RD136 - Office of the Inspector General for Behavioral Health and Developmental Services Review of the Barriers to Discharge in State-Operated Adult Behavioral Health Facilities

Executive Summary:
This Report summarizes the results of a six-month review (July-December 2011) by the OIG of the barriers that prevent the timely discharge of individuals receiving treatment in the eight adult state-operated behavioral health facilities. The complete Report No. 207-12 can be found on the OIG website at: www.oig.virginia.gov

HISTORY: In 1963, the Federal "Community Mental Health Act" ushered-in a new era for the treatment of mental illness. During the last five decades, important milestones have transformed how we view and treat individuals with mental illness. Key achievements and events in the long march towards deinstitutionalization include:

• The creation of Virginia’s forty CSBs/BHAs (1968-1982);

• "The American with Disabilities Act (ADA)" (1990);

• The "Olmstead" decision ["Olmstead v. L.C." (98-536) 527 U.S.581 (1999)];

• Virginia’s "Integrated Strategic Plan" (2006);

• The DBHDS "Creating Opportunities Plan for advancing community focused care in Virginia" (2010);

• The state’s "Comprehensive State Plan" 2012-2018. (Dec 2011).

THE CURRENT PARADIGM: The "Commonwealth’s Integrated Strategic Plan," DBHDS’s "Creating Opportunities Plan," and the current "Comprehensive State Plan" all affirm the contemporary treatment model underpinned by the goal of full participation in all spheres of community life and reflecting the values of “a consumer-driven system of services and supports that promotes self-determination, empowerment, recovery, resilience, health, and the highest possible level of consumer participation in all aspects of community life including work, school, family and other meaningful relationships” delivered in a community-based setting – instead of Virginia’s state-operated institutions. (*1)

The practical impact of this paradigm shift is confirmed by the impressive 77% reduction from 1976 to 2011 in the number of persons served by Virginia’s state behavioral health facilities: where the average daily census declined from 5,967 to the current level of 1,252 as of December 31, 2011. By any measure, the last two generations have marked a revolution in how Virginians view and treat mental illness.

Notwithstanding Virginia’s impressive progress towards a community-based system of care, a recent OIG review, focusing on scores of discharge ready people who nonetheless remain in state-operated facilities due to extraordinary barriers to discharge, supports a finding that there is an indispensible component missing from the Commonwealth’s services for its citizens with mental illness: permanent community-based supported housing.

During the six-months of this review, there were, on average, 165 individuals, or 13% of the census on December 31, 2011, who were determined clinically ready for discharge from the state’s institutions, but who could not be released due to “extraordinary barriers to discharge.” This discharge ready cohort has three distinct subgroups: adult civil patients (53%); the forensic population (27%); and the geriatric population (20%).

The most often cited barrier to discharge from state facilities is the lack of community-based supported housing. (*2)

Community-based supported housing in Virginia (and nationally) is not a new problem. The DBHDS has maintained an EBL (Extraordinary Barriers List) for over a decade. The OIG reviewed the EBL going back to 2007, and concluded that the percentage of state-operated facility residents on the extraordinary barriers list has remained between 12% and 14% for many years.

THE DYNAMICS OF RESIDENTIAL INSTABILITY AND THE MENTALLY ILL: Many people with serious mental illness (SMI), whose psychiatric condition compels them to move periodically from less restrictive community settings to more restrictive institutional settings, with greater structure and support, lose their stable housing in the process; that is, if they had stable housing at the onset of their acute symptoms.

Decades ago, when the expectation was that individuals would remain in state facilities for years, or even a lifetime, this issue lacked its present intensity; however, deinstitutionalization has ushered-in new housing challenges for persons with mental illness and for the state’s system of care.

When individuals with SMI, who are living in temporary community housing, move to a state facility, economic incentives oblige property owners to locate a replacement tenant for the residence.

Once an individual has stabilized, and is deemed ready for discharge by clinicians at a state facility, the person’s previous housing is frequently unavailable because it is occupied by someone else or the person’s behavior leading up to their institutionalization has disqualified him or her from their previous living arrangement.

In 2003, the Bush Administration’s New Freedom Commission on Mental Health report observed that “the shortage of affordable housing and accompanying support services causes people with serious mental illness to cycle among jails, institutions, shelters, and the streets; to remain unnecessarily in institutions; or to live in seriously substandard housing.” (*3)

The 77% reduction in state facility census from 1976 to 2011 noted earlier has been accompanied by a 63% increase in the state’s population during the last thirty-five years. The combination of shrinking facility beds (77%) and growing population (63%) helps explain the current housing predicament for persons with SMI.

