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Presentation to the Joint Commission on Health Care Behavioral Health Care Subcommittee James Reinhard, M.D. Commissioner Department of Mental Health, Mental Retardation and Substance Abuse Services August 4, 2004. Presentation Topics. Vision for Virginia’s MH, MR, and SA Services System

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  1. Presentation to the Joint Commission on Health CareBehavioral Health Care SubcommitteeJames Reinhard, M.D.Commissioner Department of Mental Health, Mental Retardation and Substance Abuse ServicesAugust 4, 2004

  2. Presentation Topics • Vision for Virginia’s MH, MR, and SA Services System • Reinvestment Project Updates and Operational and Financial Status of the Three Participating State Hospitals • State Facility Physical Plant Needs and Associated Costs • Update on the State Aftercare Pharmacy Program • Progress Report on the Sexually Violent Predator Program and Projections • Distribution of Funding Appropriated by the 2004 General Assembly for Community Services

  3. Vision for Virginia’s MH, MR, and SA Services System Our vision is of a community-based system of services that promotes self-determination, empowerment, recovery, and the highest possible level of consumer participation in work, relationships, and all aspects of community life.The foundation of this vision includes the following. Self-determination, Empowerment, and Recovery Consumers express pride in their accomplishments and hope for their futures. Consumers are empowered and supported in defining and reaching their own goals and making decisions about their lives and the services they receive. Providers work to expand community service options that emphasize community integration and independent living. Quality of Services  System improvement is ongoing, with stakeholder involvement and feedback mechanisms about consumer and other outcomes built into the system of care.  Services and supports are highly individualized to each consumer.  Evidence-based and best practices are expected and required, with incentives and support for providers to learn and use these practices.  Personal privacy and consumer information is respected.  Effective services and management, innovation, and efficient use of resources are rewarded. 2

  4. Vision for the MH, MR, and SA Services System -- Continued Access  Services are consumer and family centered -- ► Ability to pay is not an obstacle; ► Services are easy to navigate; ► Consumers and families receive clear information about service options; ► Consumers receive services and supports quickly and easily when needed; ► Language and cultural differences are respected and appropriately addressed; ► Services are provided in consumers’ home communities as close to family and friends as possible; and ► Services are designed to be flexible.  A full range of services and supports is available, with choices for consumers and families.  Providers and policy-makers overcome fragmentation and barriers that limit access to health, education, employment, housing, and other community services and supports. Accountability  Policy-makers and providers at the state and local levels meet the highest standards of accountability, with performance monitored with stakeholders through an open process.  Consumer outcomes are measured and monitored to assure that services are effective.  Systems of accountability will encourage and not discourage organizational learning and systems improvement. 3

  5. Vision for the MH, MR, and SA Services System -- Continued Partnerships  Consumers, families, and providers are partners in treatment.  Leadership at all levels works collaboratively with stakeholders through a partnership process where operations, policy, and funding matters and issues are addressed.  State and local governments work with public and private providers to make services available in settings that are the most appropriate to the needs of individual consumers.  The academic community partners with public and private providers to ensure clinicians and direct care staff are skilled in evidence-based and best practices.  Stakeholders have a variety of opportunities for involvement, input, and consensus building. Coordination  CSBs are the local points of accountability for the coordination of publicly funded mental health, mental retardation, and substance abuse services  Regional structures collaboratively manage service utilization across the region and provide services that are beyond the capacity of a single CSB.  Providers, consumers, and family members communicate to coordinate care at both the individual and system levels. 4

  6. Vision for the MH, MR, and SA Services System -- Continued Funding  The services system will be appropriately funded to ensure sufficient capacity to address consumer needs.  As services are developed in the community, the state share of services funding is maintained and increased to meet growing consumer needs and provide evidence-based and best practices.  The state takes full advantage of federal sources of funding.  Consumer needs drive policies that govern eligibility for and use of state and federal funds. Efficient Use of Resources  Consumers receive the level of service they need, when they need it, in the appropriate amount, and for the appropriate duration.  Policies and practices at all levels support the most efficient use of resources.  Preventive and early interventions are encouraged and supported. 5

  7. Introduction • The Governor and 2004 General Assembly took significant steps to address critical service needs and implement the landmark Olmstead decision of the U.S. Supreme Court. • But more work remains to be done to achieve our vision. • Each regional partnership has been engaged in a grass-roots strategic planning process involving key stakeholders. The Department will receive each Region’s Strategic Plan this month. • These Regional Strategic Plans and the recommendations of the Special Populations Work Groups will be incorporated into an Integrated Strategic Plan for the services system. • The Integrated Strategic Plan will be completed later this year. It will provide a framework for continuing progress toward achieving our vision of a truly community-based system of services. • We will report on our progress at the Subcommittee’s October meeting. 6

