persons with mental illness being released from jail that ensures that each jail in the Commonwealth has access to such services. The plan shall include an estimate of the cost of providing discharge planning services as well as an estimate of any cost savings that may result from the provision of such services.

Permanent Supportive Housing

From Work Group #4:

Provide $10 million in new funding for permanent supportive housing targeted to address frequent users of high-cost systems (e.g., state psychiatric hospitals and jails).

Amend the Virginia Housing Trust Fund to require that 20 percent of the Fund be used for (1) supportive services and predevelopment assistance for permanent supportive housing for the homeless and (2) temporary rental assistance.

Require the Department of Housing and Community Development, in consultation with other agencies and stakeholders, to develop and implement strategies for housing individuals with serious mental illness.

Require the Department of Medical Assistance Services (DMAS), in consultation with other agencies and stakeholders, to research and recommend strategies for financing permanent supportive housing through Medicaid reimbursement.

The Journey to the Recommendations and Actions at the October 26, 2016 Meeting

As reported in the July 2016 issue of DMHL, the four Work Groups that brought their reports and recommendation to the full Joint Subcommittee membership on October 26 had been formed in the spring of 2016, with assistance provided to the Work Groups by Expert Advisory Panels assembled by the Institute of Law, Psychiatry and Public Policy. The activities of the Work Groups and their Panels, including the presentations and materials that they considered (and which are posted on the Division of Legislative Services [DLS] website), are summarized below:

Work Group #1--System Structure and Finance

June 23, 2016 meeting: Consensus on key system problems and future system structure

Highlighted system problems

As reported in the July 2016 issue of DMHL, the SJ 47 Joint Subcommittee identified three major problems with Virginia's current public mental health services system:

(1) lack of a consistent array of services across the Commonwealth;

(2) need for uniform measures of performance and outcomes; and

(3) lack of accountability for performance and for achieving desired outcomes.

Recommended system structure

After reviewing the three major state models for community-based public mental health service systems in the U.S., Work Group #1 recommended the following at the June 23 meeting of the Joint Subcommittee:

1. That Virginia retain the current system structure, which is "largely" state funded (with some urban and suburban local governments providing substantial additional funds for services) and operated by local government agencies (the Community Services Boards) that both provide services directly and contract with private/non-profit entities for services, with the state operating the main public psychiatric hospitals; but

2. That the state substantially modify the current system by providing for "greater state direction and control"; and

3. That local entities be made "more accountable for their performance to the state and to the populations they serve."

Work Group #1's chair, Sen. Hanger, emphasized the goal of having the same behavioral healthcare services available "everywhere" in the Commonwealth, and cited the services set out in the "Certified Community Behavioral Health Clinic" model--identified by Interim DBHDS Commissioner Barber in his April 23, 2016 presentation to the Joint Subcommittee as being the model that DBHDS had embraced in its STEP-VA reform initiative--as providing a "focus" for Work Group #1's ongoing work.

August 22, 2016 meeting: System challenges and visions, and the need for reliable data

System Challenges identified by the Advisory Panel

As set out in the DLS summary of the Work Group #1's August 22 meeting (and in a memorandum from Professor Bonnie), Work Group #1's Advisory Panel identified four key system challenges that were a focus of the Panel's work:

1. Closing gaps in service capacity and access--The Panel planned to work with DBHDS to develop a cost estimate for implementing statewide the service array set out in the STEP-VA plan (based on the CCBHC model) over the course of a decade.

2. Creating necessary data capacity--The panel found that "the necessary data infrastructure does not yet exist and many of the necessary data elements are not yet available," and it planned to work with DBHDS to "build the necessary data capability to support the transformed system of care."

3. Solving cross-system challenges--Finding that the poor outcomes for people with serious mental illness often result from "gaps and misalignments in services across systems"--for example, providing safe transport for persons in crisis and appropriately diverting people with mental illness from involvement with the criminal justice system--the Panel will look at communities that have developed innovative solutions.

4. Coordinating publicly funded mental health services--The Panel submitted that lining up Medicaid funding with state and local government general funds for public mental health care is a key challenge for making the services system financially sustainable.

5. Linking community services board funding to state hospital use--Since July of 2014, when state psychiatric hospitals became the guaranteed placement of "last resort" for persons in mental health crisis, admissions to state hospitals under Temporary Detention Orders (TDOs) have increased 164%. Because the state alone absorbs the costs of this dramatically increasing admissions rate, the Panel is exploring how best to incentivize local CSBs to find better ways than hospitalization to resolve such crises.

