martinez-2014

Virginia’s Public Behavioral Health System:

Today’s Challenges & Opportunities

James M. Martinez, Jr., M.Ed. Director, Office of Mental Health Services

DBHDS

Virginia Rural Health Association December 11, 2014

Staunton, VA

Presentation Overview

• The Current Environment of Behavioral Health (BH) and Reform in Virginia

• New Laws Affecting Behavioral Healthcare in Virginia

• DBHDS Vision, Mission, Core Principles, and Transformation Process

The Current Environment of Behavioral Health (BH)

and Reform in Virginia

Typical Driver’s of Mental Health Reform

• High profile violence

• Family & consumer experiences (e.g., suicide)

• Limited access to too few services

• Highly variable local practices

• Criminalization of persons with MI

• Stigma

• Court decisions

Virginia’s current situation reflects these conditions

Current Virginia Context

• Deeds tragedy - difficulty accessing acute care from community

• Individuals with MI and SUDs in jails

• Suicide (1,053 in 2012, vs 344 homicides in Virginia)

• Discharge–ready individuals in state hospitals

• Opiate drug use and deaths, SUDs seem overlooked

• BH funding instability, current state budget shortfall

• Debate about Medicaid expansion, “Obamacare”, etc.

• Ongoing Medicaid reforms BHSA (Magellan), CCC, etc.

• DOJ Settlement Agreement (ID/DS), etc. etc.

Current Sources of Demand

There are many…

CSBs and

State Hospitals

NURSING

FACILITIES

DSS & CSA

CLINICS &

HOSPITALS

DJJ & DOC

LEAs & JAILS

EMERG. DEPTS.

SCHOOLS

COURTS

INDIVIDUALS & FAMILIES

Individuals Served (DBHDS & CSBs) FY 2014

Community Mental Health

Services 39%

State Hospital Services

2% CSB Substance Use Disorder

Services 11%

CSB Emergency Services

22%

CSB Ancillary Services

26%

33,035

76,034

115,452

4,506

*Note: FY 2014 numbers are now being validated and may change.

63,599

State Hospital Utilization

• From January 1 - June 30, 2014, overall admissions increased by 24%.

– Adults: 18% increase,

– Child and adolescent: 46% increase

– Geriatric: 42% increase.

• Total admissions are trending higher for FY 2015:

• Due to robust treatment and rapid discharge, there has been no commensurate increase in overall census, but back up capacity has been established.

FY 2013 FY 2014 FY 2015 (thru 11/14)

3,959 4,275 2,090

Adult Civil TDOs to DBHDS Hospitals FY 2014

95 100

84 80 67

56

86

103

89 97

124 136

0

20

40

60

80

100

120

140

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

Recent Commissions and Task Forces

• 2006 – 2011 – Supreme Court Commission on MH Law Reform.

• 2007 – Gov. Kaine’s Virginia Tech Review Panel.

• 2013 – Gov. McDonnell’s Taskforce on School and Campus Safety (Mental Health Workgroup).

• 2013 – 2014 – Gov. McDonnell/Gov. McAuliffe’s Taskforce on Improving Mental Health Services and Crisis Response.

*Many others preceded these…….

New Developments This Year

• Significant changes in ECO and TDO laws, as of July 1 – 8-hour ECO period, “facility of last resort” procedures,

72-hour TDO maximum, etc)

• New Medical Screening and Medical Assessment Guidance, April 1, 2014

• New Regional “Safety Net” protocols (as of June 13)

• TDO “Exception” Reporting (i.e., unexecuted TDOs)

• Psychiatric Bed Registry (operational March 3)

• Increasing demand on state hospitals

More New Developments

• Additional Crisis Intervention Teams (CIT), and Therapeutic Assessment Sites for easy transfer of custody from law officers to program

• Significant new requirements in Community Services Performance Contract between DBHDS and CSBs

• Suicide Prevention and Mental Health First Aid initiatives

• New Crisis Stabilization services for youth

• 8 Pilot programs to engage and serve older teens and young adults (Coordinated Specialty Care).

New Laws Affecting Behavioral Healthcare

in Virginia*

*Most of the slides in this portion of the presentation were prepared by Allyson K. Tysinger, Senior Assistant Attorney General, Office of the Attorney General.

