The Joint Subcommittee Studying the Future Delivery of Publicly Funded Mental Health, Mental Retardation and Substance Abuse Services (House Joint Resolution 240) was directed by the 1996 Session of the General Assembly to conduct a comprehensive evaluation of the Commonwealth's system of delivering mental health, mental retardation and substance abuse services. During the course of its two-year study, the joint subcommittee found both significant strengths and opportunities for improvement in Virginia's services delivery system. The joint subcommittee's recommendations are intended to provide future policy direction for the Commonwealth, strengthen the state-local partnership, renew the commitment to a community-based system, ensure that the system is responsive and accountable, streamline procedures, improve efficiencies, incorporate new technologies, and, most importantly ensure that the system meets the needs and respects the human rights of individual consumers and their families. Taken together, the changes recommended by the joint subcommittee initiate the first important steps toward developing and sustaining an integrated system of inpatient facilities that provide specialized care and comprehensive community services that are tailored to the needs of individuals.

Consumer Involvement, Participation, and Choice

Increasing opportunities for consumer involvement, choice, and participation are among the most important recommendations of the joint subcommittee. The joint subcommittee found that more opportunities are needed for consumers and their representatives to be involved in policy making; services planning, delivery, and evaluation; and decisions about their treatment, whether in public or private settings. Where possible, the joint subcommittee believes that consumers should have a choice of treatment providers, and services should be delivered in those settings that promote the highest quality of life for the individual. Toward that end, the joint subcommittee recommends that: (i) the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS), community services boards (CSBs), and state facilities increase the involvement and participation of consumers and family members; (ii) the pool of service providers be expanded by creating incentives for private providers and opportunities for consumers and families to provide services; (iii) consumer satisfaction measures be included in state facility and community services board performance contracts; and (iv) dispute resolution mechanisms be implemented to allow consumers and family members to have prompt and fair resolution of their concerns about services.

Future Responsibilities of State and Local Government, Private Providers, and the Academic Community

In fiscal year 1996, more than 200,000 Virginians received state facility and community services from the state and local network of publicly funded programs. However, the dual system of state-operated facilities and locally administered outpatient and residential services has often resulted in an unequal distribution of state-controlled financial resources and inconsistent service availability and accessibility.

To strengthen the state-local partnership and ensure service consistency, the joint subcommittee recommends that a local elected official be added to the membership of the State Mental Health, Mental Retardation and Substance Abuse Services Board and that the Board oversee the development of a Comprehensive State Plan and develop policies that define service priorities. The Department should: continue to be responsible to the General Assembly for all publicly funded mental health, mental retardation, and substance abuse services; provide system leadership and direction; conduct state-level strategic planning; operate state facilities; contract for community services; establish statewide standards related to consumer access and quality; and maintain a statewide services information system. In addition, the joint subcommittee recommends that the Department create separate Offices of Substance Abuse Services and Prevention, develop utilization targets for adult state psychiatric bed days, disseminate performance report cards on facilities and community services boards, and develop and update a biennial comprehensive state plan.

The joint subcommittee also believes that state government should continue to fund and operate 15 mental health and mental retardation facilities. While there will continue to be an important role for state facilities in the future, roles may focus more on specialty services, such as forensic, extended rehabilitation, and geriatric, and on services to populations with multiple disabilities or significant medical needs. The Department should develop uniform clinical protocols for admission to and discharge from its facilities and should revise state facility catchment areas as necessary to achieve better coordination and access.

To ensure an orderly and measured approach to facility downsizing, the joint subcommittee recommends that the Department develop a Community and Facility Master Plan by December 1, 1998. In developing its plan, the Department should determine the number of individuals who can be served in the community and who will continue to need facility care, the optimal size and location of facilities, and options for staff and localities that are affected by facility downsizing.

Local governments should continue to be responsible for organizing and managing community-based mental health, mental retardation, and substance abuse services and are encouraged to partner with other local governments to stay competitive and responsive to consumer needs. Localities should continue to fund local priorities that are not funded by the state.

The joint subcommittee proposes legislation to distinguish between two types of CSBs: those that function as local government departments and those that operate more autonomously. Different levels and types of accountability are recommended for each. Also recommended are: (i) the addition of case management as a mandated service; (ii) requiring one-third of CSB appointments to be consumers or family members; (iii) permitting the appointment of local government officials to the CSB; (iv) designating the CSB as the single point of entry for publicly funded services; and (v) clarifying that CSBs should be local care coordinators and not the primary or only providers of services.