DBHDS and the model for needed services

At Work Group #1's August 22 meeting, Daniel Herr, JD, Assistant DBHDS Commissioner for Behavioral Healthcare Services, made a presentation on the needed set of services in the state's behavioral healthcare system. The model of services Mr. Herr presented was an integration of the standards developed under the CCBHC model and those developed by the DBHDS Transformation Initiative. Mr. Herr noted in particular the problems in the current system with varying access to services, variation in available services across jurisdictions, and the over-reliance on more costly crisis services and institutional care. A key component of the proposed new system of care is "same day access" to "screening, assessment and diagnosis, including risk assessment," which promises to reduce crisis care and enable people to enter into care when they recognize a need for care.

DBHDS and data system challenges and recommendations

A DBHDS presentation on data collection noted the growing demand from multiple government, insurance, and grant-funding sources for data that meaningfully captures the effectiveness of behavioral health care services, and the current absence of a robust statewide system for gathering and sharing such data. The presentation recommended the development of a single electronic health records system for all of the state's CSBs, and the state's engagement with a consulting firm to help set the standards for development of a system that can collect, maintain and communicate meaningful outcome data. It was noted, however, that a lot of the needed technologies and standards are "emerging" technologies, so it is not easy to find the right people to do this important work.

The financial burden on localities in funding behavioral healthcare services

One reason for the Advisory Panel's recommendation to maintain the current public behavioral healthcare services structure has been the active participation by many local governments in funding services provided by the local CSBs and other providers. Work Group #1 received at its August 22 meeting a presentation on the challenging fiscal realities limiting local government participation in such services, along with "selected examples" of programs receiving local government financial support that have a behavioral healthcare component, and the specific experience of Roanoke County in funding such services.

October 26, 2016 meeting: A vision for how the system should look and specific interim reform proposals

As set out in more detail in the DLS summary of the Work Group #1 meeting on October 26, the Work Group developed the following major proposals:

Adoption of the STEP-VA (System Transformation, Excellence and Performance in Virginia)

The Work Group received two key documents for its deliberations on October 26. First, a report from Professor Bonnie, entitled "Interim Report on Core Services", began with a review of the various mental health system reform studies in Virginia over the prior 45 years, noting that each had identified the same deficiencies in Virginia's mental health services system--(1) the fragmented nature of the system (and in particular the lack of coordination between state and local systems) that allowed too many people to "fall through the cracks," (2) the high variability among the state's CSBs in the types, quantity and quality of services available (with financial and resource deficits in rural areas being particularly acute) and the disproportionate amount of funding going to hospital-based care, leaving community-based care underfunded and underdeveloped, and (3) the lack of clear accountability and oversight.

The Panel's report went on to note that the past reform studies had resulted in only piecemeal changes in different parts of an inadequate system (for example, funding additional crisis teams and "drop-in" centers, and reforming certain aspects of the ECO/TDO process), and that the remaining inadequacies had contributed to the "overwhelming" number of individuals with behavioral health needs who are now in correctional facilities. Virginia's opioid epidemic has made the consequences of these service system inadequacies even more dire.

The Panel submitted that Virginia needs a "road map" for "comprehensive" reform that "provides a clear vision of the behavioral health system we are seeking" and "identifies a sequence of specific steps designed to achieve that vision."

The Panel set out three broad criteria that a reformed system must meet:

1. It must "provide a consistent array of services and supports" throughout the state.

2. Those services must be of "high quality" and "based on evidence of what works."

3. The system must be "aligned" with current reforms in overall health care, "including integration of primary and behavioral healthcare, data-driven decision making, and outcome-based care."

The Panel reported that it supported the STEP-VA plan developed by DBHDS and the CSBs as providing the "needed vision" for comprehensive reform. STEP-VA builds on the "9+1" services model for Certified Community Behavioral Health Clinics (CCBHC) developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) under a grant program offered to the states.

The Panel report noted that DBHDS has provided a "potential timeline" for funding STEP-VA in stages, over time. The draft of the DBHDS plan, entitled "Preliminary Report on Services", lists and describes the core services that should be available to every person in Virginia who needs them, and provides an estimate of the cost of enabling Virginia's service system to provide these services. (These cost estimates are based on the self-assessment done by the eight CSBs that participated in the CCBHC grant project). Acknowledging that the financial resources do not exist to implement this system immediately, the report recommends a focus first on two services: "same day access to screening/timely access to assessment, diagnostic, and treatment services and referrals;" and "outpatient primary screening and monitoring services."

