The South Carolina Department of Mental Health

1. The South Carolina Department of Mental Health FY 2019-20 Budget Hearing Summary Brief South Carolina House of Representatives Ways and Means Committee Healthcare Subcommittee February 5, 2019

2. FY2019-20 Budget HearingSummary of Contents Title Page ……………………………………………………………………………….………… 1 Agency Attendees ………………………………………………………………………………. 3 Agency Information …………………………………………………………………………..….. 4 Accountability Report Highlights ……………………………………....…………………. 6 Current Year “New” Funding ………………….……………….….………………..… 7 Priorities 1-13 …………………………….………………………………………………... 9 Wrap-up ……………………………………………………………………………….........… 22

3. Agency Attendees • Mark W. Binkley, Esq., Interim State Director • Robert Bank, M.D., Medical Director • Versie Bellamy, RN, MN, DNP, Deputy Director, Inpatient Services • Deborah Blalock, M.Ed., LPCS, CPM, Deputy Director, Community Mental Health Services • Debbie Calcote, MA, Deputy Director, Administrative Services • Kimberly Rudd, M.D., Medical Director, Inpatient Services • Noelle Wriston, Director, Budget and Planning, Financial Services • Stewart Cooner, MHA, Director, Special Programs & Telepsychiatry

4. Agency Information • The South Carolina Department of Mental Health’s (SCDMH) mission is to support the recovery of people with mental illnesses, giving priority to adults with serious and persistent mental illness and to children and adolescents with serious emotional disturbances. • The SCDMH system… • Comprises 17 community-based, outpatient mental health centers, each with clinics and satellite offices, which serve all 46 counties – a total of approximately 60 outpatient sites; • Provides services to approximately 100,000 patients per year, approximately 30,000 of whom are children; • Operates several licensed hospitals, serving adults, children and adolescents, and addictive disease; • Operates four nursing homes, including three for veterans; • Includes operation of an inpatient Forensics hospital and an outpatient program; • Includes operation of a Sexually Violent Predator Treatment Program. • SCDMH is one of the largest healthcare systems in South Carolina.

5. Agency Information • SCDMH has more than 900 portals by which citizens can access mental health services, including: • a network of 17 outpatient community mental health centers, 43 clinics, multiple psychiatric hospitals, one community nursing care center, and three veterans’ nursing homes; • more than 30 specialized clinical service sites (SCDMH offices that provide some type of clinical care, but do not offer a full array of services found in a center or clinic); • more than 20 South Carolina hospitals with Telepsychiatry services; • more than 140 community sites (non-SCDMH entities or businesses where DMH staff regularly and routinely provide clinical services), and • more than 650 school mental health service program sites.

6. Accountability Report Highlights • The South Carolina Department of Mental Health (SCDMH) strives to improve and expand its mental health services to the citizens of our state. With your support, we continue to make progress. • SCDMH continues to expand and improve its community mental health services. • SCDMH continues to use innovative technology to advance and increase its services. • SCDMH is a dedicated partner in serving the citizens of South Carolina. • SCDMH is dedicated to employing an excellent, well-trained staff. • SCDMH continues to plan for the future.

7. Current Year “New” Funding • Supported Community Housing Expansion $4,452,017 • Use: SCDMH’s Community Mental Health Services (CMHS) Division is in the process of using additional funds appropriated to increase community services for adults. The expected outcome of the funding is to increase outreach to patients living with chronic mental illness who are at risk of hospitalization, by securing appropriate community housing and delivering services in the community at an intensity to meet their needs. • Child and Adolescent Intensive Community and Residential Services $2,000,000 • Use: CMHS is also in the process of using additional appropriated funds to increase community services for children, adolescents, and their families. The additional funding available to Centers will increase the availability of intensive, evidence-based services to meet patients’ needs in the community and prevent hospitalizations and out of home placements.

8. Current Year “New” Funding • School-Based Services $500,000 • Use: SCDMH is utilizing the funds to increase by 20 the number of clinical counselors who provide services in public schools. • Crisis Intervention Training $104,500 • Use: SCDMH will incorporate the funds into its existing contract with the National Alliance on Mental Illness (NAMI) to expand availability of the Crisis Intervention Training provided by NAMI instructors. • Community Health Centers $50,000 • Use: SCDMH will use the funds to reimburse community mental health centers for time SCDMH staff serves as instructors in Crisis Intervention Training.

