More than 100,000 people in the United States died from drug overdoses in 2021; 2,656 of those were Virginians. The Roanoke Valley is one of the hardest hit regions of Virginia that is suffering from substance use disorder (SUD), the Commonwealth of Virginia is determined to fight this epidemic.

Item 283 of the 2022 Appropriations Act directed the Secretary of Health and Human Resources to “contract for a feasibility analysis to transform the Catawba Hospital Campus into a state-of-the-art campus at which a continuum of substance abuse treatment and recovery services, including long-term, short-term, acute and outpatient services, is provided in addition to the array of behavioral health services currently provided to the individuals in need of behavioral health care services."

The Secretary of Health and Human Resources, in coordination with the Department of Behavioral Health and Developmental Services (DBHDS) contracted with JLL to perform that feasibility analysis. To begin, JLL held a visioning session on November 17, 2022, with DBHDS, Catawba Hospital leadership, and stakeholders in the region. During the session, participants discussed perceived regional needs and guiding principles for further inquiry.

Inpatient Demand Estimates within the Catawba market obtained from IBM/Watson and DBHDS provided historical data were used to determine the need and the best location to provide continuum of substance use disorder treatment services given population size, location of facility vice population, and availability of workforce. Inpatient Demand DRG Estimates provides the total volume of annual acute care admissions and patient days. The current primary and secondary Catawba Hospital market areas were used as a baseline for inpatient bed projections for both behavioral health and substance use disorder diagnosis.

The transformed Catawba Hospital campus would support patients with dual diagnoses, a person who experiences both a mental health issue such as depression, and a substance use disorder concurrently, who significantly struggle with obtaining treatment in the private sector. Today we know that individuals who are dual diagnosed with disorders who have successful and long-lasting recovery must be treated for both conditions at the same time for recovery. The DBHDS data analysis showed that between 35% and 55% of all patients at the three hospitals (Western State Hospital, Catawba Hospital and Southwestern Mental Health Institute) had SUD and a mental health illness, and only 10% of the patients were diagnosed with SUD with no underlying mental illness. After fully analyzing the IBM/Watson data and the DBHDS historical data, it was determined that there is a need for approximately 100 – 150 Acute Behavioral Health Beds, 80 - 120 residential SUD treatment beds and 16 Detox Beds in the surrounding Catawba Hospital area through 2030.

JLL considered whether Catawba Hospital was the right hospital location for this transformational model program with both Western State Hospital and Southwestern Mental Health Institute (SWVMHI) located in the valley; however, the expansive Catawba Hospital campus provides considerable space to grow. To assess the existing facility’s capability to support much needed SUD services, a multi-disciplinary group of architects and engineers assessed the condition of each building on the Catawba Hospital campus to ascertain the condition and suitability for reuse and repurposing to support this program. Concurrently with the building assessments, the architects identified the types and sizes of spaces necessary to provide the continuum of care services per best practices.

The functional and space programs were developed along three models – a mini-continuum of care, a base continuum of care, and an enhanced continuum of care. In all three models, the full range of services planned with each model providing for a different number of patients to be treated effectively through the full continuum of care. More details on each model are provided below:

Option A – Mini-Continuum of Care Model

This model is considered the minimum effort necessary to effectively deal with the increasing SUD cases in the area. To accomplish this, building 15 would have 1 ½ floors dedicated to residential treatment of SUD patients – providing 48 beds. One-half of a floor would become the detox unit for the facility which would provide 16 beds. The result would be to provide 64 beds dedicated to SUD patients.

Sixty-four behavioral health patient beds would be provided in a new building that will meet best practices and conform it into a state-of-the-art building that is desired by the Commonwealth. The existing treatment mall would be renovated and updated to current treatment standards. Forty-six beds of acute behavioral would remain in building 15.

A new 52,000 square foot three-story outpatient facility would be built adjacent to building 15 to provide outpatient services, additional administrative, clinical, educational and research space unique to SUD treatment.

Option B – Base Continuum of Care Model

To accomplish this model, building 15 would have 2½ floors dedicated to residential treatment of SUD patients – providing 80 beds. One-half of a floor would become the detox unit for the facility which would provide 16 beds. The result would be to provide 96 beds dedicated to SUD patients.

The 96 behavioral health patient beds would be provided in a new building that will meet best practices and conform it into a state-of-the-art building that is desired by the Commonwealth. The existing treatment mall would be renovated and updated to current treatment standards. Fourteen beds of acute behavioral remain in building 15 and Floor 1, Floor 2 and Floor 4 of building 15 could be utilized for future expansion of 80 residential treatment beds.