As the Panel notes in its report, starting with "same day access" places emphasis on the "front door" of the system to increase the engagement of individuals by responding immediately when they report that they need services. The current weeks-long waiting process in many CSBs (a few have actually implemented "same day access" already) results too frequently in people being unable to follow through with services, or experiencing crisis while waiting for an initial appointment and needing more intensive services. Seeing these individuals quickly will also need to be followed with promptly matching them with the services that they are found to need. The potential "payoff" is that early engagement will result in better treatment outcomes, fewer crises, and fewer incidents that result in coercive involvement with the criminal justice and social services systems. The second listed priority--primary care screening--recognizes that behavioral health cannot be separated from general health, and that addressing individuals' general health conditions significantly impacts the success of their behavioral healthcare.

The Advisory Panel report noted that realizing this vision in the step-by-step process proposed would require two key commitments:

1. Funding - There would need to be a commitment to tapping "all available funding sources": Medicaid (current and "expanded"), federal block grants, state and local funds, Comprehensive Services Act (CSA) funds, and others, and to producing efficiencies in various ways.

2. Accountability--"Virginia must establish a cross-cutting accountability structure" to monitor implementation and respond to issues that arise.

The DBHDS preliminary report added another key need: information technology and infrastructure upgrades to support implementation of the new system. The estimated cost of these upgrades is just over $20 million.

Specific Reform Initiatives

Hospital Bed Utilization:

The Panel's proposal on state hospital utilization noted that, after reform legislation in 2014 made the state psychiatric hospitals the guaranteed placement of "last resort" (for individuals in custody under ECOs who meet TDO criteria), the census at those hospitals dramatically increased, and remains above 95%, with some facilities exceeding 100%--well above levels where patient and staff safety start to decline. (Best practices set a hospital census limit of 85%.) Virginia already has a higher ratio of state hospital beds per population than the national average (17.3 per 100,000 vs. 15 per 100,000). Improving local services to reduce the need for hospitalizations is a challenge for local programs, as Virginia's state hospitals split the state behavioral healthcare budget with local services at a 50/50 rate, while nationally the split is 23% to state hospitals and 75% to local services.

A key fact noted by the Advisory Panel is that the state assumes all of the costs of caring for a person in a state psychiatric hospital; there are no financial costs to a locality when a person is sent to a state facility. A question for the Panel was whether a financing structure that created incentives for localities to prevent state hospitalizations would help to reduce the current hospitalization rate. The Panel looked at the practices of a number of different states. They noted that, as is "well understood", having the same "entity" responsible and accountable for both clinical outcomes and financial expenditures results in the most efficient delivery of the most effective care. Short of having a "single entity" approach, the Panel found a "variety of mechanisms" (cited in the proposal) in different states that "can create sufficient incentives for community providers to effectively manage state hospital utilization."

The Panel then went on to note that, in May, DBHDS started "an ongoing dialogue" with the state's CSBs and state hospitals on strategies to reduce and stabilize the utilization rate for those hospitals, including improved communication, training, transportation, discharge planning, and enhanced participation and cooperation by private psychiatric hospitals. DBHDS at that time had also identified just over 8.5 million dollars for "capacity-building" to improve locally based crisis services and enhance local capacity to care for hospital patients ready for discharge. (A DBHDS power point presentation sets out the extent of the hospital utilization problem and the various strategies being adopted with different CSBs to reduce the hospital census.) While "applauding" this initiative, the Panel noted its limited funding and scope, and the still un-addressed "structural incentives" that now exist for increased hospitalization: the "last resort" laws; the "free care" provided by state hospitals; the "discretion granted" to local private hospitals to refuse admissions; and the bias toward involuntary (vs. voluntary) care.

The Panel made the following recommendations regarding hospital utilization:

1. That DBHDS and the CSBs implement the census reduction initiative and report on the results to the SJ 47 Joint Subcommittee.

2. That DBHDS and the CSBs develop budget request(s) for FY 2018 to support the initiatives needed to keep state hospital utilization at or below 90% capacity.

3. That study continue of the elements of the current behavioral health system that are not aligned with strategic and operational objectives, or that create impediments to efficient and effective care, and recommend solutions to the Subcommittee by October 30, 2017, including the use of financial risks and incentives to achieve performance objectives.

4. That DBHDS and the Department of Medical Assistance Services (DMAS) study: (a) the potential use of the Involuntary Mental Commitment Fund (IMCF) for both voluntary inpatient treatment and involuntary temporary detention, to create an incentive to reduce the use of involuntary treatment statewide; (b) possible transfer of the IMCF fund from DMAS to DBHDS; and (c) other strategies for improving the use of these funds.

