RD91 - SFY 2021 Annual Mortality Report – December 2021

Executive Summary:

This is the seventh Annual Mortality Report of the Virginia Department of Behavioral Health and Development Services (DBHDS). The information contained in this report is based on reviews of the deaths of individuals with a developmental disability that occurred during the timeframe of July 1, 2020 to June 30, 2021 as reported in the DBHDS incident reporting systems. This report compares state fiscal year (SFY) 2021 mortality review data to that in previous years. The interpretation of information presented in this report is not intended to be used for direct comparison with the mortality reviews and reports of other states. Each state utilizes its own specified population, definitions, processes, and different methods or analyzed data which is relevant to their need or state requirements, and generalized findings or comparisons of mortality rates is limited.

As of June 30, 2021, there were 15,221 individuals enrolled on a Virginia Developmental Disability (DD) Home and Community Based Services (HCBS) waiver(*1). DBHDS authorizes many specialized services to thousands of residents for the following waivers: Community Living, Family and Individual Supports, and Building Independence.

As a commitment to the Commonwealth of Virginia, DBHDS and the Developmental Disabilities Mortality Review Committee (MRC or Committee) contribute to system of care improvements through integration of clinical evidence, data driven determinations, and evidenced based quality improvement recommendations. Deaths of all individuals who were receiving a service licensed by DBHDS at the time of death and diagnosed with an intellectual disability and/or developmental disability (I/DD) are reviewed. Analysis of the mortality trends, patterns, and problems can identify opportunities for system improvements to reduce risks to all individuals with developmental disabilities receiving behavioral health and/or developmental services. On an ongoing basis, DBHDS seeks to prevent instances of abuse, neglect, exploitation, and unexplained or unexpected death by identifying and addressing relevant factors during mortality reviews. Mortality review determinations are then utilized to develop quality improvement initiatives in order to reduce mortality rates to the fullest extent practicable.

Over the past year, the MRC saw the impact of two significant events that are woven throughout the data. The first is the impact of legislation that began July 1, 2020, which allowed the MRC access to greater information from providers who are not directly licensed by DBHDS. Legislation resulted in almost triple the amount of documentation for each case reviewed, describing more clinical detail, state death certificates, records from medical and rehabilitation centers, hospice, and other community care. This resulted in the increased identification of deaths that were considered to be potentially preventable and fewer deaths where the cause of death was unknown, such that the overall quality and completeness of the data has improved significantly. The other significant event, which began in the middle of state fiscal year 2020, which continues to have significant impact, is the ongoing transmission of COVID-19. However, in this fiscal year, several COVID-19 vaccines and biological therapeutics became available to mitigate the morbidity and mortality of COVID-19. While availability and priority was phased, individuals with developmental disorders, high-risk medical conditions, those in congregate settings and frontline essential workers, received priority during the initial distribution and administration of vaccines. COVID-19 continues to pose a threat in Virginia due to the continued high transmission of novel variants, and the provider community should be commended for their ongoing dedication to serve individuals with I/DD in those critical settings, despite the multiple workforce, financial, and service delivery challenges that have impacted all healthcare providers as a result of the pandemic.

(*1) Virginia Waiver Management System. Accessed by DBHDS on Aug 13, 2021.