THE U. S. DEPARTMENT OF JUSTICE: Based on the 2011 "Findings" of the DOJ in the state of New Hampshire, Virginia is at risk for a similar finding of noncompliance with the relevant aspects of the "Americans with Disabilities Act (ADA)" as interpreted in the "Olmstead" decision. In New Hampshire’s case, the DOJ concluded that:

"The State’s failure to develop sufficient community services is a barrier to the discharge of individuals…who could be served in more integrated community setting with adequate and appropriate services and supports.…In general, therefore, systemic failures in the State’s system subject qualified individuals with disabilities…to undue and prolonged institutionalization and place them at risk of unnecessary institutionalization now and going forward. All of this violates the ADA. [Emphasis supplied by the OIG]

This OIG study concludes that important aspects of Virginia’s behavioral health system are analogous to those found objectionable by the DOJ in New Hampshire:

• Virginia’s failure to develop sufficient community services is a barrier to the discharge of individuals who could be served in a more integrated community setting with adequate and appropriate services and supports;

• The lack of community-based permanent supported housing is a barrier to discharge for a significant number of individuals in state-operated facilities;

• The lack of community housing places disabled persons with mental illness at risk for unnecessary institutionalization today and in the future; and,

• Virginia continues to fund more expensive institutional care when less expensive and therapeutically effective community-based care could be developed.

THE FISCAL IMPACT OF INSTITUTIONAL VS. COMMUNITY CARE: The average annual cost of serving an individual in a state-operated facility is $214,000; (*4) while a conservative estimate for serving the people on the discharge-ready list in the community is approximately $44,000 per year.

The Commonwealth could annually save approximately $170,000 (per person) if it served this cohort in the community rather than continuing to serve them in state facilities. Currently there are at least 70 individuals who could reside in the community with appropriate community housing and this alone would save almost $12,000,000 annually in exchange for an estimated upfront expense of just over $3,000,000. (*5)

THE IMPACT ON SAFETY NET TDO ADMISSIONS: The OIG recently published the findings of a three-month study confirming anecdotal reports of “streeting.” A term subsequently reframed as “Failed TDOs.” (*6) Of the 72 failed TDOs (a statewide average of six individuals weekly) 75% occurred in Hampton Roads and Southwest Virginia. This review of the barriers to discharge concludes that, during the July-September period of the failed TDO study, the state facilities serving these two regions on average had 51 beds (ESH) and 8 beds (SWVMHI) occupied by individuals who were ready for discharge but remained in the state facility due to extraordinary barriers to discharge.

It could be plausibly argued that, if community services – including supported housing – had been available in Hampton Roads and Southwest Virginia, ESH and SWVMHI could have admitted many of the 54 persons meeting criteria for temporary detention (the so-called “failed TDOs”) that were denied admission and referred to less intensive services than they had been clinically determined to require.

Additional OIG Findings and Recommendations appear on pages 28 - 30 of the Report and include:

• The state does not offer community services and supports in sufficient quantities to serve all Virginians;

• An average of 165 adults remained institutionalized for roughly eight months during this review;

• Recommended that the DBHDS publish on its website a quarterly HIPAA compliant summary of individuals on the EBL at each state-operated facility including the specific barriers to discharge, the time on the list, and the estimated cost to discharge the person;

• That the DBHDS’s work with regional access committees to evaluate the housing needs of each region and identify the housing requirements of each PPR to curtail the extraordinary barriers list;

• That the DBHDS evaluate the discharge practices at all state-operated hospitals and replicate the best practices that have produced measurably superior discharge outcomes;

• That the DBHDS seek to expand funding for discharge assistance projects to help individuals transition to the community.

Office of the Inspector General

The Office of the Inspector General (OIG) is established in the VA Code § 37.2-423 to inspect, monitor and review the quality of services provided in the facilities operated by the Department of Behavioral Health and Developmental Services (DBHDS) and providers as defined in VA Code § 37.2-403. This definition includes all providers licensed by DBHDS including community services boards (CSB) and behavioral health authorities (BHA), private providers, and mental health treatment units in Department of Correction facilities.

It is the responsibility of the OIG to conduct announced and unannounced inspections of facilities and programs. Based on these inspections, policy and operational recommendations are made in order to prevent problems, abuses and deficiencies and improve the effectiveness of programs and services. Recommendations are directed to the Office of the Governor, the members of the General Assembly and the Joint Commission on Healthcare
(*1) DBHDS State Board Policy 1036 (SYS) 05-3 cited in "Comprehensive State Plan" 2012-2018.
(*2) "Safe, decent, and affordable housing is essential to recovery, and housing stability is correlated to lower rates of incarceration and costly hospital utilization.” "Comprehensive State Plan."
(*3) "Op. Cit."
(*4) "Major Issues Facing the Commonwealth’s Behavioral Health & Developmental Services System," January 13, 2011.
(*5) The actual savings would not be immediate or linear because, in order to realize the savings, the structural operating cost of the state facilities would have to be reduced. For some period, facility operating cost would remain relatively unaffected by a gradually reduced census.
(*6) OIG Report No. 206-11, "OIG Review of Emergency Services: Individuals meeting criteria for temporary detention not admitted to a psychiatric facility for further evaluation and treatment." February 28, 2012.