Telemental Health:

The Advisory Panel noted that research and practice in Virginia and in other states has established that a variety of mental health services can be provided through telecommunication--from expert consultation with healthcare providers to conducting diagnostic and treatment sessions with patients to remotely monitoring a patient's health and behavior--thereby making services available to individuals (particularly those living in the rural areas of the state) who otherwise would be unable to reach those services. Thus, telemental health is "not only a viable but an essential tool for bridging the existing care gap." However, "despite its demonstrated utility," it has not been widely adopted in Virginia. A Telemental Health work group was formed to look at the current barriers to wider use of telemental health services and to recommend actions to overcome those barriers. Its report identified and addressed five types of barriers: provider barriers, workforce barriers, financial barriers, patient/client barriers, and policy barriers. It listed 30 policy and practice options for overcoming these barriers, and made 12 specific recommendations for immediate consideration. For most of those, the work group recommended, and the Panel concurred (in a document entitled "Expanding Use of Telemental Health Services in the Commonwealth"), that the Joint Commission on Health Care is the most appropriate body for further reviewing and developing implementation strategies for those recommendations, and reporting its findings and recommendations to the Joint Subcommittee in 2017.

Data Sharing Challenges

The Panel noted that key data for evaluating the mental health emergency response system includes information from involuntary commitment hearings. Because Virginia law has no provision for enabling the Supreme Court of Virginia to share with DBHDS the confidential data from commitment hearings, the Panel proposed an amendment to Virginia Code [section] 37.2-818 to require district courts to provide this information to DBHDS upon request.

Work Group #2--Criminal Justice Diversion

June 23, 2016 meeting: Selecting priorities for criminal justice diversion

As reported in the July 2016 issue of DMHL, by June of 2016 Work Group #2's interests had coalesced around the following matters: (1) how persons with mental illness are diverted from the criminal justice system in other states, including the stage or stages in the criminal justice process at which diversion occurs, and the crimes that are eligible for diversion; (2) mental health courts, with a focus on showing how such courts actually improve outcomes for the individuals who participate in them, how best to ensure uniform "best practices" in their operation across the state (if implemented), and an explanation of why defendants choose to participate in these courts when they require defendants to comply with so many conditions, including additional services, supervision and review hearings; (3) consideration of codifying or otherwise formalizing the creation of Mental Health/Criminal Justice Stakeholder groups in the Commonwealth; and (4) how best to standardize mental health screening for inmates, ensure access to needed psychiatric medications for those in jail, and provide effective discharge planning to link inmates with mental illness to community services upon release.

In meetings in June and July, the Advisory Panel discussed issues and established working groups regarding: mental health courts (and in particular legislators' concerns about costs, efficacy, and the public perception of different, and therefore unequal, treatment of individuals in these courts); treatment in jails of persons with serious mental illness; creation of Mental Health/Criminal Justice Stakeholder groups; and mental health discharge planning for persons with serious mental illness being released from jail.

August 22, 2016 meeting: Looking at mental health courts, diversion services, and investigations into mental health treatment in jails

Mental Health Courts

Work Group #2 heard a presentation from the Hon. Jacqueline Talevi, Chief Judge of the General District Court for the 23rd Judicial District (Roanoke and Salem), regarding the "therapeutic court" established there for persons with serious mental illness. That program, with screening of willing participants, intensive treatment and support services, supervision and review, a 12-month time frame, and reduction of sentence or sentencing to "time served" for those completing the program, is similar to other programs elsewhere in Virginia. However, as shown by the Virginia Mental Health Docket Matrix developed by Jana Braswell of DBHDS (and a member of the Advisory Panel), there are notable differences among the seven dockets that are compared in the matrix. There is only one circuit court--the Norfolk Circuit Court--identified as having a mental health docket.

Diversion and Community Services

Michelle Albert, LPC, CSOTP, the Jail Diversion Therapist Supervisor for the Alexandria CSB, provided a power point presentation on Alexandria CORE (Collaboration for Recovery and Re-Entry). The CORE program is an interagency collaboration that operates under the Alexandria Community Criminal Justice Board (CCJB) and the Board's Jail Diversion Subcommittee. The program utilizes the 5-stage sequential intercept model, and identifies individuals in those different stages of criminal justice system involvement who have serious mental illness and appear to be amenable to services to help them stabilize and avoid re-arrest and incarceration. Most of the program participants enter the program as part of the jail pre-discharge planning process (Stage 4: Re-entry) or while under community probation supervision (Stage 5: Community Corrections/Community Support). Among the remarkable accomplishments of the program staff working with these individuals is their securing key benefits--insurance coverage, SSI or SSDI benefits, supportive housing--that significantly improve and stabilize clients' living conditions. In a study of program efficacy, it was found that, in the year following their discharge from jail, CORE clients experienced an 82% reduction in their total days of incarceration, and 78% of them were not re-incarcerated at all.