  8. Update on the Reinvestment Projects • Regional Reinvestment Projects at Central State Hospital, Eastern State Hospital and Western State Hospital were authorized in Item 329 of the 2003 Appropriation Act. • These projects focus primarily on adult mental health services. • The projects have been successful in fostering partnerships among the community services boards (CSBs), state facilities, and private providers with the goal of: • Expanding services in the community, • Promoting local and regional management of state facility and publicly funded community inpatient services, and • Reducing reliance on state facilities for services that could be provided more appropriately in the community. 7

  9. Update on the Reinvestment Projects • Recap of State Facility Dollars Reinvested in Community Services: • $ 3.3 million (annualized) has been transferred from Central State Hospital to the Region IV Central Virginia CSBs • $ 6.5 million (annualized) has been transferred from Eastern State Hospital to the Region V Eastern Virginia CSBs • $ 1.4 million (annualized) has been transferred from Western State Hospital to the Region I Northwestern Virginia CSBs • The Department also transferred $ 2.4 million (annualized) from the Northern Virginia Mental Health Institute to the Region II (Northern Virginia) CSBs for their management of local hospital bed purchases. 8

  10. Central Virginia Reinvestment Project Accomplishments • Closed two civil units (45 beds) at Central State Hospital (CSH) in May and August 2003, reducing CSH’s civil bed capacity from 135 to 100 beds. • Regional Initiatives • Crisis Stabilization Unit: This 6 bed program, operated under contract with Rubicon, Inc., has served 145 clients between 10/22/2003 and 7/20/2004. • Jail Team: Recruitment is underway, with a psychologist on board and other clinicians coming on board or being interviewed in August. A psychiatrist under contract with CSH will begin in August. Memoranda of Understanding have been completed with Riverside Regional Jail and Richmond City Jail (awaiting signatures). • Nursing Home Services: Consultants reviewed regional issues and resources in June and will report their findings soon. • Individualized Client Services: Four CSH patients have been successfully placed in community living arrangements. Two of these four individuals had been on the CSH extraordinary barriers to discharge list. • Behavior Support Team: A Memorandum of Agreement has been completed with the VCU/Department of Social Work. Interviews for the psychologist were held on July 15. Applications are being screened for the clinician. 9

  11. Central Virginia Reinvestment Project Accomplishments - continued • Local Initiatives • A total of $1,331,016 has been budgeted for FY 2005. These targeted programs directly benefit consumers who have been CSH patients and individuals at risk of requiring residential care. • Services provided at the end of the third quarter FY 2004: • Case management 1,531 hours • Hospital liaison 511 hours • Day support/treatment 1,744 hours • Medical services 1,270 hours • Residential care 3,065 days • The Region IV Reinvestment Initiative has benefited from the close relationship and coordination with the Region’s Acute Care Diversion Project and the weekly review of CSH utilization. 10

  12. Eastern Virginia Reinvestment Project Accomplishments • Closed 43 Eastern State Hospital (ESH) acute beds in November 2003 • Entered into contracts with Riverside Behavioral Health Center, Maryview Behavioral Medicine Center, and Virginia Beach Psychiatric Center • Unduplicated Number of Individuals Served (11/15/2003 to 6/30/2004) – 958 • Many of these individuals are new to the public services system • Mean Census – Just under 30 (27.93) • Average Length of Stay – 5.66 days • A Regional Authorization Committee is working to enhance communication and cooperation among CSBs, ESH, and contract hospitals 11

  13. Region V Reinvestment Project Quarterly Report, July 2004 * Data from 2002 includes local private hospital bed purchases 12

  14. Western Virginia Reinvestment Project Accomplishments • Closed one unit (25 beds) at Western State Hospital (WSH) and consolidated other WSH units to allow for the closure of one building, saving energy and maintenance costs. • Discharged 35 long-term WSH patients, each of whom had an individualized treatment plan for services that included supervised residential, SA treatment, and community supports. • Purchased acute care beds to assist in census management at WSH. • Between April and July 2004, the region bought 197 bed days for 44 patients (up to 6 bed days each), spending a total of $108,350. • Developed a utilization management program that includes a protocol for purchasing and authorizing private bed days, and that specifies CSB and hospital roles in discharge planning. 13