The joint subcommittee encourages the Department to: (i) examine the needs and opportunities for regional cooperation; (ii) continue to expand the involvement of private providers in policy development, planning, service delivery, and oversight and evaluation; and (iii) establish a forum for expanding linkages between the academic community and state facilities and CSBs.

Accountability

Virginia's public mental health, mental retardation, and substance abuse services system is accountable to consumers, family members, government officials, and taxpayers, but the absence of outcome data, uniform cost accounting standards and systems, compatible management information systems, and consistent data bases make meaningful evaluations difficult. The joint subcommittee supports advancing to the next phase of implementing the Performance and Outcome Measurement System (POMS) and developing a strengthened version of the performance contracts with CSBs and facilities. These enhanced performance contracts would include approaches to reward superior performance and deal with poor performance of CSBs and state facilities.

Human Rights

Following reports of serious incidents and deaths in state mental health and mental retardation facilities, the joint subcommittee asked the State Mental Health, Mental Retardation and Substance Abuse Services Board to study and provide recommendations on issues related to human rights protections afforded consumers in state facilities and community programs. Based on that report, the joint subcommittee recommends strengthening the human rights programs in state facilities and communities, revising and consolidating the regulations, and assuring adequate standards and oversight. Moreover, the joint subcommittee agrees that the most effective structure and location of an external human rights protection system should receive further study. Key to the effectiveness of any system are free and open access to advocacy services, equal availability of services, adequate resources, mechanisms for the standardization and coordination of rights protection systems, and reliable, accessible, and timely data.

Restructuring the flow of funding and maximizing Medicaid

Since 1991, community Medicaid funds for mental health and mental retardation have grown from $15 million to $134.9 million for fiscal year 1998. While the increase has resulted in an expansion of total spending for the community services system, it has exacted a price from existing financial resources. Through fiscal year 1997, over $42 million of CSB state general funds have been transferred to the Department of Medical Assistance Services (DMAS) for Medicaid match. The transfer has reduced state funding for consumers who are not Medicaid-eligible and has limited the ability of the Commonwealth to address the significant unmet need for community services. In addition, if community capacity were expanded through the Medicaid Waiver, mental retardation facility beds could be reduced by approximately one-half; but the state general fund match for private providers comes from the CSB base budget, a practice that is inconsistent with the allocation of the general fund match for other Medicaid services.

The joint subcommittee recommends that state general funds currently used by CSBs to match Medicaid dollars be restored to the CSBs to provide individualized packages of services in the communities for individuals who are on waiting lists or can be discharged from state facilities. In addition, match funding should be appropriated to the Department of Medical Assistance Services for mental health, mental retardation services, and substance abuse services as it is for all other health care services. Finally, Medicaid coverage of mental health, mental retardation, and substance abuse services should continue to be expanded to ensure the maximum use of federal funds for Medicaid-eligible persons.

To restructure the flow of funds and to achieve a full integration of Medicaid, the joint subcommittee makes these recommendations: (i) the DMHMRSAS should develop and implement a funding mechanism that reallocates a reasonable proportion of resources saved through state facility bed reductions to CSBs, provided that facilities continue to meet appropriate standards of care; and (ii) the Secretary of Health and Human Resources, the DMH1vIRSAS, and the DMAS should present a plan to subcontract (carve-out) the administration of Medicaid-covered mental health, mental retardation, and substance abuse services to the DMHMRSAS prior to the 2001 Session of the General Assembly.

Mental health, mental retardation, and substance abuse services

The joint subcommittee found that issues related to residential alternatives, primary health care, and geriatric services affected consumers of mental health, mental retardation, and substance abuse services. For example, over 11,000 individuals are currently waiting for residential services; publicly funded primary health care is being delivered increasingly through health maintenance organizations, raising questions about adequacy and the desirability of integrating primary health care and behavioral health care; and elderly Virginians with mental disabilities or substance abuse disorders require special services that will integrate treatment for their disorders with services to address the effects of aging.