The Challenge of Law Reform

• There are two ways to address people who don't seek treatment:

1. coerce people into treatment by expanding coercive treatment laws.

2. induce more people to seek treatment voluntarily by offering better services.

• Reform cannot just be about making coercive treatment laws “better”. It must also be about reducing the need to use these laws.

The Challenge of BH Crisis Intervention

• Our goal is a person-centered, recovery-oriented system of services and supports that helps people get their lives back.

• Crisis contact and intervention, including the involuntary admission process, is a critical point of engagement – or not

• In crisis, what are we trying to do?

• For whom?

Psychiatric Bed Registry (SB260/HB1232)

• DBHDS to develop and administer web-based acute psychiatric bed registry to contain information about available acute beds in public and private inpatient psychiatric facilities and residential crisis stabilization units to facilitate identification and designation of facilities for temporary detention of individuals who meet the TDO criteria


• Bed registry shall: – Include descriptive information for each inpatient

psychiatric facility and residential crisis stabilization unit, including contact information

– Provide real-time information about the number of beds available and for each bed

• The type of patient that may be admitted

• The level of security provided

• Any other information to allow identification of appropriate facilities for temporary detention


• Registry shall allow searches by:

–CSBs

– Inpatient psychiatric facilities

–Residential crisis stabilization units

–Health care providers working in an ER or other facility rendering emergency medical care


• Who is required to participate in the bed registry?

– State facilities

– CSBs

– Private inpatient providers licensed by DBHDS

• Participants must designate employees to submit information to the system and serve as a point of contact for requests for information

Emergency Custody (SB260/HB478)

• ECO valid for a period not to exceed 8 hours from the time of execution

–8-hour period applies to paper ECOs and “paperless” ECOs

–Old Law: 4 hours with possible 2-hour extension

• Provision for extension has been removed

• 8 hours to execute an ECO from its issuance

–Old law: 6 hours

Emergency Custody (SB260)

• If the individual is detained in a state facility at the expiration of the 8-hour period because a facility of temporary detention could not be identified, the CSB and the state facility may continue to attempt to identify an alternative facility for an additional 4 hours

– This provision expires June 30, 2018

– Also see HB1172


• Law enforcement agency that executes the ECO shall notify the CSB responsible for conducting the evaluation as soon as practicable after taking the person into custody

–Applies to paper ECOs and “paperless” ECOs


• Any person taken into emergency custody shall be given a written summary of the emergency custody procedures and the statutory protections associated with those procedures

Determining Temporary Detention Facility (SB260/HB293)

• Upon receiving notification of the need for an evaluation, the CSB shall contact the state facility serving the area in which the CSB is located and notify it that the individual will be transported to it upon the issuance of a TDO if an alternative facility cannot be identified by the expiration of the 8 hour emergency custody period

• Upon completion of the evaluation, CSB shall provide information about the individual to the state facility to allow it to determine the services the individual will require on admission


• Once notified, the state facility may conduct a search for an alternative facility

–May contact another state facility if it is unable to provide temporary detention and appropriate care

• If state facility finds an alternative facility, it shall notify the CSB and the CSB shall designate the alternative facility on the preadmission screening report


• A state facility shall not fail or refuse to admit an individual who meets the criteria for a TDO unless an alternative facility agrees to accept the individual

• An individual who meets the criteria for a TDO shall not be released


• If a facility of temporary detention cannot be identified by the expiration of the 8-hour emergency custody period, the individual shall be detained in the state facility

• State facility shall be indicated on the TDO

Change of Temporary Detention Facility (HB1172)

• CSB may change the facility of temporary detention and may designate an alternative facility at any point during the period of temporary detention

– Must determine that the alternative facility is a more appropriate facility given the specific security, medical, or behavioral needs of the person

– CSB must provide notice to the clerk of name and address of the alternative facility

Change of Temporary Detention Facility (HB1172)

• If facility of temporary detention ischanged, transportation is provided in accordance with §37.2-810

– If law enforcement or an alternative transportation provider has custody of the person when the change is made, individual shall be transported to alternative facility