  15. Impact of the Reinvestment Projects on theOperational and Financial Status of CSH, WSH, and ESH • Over the past three fiscal years, the average daily census at the three hospitals participating in Reinvestment Projects has declined. • The hospitals did not report financial problems in FY 2004 associated with the Reinvestment Project transfer of funds to the community. 14

  16. State Facility Physical Plant Needs • In spite of continuing efforts to patch and incrementally renovate a limited number of buildings, state facilities have a number of critical capital needs. • Aging infrastructure services are breaking down, resulting in unreliable water and steam distribution and significant operating inefficiencies. • With an average age of over 40 years, many buildings cannot meet current building codes without significant changes at prohibitive costs. Primary systems (electrical, heating, and plumbing) must be replaced. • Four facilities are at risk of losing millions of dollars in Medicaid and Medicare funds due to physical plant issues -- Eastern State Hospital, Central VA Training Center, Piedmont Geriatric Hospital, and Southside VA Training Center. • Most facilities were not designed to provide appropriate space for treatment activities or to accommodate the needs of increasingly disabled patients and residents. 15

  17. State Facility Physical Plant Needs - continued • Census reductions over the past 20 years have resulted in vacant buildings that are rapidly deteriorating, too expensive to demolish, and overly-large campuses that are inefficient to maintain. • Status of the Department’s 2004-2006 capital budget request: • Maintenance Reserve: $4,030,000 of the needed $54.53 million was funded. The $50.5 million backlog in this area represents over 5% of the state facilities’ capital value. • Umbrella Projects (Life Safety Code and Asbestos Abatement): $7,588,000 of the requested $24,739,000 for 4 projects was funded • Line Item Facility Projects: None of the requested $78,503,000 for 9 projects was funded. • The Department has received unsolicited Public-Private Education Facilities and Infrastructure Act (PPEA) proposals for a new SVP facility ($32 million) and a new Hancock Geriatric Center at ESH ($23 million). These are under consideration. 16

  18. Capital Improvement Recommendations • State MH and MR facilities are essential components of a fully developed community-based system of services. State facility services must be provided in environments that promote effectiveness, efficiency, and safety. This is an increasingly difficult challenge given the pervasive physical plant needs. • At a minimum, major infrastructure replacements and building renovations must be made at: Eastern State Hospital Western State Hospital Central State Hospital Piedmont Geriatric Hospital Central VA Training Center Southside VA Training Center Southwestern VA Training Center Southeastern VA Training Center • It’s time to seriously consider the investment benefit of replacement versus continuing renovation of some facilities. 17

  19. Capital Improvement Recommendations - continued • Southwestern Virginia Mental Health Institute in Marion represents a model for facility consolidation and alternate use of vacant buildings. • Southwestern State Hospital was modernized in the late 1980s, building a smaller more efficient Institute on the existing campus. • Vacant buildings were razed or leased for other uses including: • A public-private partnership lease to treat CSA adolescents closer to home versus distant placements, • Transfer of property and buildings to the Department of Corrections, and • Lease of buildings to state agencies and local government. 18

  20. State Facility Operating Needs • All state facilities anticipate financial difficulties in FY 2005 and FY 2006 resulting from significant rising costs in the following areas. • Significant increases in the costs of utilities, • Escalating costs of medications, • Personnel costs associated with replacement of direct care staff (RNs, pharmacists) and matching competitive salary offers, and • Increasing costs of Special Hospitalization and medical consults. 19

  21. State Aftercare Pharmacy Program • In FY 2004, the Aftercare Pharmacy budget totaled $21,793,693. • Aftercare Pharmacy costs in FY 2004 were $25,214,776, resulting in a deficit of $3,421,083. • The Department used one-time special revenue collections, Central Office and state facility balances, and additional federal block grant funds to cover this deficit. • Although the Department and CSBs continue to work together to manage utilization, educate CSB psychiatrists, and increase efficiencies, this deficit is likely to increase because of additional costs associated with: • Introduction of new medications into the Aftercare Pharmacy formulary; • Additional numbers of consumers receiving medications through the Aftercare Pharmacy, particularly indigent persons served by the Reinvestment Projects who are new to the public services system; and • Potential medication price increases. 20

  22. Sexually Violent Predator Program • The SVP program opened in September 2003. It is currently housed in two renovated buildings on the Southside Complex. Each building has two 9-bedroom wings and a wing for programs. • The SVP program census on July 22, 2004 was 9. • The program currently has 70 staff on board, which include administrative, security, and clinical and medical staff. • The SVP Program operating budget is $5.8 million in FY 2005 and FY 2006. • Projections, based on a commitment rate of 8% of all inmates referred for evaluation or an average of 2 per month, have proven to be accurate. 21