9. Priority 1 - Capital Budget Request • Certification of State Match (VA Nursing Homes) $37,065,450 • Justification: SCDMH received Notice from the Veterans Administration of funding availability for the three VA construction grants it submitted in April of 2015 on behalf of the State for three additional State Veterans Nursing Homes. The agency in its continuing design of the three facilities received updated construction cost estimates, and each facility’s estimated construction cost was in the range of $55,000,000 per facility, approximately 40% higher than the preliminary cost estimates in the 2015 Veterans Administration construction grant applications. The result of the far higher construction cost estimates, combined with the cap on the VA grant funding, means the potential State Match for the projects would exceed the amounts SCDMH reserved for the State Match by the requested amount. SCDMH met the August 1, 2018 deadline for submission to the U.S. Veterans Administration of the required Environmental Assessments and 35% complete design drawings. The agency expects the Undersecretary of Health for the VA will approve the conditional construction grant awards for all three projects in September. To receive the VA construction grants the State must be ready to proceed with construction no later than 180 days following notification of the conditional award, to include having already awarded a construction contract. Additionally, SCDMH must certify, on behalf of the State, that it has the necessary State match funds. • Methodology: This request covers 3 CPIP projects. Each was for the First year and are priority #3, 4, and 5. If the requested appropriated state funding is denied then the agency will have to apply for state bonds to fund the 3 projects. • Potential Offsets: SCDMH Capital Improvement and Maintenance Funds have been invested in this project to get the plans to 35% completion for the 3 facilities. This was done to meet the August 1st deadline set by the VA for the matching funds. The agency received cost estimates based on the design development drawings in July 2018, and each facility’s estimated project cost was in the range of $55,000,000 per facility, approximately 40% higher than the preliminary cost estimates in the 2015 Veterans Administration construction grant applications. Per the VA, the VA construction grants will fund up to 65% of the construction cost, but only to a maximum of 10% above a State’s preliminary cost estimates, and the State would be responsible for 100% of the construction costs for any excess.

10. Priority 2 - Recurring Budget Request • Crisis Stabilization Units $1,000,000 • Justification: The requested funds would enable the agency to continue to partner with local hospitals and other community officials to increase residential crisis stabilization programs beyond the four (4) currently in existence or in the planning stages. Such programs help divert individuals in a psychiatric crisis who can be safely cared for outside of a hospital emergency department. • Methodology: The request for funding is based on an estimate of the total funds required to meet the financial obligation. • Potential Offsets: No potential offsets.

11. Priority 3 - Recurring Budget Request • Improving Local Access $1,000,000 • Justification: Patients in need of psychiatric hospitalization generally are best served if they can be hospitalized as close to their homes and families as possible. Receiving hospital services locally enables patients to maintain contact with family and other existing community support systems, and frequently results in shorter lengths of stay. Hospitalizing patients in need of emergency admission locally also reduces the transportation requirements for local law enforcement and improves safety for both the patient and law enforcement officers. The requested funds would enable SCDMH to identify 2 or 3 willing community hospitals with which to pilot the establishment of small psychiatric units for patients in a psychiatric crisis needing stabilization in a hospital setting. The funds would enable the Department to purchase a minimum of 1,535 bed days for uninsured patients. Current State Health Plan provisions permit hospitals partnering with SCDMH to receive a Certificate of Need for a small number of psychiatric beds designated for crisis stabilization. The goals of the pilot units would be to demonstrate: • An increase in the number of community hospitals with psychiatric beds able to provide short-term acute care for psychiatric admissions; • Improvement in the timeliness of admission for patients presenting in hospital emergency departments in need of psychiatric hospitalization; • Reductions in the lengths of stay for patients needing psychiatric hospitalization, both in emergency departments and following admission; and • Reductions in the demands on local law enforcement agencies for out-of-county transports of patients requiring an involuntary emergency admission. • Methodology: The request for funding is based on an estimate of the total funds required to meet the financial obligation. • Potential Offsets: No potential offsets.

