HD46 - Interim Report on The Study of Commitment Options for Persons with Primary Substance Abuse Problems


Executive Summary:
HJR 269 was passed by the 1994 Session of the General Assembly to address the impact persons with primary substance abuse problems have on local services and state mental health facilities. The impetus for the study arose from a prior study, "The Impact of Public Inebriates on Community and Criminal Justice Services, Systems" (House Document 46, 1994 Session of the General Assembly). In addition, the Department of Mental Health, Mental Retardation and Substance Abuse Services began studying the significant number of admissions who were primary substance abusers to state mental health facilities.

Although substance abuse can co-exist with serious mental illness, the individual experiencing primary substance abuse does not present the duration of impaired functioning consistent with serious mental illness. Primary substance abuse does present episodic impairment in functioning. The periodic nature of impairment, even if severe, does not indicate the need for the milieu or ancillary services currently provided by state mental health facilities.

In Virginia, public substance abuse treatment services are provided by a community services board system, which provides mental health and mental retardation and substance abuse services throughout the state. In Fiscal Year 1993, $70,861,482 was allocated for substance abuse treatment to the community services boards which provided substance abuse treatment services to 56,548 individuals. All community services boards must provide, at a minimum, emergency services. All do provide outpatient services, and all have access to residential services such as community-based detoxification, primary care and therapeutic communities. However, community programs are generally operating at capacity, and often have waiting lists for services.

In fiscal year 1994, 1,693 admissions occurred to state mental health facilities for persons with primary substance abuse. At an average estimated per diem of $234, and an average length of stay of nearly 26 days, the cost amounted to $10,144,230, resulting in an average cost per admission for a person with primary substance abuse of $5,991. By comparison, the estimated per diem of residential treatment for primary substance abuse in the community is $78, with an average cost per admission of $1,540.

In addition to cost issues, the milieu of state mental health facilities is not clinically appropriate for persons with primary substance abuse. Although these persons do experience life-threatening crises, these could probably be addressed more appropriately in community based programs. Admission to state mental health facilities may not be the best intervention, either clinically or from the perspective of cost-effectiveness.

Three major categories of options to changes in the Code of Virginia can be pursued by the study committee:

Option A: Continue current practice of civil commitment for person with primary substance abuse to state mental health facilities;

Option B: Amend the Code to exclude civil commitment to state mental health facilities for persons with primary substance abuse and amend Department policy to exclude voluntary admissions to state mental, health facilities with primary substance abuse;

Option C: Amend the Code to establish specific civil commitment options in the community for persons with primary substance abuse and reinvest current department resources in the community in order to insure that capacity .and programming are sufficient and appropriate to meet demand created by diverting this population.

It is Option C that best addresses the intent of HJR 269, and so it is this option which the study is designed to explore in detail. The study will utilize survey techniques to select clinical records of patients admitted three or more times during Fiscal Years 1993 and 1994 to state mental health facilities. Information will be collected to indicate the types, levels and capacity and locations of services necessary to serve the patient in the community. In addition, sheriffs and judiciary will also be surveyed to collect information regarding the impact of such a proposed change.

This information will form the basis of recommendations focused on redesigning the substance abuse treatment service delivery system so that persons with primary substance abuse receive the best clinical care at the least burden to the taxpayers of Virginia. These data will provide information regarding the types, capacity and geographic distribution of needed services, the cost of providing them in the community and ideas for funding through reinvestment, the impact on local law enforcement and the judiciary.

The study group will propose amendments to the Code to provide appropriate authority and support for improving the service system. Also, the group will review Department policy and suggestions for revisions, with the end result being that commitment to state mental health facilities is eliminated as a commitment option, and community-based commitment options for persons with primary substance abuse are created.

Thorough review and discussion of the information collected in this process will insure that sound, clinically appropriate treatment is available and accessible at the community level for persons with primary substance abuse now being admitted to state mental health facilities, and that available resources are used more efficiently.