The Behavioral Health Commission’s October 7 meeting featured presentations reviewing the progress of major initiatives aimed at improving access to community-based services and providing alternatives to involuntary hospitalization.
STEP-VA performance monitoring and evaluation: Commission staff reviewed the implementation of the STEP-VA system as part of the Commission’s responsibility for ongoing monitoring of major behavioral health initiatives. STEP-VA, first enacted in 2017 and phased in from FY 2018 through FY 2023, aims to establish a standard array of nine services at each Community Services Board (CSB). Virginia’ s approach was patterned after the national Certified Community Behavioral Health Clinic (CCBHC) model, although Virginia opted not to structure Medicaid funding for STEP-VA through the prospective payment system that is traditionally used for CCBHCs. Under the prospective payment system, the state would develop a daily or monthly rate that would cover the full cost of providing a set of required services; instead, STEP-VA’s Medicaid funding is provided through per-service rates, and CSBs have continued to struggle with Medicaid billing and reimbursement. Virginia considered the prospective payment structure in the past, but decided against it due to the significant changes that would be required to existing system structures and contracts; in addition to recommending state assistance to CSBs with improving processes for billing and collecting Medicaid revenue under the current system, Commission staff recommended revisiting the prospective payment system option and determining which process changes would be required to implement the alternative approach.
STEP-VA is now fully implemented, with all required services available at each CSB; however, there is some variation among CSBs, such as the specific services offered in each locality, hours of service, office locations, and the length of wait lists. Staff recommended that the Secretary of Health and Human Resources be directed to convene a task force to develop a strategic vision for STEP-VA, which could then be codified, noting that the legislature’s current vision for STEP-VA appears to be limited to the deployment of services. Staff also found that current performance measures largely focus on compliance with program requirements and processes, and do not capture program quality or outcomes; current limitations on data availability hamper the evaluation of STEP-VA service quality.
Staff also encouraged revisiting the funding structure of STEP-VA, which currently allocates funding for each service separately, without the ability for CSBs to transfer funding between services based on community needs. Although substantial funding has been appropriated for the initiative overall, some CSBs need more funding for some services and less for others, and staff suggested that the Appropriation Act and CSB performance contracts should be amended to allow more flexibility in the distribution of funding.
Staff’s presentation is available at this link.
Aligning crisis services and civil commitment process: Legislation passed in 2024 directed this two-year study, which required staff to examine the interaction between the civil commitment process and the state’s crisis services and to make recommendations for changes needed to maximize crisis services and minimize civil commitments. Staff reported that the state’s crisis system is generally oriented to serve voluntary patients and not individuals who are at risk of civil commitment. In particular, staff noted that although the state has developed mobile crisis teams, which are dispatched through the 988 call centers, those teams rarely respond to calls with higher levels of urgency (as stratified by the state’s multilevel triage framework); most Level 3 calls (which are considered urgent, but could receive a behavioral health response) are made to 911 rather than 988, and generally receive a response from law enforcement. Staff suggested several options to improve the response to Level 3 calls in order to improve the likelihood that these callers may be diverted from the civil commitment process, including funding a pilot program to enable regional mobile crisis teams to be dispatched to Level 3 calls and investigating what changes may be necessary in order to enable mobile crisis dispatch based on third party referrals. Staff also found that crisis facilities generally serve voluntary patients, and recommended identifying strategies to incentivize these facilities to serve individuals subject to an Emergency Custody Order or Temporary Detention Order. Staff’s briefing may be found at this link.
The Commission’s next meeting is scheduled for November 12.
VACo Contact: Katie Boyle