In-custody jail death investigations

The Work Group also heard a presentation from Colonel Bobby D. Russell, Superintendent of the Western Virginia Regional Jail and President of the Virginia Association of Regional Jails, on the investigation of deaths of inmates in jail custody. According to Colonel Russell, whenever there is such a death, the jail contacts: (1) either the local law enforcement or the State Police, for an independent investigation; (2) the Office of the Medical Examiner (since an autopsy is performed for any such death); and (3) the Board of Corrections (BOC), which is responsible for jail oversight and conducts jail inspections through the Department of Corrections. In any death the regional jail also conducts its own internal investigation concurrently with the law-enforcement agency investigation. Colonel Russell saw the BOC as the most appropriate body for assessing jail performance, given its statutory duty and authority in regard to jail operations and its familiarity with those operations. He did not see the Office of the State Inspector General (OSIG) as "set up" to investigate local and regional jails and other agencies, and he was not surprised at the OSIG's report that, in its investigation of the death of Jamycheal Mitchell at the Hampton Roads Regional Jail, the OSIG was unable to gain access to the jail for purposes of investigating Mr. Mitchell's death.

A summary of the Work Group's August 22 meeting, which is posted on the DLS website, can be found here.

October 26, 2016 meeting: Setting criminal justice diversion priorities

As set out in more detail in the DLS summary of the Work Group's meeting on October 26, Work Group #2 developed the following major proposals:

Authorizing an appropriate independent entity to investigate treatment of inmates at jail facilities

The Work Group heard from employees of the Office of the State Inspector General (OSIG) who had acted as "whistleblowers" in claiming that, in its investigation into the 2015 death of Jamychael Mitchell at the Hampton Roads Regional Jail, the OSIG, among other things, (1) failed to use its authority to investigate the role of the jail and its medical services provider in Mr. Mitchell's death, (2) had undisclosed and compromising conflicts of interest due to OSIG staff relationships with leadership in DBHDS, (3) had been aware, prior to Mr. Mitchell's death, of information on serious patient and staff safety issues and staff workload problems at Eastern State Hospital that had been actively suppressed. In a statement submitted to the Work Group, the whistleblowers questioned whether, given the cited problems, the OSIG could be entrusted with the responsibility to conduct independent investigations of the mental health treatment of inmates in local and regional jails. They noted that the Attorney General's request to the U.S. Department of Justice to conduct an investigation into Mr. Mitchell's death indicated the serious loss of confidence in the efficacy of the OSIG, and they asked for action by the General Assembly to ensure that jail inmates with mental health needs receive the care they need. The whistleblowers responded to a number of questions from Work Group members.

In the follow-up discussion, there was consensus that an "appropriate entity" must be given clear authority to conduct investigations into "in-custody deaths" in jails, and while much of the discussion centered on the possibility of giving the Board of Corrections this authority, no consensus was reached.

Requiring the use of a standardized instrument at intake to identify persons coming into jail who have mental illness needing treatment

DBHDS Commissioner Barber made a PowerPoint presentation to the Work Group on mental health screening in local and regional jails, showing that there are validated screening tests (75% accuracy) that can be used by trained jail staff to identify inmates who have mental health conditions requiring treatment. The Commissioner noted that, while Virginia has long encouraged jails to use a screening instrument, many jails still do not use one, and the jails using screening instruments are using different ones. He recommended that the General Assembly support/mandate the use of standardized mental health screening processes in local and regional jails, noting that the requirement for such screening can be incorporated into state regulations or included in budget language. Commissioner Barber recommended that, rather than mandate a particular screening instrument, the General Assembly give the DBHDS Commissioner, or the Board of Corrections, the authority to name the tool to be used.

The Work Group's Advisory Panel also recommended that jails be required to use a standardized mental health screening instrument, as set out in a presentation to the Work Group by the Panel's chair, Leslie Weisman, LCSW. The Work Group voted to adopt and put forward that recommendation.

Developing a plan for mental health discharge planning services for persons with mental illness being released from jail

In her presentation to the Work Group regarding recommendations from the Panel, Ms. Weisman reported that jail discharge planning was deemed by the Panel members to be of paramount importance, and that every jail should have access to a jail discharge planner. She noted that community services boards (CSBs) currently perform this service for individuals being discharged from state hospitals, and submitted the Panel's recommendation that DBHDS develop a plan to ensure that discharge planning occurs at every jail.

