Va. agency abandons mental health plan

The cries for help keep pouring in.

From David Cooper, a father in Doswell whose mentally ill and drug-addicted daughter got stable and sober through treatment, only to relapse when she was released on the streets without a plan in place for where she would live.

From Beth Tolley, a grandmother in Henrico County whose son took his own life years ago and whose 10-year-old granddaughter now battles mental illness every day.

"I don't want to lose this child," Tolley recently told Virginia lawmakers. "I don't want to lose her to out-of-home placement; I don't want to lose her to suicide; I don't want to lose her to the criminal justice system. I want help."

Cooper and Tolley joined scores of Virginians who have been pleading with officials for years to address gaps in the state's mental health system, but the latest message from the state is one they have heard before: You'll have to wait.

The Virginia Department of Behavioral Health and Developmental Services has decided to abandon a pilot program that would have significantly expanded access to services for people seeking mental health help at eight of the state's 40 public treatment centers, known as community services boards, or CSBs. The expansion was deemed too costly and ambitious.

State officials instead are working on a plan to make changes at all 40 community services boards, saving money by spreading the reforms over the next decade. The CSBs often function as the front line for Virginians in need of mental health treatment, especially for those in crisis.

Elected lawmakers and the department officials charged with administering the public mental health system agree that there is a serious need for change.

Dr. Jack Barber, interim commissioner at the Department of Behavioral Health and Developmental Services, said Virginia needs to move toward a system that allows people experiencing a mental health crisis to be seen the same day they walk into a CSB for help - not weeks or months later, when it may be too late.

He said the state also needs to direct resources toward a more robust community-based structure aimed at keeping people with mental illness stable in their own homes so they do not wind up in crisis in hospitals or CSBs.

"There is a way to do that, but it will take resources, and this is a tough time for that, given the revenue picture," Barber recently told the Richmond Times-Dispatch.

Lawmakers will be facing a $1.48 billion revenue shortfall when they convene in January.

Mental Health America, a national nonprofit, recently ranked Virginia 38th among states in terms of the prevalence of mental illness among residents and their ability to access care. The commonwealth was ranked 27th in 2011.

Virginia ranked 49th among states for the share of its youth - about 75 percent - who do not receive treatment for depression, according to Mental Health America's study.

Karen Cameron, health care director with the Virginia Interfaith Center for Public Policy, urged lawmakers to consider expanding Medicaid to thousands of uninsured Virginians so they can get help before they are in crisis.

The state is grappling with a shortfall of providers - psychiatrists, psychologists and therapists - who are able to help people manage their medications and their illnesses through psychotherapy, but Cameron argued that increasing the supply of people with insurance would likely result in an increase in the number of professionals who can help them.

"Not only will people be able to choose the most appropriate care and provider available, but universal coverage would likely increase the number of mental health providers in underserved areas because there will be a payment source for a large majority of those living in underserved communities," Cameron said.

Medicaid expansion is a politically fraught issue. Gov. Terry McAuliffe staunchly supports it, but Republicans in the General Assembly have blocked his efforts to pass it.

Faith leaders often find themselves having to grapple with mental health problems of parishioners and their family members, Cameron said.

In one case, a mother approached her pastor about her severely depressed son, who was uninsured, Cameron recently told lawmakers. The mother had taken him to the community services board where she lived, but he could not be seen there because he was not a resident of the region.

She took him to the CSB in his own community, but it did not have the same set of services as the one in her city. The mother turned to the pastor for help, but the son committed suicide, Cameron said.

Disparity among CSBs is one of the major challenges the state is trying to resolve.

Virginia was part of a pilot program administered by the federal government to study enhancing services with eight of its 40 CSBs. Twenty-four states, including Virginia, were selected for a planning grant as part of the first phase, and eight of those states will ultimately compete for grants to implement changes in the next phase.

Virginia has decided not to move forward with the next phase of the program, Barber said, because the state's community-based system is underfunded and it would be too costly to raise the bar right away.

Consultants analyzed the eight CSBs - the Richmond Behavioral Health Authority was among them - based on 11 types of services. None of the eight was ready to implement the program in its entirety, according to the analysis.

The services that need the most improvement include outpatient mental health and substance abuse treatment and outpatient primary care screening and monitoring of patients' health. The eight CSBs were rated highest for their psychiatric rehabilitation services and targeted case management.

Across the country, states spend about 75 percent of total behavioral health expenditures on community-based mental health services, and the rest is spent on inpatient treatment at state mental hospitals. In Virginia, the share of expenditures is split almost evenly at 50 percent between community services and hospital treatment.

The federal matching grant dollars would not have covered the cost of the program, and they would have dried up after two years, Barber said. That means Virginia either would have to find the money to pay for the program on its own or revert to the services that currently exist.

"Given the revenue situation, it just doesn't work at this point," Barber said. "And a number of other states are finding the same problem."

Barber said the planning phase was useful because it helped the state define what services need to be provided and establish an accurate price tag for making the changes.

"I wouldn't want people to think that the planning grant was a waste of time," Barber told lawmakers. "We got a lot out of it."

Based on information gleaned from the planning grant study, Barber recently proposed a program called STEP-VA, which stands for System Transformation, Excellence and Performances in Virginia.

It would initially emphasize same-day access to care at all CSBs, Barber said, and other changes would be rolled out over a number of years to keep the costs under control. Under the model, patients would be evaluated the same day they call or stop by a CSB, and a follow-up appointment would be set no later than 10 days out.

"It's really, in our opinion, the best lever for shifting care away from crisis response," Barber said.

"It's more encompassing than just calling up and somebody talking to you," he added. "From a recovery standpoint, this addresses hope and connection."

Once patients feel connected to the system and feel hopeful that recovery can take place, they are more likely to show up for future appointments and less likely to wind up in crisis needing intensive care, Barber said.

As of July 1, the state and CSBs increased the standards for emergency evaluators, Barber told lawmakers. Now, all new hires must have master's or doctorate degrees, and their supervisors must be licensed and have at least two years of experience.

Any evaluators without the new educational requirements must have at least eight years of experience to continue doing their jobs.

Margaret Nimmo Holland, executive director of Voices for Virginia's Children, has been closely following the state's mental health reform discussions. She supports a model that expands services in all CSBs rather than just the eight that were part of the federal grant program.

"I think the work that they did in the year of the planning grant was very helpful in developing a comprehensive plan for the state," Holland said.

She also supports Medicaid expansion, which could help pay for the STEP-VA program as it gets started and would allow CSBs to be reimbursed for more clients. About half of the people who visit CSBs for services are uninsured.

Patients who are not served "end up in places like jail," Holland said, or their care has to be "totally subsidized because they have no insurance and no ability to pay themselves."

skleiner@timesdispatch.com

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