  23. Sexually Violent Predator Program - continued • The Center is opening the second wing and is recruiting 17 new security positions. • To accommodate projected growth, additional residential wings will need to be opened through FY 2005 and FY 2006, resulting in a projected program budget of $7.8 million in FY 2006. • Based on current projections, the SVP program will exceed maximum capacity between late 2005 and early 2006. • A new facility will be necessary to accommodate future growth. • If funding is received from the 2005 General Assembly session, the earliest possible occupancy date for a new facility would be August 1, 2006. 22

  24. New Funding for Community Services 23

  25. Allocation Guiding Principles and Process • Guiding Principles • Consistency with the Department’s Vision for the Services System, • Accomplishment of Regional Restructuring Objectives, • Consistency with the Olmstead Decision, and • Balanced Distribution of Resources Across the Regions. • The Regional Partnerships developed PACT, DAP, and Inpatient POS fund proposals that discussed: • How the proposed services related to the Region’s restructuring plans and their impact on the Region’s use of state facility resources; • Consumer, family member, and other stakeholder involvement in the development and implementation of the proposed services; and • Opportunities for regional management of DAP and Inpatient POS. 24

  26. PACT Allocations • Funding for new PACT teams has been allocated and is being dispersed to the: • Mt. Rogers CSB (Far Southwest Region), • Danville-Pittsylvania CSB (Southern Region), and • Portsmouth/ Chesapeake CSBs (Eastern Region). • These CSBs have the highest relative demand for PACT services. • Funds also will provide training in FY 2005 and other needed support for implementation. 25

  27. DAP Allocations • DAP funds have been allocated and are being dispersed to all seven regions, based on the: • Numbers of individuals with serious mental illnesses by Region, • Numbers of patients in state mental health facilities on facility extraordinary barriers to discharge lists, and • Number of current NGRI patients eligible for future conditional release. • CSBs in each region will work together to manage these funds. • This allocation also includes ongoing support to leverage the Department for the Aging Guardianship program; NGRI Conditional Release supports for CSBs; and and other needed support for implementation. 26

  28. Local Inpatient POS Allocations • Local Inpatient POS funds have been allocated and are being dispersed to the Northwest, Far Southwest, Catawba, and Southern Regions. • These regions do not currently have POS funding. • The CSBs, state facilities and private hospitals will work together to regionally manage utilization of these funds. 27

  29. Allocation of New Funding for PACT, DAP, and POS 28

  30. MH Services for Non-Mandated CSA Children and Adolescents • The Department has allocated and is dispersing $50,000 to each CSB. • Services must be based on the individual needs of the child or adolescent and included in an individualized services plan. • CSBs must ensure local coordination with local Family and Assessment Planning Teams and Community Policy Management Teams. 29

  31. MR Waiver Slots to Address the Urgent Waiting List • The 700 MR Home and Community-Based Waiver slots have been allocated as follows. • Each CSB received one slot. • The remaining slots were distributed based on the CSB’s percentage of persons on the Medicaid Urgent Waiting List on June 1, 2004. • There were 1,384 individuals on the June 1, 2004 Urgent Waiting List. • Appropriation Act language speaks to the possibility of adding 180 additional MR Waiver slots next year to address demonstrated need. 30

  32. MR Waiver Slot Allocation by CSB 31

  33. MR Waiver Slots for State Training Center Residents on Discharge Waiting Lists • The Department has established a work group comprised of CSB MR directors, Training Center directors, and other key stakeholders to establish an allocation plan for the 160 slots. • Initial Allocation of Waiver Slots by Training Center • Central VA Training Center 65 • Southside VA Training Center 62 • Southwestern VA Training Center 17 • Northern VA Training Center 8 • Southeastern VA Training Center 8 • CSBs will develop discharge plans for training center residents choosing community services and will manage these slots. • Specific resident needs and the availability of providers could change the final slot allocation decisions. 32

  34. MR Waiver Day Slots • The Department will work with the Department of Medical Assistance Services, CSBs, and other key stakeholders this year to develop a new MR Waiver Day Slot Program. Early Intervention Services • These funds will help to maintain current service levels and help localities address existing program funding deficits • Allocation will be based on the localities’ annualized child counts. 33

  35. Conclusion • Our vision articulates how Virginia’s mental health, mental retardation, and substance abuse services system can continue to be transformed. • Transformation of our system will happen when we understand and embrace the concepts of recovery, self-determination, and community integration. • We are very appreciative for the new funding provided for community services by the General Assembly, encouraged by our progress to date, and look forward to continuing to work with our partners to achieve this vision. 34

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