– If individual has been transported to initial TDO facility, CSB shall request the magistrate to enter an order specifying an alternative transportation provider or, if no alternative transportation provider, the local law enforcement agency where the person resides or is located if 50-mile rule is applicable

Temporary Detention Written Summary (S260/HB478)

• Person detained shall be given a written summary of the temporary detention procedures and the statutory protections associated with those procedures

Length of Temporary Detention (SB260/HB574)

• Commitment hearing shall be held within 72 hours of execution of the TDO

• If 72-hour period ends on a Saturday, Sunday, legal holiday, or day on which the court is lawfully closed, person may be detained until COB on the next business day when the court is open

–Old Law: 48 hours

Commitment Hearing Procedure (SB260/SB439/HB574)

• When judge informs the individual of his right to apply for voluntary admission and advises him that if he chooses to be voluntarily admitted he will be prohibited from possessing or purchasing a gun, the judge must now advise the individual that he will also be prohibited from transporting a gun.

–Consistent with § 18.2-308.1:3

Filing Commitment Orders with Court Clerk (SB576/HB743)

• Judge or special justice shall file orders from a commitment hearing for involuntary admission, MOT, or voluntary admission after a TDO with the clerk as soon as practicable but no later than COB on the next business day following completion of the hearing

Mandatory Outpatient Treatment (SB439/HB574)

• CSB must acknowledge receipt of an MOT order to the clerk within 5 business days

• CSB shall acknowledge receipt of an order transferring jurisdiction of an MOT case within 5 business days

Treatment of Minors (SB260/HB478)

• ECO period increased to 8 hours (was 4)

– Provision for extension removed

– 8 hours to execute an ECO (was 6)

– TDO period unchanged for minors (96 hours)

• Law enforcement agency that executes the ECO shall notify the CSB responsible for conducting the evaluation as soon as practicable after taking the person into custody.

– Applies to paper and “paperless” ECOs

Treatment of Minors (SB260/HB293)

• Provisions for determining the facility of temporary detention are the same as for adults – State facility if an alternative facility is not identified

before expiration of the ECO

• If the individual is detained in a state facility at the expiration of the 8 hour period because a facility of temporary detention could not be identified, the CSB and the state facility may continue to attempt to identify an alternative facility for an additional 4 hours – Expires June 30, 2018

– HB1172 only applicable to adults

Annual Report Required (SB260/HB293)

• DBHDS must submit an annual report on June 30 of each year to the Governor and Chairmen of House Appropriations and Senate Finance

– Number of notifications of individuals in need of facility services by CSBs

– Number of alternative facilities contacted by CSBs and state facilities

– Number of temporary detentions provided by state facilities and alternative facilities, the lengths of stay, and the cost of the detentions

Governor’s TF Study Use of Law Enforcement (SB260/HB478)

• Governor’s Task Force on Improving Mental Health Services and Crisis Response shall identify and examine issues related to the use of law enforcement in the involuntary admission process

– Consider options to reduce the amount of resources needed to detain individuals during the ECO, including the amount of time spent transporting. Options shall include:

• Developing crisis stabilization units in all regions

• Contracting for retired officers to provide transportation

• Report of findings and recommendations to Governor and General Assembly by October 1, 2014

Study of CSB Evaluators (SB261/HB1216)

• DBHDS shall review the requirements related to qualifications, training, and oversight of individuals performing preadmission screening evaluations

• Make recommendations for increasing qualifications, training, and oversight

• Report findings to the Governor and General Assembly by December 1, 2014

Disseminating Info on Effective Crisis Strategies (HB1222)

• Secretaries of Public Safety and HHR shall encourage the dissemination of information about specialized training in evidence-based strategies to prevent and minimize mental health crises. Strategies shall include:

– CIT training

– Mental Health First Aid

• Information disseminated to law enforcement, first responders, ER personnel, school personnel, and other interested parties

Joint Subcommittee to Study Mental Health Services (SJR 47)

• 12 legislative members (Sen. Deeds, Chair; Del. Bell, Vice-chair)

• Review and coordinate with work of Governor’s Task Force

• Review laws governing the provision of mental health services, including civil commitment laws

• Assess the systems of publicly funded mental health services (emergency, forensic, long-term, and services in jails and juvenile detention facilities)

