Deinstitutionalization, in the original concept of moving individuals out of institutions and providing them with community supports to achieve their treatment goals, is no longer a goal, but an actuality. Many Virginians with mental health needs are currently receiving services in the community which has enabled them to avoid institutionalization, thus bypassing the heretofore traditional usage of the term "deinstitutionalization." While institutions rightfully must be a vital part of the continuum of services needed by some clients, it is but one part of that continuum.

The Commonwealth, like many other states over the past thirty years, has endeavored to find ways to provide the community supports necessary to met the crucial needs of the client requiring services from the mental health, mental retardation and substance abuse system, but has encountered numerous impediments to a design which recognizes a true continuum of services where the funding stream meets the needs of the individual rather than the system structure. The concept of "single stream funding" has long been the goal of the system but implementation has been hindered because of a system which does not allow substantial reinvestment of institutional savings to meet the need of the client in the community. The joint subcommittee, after hearing much testimony and examining the needs of the system which provides services to the mentally disabled, concluded that the time has come to look to the future and develop a system which can more fully help current clients as well as those on waiting lists.

During this time period, since the inception of the community-based treatment and the establishment of the community services boards system, several legislative commissions, including the Bagley and Hirst Commissions, as well as studies by the Joint Legislative Audit and Review Commission, have endorsed the importance of care in the least restrictive environment possible. In that time, the average daily population census of mentally ill clients treated in state mental health facilities has dropped from 9,343 in 1970 to 2,417 in 1995, and the census in the state mental retardation facilities has likewise dropped from 5,327 to 2,249 in that same period. But recent figures show that while facilities serve only 4.8 percent of the mentally disabled population, funding for those facilities accounted for 68.1 percent of state support for the mental health budget and 49.7 percent of the system's total federal, state, local, and fee support. On the other hand, approximately 95.2 percent of the mentally disabled population were served through the community services boards, using 26.6 percent of the state budget and 46.7 percent of the system's total federal, state, local, and fee support. Unfortunately, while specific projects have been able to transfer funds for the purposes of census reduction, state budgeting and statutory restrictions prohibit the general transfer of any resultant savings at institutions to the community services sector. Funds realized through budget economies usually return to the General Fund. Today, although the state serves over 185,000 citizens each year, another 10,000 remain on waiting lists. As a caveat, though, differentials must be noted when comparing a number of services, both in their intensity and resultant cost. Services provided in facilities are clearly more intensive and therefore are more expensive than community services in general, so there is not a direct one-to- one correlation. However, the Joint Subcommittee, while recognizing these differentials, felt that it would behoove the state to carefully examine other funding methodologies which might have the potential capacity to more nearly serve the clients' needs in a fiscally responsible and efficacious manner. Clearly, a change is in order and is supported by all of the various players, including the Department of Mental Health, Mental Retardation and Substance Abuse Services, the CSBs, and consumers and families.

The joint subcommittee made significant headway in putting these issues on the table and identifying a number of concepts which, if implemented properly, it felt would enhance the mental health service delivery system and truly provide adequate and appropriate services to the client. These concepts, in brief, include:

• The Department of Mental Health, Mental Retardation and Substance Abuse Services is the state MHMRSAS authority, responsible for the overall planning and development of a continuum of mental health, mental retardation and substance abuse services to individuals with serious mental illnesses, mental retardation and substance abuse problems throughout the Commonwealth. As the state MHMRSAS authority, the Department is responsible for assuring accountability to the Governor and General Assembly through such mechanisms as licensing providers, negotiating performance contracts with CSBs, establishing guidelines for services, monitoring outcomes, and assuring consumer access, participation and rights. However, it is imperative that community-based planning, including consumers, families, local government, providers and others who have a stake in the provision of care, continue to be a vital, driving force in the determination and provision of such care.

• The Commonwealth, in developing a system that not only contains cost but also is outcome oriented to provide for better, more appropriate care, must place the needs and desires of the client in primary focus.

• Funding for services for the mentally disabled in the Commonwealth does not yet meet the needs of the client population and, therefore, should not be decreased at this time. Inherent in this concept is the determination or definition of eligible populations.

• Savings realized from the downsizing of mental health facilities should be redirected to the benefit of the client population rather than the general fund as currently mandated by the Department of Planning and Budget.

• In this day of increased pressures brought on by continued downsizing of state facilities without reinvestment of funds saved into the system, anticipated changes in federal programs of Medicaid and mental health and substance abuse block grant funding, and greater use of managed care, every effort must be taken to maximize and protect the funds which are available through a number of methods, including waivers for "carve-outs" for Medicaid funds which are used for the delivery of mental health and mental retardation services or to ensure that the same funds are available under a state block grant scheme.

• In order to accomplish single stream funding, consideration must be given to the idea of redirecting facility funding to be integrated with all other mental health, mental retardation and substance abuse funding currently available to serve Virginians in need of such services so that, indeed, the stream of funding follows the client.

• To deliver adequate services which are appropriate to the client, a network of public and private providers must continue to be utilized and expanded.

• To be fiscally responsible, the system should contain costs and not be shifted to local governments.

• In order to test the concept of redistribution of funds from institutions to community-based care, the joint subcommittee supports the creation of one or more pilot projects, to be implemented by the Department of Mental Health, Mental Retardation and Substance Abuse Services. Plans for such projects should be presented prior to implementation and should include requirements for regular oversight and evaluation.

The joint subcommittee, during its first year of deliberations, did offer legislation to enhance the process of outpatient commitment. Serving the client in the community is the hallmark of the community-based system of services, but determination of appropriate clients who can be properly treated in the community is difficult. Judges, for the most part, must decide, based on testimony from the client, advocates, and mental health professionals whether the client is capable of benefiting from such treatment and these judges have stated that the guidelines were too vague, and guarantees of services to be provided were not always available. To address this, the joint subcommittee recommended legislation which would provide additional guidelines for the judge as well as guarantees of service provisions and a "contract" with the client in which the client indicates a desire for outpatient treatment and agrees to participate in his treatment. House Bill 2126, passed by the 1994 Session of the General Assembly, added language to the Code regarding involuntary commitment and treatment (5 37.1-67.3) which provides that after the judge initially determines that the client needs treatment and that less restrictive alternatives to institutionalization are suitable, and if the judge subsequently determines that . . ."(i) the patient has the degree of competency necessary to understand the stipulations of his treatment, (ii) the patient expresses an interest in living in the community and agrees to abide by his treatment plan, (iii) the patient is deemed to have the capacity to comply with the treatment plan, (iv) the ordered treatment can be delivered on an outpatient basis, and (v) the ordered treatment can be monitored by the community services board or designated providers, then the judge shall order outpatient treatment ..."