HD76 - The Cost and Feasibility of Alternatives to the State’s Five Mental Retardation Training Centers


Executive Summary:
The Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) has studied the cost and feasibility of: i) developing community-based alternatives to the state’s five mental retardation training centers, (ii) renovating the state’s five mental retardation training centers, or (iii) a combination of both to meet the future care and housing needs of these individuals, as required by Item 330 P of the 2005 Appropriation Act for the Chairmen of the Senate Finance and House Appropriations Committees. The feasibility study report includes an overview of Virginia’s mental retardation system: its vision, values, progress, and challenges, the process used for completing the study, a description of the findings, and the identification of the most feasible and cost effective option, with strategies and related costs.

The study reinforced that the Commonwealth’s mental retardation system is underfunded, many Virginians with mental retardation are underserved or unserved, and the “dual system” that exists (state training centers and community services) is difficult to coordinate and is not the most efficient or effective approach to support. The most feasible, cost-effective option for Virginia is the combination of developing community alternatives, reducing the size of the state training centers by re-focusing their purpose and function, and making needed renovations to these centers necessary for the maintenance of safety standards and increased efficiency.

The strategies for developing community alternatives, while refocusing the role of the state training centers include:

• Increase Mental Retardation (MR) and Day Support (DS) Waivers’ Rates

Creating community alternatives will not be possible until the Waiver rates are increased to a level that enables providers of services to stabilize their workforce through competitive pay rates and provide assurances that all standards of sound business and safety practices are maintained.

1. Increase the MR and DS Waivers’ reimbursement rates 20% across all services in the next four biennia.

2. Make an annual cost of living adjustment (COLA) for all MR and DS Waiver rates.

3. Have an additional 17% rate differential for Northern Virginia programs.

4. Create an additional 10% differential for all congregate residential services that are 4 beds or less (except for sponsored residential) and for In-Home Residential Support.

• Develop Community Alternatives for Residents of Virginia’s Five State Training Centers

Develop community alternatives for 100 residents of the five state mental retardation training centers per year for the next 4 biennia.

1. Modify the Mental Retardation (MR) Waiver to allow reimbursement for therapeutic behavioral consultation to a wider range of persons practicing behavioral interventions, as qualified Waiver providers, (PBS, ABA, etc.) thereby offering more options to support individuals in the community.

2. Provide for increased personnel costs for DMAS and DMHMRSAS staff associated with the large volume of new community services.

3. Provide Community Investment Grants in the form of one-time grants to Community Services Boards and Behavioral Health Authorities (CSBs/BHAs) and private providers to make modifications as needed designed to establish the necessary supports for community living alternatives for individuals choosing to leave the state training centers.

4. Increase the Medicaid Waiver rate for skilled nursing to allow for more competitive reimbursement of nursing services in the community system enabling more persons to remain in their home communities.

• Increase Efficiencies in the MR and DS Waivers that Promote Greater Service Satisfaction with More Efficient Use of Dollars

1. Increase flexibility in the MR Waiver through consumer direction and personal budgets.

2. Increase the rate for Supported Employment to equal the average rate currently offered by the Department of Rehabilitation Services (DRS).

3. Develop a Supports Waiver, with personal budgets, consumer direction, and individual capitation of dollar amounts for persons on the waiting list for MR Waiver services.

• Develop the Community Infrastructure to Better meet the Needs of Individuals Whose Only Current Option Is Readmission or New Admission to a State Training Center

1. Approve 1,000 slots (over the next four biennia) for the MR Waiver.
2. Increase Family Support funding.
3. Establish public guardianship programs.
4. Train providers of services and families.
5. Develop a system to administer grants for non-waiver services for people with mental retardation.

• Reduce the Size of the State Mental Retardation Training Centers, Refocus their Purpose and Function, and Make Renovations Necessary To Maintain Safety and Meet the Needs For the New Purpose and Function

Respecting individual/family preferences and providing choice, some individuals may choose to live in the state training centers. It will be necessary for the Commonwealth to ensure individuals that choose to live in the state training centers continue to receive quality, high intensity care.

1. Reduce census at the state training centers by 100 people per year for the next 4 biennia.

2. Refocus the specialized services at the training centers to become Regional Community Support Centers (RCSC). Each RCSC will offer specialized services in dentistry, medical specialty areas, and behavioral therapies both on-site and through satellite clinics. RCSCs also provide staff training and linkages with universities for the “next generation” of service providers for people with mental retardation.

3. Change the role of state training centers to Intensive Support Centers (ISC), which are residential, for individuals with the highest levels of support need. Options include:

• Short-term residential options for persons in need of intensive support due to behavioral or high medical support issues before returning to the community placement.

• Temporary emergency support for persons with specialized needs due to mental retardation during periods of natural or man-made disasters or individual crisis when other community options are exhausted.

• Long-term residential specialized support for persons with mental retardation who have the highest level of long-term medical needs or behavioral needs that are preventing successful community living.

The vision for the future of Virginia’s MR services is to offer a “seamless” system of supports that provides individuals with mental retardation with a choice of options to support their quality of life and keep them involved with their families and communities, offering only the level of support needed to be successful. The blending of the “dual system” to a “seamless system” of supports will improve coordination, collaboration, and management of MR services. Virginians with mental retardation and their families will have easier access within the supports and services offered to have their needs met, and not be restricted by the types of funding, programmatic definitions, or other restrictions that currently exist. The anticipated outcome is a well-balanced system of supports that offers an array of service options while ensuring the health and safety of all Virginians with mental retardation.

The well-balanced system of supports, however, cannot be a reality without significantly increased funding. The findings of this report, and other recent reports, such as the recent JLARC study on the Medicaid Waiver rates, the DMHMRSAS report on the capital improvement needs of the state training centers to meet safety standards, and the DMHMRSAS Comprehensive State Plan, 2006 – 2012 all provide documentation that the MR system is largely underfunded. Additional indicators, such as the steady climb of the number of people on the waiting list for MR Waiver services to nearly 3,000 Virginians and the significant numbers of individuals with mental retardation who need services, but who are not eligible for Waiver services shows clearly the situation will only get worse without additional resources. Transforming the MR system and properly addressing the recommended strategies in this report will require an investment of Virginia resources over a period of time. This plan lays out an eight-year effort that will put Virginia back on course to more fully addressing the needs of its citizens with mental retardation. Over the next eight years, this plan will:

• Establish a means of providing some level of support to individuals who are on the waiting list for full Waiver services while waiting for a slot to become available.

• Provide for an appropriate community alternative for most persons whose only current option for services is to live in a state mental retardation training center.

• Increase the total number of Virginians with mental retardation who are being served by 4,000 individuals, addressing underserved and unserved individuals.

• Develop a more efficient system of supports for all persons served.

• Change the role of the state training centers to a state operated support service for those persons requiring the highest level of intensive supports while supporting community placement alternatives through consultation and direct provision of off-site specialized support teams (RCSC).