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Deeds subcommittee to consider financial restructuring of Virginia mental health system

News & Advance - 11/29/2017

A joint legislative subcommittee created almost four years ago after a state senator's family tragedy now faces an urgent deadline to transform Virginia's mental health system to shift patient care and taxpayer funds away from state institutions.

The Joint Subcommittee to Study Mental Health Services in the 21st Century has two years left to guide the restructuring of a mental health system that spends half of its money on institutions that serve just 3 percent of the Virginians who receive public mental health care in the state. Virginia spends twice the national average on institutional care.

Nine institutions - most of them housed in antiquated facilities that require replacement or major renovations - are under unsustainable pressure to care for the sickest patients turned away by private hospitals with nowhere else to go, warned Dr. Jack Barber, interim state commissioner of behavioral health and developmental services.

"We're already on fire - and the fire is going to get hotter," Barber told a work group of the joint subcommittee, which is scheduled to meet Tuesday to make recommendations to the General Assembly on how best to realign the way Virginia pays for services for people with mental illness and other behavioral health disorders.

Subcommittee Chairman R. Creigh Deeds, D-Bath, said the state inevitably must shift most of its money into community-based services instead of institutions, even if it means closing state hospitals that long have been sources of jobs and a lifeline for people with mental illness.

"We get too hung up on institutions because of jobs in the community," he said after a work group meeting Monday on system structure and financing. "We have to focus on the welfare of people - that's the bottom line."

It was Deeds' family tragedy that led to the subcommittee's creation in 2014, initially for four years and extended this year to Dec. 1, 2019. His 24-year-old son, Gus, killed himself after repeatedly stabbing his father in November 2013, less than 13 hours after being released from court-ordered emergency custody because the system failed to find a psychiatric hospital bed for him in time.

The subcommittee was created as part of a package of legislation that ultimately guaranteed a bed in a state mental hospital for anyone who, like Gus, had been found a danger to himself or others but could not be placed in a private psychiatric hospital.

The guarantee effectively ended the practice of "streeting" people who meet the standard for involuntary commitment, but it also created unbearable pressure on state hospitals that have seen an increase of 3,000 people admitted each year under temporary detention orders. The hospitals cannot discharge people fast enough, often because they have nowhere to go, so 171 people who were clinically ready for discharge remained institutionalized in September.

"I can't imagine what it's like to be ready to leave the hospital and be told to wait," said Barber, a psychiatrist who previously served as the longtime director of Western State Hospital in Staunton.

The state has increased its spending on ways to better serve people in community settings through the STEP VA initiative adopted early this year, as well as permanent supportive housing for people to live in after leaving hospital care, and the purchase of beds in private psychiatric hospitals to relieve stress on state institutions.

But the percentage of patients admitted to private institutions under temporary detention orders has declined from 93 percent in 2014 to an estimated 81 percent in this fiscal year.

"This is putting a much greater demand on TDO admissions to state hospitals," Barber told the House Appropriations Committee at its budget retreat in Portsmouth two weeks ago.

His proposed solution is a major increase in state spending to expand options to care for people in community settings and allow state hospitals to discharge people who are clinically ready to go.

Even if the state continues "business as usual," with an additional $34.2 million in the next two-year budget and $67.5 million in the following biennium, the number of people committed to state hospitals still would exceed their capacity in four years.

Currently, the hospitals are operating at 95 percent of their capacity and growing at 2 percent a year.

"When you have this many people in the hospital, you can't separate people," Barber told the Appropriations Committee on Nov. 14. "You have to put people together who don't belong together."

So, he is proposing a four-year plan to build community capacity for mental health treatment that would relieve pressure on the hospitals and allow the state to fundamentally realign the way it pays for services. The plan would require an additional $20.4 million in this biennium for a total of $54.6 million and an additional $15.5 million in the next for a total of $83 million in 2020-2022.

The "community integration plan" would create more supported housing opportunities for people in community settings and enable the state to discharge more people from institutions - 178 the first year and 144 the next. By the third year, the state proposes to reduce its daily hospital census by 80 beds and begin preparing for financial alignment after the fourth year.

Instead of funding the state and community systems separately, financial realignment would send the money to community services boards and behavioral health authorities to provide all necessary services. "We put the money into the communities and let the communities buy the services," Barber said Monday. "If the person needs to be in the (state) hospital, you pay the hospital."

For the plan to work, Senate Finance Co-Chairman Emmett W. Hanger Jr., R-Augusta, said the state would have to provide "bridge funding" to prepare communities to accept patients who now depend on institutional care.

"You have to build community-based capacity before you downsize the institutions," Hanger said.

 
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