The joint subcommittee recommends that (i) pilot projects be developed to determine the appropriate treatment and supports for persons with mental illness, mental retardation, or substance abuse problems who reside in adult care residences and (ii) a study be conducted on the feasibility of creating a capital fund to address the housing needs of persons with mental disabilities or substance abuse problems. The joint subcommittee also recommends that an assessment be made of the primary health care needs of persons with mental illness, mental retardation, and substance abuse problems, and that the feasibility of providing a supplement to private nursing homes and other alternatives to expand community-based services for elderly individuals with mental disabilities and drug abuse problems be examined.

The availability of the new atypical antipsychotic medications, intensive treatment programs, and psycho-social rehabilitation in community settings is critical to keeping consumers in the community and to downsizing state facilities successfully. Individuals with brain injuries who receive treatment in the mental health system, individuals who are deaf or deaf and blind and have mental disorders, and children with or at risk of serious emotional disorders require additional services and plans for tailoring services to their individual needs. The joint subcommittee recommends that (i) the availability of antipsychotic medications be increased; (ii) intensive community treatment teams be established in communities with the highest usage of state mental health facility beds; (ii) psycho-social rehabilitation services continue to be available for consumers; and (iv) plans be made for enhancing services for persons with brain injuries who receive treatment in the mental health system, persons who are deaf or deaf and blind and have mental disorders, and children with or at risk of severe emotional disturbance.

The joint subcommittee believes that persons with mental retardation should be provided with a full array of supports and services, including both state facility and community-based services, so that access to services can adjust to meet the changing needs of the individual. Toward that end, the joint subcommittee recommends that Medicaid funding for mental retardation services be maximized; state general funds be allocated for consumers in the greatest need on the basis of individualized service plans; plans be made to implement aggressive prevention programs; and pilot projects be implemented for housing development, mobile community crisis stabilization, community facilities for medically fragile children, a Center for Developmental Medicine, and regional emergency management funds.

The joint subcommittee learned that drug addiction affects everyone, either directly or indirectly, because substance abuse is often at the root of crime, family violence, poverty, diminished physical and mental well-being, and lost productivity and income. The Department of Mental Health, Mental Retardation and Substance Abuse Services estimates that more 500,000 Virginians need treatment for alcohol and other drug abuse. To combat the problem of substance abuse, the joint subcommittee recommends that (i) leadership and coordination of substance abuse services and resources be strengthened among state and local agencies; (ii) consumers have access to a continuum of care, including prevention, in every community; and (iii) offenders have access within available resources to substance abuse treatment. The joint subcommittee also recommends further study of welfare reform and substance abuse policy and exploring the feasibility of expanding Medicaid reimbursement for substance abuse services.

Resource requirements

In the Comprehensive State Plan for 1998-2004, the CSBs identified $75.11 million in unmet community need for fiscal year 1999, $150.23 million for fiscal year 2000, and over $360 million annualized for the six-year period from 1998 to 2004. The Plan also proposed that $31.7 million in fiscal year 1999 and $36.9 million in fiscal year 2000 be allocated to expand community services and avoid the use of state facilities. The mental health, mental retardation, and substance abuse work groups confirmed that funding such items as atypical medications, intensive community treatment programs, adult care residences pilot projects, drug courts, treatment for offenders, wrap-around services, Medicaid mental retardation waiver expansion, crisis stabilization teams, housing projects, and alternative community facilities for medically fragile children would support needed policy and treatment advances in Virginia. Although some items have a delayed implementation, the joint subcommittee recommends a total of $400 million in new spending over the next biennium to implement their recommendations.

Conclusion

Following two years of review and analysis, the Joint Subcommittee Studying the Future Delivery of Publicly Funded Mental Health, Mental Retardation and Substance Abuse Services has made recommendations to effect sweeping changes in the governance and structure of the system, allocation of resources, access and availability of publicly funded services, the use of managed care techniques, accountability, consumer participation, and protection of human rights. The joint subcommittee believes that many additional issues still need to be resolved and oversight is required for the implementation of recommendations contained in this report. The joint subcommittee's final recommendation is that the review of publicly funded mental health, mental retardation, and substance abuse services be continued to oversee the following areas: (i) implementation of the numerous statutory and policy changes and budget initiatives recommended by the joint subcommittee, (ii) the results of the Performance and Outcome Measurement (POMS) project, (iii) development of the Community and Facility Master Plan, (iv) implementation of the Medicaid carve-out, (v) results from the priority population pilot projects and the primary health care needs assessment, and (vi) the findings from recommended studies on human rights and other significant issues identified by the joint subcommittee.