12. Priority 4 - Recurring Budget Request • Sexually Violent Predator Treatment Program $481,974 • Justification: The requested amount would enable the Department to fund a CPI increase for its contractor operating its Sexually Violent Predator Treatment Program (SVPTP). The contractor’s labor, pharmacy and medical costs have all been increasing. • Methodology: The request is based on an assumed Southeast Medical CPI of 3% and estimate of the cost per resident of a census which is projected to increase by 12 additional residents. • Potential Offsets: No potential offsets.

13. Priority 5 - Recurring Budget Request • Contractual Adjustment – Inpatient Services $1,334,424 • Justification: The requested amount represents expected contractual obligations in FY2020 related to CPI adjustments for the Department’s forensics program and veterans’ nursing homes: Forensics (CPI): $604,481; Contracted Veterans Nursing Homes (CPI): $361,387 and $368,556. • Methodology: This request is based on an approximation of FY2020 contractual obligations. • Potential Offsets: No potential offsets.

14. Priority 6- Recurring Budget Request • School Mental Health Services $1,250,000 • Justification: SCDMH school mental health services improve access to needed mental health services for children and their families. A shared goal of SCDMH and the Department of Education is to have school mental health therapists serving the students and families in every public school by 2022. • Methodology: The requested funding would enable the agency to increase by at least 50 the number of school mental health therapists based on the average State support needed to sustain a position being $25,000 per school-based therapist. • Potential Offsets: No potential offsets.

15. Priority 7 - Recurring Budget Request • Psychiatric Medical Services $1,394,000 • Justification: The requested funding will support recruitment and retention for psychiatrists, psychiatric Advanced Practice Nurses (APRNs) and Physician Assistants (PAs). SCDMH is committed to providing outstanding mental health services to residents of this state. The Statewide and nationwide shortages of psychiatrists has already adversely affected a number of State agencies. In addition to its hospitals, the Department has 60 community mental health clinics throughout South Carolina. The Department’s use of telehealth technology has enabled it to more efficiently and effectively use its limited number of psychiatrists by doing away with the need for its psychiatrists to travel between the Agency’s multiple outpatient locations. Utilizing Advanced Practice Nurses (APRNs) and Physician Assistants (PAs) with the authority to prescribe medication under the supervision of a psychiatrist is another established method that SCDMH has been pursuing to serve the increasing numbers of citizens in need of psychiatric care. • Methodology: While technology has been helpful, market competition for psychiatrists, psychiatric APRNs and PAs has reached the point where SCDMH must increase compensation for these scarce professionals in order to recruit and retain a sufficient number to meet the growing demand and sustain its effective public mental health system. • Potential Offsets: No potential offsets.

16. Priority 8 - Recurring Budget Request • First Episode Psychosis (FEP) Programs $600,000 • Justification: The first symptoms of psychotic disorders typically manifest in individuals between the ages of 16 and 25. Young adults are a challenging population to engage and stay in treatment. FEP programs are 2 year intensive programs with small caseloads using a person-centered team approach. Also known as “Coordinated Specialty Care,” FEP programs are aimed at guiding young adults experiencing psychosis (and their families) toward mental, physical and functional health. Studies have shown that Coordinated Specialty Care programs improve treatment engagement and adherence and substantially reduce the likelihood that patients’ psychotic disorders will lead to long-term disability. The majority of patients are able to stay in school or remain employed, and remain connected to family, friends and social supports. Correspondingly, patients’ use of emergency services, such as hospital Emergency Departments and calls to law enforcement is significantly reduced. Despite the clear benefits of these programs for patients and for reducing long-term care costs, neither public nor private insurance currently reimburse many of the services provided by Coordinated Specialty Care programs. • Methodology: Funds will support two (2) programs for individuals who have experienced the early onset of a psychotic disorder, such as Schizophrenia. • Potential Offsets: No potential offsets.

