HD101 - Report of the Joint Subcommittee to Evaluate the Future Delivery of Publicly Funded Mental Health, Mental Retardation and Substance Abuse Services

Executive Summary:

The Joint Subcommittee to Evaluate the Future Delivery of Publicly Funded Mental Health, Mental Retardation and Substance Abuse Services, with active participation by consumers, family members, the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS), community services boards (CSBs) and private providers, has refocused the publicly-funded system from one driven largely by the needs of state facilities to a system that successfully responds to the growing demands for community-based, individualized services. The recommendations of the joint subcommittee, which total 159 over four years, are linked together by four principles: (i) increased accountability for CSBs and state facilities; (ii) increased transition capacity to enable long-term state facility patients to return to their communities; (iii) expanded individual consumer and family-focused services in the communities; and (iv) strengthened consumer protection and advocacy.

Increased Accountability

On the recommendation of the joint subcommittee, the 1998 Session of the General Assembly passed and the Governor signed House Bill 428, which provided important tools for increasing accountability at the state and local levels. Community-based services that meet the individual needs of consumers are at the core of Virginia's publicly-funded system. House Bill 428 established clear administrative relationships between CSBs and local governments and between CSBs and the DMHMRSAS; mandated greater involvement and participation of consumers and family members in policy decision-making and services planning, delivery and evaluation; and provided for strengthened performance contracts between CSBs and the DMHMRSAS. Performance contracts contain specific requirements for receipt of state funding, including consumer outcomes, consumer satisfaction and requirements for standardized cost accounting and financial management systems.

The DMHMRSAS is required by § 37.1-48.1 of the Code of Virginia to develop a comprehensive state plan, with biennial updates and revisions to "identify the needs of and the resource requirements for providing services and supports to persons with mental illness, mental retardation or alcohol or other drug abuse problems or dependence across the Commonwealth and propose strategies to address these needs."

The new Performance and Outcomes Measurement System (POMS), which was enthusiastically endorsed by the joint subcommittee, will use the data from CSBs and state facilities to measure access to services, quality and appropriateness of services, human rights, consumer and family involvement, consumer satisfaction, and consumer outcomes. For the first time, the General Assembly, the Governor, consumers, families and the general public will have reliable and consistent data to evaluate consumer services and outcomes.

Increased Transition Capacity

In recent years, admissions and the average daily census have declined significantly for mental health and mental retardation facilities. The availability of new medications, new treatment models, and a broader array of community services have increased community treatment options as alternatives to state facility admissions. The number of individuals who receive CSB services has grown substantially, increasing from 181,799 in 1988 to 208,980 in 1998, as community-based services have increased and diversions from state facilities have been accomplished. CSBs, in consultation with state facilities, are required to prepare discharge plans for individual consumers, with the involvement and participation of the consumer or his representative, prior to the discharge of the person from a state facility to the community. Individualized services plans, which include an array of service and financial options, are approved and monitored by the DMHMRSAS.

Over the last two years, a record increase of $171 million in state general funds has been added to strengthen the system of care for mentally disabled persons in Virginia. Approximately $13.7 million of the increased funding will support the continued census reduction in state facilities, mostly for the purchase of individualized services and special projects. The demand for community services currently exceeds the capacity of the system, although the increased appropriation has helped to reduce the waiting lists for services.

The Program of Assertive Community Treatment (PACT) is a service-delivery model that provides comprehensive, locally-based treatment to people with serious and chronic mental illness. PACT, which has been implemented on a pilot basis, has been instrumental in decreasing the number of admissions to state mental health facilities. Because of PACT'S success, the joint subcommittee recommended that the DMHMRSAS and the Department of Medical Assistance Services (DMAS) develop a plan for statewide implementation of PACT.

Expanded Consumer and Family-Focused Services in the Community

On the recommendation of the joint subcommittee, more than $100 million in new state general funds were appropriated for community services in the 1998-2000 biennium. About $52.2 million were added to improve community services for mentally ill citizens and $42 million were added to improve services for mentally retarded citizens. Another $6.8 million in state general funds and $8.2 million in federal funds were appropriated for community substance abuse services. The joint subcommittee's budget recommendations for the 2000-2002 biennium total more than $55 million.