A new 52,000 square foot, three-story outpatient facility would be built adjacent to building 15 to provide outpatient services, additional administrative, clinical, educational and research space unique to SUD treatment.

This option will require significant upgrades to the wastewater treatment system as well as some upgrades to the water system.

Option C – Enhanced Continuum of Care Model

For this model, building 15 would have 4 floors dedicated to residential treatment of SUD patients – providing 128 beds. The 16-bed detox unit would be moved out of building 15 to the new behavioral health building.

The 128 behavioral health patient beds would be provided in a new behavioral health building that will meet best practices and conform it into a state-of-the-art building that is desired by the Commonwealth. The existing treatment mall would be renovated and updated to current treatment standards. The 16-bed detox unit formerly located in building 15 per Options A and B will now be in the new behavioral health building. No beds of acute behavioral beds remain in building 15 and Floor 1 and Floor 2 could be used for future expansion and provide 48 residential treatment beds.

A new 70,000 square foot four-story outpatient facility would be built adjacent to building 15 to provide outpatient services, additional administrative, clinical, educational and research space unique to SUD treatment. One story would be shell space for future growth.

This option will require significant upgrades to the water and wastewater treatment system.

The team considered the option of a full replacement facility for the noted services, but this option would have resulted in project costs nearly twice as high for the same level of services.

Workforce Development

The options identified above are primarily brick and mortar issues. To be successful, workforce development must also be addressed.

Staffing and Staff Development

Currently Catawba Hospital has sufficient staff to perform its mission. However, in all three option models, additional staff with potentially different expertise will be needed. The effects of the pandemic on the healthcare workforce and rising wages have resulted in a tight labor market across the country. Virginia is no different and is not immune to these effects. To recruit and retain the workforce at the transformed Catawba Hospital, the Commonwealth should considerer partnerships with education institutions that provide training and research opportunities for both the current and future staff. Further, the commonwealth and its partners should consider innovative programs and initiatives to increase the attractiveness of the Catawba Hospital campus for professionals to start and further careers in mental health and substance use disorder.

Transportation

The current lack of reliable public transportation is a significant barrier to transforming the Catawba Hospital campus into a best-in-class expanded facility. As part of this study, Valley Metro, the public transportation agency in the region, was contacted and discussed the possibility of extending bus service from Roanoke to Catawba Hospital. While such an extension would solve many of the hospital’s current transportation issues, a decision to extend the service would require an agreement from the Valley Metro Board of Directors, Roanoke County, and other Valley Metro stakeholders. The extension may also require subsidization by the Commonwealth.

Public-Private Partnership

A public-private partnership (PPP) arrangement can facilitate the shared responsibility of providing access to the continuum of care in the region. Under a PPP, a partnered company could be responsible for managing the day-to-day operations of the new residential treatment program and outpatient facility. This would include the responsibilities of hiring and supervising staff, managing budgets, and providing clinical services to patients.

The Department of Behavioral Health and Developmental Services and Catawba Hospital may provide funding for the facility and set performance standards and quality benchmarks for the private company to meet. The partner company may be required to meet certain financial and performance targets set by DBHDS and Catawba Hospital such as reducing costs or improving the quality of care.

Private sector partners have expertise in managing and operating SUD facilities more efficiently, leading to cost savings, improved quality of care and utilization of new technologies, approaches, and practices that may not be possible without their participation.

Catawba Hospital already collaborates with a number of regional providers and educators, including the Virginia Tech School of Medicine, Radford University, the local Hospital Corporation of America (HCA), and Carilion Clinic.

Further use of PPPs should be explored for the Catawba Hospital transformation. The benefits of one or more partnerships with the private sector and academia can be the catalyst needed to complete this continuum of care model at Catawba Hospital and replicate it to other regions of Virginia.

These models can be beneficial for the transformation of Catawba Hospital and some of these models may require legislative approval before they can be enacted or explored such as the model used for the Virginia Center for Behavioral Rehabilitation (§ 37.2-909(A)) which focused on patients with dual diagnoses of behavioral health and substance use disorders. By exploring different PPP models and partnerships, Catawba Hospital will identify the most effective ways to address the behavioral health continuum in their region and ensure that patients receive the care and support they need, by utilizing PPP models and partnerships.