The purpose of this report is to provide a summary and recommendations from the Children’s Inpatient Workgroup, to the General Assembly of Virginia, based on the collective views of Virginia’s child-serving system of behavioral health care in addressing the rising census of the only state hospital for children in Virginia, the Commonwealth Center for Children and Adolescents (CCCA). Over the past three years, CCCA has experienced a rapid growth in admissions. In FY2019, there were over one thousand admissions, the highest reported number of admissions in the history of CCCA. While the majority of other states have reduced the capacity or completely eliminated their state psychiatric hospital for children, in Virginia, CCCA experiences enormous pressure – at times operating over census capacity – to meet the acute behavioral health crisis needs of children.

The population of children served by CCCA has shifted over the past several years. CCCA now serves nearly exclusively acute, involuntary admissions. Claims data from Virginia Medicaid (FY 2017-2019) indicates that CCCA serves as the first point of entry for inpatient psychiatric care for three-fourths of children covered by Medicaid. In addition, disparities exist among the population served by CCCA, such that 64 percent of CCCA admissions are male, and while African American youth constitute 19 percent of the child population of Virginia, they represent 40 percent of the CCCA admissions. Thirty percent of the children have diagnoses of intellectual disability, autism, or developmental disabilities, and 25 percent of children admitted are in the custody of the Department of Social Services.(*1)

To address the systemic causes for the rising CCCA census and identify solutions for alternative private settings for inpatient psychiatric care, from February 2020 through May 2020, the Department of Behavioral Health and Developmental Services (DBHDS) convened and led the Children’s Inpatient Workgroup and the findings and recommendations will aid DBHDS in developing a Request for Proposal for children’s psychiatric inpatient services. Workgroup participants included representatives from 31 distinct stakeholder groups including state agencies; advocacy, provider, and professional organizations; hospital systems; and health care payers (i.e. managed care organizations and the behavioral health service administrator). While many different perspectives were discussed, a view that was shared by nearly all participants is that Virginia still needs a state hospital for children to serve as the safety net for youth with the highest and most complex behavioral health conditions. However, children need a more robust system of behavioral health care that allows for earlier intervention so that the safety net is not the only net.

The vision for Virginia’s behavioral health system is to provide high-quality, evidence-based, cost-efficient services in the least restrictive environment, appropriate to the child’s need, in the community where the youth resides. This includes the integration of trauma-informed care principles across the continuum to empower individuals to build resiliency and overcome the impact of adverse experiences so that they can lead meaningful, productive lives in the community. The terms “least restrictive environment" and “appropriate to meet the child’s needs" originate from the Federal Individuals with Disabilities Education Act (IDEA), which is intended to ensure that children with special needs, including behavioral health needs, are integrated with their peers and receive the services they need. As importantly, the Federal Early Periodic Screening and Diagnostic Testing (EPSDT) program supports that a behavioral health system for children must include prevention and early intervention of mental health problems to allow each child the chance to reach their full developmental potential. Significant work has been underway toward that vision through System Transformation Excellence and Performance – Virginia (STEP-VA), which stakeholders widely cited as needing continued and full support for complete implementation. In addition, the proposed Medicaid Behavioral Health Enhancement is seen as an opportunity to build out services absent from the current system of care, and ongoing investment is needed to address the systemic issues that drive inpatient admissions. Virginia must better meet the behavioral health needs of children. Combined effort across the child-serving systems of Virginia will ensure that children’s mental health remains a priority.

Key findings from the workgroup are:

• Increasing the number of inpatient psychiatric beds across the Commonwealth was not seen as the only avenue to address the systemic issues contributing to the increasing admissions to CCCA.

• The “Bed of Last Resort" legislation (§37.2-809) was cited as an important factor contributing to the increasing admissions at CCCA. However, the majority of participants felt that the period for the Emergency Custody Order for minors was adequate.

• Adolescents presenting with acute behavioral aggression pose a challenge to community private psychiatric hospitals due to an increased need for staffing to maintain safety for staff and other patients.

• Children and adolescents with an intellectual disability or developmental disability pose a challenge to community private psychiatric hospitals due to a need for specialized programming and therapies that match the individuals’ needs and level of functioning.

• Greater investment in a comprehensive continuum of child and adolescent behavioral health services ranging from prevention, early intervention, treatment, and recovery that is wellcoordinated across state agencies is needed to fully address the systemic causes that drive inpatient admissions.

• Investments are needed to increase behavioral health workforce capacity serving children and adolescents in all areas of Virginia through possible loan forgiveness or training programs.

• Person- and family-centered care should drive the funding, priorities, and processes that address the mental health needs of children and adolescents rather than availability and eligibility for services. This can be accomplished by including family voice and active involvement in service planning along with Family Support Partners who have lived experience navigating the children’s behavioral health system.

• The top three most effective solutions identified to divert from admission to CCCA were:

1. Community-based Mobile Crisis Services and intensive community-based treatment (Multisystemic Therapy, Functional Family Therapy, Partial Hospitalization Programs, and Intensive Outpatient Programs);

2. Crisis stabilization units;

3. Intensive care coordination using High Fidelity Wraparound.

• The top three most effective solutions identified to effectively step-down individuals from CCCA were:

1. Intensive care coordination using High Fidelity Wraparound;

2. Short-term residential or group home settings;

3. Expansion of telehealth treatment modalities.

Recommendations for reducing admissions to CCCA:

• The General Assembly, Administration, and various state agencies should develop a shared definition of the role of CCCA, as a state hospital, including specific admission criteria, to establish clear expectations around utilization as the facility of last resort for children.

• Direct funding for inpatient psychiatric services to increase the total number of beds in the system and to enhance the existing beds by investing in therapeutic programs, services and supports, staffing models, and training to reduce the use of seclusion and restraints.

• Direct funding and resources toward community services that divert from or step-down from acute inpatient psychiatric treatment.

• Direct initial investments for community services toward step-down levels of care including mobile crisis stabilization, intensive care coordination using evidence-based practices such as High Fidelity Wraparound, and intensive community-based services such as Multisystemic Therapy, Functional Family Therapy, Partial Hospitalization Programs, and Intensive Outpatient Programs. Residential treatment and therapeutic group homes are additional potential step-down options, however these levels of care should be further developed to ensure they are effectively utilized as short-term treatment settings.

• Decrease the racial, socio-economic, and geographic disparities that are disproportionately represented among those served by CCCA by increasing resources across public and private stakeholders to include population health initiatives.

• Expand access to evidence-based mental health treatments that decrease long-term morbidity due to mental illness via services such as Virginia’s Coordinated Specialty Care, a program for individuals ages 15-25 years old who have experienced first episode psychosis.

• Develop comprehensive crisis services throughout Virginia including 24/7 mobile crisis in all localities as well as additional crisis stabilization units for children and adolescents in additional areas of Virginia.

• Integrate crisis mental health services within schools and other non-traditional mental health settings through the 24/7 support line, which is being created through the Crisis Step of STEP-VA, and align Medicaid rates with the care provided to help increase availability of these services.

• Increase systemic coordination by directing resources to expand the availability of training to facilitate diverting admissions from CCCA while someone is under an ECO. For youth who are admitted to CCCA, actively begin discharge planning at the time of admission, involving all supports and services in the process, including the use of peer services.

• Examine the applicability of value-based care models for behavioral health care for children to comprehensively address preventive services as well as acute care needs.
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(*1) DBHDS State Hospital Data, FY 2019.