RD376 - Study of Piedmont Geriatric and Catawba Hospitals (Item 307.R) - November 10, 2015


Executive Summary:
This report was developed in accordance with 307.R of the 2015 Appropriation Act which requires the Department of Behavioral Health and Developmental Services (DBHDS) to undertake a review of Piedmont Geriatric and Catawba Hospitals.

"R. The Department of Behavioral Health and Developmental Services shall undertake a review of Piedmont Geriatric and Catawba Hospitals. This review shall evaluate the operational, maintenance and capital costs of these hospitals, and study alternate options of care, especially geriatric psychiatric care for patients residing in these hospitals. The department shall develop recommendations and report to the Chairmen of the House Appropriations and Senate Finance Committees by November 1, 2015."

To support the report requirements, DBHDS engaged Public Consulting Group, Inc. (PCG) to conduct system-wide research, provide consultation on national best practices, and to assist with recommendations for the future of Virginia’s behavioral health services system. PCG engaged with staff at all levels including those based at DBHDS central office, as well as those located at each of DBHDS’ eight adult mental health hospitals, including PGH and Catawba. The research also involved extensive analysis of data supplied by DBHDS central office and facilities, as well as publicly available data regarding utilization and cost of behavioral health services in Virginia and other states. A sample of ‘peer states’ were examined for more detailed comparison with Virginia. Appendix B provides information about Virginia’s publicly funded behavioral health system, including numbers served by state mental health hospitals and through the Commonwealth’s 40 community services boards. Appendix C provides a national perspective about the state inpatient bed capacity, community capacity and funding for the states selected as Virginia’s peer states.

"While the Appropriations Act language is focused on PGH and Catawba, in order to generate comprehensive and responsible recommendations for alternate options of care, DBHDS found it necessary to consider PGH and Catawba in the broader landscape of the other state-run hospital facilities and community-based services." The end result of this comprehensive analysis includes findings related to the behavioral health system, as well as options for re-aligning the delivery of needed services to the targeted population.

Highlights among the findings include:

1. Virginia’s adult state hospital capacity of 17.3 beds per 100,000 people is higher than national averages (15 per 100,000) and considerably higher than peer states and states with county or locally-based community service systems (12.4 beds per 100,000). Additionally, the percentage of state hospital beds in Virginia as a percentage of total public and private beds (45.2 percent) is higher than the national average (40.6 percent).

2. Virginia’s per capita expenditure on mental health ranks 31st among the 50 states, has not kept pace with state spending overall, and has marginally declined over time.(*1) Total department expenditures were $93 per capita in 2013, while peer states range from $41 in Texas to $287 in Pennsylvania. The national average for per capita spending is $130.

3. State mental health hospital (“state hospital”) spending consumes a disproportionate share of Department funds. In 2013, inpatient state hospital spending comprised nearly half (46 percent) of overall state mental health agency spending in Virginia. This exceeds the national average (29 percent) and the highest proportion of such spending among peer states (36 percent in Georgia and Texas). DBHDS maintained this level of spending on inpatient state hospital beds from $332 million in 2009 to $340 million in 2013. These funds support nine state hospitals housing an average daily population of 134 individuals per facility or, on average, 5,259 individuals.(*2)

4. Virginia has not transitioned behavioral health funding from institutional care to community treatment as thoroughly as peer states or national trends. While Virginia spends approximately 41 percent of its behavioral health budget on community services, at $47 per capita, nationwide expenditures on community services make up 75 percent of total spending, with an average of $89 spent per capita.(*3)

5. Virginia’s funding structures and organization of community services continue to prioritize inpatient care over community treatment, resulting in inadequate access to services and significant deficiencies in the continuum of care. While total spending on mental health services in Virginia (approximately $726 million annually) is on par with peer comparisons, the distribution of spending between community and institutional care is quite disparate (see section 3 and 4 above). The systems of care are not sufficiently coordinated or supportive of each other, and the opportunity cost of this is significant; a Virginia Office of the State Inspector General report from 2014 states that the annual average cost of care per recipient in the Virginia state hospital system is $231,161, while community services cost the Department $27,027 per individual.(*4) Although Virginia has seen a modest expansion of specialized services in targeted areas, such as Crisis Intervention Teams, PACT teams, and crisis stabilization programs, there has not been a concentrated focus on building a consistent continuum of care in each community. This results in a continued heavy reliance upon an inpatient system.

6. With recent census increases, Virginia’s hospital infrastructure would require significant investment and modification in order to meet current demand and exercise its full potential, including:

1. Expanding capacity at certain locations may be required, necessitating additional staffing,
2. Investing in physical plants to modernize facilities and maximize efficiency,
3. Considering consolidation options, and
4. Addressing the quality of care considerations, adequacy of staffing, and increased risks to patient and staff safety which are persisting challenges for facilities operating at above 85 percent capacity through increased funding for staff, enhanced community discharge options, and changes in bed capacity to adjust to current demand.

7. Due to age and deferred maintenance at several state hospitals within the last decade, significant investment will be needed to retain or replace Virginia’s current facility infrastructure and bed capacity, at considerable expense to the Commonwealth. Catawba and PGH alone will require an estimated $94.1 million in capital outlay funding simply to continue to operate the hospitals at current levels.

8. Analysis of hospital utilization patterns in the state reveals wide variation in local demand for beds, both regionally and by CSB. CSB utilization varies from less than 3 beds per 100,000 to more than 46 beds per 100,000, pointing to inconsistent utilization management statewide. Rural localities utilize state hospital beds at higher rates than urban localities, reflecting both the scarcity of private inpatient beds and alternative community services.

9. Virginia’s extraordinary barriers to discharge list (EBL) indicates that 10-15 percent of state hospital patients are clinically ready for discharge and could be appropriately treated in a community setting. This number includes 150 people on the EBL (who have been clinically ready for discharge in excess of 30 days) and another 60-70 individuals who have been clinically ready for discharge for less than one month.

10. Hospital utilization and waitlist patterns demonstrate that the demand for acute care and forensic beds is greater than geriatric beds within Virginia’s state hospital system. Based on the EBL, geriatric individuals account for approximately 30 percent of the persons on the EBL, indicating the need for additional community capacity to serve older adults in the community.

11. Forensic admissions to state hospitals have increased by 13.5 percent in the past year, and individuals with criminal justice involvement use 38 percent of state hospital beds. Forensic services will continue to be an issue in the future and the configuration of beds will need to be adjusted to accommodate this trend.

12. Current fiscal policy regarding admissions and discharges encourages behavioral health providers to use state hospital beds. Because state hospital care is “free” to the communities, fiscal incentives are misaligned with the goal of a strong, consistent, and adequately sized community-oriented system.

13. The continuum of care is also limited by a lack of consistent funding for services across the life span and the fact that the Code only requires the CSBs to provide three services: emergency services; discharge planning; and case management when funds allow. This permits significant variations in local priorities, capacities, and funding. An additional factor may be the insufficient coordination of service provider groups.

14. State hospital overall utilization rates have steadily increased in the year following the civil commitment reforms, moving from 88 percent to 90 percent within 14 months.
___________________________________________
(*1) Virginia 2013 NRI State Mental Health Agency Data
(*2) 2012-13 CMHS Uniform Reporting System and 2013 State Hospital Analysis
(*3) NRI State Profile data, FY 2013.
(*4) Virginia Office of the State Inspector General, “Discharge Assistance Program Performance Review”, https://osig.virginia.gov/media/2475/2014-bhds-005dap.pdf , February 14, 2014, accessed August 31, 2015.