The Work Group adopted a proposal that DBHDS develop a plan for the provision of discharge planning services for persons being released from jail that ensures that each jail in the Commonwealth has access to such services. The plan must include an estimate of the cost of providing discharge planning services, as well as an estimate of any cost savings that may result from the provision of such services.

Other criminal justice diversion services remaining under study

As reflected in Ms. Weisman's report to the Work Group on October 26, and in the summaries of the Panel's meetings on September 15 and October 11, the following matters remain under study.

Mental Health Dockets: As reported by Ms. Weisman at the Panel's September and October meetings, the Virginia Supreme Court formed a Behavioral Health Docket Advisory Committee, chaired by Judge Talevi, to establish standards that must be met by any court that wants to establish a behavioral health docket. Ms. Weisman also noted to the Panel members that Work Group #2 members wanted more information on why defendants agree to participate in these dockets when they demand so much compliance with various services and what the source of satisfaction is for defendants who complete the special docket program. The Panel members made plans to conduct research on these questions in 2017, including interviews with participants in current Virginia programs.

(Note: In an action taken on November 14, 2016 and effective January 16, 2017, the Virginia Supreme Court adopted and promulgated a new Rule 1:25, "Specialty Dockets," establishing a set of standards and procedures that any district or circuit court must follow if it wishes to establish one or more "specialty dockets," which are defined as "specialized court dockets within the existing structure of Virginia's circuit and district court system offering judicial monitoring of intensive treatment, supervision, and remediation integral to case disposition." Rule 1:25 recognizes three types of "specialty dockets"--drug treatment courts, veterans dockets, and behavioral/mental health dockets--with behavioral/mental health dockets described as dockets that "offer defendants with diagnosed behavioral or mental health disorders judicially supervised, community-based treatment plans, which a team of court staff and mental health professionals design and implement." A district or circuit court wishing to establish one of these specialty dockets--or to continue an existing one--must petition the Supreme Court for authorization, and in that petition it must "demonstrate sufficient local support for the establishment of this specialty docket, as well as adequate planning for its establishment and continuation."

The new rule empowers the Chief Justice to establish, by order, a Specialty Docket Advisory Committee and appoint its members, and to also establish and select the members of the advisory committees for each of the approved types of specialty dockets. (The rule declares the State Drug Treatment Court Advisory Committee, established under Va. Code Section18.2-254.1, as constituting the Drug Treatment Court Docket Advisory Committee under this rule.)

The new Rule 1:25 is on the Virginia Supreme Court website, and is linked here.

Standardized Mental Health Treatment in Jails:

The Panel noted in its discussions the recommendation of the DBHDS "Justice-Involved Transformation Team" that there be standardized mental health treatment in jails, and in her presentation to the Work Group, Ms. Weisman submitted the need for "minimum standards" for mental health treatment in jails. This issue was not taken up by the Work Group at the October 26 meeting.

Criminal Justice Stakeholder Groups:

In the meetings of both the Panel and the Work Group, Ms. Weisman has argued for the importance of local stakeholder groups in monitoring any changes in services provided to persons with mental illness. While no consensus on this has developed, the Panel is developing a survey to send out to CSBs to determine what similar stakeholder groups are already operating.

Work Group #3--Mental Health Crisis Response and Emergency Services

June 23, 2016 meeting: Selecting mental health emergency service priorities, and reviewing alternative transportation models for persons in mental health crisis

As reported in the July 2016 issue of DMHL, the Advisory Panel report to the Work Group identified four main subject areas in need of immediate attention: (1) the development of regional psychiatric emergency services (PES) units to improve crisis outcomes and reduce both "psychiatric boarding" in hospital Emergency Departments and psychiatric hospitalizations; (2) the use of telepsychiatry in the crisis context to increase access to psychiatric treatment in mental health crises; (3) the use of a medical or other alternative model of transportation for individuals in crisis in place of the current law-enforcement model, to reduce trauma for individuals and families while maintaining safety and to use law enforcement services more effectively; and (4) the identification of a core service model of treatment services for those in crisis. The Work Group reviewed the Panel recommendations at its June 23 meeting, and also received a presentation from DBHDS on the alternative transportation pilot project in the region served by the Mt. Rogers Community Services Board, and a presentation from the Virginia Sheriffs Association on the impact of required law enforcement transportation on local sheriffs departments and the Association's support for the Mt. Rogers project and similar alternative models.