Virginia has historically adopted more restrictive Medicaid criteria than most states, but the joint subcommittee believes that Medicaid is an important financing tool for improving access to community services. For the 2000-2002 biennium, the joint subcommittee recommended: (i) changes in the structure and administration of Medicaid- covered mental health, mental retardation and substance abuse services to enable easier access to Medicaid covered services in the community; (ii) support for the first-line use of the new antipsychotic medications in Medicaid managed care plans; (iii) new funding to permit incremental increases in the Medicaid "medically needy" income criteria to enable more disabled persons to access Medicaid; (iv) new funding for Medicaid reimbursement for substance abuse treatment; and (v) an interagency task force to streamline procedures and add flexibility to service definitions in the Medicaid mental retardation home-and-community-based waiver.

Virginia's welfare reform efforts, coupled with the effects of a strong economy, have led to almost a 50 percent reduction of Temporary Assistance to Needy Families (TANF) cases. Many of the remaining TANF cases are considered "hard-to-serve" because they experience multiple barriers, including substance abuse, borderline mental retardation, and mental illness. As many as 7,225 TANF clients may have a substance abuse problem at any point in time. The joint subcommittee recognized the need to address substance abuse among TANF clients in its first interim report, House Document 77, in 1998. Since that time, the DMHMRSAS, the Department of Rehabilitative Services, and the Department of Social Services have taken a number of actions to address the issue, including funding, policy changes, local initiatives, and screening, assessment and treatment. The joint subcommittee recommended that these efforts continue and that the departments provide continuing information on the progress of the initiatives.

According to testimony heard by the joint subcommittee, children and adolescents are underserved in the public mental health, mental retardation and substance abuse treatment systems. In addition, families need support services such as respite care, specialized child care, specialized transportation, community-based parenting and support groups, and in-home parent training. Noting the high cost of residential and specialized treatment for children eligible for funding from the Comprehensive Services Act (CSA), the joint subcommittee asked the CSA Executive Council to examine the potential use of unused space in state facilities for residential programs and to develop criteria for providing additional reimbursement for costly specialized care. The joint subcommittee also endorsed the 2000-2002 biennium budget request by the DMHMRSAS for $36.6 million to fund initiatives for children and adolescents who need mental health, mental retardation, and substance abuse treatment in the communities or in juvenile justice facilities.

The joint subcommittee recognized the importance of and requested special reports on (i) the need for adequate housing and residential supports; (ii) appropriate treatment for persons with mental illness, mental retardation or substance abuse problems who reside in adult care residences; (iii) services for persons with traumatic brain injury; (iv) employability of persons with mental disabilities; and (v) the primary health care needs of persons with mental disabilities. Summaries of those reports are included in this document.

Strengthened Consumer Protection and Advocacy

Two distinct statewide programs exist to protect the rights of persons with disabilities: (i) the Office of Human Rights in the DMHMRSAS and (ii) the federal Protection and Advocacy for Individuals with Mental Illness Act and the Developmental Disabilities Assistance and Bill of Rights Act, as administered by the Department for Rights of Virginians with Disabilities.

To strengthen protection and advocacy, the joint subcommittee recommended increased staffing for the Office of Human Rights in the DMHMRSAS and funding and legislation to create a new independent Office of Protection and Advocacy that will include an ombudsman division and sufficient resources to provide protection and advocacy to persons with mental illness who are discharged from state facilities and return to their communities.

What the Future Holds

Much has been accomplished by past legislative studies of the public system of mental health, mental retardation and substance abuse services, as well as the ongoing work of this joint subcommittee. The future will continue to be influenced by improvements in treatment options, advances in information technology, consumer demands, resource availability, and the enforcement and interpretation of state and federal legislation. As the system evolves, continuous oversight and evaluation by the General Assembly will be necessary to ensure that the needs of Virginians with mental disabilities receive the highest priority consideration. Toward that end, the joint subcommittee recommended that a Joint Commission on Behavioral Health Care be created to focus attention on the needs of those persons requiring mental health, mental retardation, and substance abuse services and their families.