17. Priority 9 - Recurring Budget Request • Additional Community Supportive Housing $2,400,000 • Justification: SCDMH has a long history of making efforts to foster more supportive community housing for its patients, including permanent independent housing. Appropriate housing is often the single biggest factor in determining whether a patient with serious psychiatric impairments is able to remain successful in their recovery in the community. The Department since 1990 has funded various types of supported community housing, recognizing that patients are individuals whose support needs differ, and includes: • Homeshare; • Community Residential Care Facilities (CRCFs); • Supported apartments. Funds will be used to expand all types of supported community housing options for long-term patients who have presented as discharge challenges at Bryan Psychiatric Hospital -- both civil and forensic patients -- as well as Harris Psychiatric Hospital. Goal would be to increase availability of CRCF beds as well as Homeshare settings and supported apartments. Funds would also be used for rental assistance in supported apartments and for transitioning patients into independent living. The expected outcomes will be reduced lengths of hospitalization and longer, hopefully permanent, community tenure. Successful discharges of long-term patients will also result in additional inpatient capacity as lower lengths of stay and bed turnover will result in increased bed availability for new patients in need of hospitalization. • Methodology: The request for funding is based on an estimate of the total funds required to support the scope of this program. • Potential Offsets: No potential offsets.

18. Priority 10 - Recurring Budget Request • Information Technology $2,600,000 • Justification: The requested funds will replace one-time funds to support the Department’s operations, including its expanding telepsychiatry network, its Inpatient Services and Community Mental Health Services electronic health records, information technology support, and its network infrastructure support, including contractual services maintenance, software product costs, training, and funds associated with vacant and requested Information Technology staff positions. • Methodology: This request is considered in the Department’s annual information technology and security plans. This request includes consultation with the Department of Administration in its development. • Potential Offsets: No potential offsets.

19. Priority 11 - Recurring Budget Request • DMH Crime Victims Counseling Support $1,750,000 • Justification: The program would be based on a successful partnership between mental health and law enforcement agencies in Charleston and Dorchester counties. In 2014, the Department’s Charleston Dorchester mental health center embedded a MHP in the Charleston Police Department’s headquarters to create a “Family Violence Unit.” The purpose of the Unit was to immediately respond to domestic violence scenes and to screen children witnessing violence for mental health needs related to the potentially traumatic event. Therapy services are offered to 100% of the victims at the time of the first meeting/intervention. The Family Violence Unit was modeled after a similar project in New Haven, Connecticut addressing the needs of children who were present when police responded to domestic violence in the home. A high percentage of children exposed to domestic violence are removed by the Department of Social Services (DSS). Over the past three years, in cases in which the Family Violence Unit responds, families are more likely to contact police regarding further incidents involving violence, families feel safer and more positive about the police, and families are more likely to engage in mental health treatment and other family support services. The MHPs stationed on-site at the Police/Sheriff’s Departments will provide mental health assessments and evidence-based Trauma-Informed therapy for victims. The therapists may also participate in weekly case reviews where their input is presented regarding the ongoing investigation of child abuse cases, if applicable. Detectives will be able to regularly staff a variety of victim cases with the MHP for guidance. • Methodology: The funds would be used to station 20 SCDMH Mental Health Professionals (MHPs) in South Carolina police and sheriffs’ departments to provide direct services to adult and child victims of domestic violence. • Potential Offsets: No potential offsets.

20. Priority 12 - Non-Recurring Budget Request • Community Mental Health Services – Outpatient EHR $4,500,000 • Justification: The requested funds would be used for the procurement of an integrated software solution for SCDMH’s Community Mental Health Centers (CMHC) that will either augment or replace SCDMH’s current billing and electronic medical records software applications and any services associated therewith. • Methodology: The request for funding is based on an estimate of the total funds required to meet the financial obligation. This initial request will fund the first stage of the full implementation of this system. Additional non-recurring funds may be requested in future years as the system is implemented in its entirety. • Potential Offsets: No potential offsets.