• Identify gaps in services and types of facilities and programs needed

• Recommend statutory or regulatory changes to improve access to services, quality of services, and outcomes for individuals

• Interim report by December 1, 2015; final report by December 1, 2017

Transportation for Temporary Detention (HB323)

• In determining the primary law enforcement agency to provide transportation, magistrate shall specify in the TDO the law enforcement agency of the jurisdiction where the person resides or any other willing law enforcement agency that has agreed to provide transportation

DBHDS Vision, Mission, Core Principles, and

Transformation Process

Our Vision and Mission

• DBHDS has adopted a new Vision:

A life of possibilities for all Virginians

• We also have a new Mission:

Supporting individuals by promoting recovery, self-determination, and wellness in all aspects of life

Process of Recovery in People

Person

Illness

Illness

Person

Process of Recovery (cont)

Friends

Person

Illness Employment

Leisure Activity

Family

Slide Source: Recovery-Oriented Practice by Pat Deegan, Ph.D.

The Disease-Centered Model

Professional Role

1. Hierarchical

2. Paternal

3. In-charge

4. Holds the important knowledge

5. Responsible for treatment

6. Disease is focus

Patient Role

1. Subservient

2. Obedient

3. Passive

4. Recipient of knowledge

5. Responsible for following treatment

6. Host of disease

Slide source: Recovery-Oriented Practice by Pat Deegan, Ph.D.

The Person-Centered Model

Person’s Role

1. Personal power

2. Personal knowledge

3. Personal responsibility

4. Person in context of life is focus

5. Person is self-determining

Professional Role

1. Power sharing

2. Exchange information

3. Shared decision-making

4. Co-investigator

5. Professional is expert consultant on journey

DBHDS Core Principles

• Individuals can and do recover from mental illness and substance use disorders.

• Across the entire Commonwealth, Virginians should have access to quality mental health services.

• Interventions should be focused on prevention and early intervention.

• Services must be individualized, consumer-driven and family-focused.

• To best promote recovery, interventions should be holistic, and include necessary primary health care, housing and employment supports.

What This Means

• All of our services and supports are grounded in principles of recovery and resiliency.

• Our system delivers well-functioning and responsive emergency services.

• Our services reflect a commitment to prevention and early intervention.

• Individuals with mental illnesses are deflected from inappropriate service systems (like criminal justice).

• We increase our emphasis on children's behavioral health, particularly for transition age youth.

• With these principles in mind, we are asking ourselves what are we trying to do? For whom?

DBHDS Transformation • Commitment to Best Practices Implementation

Calling on national expertise

Incorporating lessons learned from other states

Utilizing previous data, studies, and recommendations from former and current task forces and commissions

• Accountability

New Performance Contract Addendum

Bed registry implementation and monitoring

• Transparency

Information available on new DBHDS website

• Communication

Commitment to regular communication with stakeholders about changes in practice and policy

• Collaboration

Working with system partners to incorporate their input

Transformation Approach

• Commissioner-convened small transformation teams focused on four areas (initially):

Adult behavioral health,

Adult developmental services,

Children’s behavioral health, and

Justice-involved behavioral health and developmental disability services.

• Identify structures and processes to aid, enhance and expand services delivery.

• Report on key deliverables in 6, 12, 18 and 24 months.

We are ALL IN! • ALL IN! is the name of our newsletter. What does it mean? • ALL IN! speaks to our level of commitment and sense of urgency. • ALL IN! acknowledges that transformation requires broad

partnerships - with those we serve, their families, advocates, state agencies and community partners.

• ALL IN! commits to inclusiveness. We are dededicated to a life full of rich possibilities for everyone.

• ALL IN! recognizes our responsibility to all of Virginia, from the Shenandoah Valley to the Eastern Shore; from Coeburn to Fairfax. Virginia deserves the most robust, comprehensive service system we can provide. We believe we can have a model system.

• Everyone can be a part of this process. • Although we face challenges, we also have a unique opportunity

to truly transform our system for those we serve. We are ALL IN and we are counting on you being ALL IN! too.

Thank you,

for all you do,

every day!

My Contact Information

James M. Martinez, Jr.

804-371-0767 (office)

804-786-4837 (OMH main)

[email protected]

martinez-2014

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