STEP-VA is a set of services provided by the Community Services Boards (CSBs) to individuals in Virginia. The design of the program was inspired by the Certified Community Behavioral Health Clinic (CCBHC) model. Both STEP-VA and CCBHC aim to provide consistent, high-quality behavioral health services. Despite significant progress, there are several areas where Virginia’s CSBs are not yet current with expected STEP-VA outcomes. DBHDS continues to define the requirements for STEP-VA and has put more emphasis on encouraging evidence-based practices (EBPs). Additionally, as the CCBHC model continues to evolve, and the federal government highlights new criteria for CCBHCs, there will be a continued need for investment from the Commonwealth and for alignment with federal requirements. This is especially true if the Commonwealth continues to pursue the federally identified best practices of CCBHC.

To address these gaps, the Virginia Department of Behavioral Health and Developmental Services (DBHDS) used cost and utilization data from CSBs, based on federal cost-reporting standards, to calculate expenses. DBHDS reviewed the data provided by CSBs in conjunction with workforce data and inpatient hospitalization data. The assessment identified some workforce deficits, funding needs for private provider support, and unmet demand for telehealth expansion, particularly in rural areas where access to psychiatric care is limited. However, these results are preliminary due to the following limitations:

1. Need for additional review and revision of the cost report format to improve consistency in submissions from CSBs

2. Lack of alignment between Federal Cost Report classification of employee roles and CSB classification of employee roles

3. Lack of adequate time and resources to provide Technical Assistance to CSBs completing the cost report to support quality submissions and address issues of misinterpretation of cost report instructions

4. Lack of adequate time for the state to reconcile with CSB submissions (DBHDS had only six months to complete a cost report and needs assessment for all 40 CSBs) as well as ability to reconcile against their certified financial statements

DBHDS suggests allowing for more time to work through these data issues to better refine the information, as well as to allow DBHDS time to receive initial electronic health record (EHR) data utilizing the Data Exchange. The Data Exchange is currently being developed by the CSBs and DBHDS, with a scheduled go-live date of July 2025.

Preliminary data highlights the funding gas and workforce shortages that limit the capacity of CSBs. The CSBs reported an estimated need of 773 additional full-time employees and compensation adjustments totaling $135 million in direct costs (personnel and supplies) to meet community demands. Furthermore, the CSBs have identified $37 million for administrative and overhead expenses, including facility upgrades and administrative support. It is important to emphasize that a review of data completed by DBHDS, as well as comments by CSBs, indicated that data provided by the CSBs potentially lacked validity and further refinement is needed.

Other factors to consider when evaluating any potential timeline for the continued implementation of the STEP-VA model in Virginia:

1. Changing STEP-VA Requirements - DBHDS has continued to work with the CSBs on requirements related to needed evidence-based practices. In addition, federal CCBHC requirements have continued to evolve since when STEP-VA was created. Additional time is needed to review newly established performance measures and the results of the CSBs. DBHDS has provided a side-by-side comparison of where STEP-VA requirements are the same or different than CCBHC (Appendix 1).

2. Investments in Crisis Options – The Governor the General Assembly have provided significant investments in the crisis continuum over the last two budgets. These investments will take time to come to fruition and will provide benefits for the current populations that the CSBs serve.

3. Medicaid Redesign - The Virginia Department of Medical Assistance Services, as directed by the General Assembly, is currently redesigning rates and requirements for Behavioral Health Medicaid services. As the majority of the CSB clients have Medicaid, these prospective changes will have a significant impact on the types of services the CSBs provide.

DBHDS recommends allowing additional time for the implementation of the Medicaid Redesign, collection of data from newly established performance measures, and further refining of the cost report data before additional decisions are made on funding.