August 22, 2016 meeting: Confirming the importance of telemental health services

At its August 22 meeting (described in more detail in the DLS summary found here on the DLS website), the Work Group received (1) a presentation from the University of Virginia on its telepsychiatry program and the demonstrated effectiveness of telepsychiatry, particularly in reaching individuals in seriously under-served rural jurisdictions; (2) a presentation from Centra Health on its use of telepsychiatry in its outpatient mental health programs, with important observations on the need for such technology in the face of the current serious shortage of psychiatrists, particularly for children and adolescents; and (3) a presentation from the Virginia Association of Health Plans and Virginia Premier Health, Inc., regarding the value of telepsychiatry in various settings--particularly in the treatment of children and elderly nursing home residents--and the challenges posed by uneven insurance coverage for such services.

October 26, 2016 meeting: Recommending reform action

The Advisory Panel submitted a report to the Work Group in preparation for its October 26 meeting setting out recommendations regarding the key reform measures, including: On transportation: supporting the continuation and possible expansion of the Mt. Rogers pilot (if certain cost issues could be controlled), initiation of a similar pilot in an urban community and continued research into other models and possible funding mechanisms. On telemental health: support for the recommendations from two separate telemental health groups: (1) the recommendations from Sen. Dunnavant's "stakeholders group" on enabling the prescribing of Schedule II-V drugs via telemental health services; (2) overcoming the multiple barriers to expanded use of telemental health services through the initiatives recommended by the telemental health group established jointly by the Work Group #1 and Work Group #3 Advisory Panels. (As noted above, Work Group #1 and its Advisory Panel specifically recommended referral of the telemental health group's recommendations to the Joint Commission on Health Care for further study and action.)

On Psychiatric Emergency Services (PES) units: support for continued study of potential models from other states, and possible future pilot sites developed from existing CIT Assessment Centers.

On Core Emergency Services: support for the STEP-VA initiative in identifying and defining the set of "core" services needed to establish an effective community-based mental health services system. (This has since become a key part of the work of Work Group #1.)

At the October 26 meeting itself (as set out in more detail in the DLS summary found here), the Work Group considered the following:

Support for alternative transportation

Del. Garrett, the Work Group chair, discussed the Mt. Rogers project, which, with over 300 alternative transports without any incident, has helped to establish that non-law enforcement crisis transport can be provided safely. However, he noted, costs and other considerations preclude continuing that particular project. Based on his discussions with various stakeholders, Del. Garrett suggested, and the Work Group members supported, a possible Section 1 bill for the 2017 session, directing DBHDS and DCJS, with full stakeholder participation, to develop a comprehensive model for alternative transport of persons in mental health crisis. A report and proposed model would be due to the Joint Subcommittee by October 1, 2017.

Support for code and regulatory changes to enable medication prescription through telepsychiatry

W. Scott Johnson, Esq., who coordinated the stakeholders group established by Sen. Dunnavant to address statutory and regulatory restrictions on medication prescription via telepsychiatry, spoke to the Work Group (with Sen. Dunnavant attending and sitting with the Work Group members). As set out in more detail in Mr. Johnson's letter to Del. Garrett and Sen. Dunnavant (and in the DLS summary), under federal law Schedule II-V controlled substances cannot be prescribed by a physician via telemedicine unless the patient (1) is in a hospital or clinic that is registered with the Drug Enforcement Administration (DEA) as a permitted drug-dispensing site or (2) is in the presence of a DEA registered practitioner (a physician or "mid-level provider"). Mr. Johnson reported that, as part of the stakeholders group initiative, DBHDS and the Board of Pharmacy have been working together on a process to enable local CSBs to obtain state controlled substance registrations through the Board of Pharmacy that would enable the CSBs to obtain a DEA registration and thereby have active telepsychiatry, including medication prescriptions via telepsychiatry, at the CSB sites. The Board of Pharmacy noted that legislation is required to clearly authorize the issuance of controlled substance registrations to the CSBs. A proposed amendment to Virginia Code Section 54.1-3423 to provide such authorization was attached to Mr. Johnson's letter.

Mr. Johnson also reported that Section 54.1-3303 of the Virginia Code is the primary statute that sets out "what constitutes a valid prescription," and that the statute includes language addressing the prescribing of Schedule VI drugs via telemedicine. Noting that an "action item" for both the stakeholders group and the SJ 47 Work Group #3 was to ensure that state laws on telemedicine are not more restrictive than federal laws, the group's recommendation is to amend Section 54.1-3303 to clarify that a practitioner's compliance with federal law constitutes compliance with state law. A proposed clarifying amendment to Section 54.1-3303 was attached to Mr. Johnson's letter.

Delegate Garrett and Senator Dunnavant expressed their support for these proposed changes to facilitate telepsychiatry, and they described telepsychiatry as an innovative and needed way to connect health care providers to underserved populations in both rural and urban areas across the Commonwealth.