21. Priority 13 - Capital Budget Request • Suicide Prevention – Ligature Resistant Fixtures $1,252,786 • Justification: SCDMH’s psychiatric hospitals, G. Werber Bryan Psychiatric Hospital (BPH) in Columbia and Patrick B. Harris Psychiatric Hospital (HPH) in Anderson, are accredited by the Joint Commission and certified by the Centers for Medicaid and Medicare Services (CMS). Such accreditation and certification are not only evidence that the psychiatric hospital services at those facilities meet the highest standards of quality, they enable the Department to bill Medicaid and Medicare for medically necessary services and to qualify for disproportionate share Medicaid payments to offset the cost of the indigent care both facilities provide. Recently both the Joint Commission and CMS, in an effort to prevent suicide in hospitals, promulgated stringent standards requiring hospitals eliminate fixtures that could potentially be used as ligature point, such as door hinges, and standard sink and shower fixtures. Both BPH and HPH are under time deadlines from the Joint Commission and CMS to replace all fixtures in patient areas with ligature resistant fixtures. The funds requested represent the cost to SCDMH of replacing all of these fixtures. • Methodology: This request covers 2 CPIP projects. One for Bryan Psychiatric Hospital and the other for Harris Psychiatric Hospital. The project for Bryan is J12-9755 and was not included on this year’s CPIP. The Bryan project was on the CPIP for last 3 years except this year. The project for Harris was included in this year’s CPIP as year 3 priority 4. Recent Joint Commission Accreditation inspection cited both facilities anti-ligature fixtures as being deficient. • Potential Offsets: Three of the 6 lodges at the Bryan facility have already been completed using Capital Improvement & Maintenance Funds totaling $465,000. A budget increase will be requested for the remaining lodges in the amount of $600,000. The Harris facility has 6 lodges that have had nothing done and an A1 Phase I has been submitted using Capital Improvement & Maintenance Funds. The project, once complete, should not impact the normal operation costs of the facilities. The cost savings will be seen in keeping the facility certification so that Medicaid/Medicare revenue can be claimed. SCDMH should have 20+ years of service from these improvements.

22. Wrap-up • The South Carolina Department of Mental Health has identified several significant challenges that it will encounter in the future. A brief description of each issue is provided below. • Increasing Access to Veterans Nursing Home Beds – Based on a formula promulgated by the Department of Veterans Affairs, there exists in South Carolina the need for additional veterans long-term beds. Title 38, Part 59 provides the total number of allowed State Home beds, which, when netted with the number of current State Home beds (530), indicates a need for an additional 559 veterans nursing home beds. • Reducing the Time for Forensics Admissions – By law, criminal defendants found incompetent to stand trial due to a mental illness must go through a commitment process to a SCDMH hospital. Because of a significant increase in commitment orders, the length of time that defendants must wait for admission substantially increased. As a result, in June, 2016, SCDMH made reducing the wait time for forensic admissions its first priority and developed a multi-faceted Action Plan. • Increasing Hospital Capacity without Increasing Hospital Beds – If SCDMH is able to increase the availability of intensive community mental health services and increase the availability of supported community housing, it will lead to shorter hospital lengths of stay. In effect, expanding community housing and intensive mental health services will result in SCDMH being able to hospitalize more patients with its current number of beds. The challenge is to fund increased community housing and additional mental health services delivered at a patient’s residence. SCDMH has requested recurring appropriations to support these services. • Addressing Crisis Stabilization – It is critical the SCDMH be able to partner with local hospitals and other community officials to increase residential crisis stabilization programs. Such programs help divert individuals in a psychiatric crisis who can be safely cared for outside of a hospital from emergency departments. Charleston has opened a 10-bed Crisis Stabilization Center and discussions are ongoing with other communities. • Addressing Workforce Recruitment and Retention - Like many healthcare providers, SCDMH is faced with enormous challenges in recruiting and retaining all of the healthcare professionals it needs, including competing with other public and private healthcare providers for a limited supply of psychiatrists, nurses, and counselors. SCDMH is pursuing a number of new measures to reach prospective employees, including dedicating recruiting staff to attend job fairs, expanding its presence on social media, and placing job announcements in professional publications. SCDMH’s Human Resources office is also streamlining the hiring process with the goal of significantly shortening the time between receiving job applications and being able to offer positions. • This list of significant challenges that SCDMH will encounter in the future is not complete. However, the items listed above are ongoing and, consequently, require ongoing consideration.