Improving Response to Mental Health and Drug Use Emergencies through Emergency Department Care Coordination

Representatives of the Virginia Hospital and Healthcare Association, the Virginia Association of Health Plans, and the Commonwealth Strategy Group made a PowerPoint presentation on the "Care Coordination and Improvement Initiative" that arose out of language in the General Assembly's 2016 budget mandating the Department of Medical Assistance Services (DMAS) to convene a work group to improve emergency department (ED) care. As the presentation emphasized, ED staffs face a highly fragmented health care system with poor communication and little information sharing among its various parts. This seriously compromises the ability of ED staff to effectively serve patients and refer them to community based follow-up services that prevent returns to the ED.

The work group found that other states, including Washington and Oregon, have successfully implemented a system of "real-time electronic communication among providers and across systems" that enables ED staff to better assess, treat and refer patients. This has resulted in improved care coordination and cost savings.

The care coordination model focuses particularly on "super utilizers": individuals who repeatedly use the ED but could be better served with coordinated outpatient care. Timely information sharing among providers improves treatment in the ED and enables continuity of care for these individuals instead of repeated crises and ED visits. Washington experienced a 9.9% drop in emergency room visits by the Medicaid population after the incorporation of this model, with roughly $34 million in savings and a 27% reduction in opioid deaths.

A governance model is being developed for Virginia, which will identify the ongoing key stakeholder leadership and form a sustainable funding model, with the system to be running by July 1, 2017. An RFP process will be used to select a vendor to integrate the electronic information systems of the involved entities.

Work Group #4--Housing

June 23, 2016 meeting: Confirming the evidence that "Permanent Supportive Housing" dramatically improves the lives of persons with serious mental illness and lowers the costs of care

As reported in the July 2016 issue of DMHL, Senator Howell, the chair of Work Group #4, noted at the June 23 meeting of the SJ 47 Joint Subcommittee that "permanent supportive housing" is a "universally accepted 'best practice'" in effectively reducing homelessness among persons with serious mental illness." Its effectiveness in both stabilizing the lives of persons with serious mental illness and dramatically reducing the costs of service to them (through reductions in ER visits, involuntary commitments and criminal justice system involvement encounters) has been demonstrated in Virginia's own programs (as shown here). The Work Group's Advisory Panel submitted a number of tentative recommendations for securing additional permanent supportive housing services.

August 22, 2016 meeting: Permanent supportive housing as a necessary service for compliance with Americans with Disabilities Act (ADA) under the Olmstead decision

At the August 22 meeting, the Work Group considered the need for a more robust permanent supportive housing program for individuals with serious mental illness in order to comply with the standards of the ADA. In a PowerPoint presentation to the Work Group, Ms. Martha Kinsley noted that, in its 1999 decision in the Olmstead case, the U.S. Supreme Court held that under the ADA "states have an affirmative obligation to ensure that individuals with disabilities live in the least restrictive, most integrated settings possible." Ms. Kinsley is the "Olmstead Independent Reviewer" for implementation of the settlement agreement between the U.S. Department of Justice and the State of North Carolina, under which the state has agreed to establish a program of permanent supportive housing, including specified related supportive employment and other services, to enable individuals with serious mental illness to live in "the least restrictive, most integrated settings possible." Ms. Kinsley pointed out that settings that are deemed "segregated" include adult/personal care homes, nursing homes, and segregated day programs, which are placements typical of those made in Virginia for many persons with serious mental illness.

October 26, 2016 meeting: An agenda for expanded permanent supportive housing

At its October 26 meeting, the Work Group accepted and presented to the SJ 47 Joint Subcommittee the following recommendations from its Advisory Panel (set out in more detail here):

1. Seek General Assembly funding for the operation of additional permanent supportive housing units, with a focus on frequent users of "high-cost systems" (e.g., psychiatric hospitals and jails).

2. Amend Virginia law to increase to 20% the percentage of funding from the Virginia Housing Trust Fund designated for (a) supportive services and assistance for permanent supportive housing and other long-term housing options for the homeless, and (b) temporary rental assistance (not to exceed one year).

3. Include in the General Assembly's charge to the Department of Housing and Community Development (DHCD) a requirement that it develop and implement, with participation by multiple agencies and stakeholders, strategies for housing individuals with serious mental illness.

4. Include budget language that requires DMAS to research and recommend, with participation by multiple agencies and stakeholders, strategies for the financing of supportive housing services through Medicaid reimbursement.

The last meeting of the SJ 47 Joint Subcommittee for 2016 is currently set for December 6. It is expected that action will be taken on a number of the proposals from the Work Groups.
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Publication:Developments in Mental Health Law
Date:Oct 1, 2016
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