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Mental Health Commission Begins 2021 Work with Focus on Law Enforcement Mental Health Transports

The Joint Subcommittee to Study Mental Health Services in the 21st Century met on April 20 to map out its planned work for 2021.  Joint Subcommittee members first paused to take stock of how their proposals fared in the recently-concluded legislative session; recommendations to reform the use of mandatory outpatient treatment, study the compilation of behavioral health and criminal justice data, and restore funding for discharge planning in jails were largely successful.  Notably, the remaining Joint Subcommittee recommendation from its 2020 work, the establishment of a permanent Behavioral Health Commission, was also successful; legislation creating the new Commission was enacted during the session, taking effect July 1, 2021, and funding for staffing was included in the Appropriation Act.  Transition to the new Commission structure will likely be part of the Joint Subcommittee’s work this summer.

A series of other issues remain before the Joint Subcommittee, including the continued implementation of STEP-VA and work underway at the Department of Behavioral Health and Developmental Services (DBHDS) and the Department of Medical Assistance Services (DMAS) to align Medicaid funding with services necessary to implement several initiatives across the human services spectrum; this project, formerly known as behavioral health enhancement, has been termed Project BRAVO in honor of the aircraft call sign of the late DBHDS Commissioner Dr. Hughes Melton.

An ongoing issue of significant concern is the continued overcrowding of the state’s mental health hospitals, a problem DBHDS Commissioner Alison Land characterized as dangerous to both patients and staff.  Commissioner Land outlined the Department’s efforts to improve this situation, including work to reduce the number of individuals who are clinically ready for discharge but have certain barriers to finding a suitable placement; a pilot project and a workgroup to find alternatives to state hospital placements for individuals with dementia; and efforts to address staffing shortages in the state hospitals.

A related topic generating significant discussion and concern among Joint Subcommittee members was the effect of state hospital overcrowding on law enforcement staff who are tasked with transporting individuals who are subject to temporary detention orders.  The pandemic has worsened this long-standing problem by creating delays in admissions while state hospital staff work to free up bed space; at times, law enforcement personnel have had to remain with an individual in crisis in a hospital emergency department for days at a time while awaiting a bed in a state hospital – a situation that strains law enforcement resources and can cause additional stress and trauma for the patient.  While the state’s contract with a provider of alternative transportation services has significantly reduced law enforcement involvement in transporting patients to state hospitals, waiting with the patient while a bed is found is not covered by the contract.

In response to these concerns, a new workgroup was formed to examine the impact of delays in hospital admissions on law enforcement and find potential solutions.  That workgroup, which is chaired by Senator Monty Mason, met on May 4 for further discussion, and received presentations by Commissioner Land, the Virginia Hospital and Healthcare Association, the Virginia Association of Community Services Boards, and the Virginia Sheriffs’ Association.  Commissioner Land outlined several short- and long-term proposals under consideration at DBHDS.  Near-term solutions include expanding the alternative transportation provider’s contract to cover waiting with the patient, so as to allow law enforcement to return to their regular duties more quickly; requiring hospital emergency departments to begin to provide treatment to individuals waiting for transportation when admission is delayed; and continuing to pursue contracts and pilot projects with private hospitals.  Longer-term proposals included addressing recruitment and retention of state hospital staff; continuing to implement a full continuum of crisis services; continuing to implement the array of community-based services required by STEP-VA and those funded through Project BRAVO; and reconsidering whether the renovated Central State Hospital should include the additional 48 beds it currently contains (current plans would not include those beds).  She also encouraged consideration of additional funding to enable state hospitals to discharge patients on weekends.

Jennifer Wicker, Director of Intergovernmental Affairs for the Virginia Hospital and Healthcare Association, spoke to pressures on private hospitals, including an increase in the number of individuals voluntarily seeking inpatient treatment; significant challenges with workforce recruitment and retention; higher levels of patient acuity; and limited capacity to serve special populations, such as children.  VHHA’s proposed solutions included state funding for travel nurses so that beds that are not currently staffed can be opened; funding and authorization for the alternative transportation provider to wait with the patient; and greater availability of community-based services.

Jennifer Faison, Executive Director of the Virginia Association of Community Services Boards, provided an overview of the function of the CSB pre-screener in the TDO process, emphasizing that person’s key role of coordinating among the many stakeholders involved (including law enforcement, magistrates, state hospitals, private hospitals, emergency department providers, and the CSB, in addition to the individual in crisis).  She noted that workforce challenges are present throughout the behavioral health system.  She encouraged legislators to direct resources toward building out a full continuum of crisis services, but also suggested that for the near term, the state will need to support both the current inpatient system as well as the community services, while the community capacity is built up so that ultimately the need for inpatient beds can be reduced.

John Jones, Executive Director of the Virginia Sheriffs’ Association, reiterated the stresses on law enforcement created by lengthy delays in admissions, and strongly encouraged the establishment of more inpatient beds, whether public or private.  He endorsed the expansion of alternative transportation to include waiting with the patient for admission, as well as a proposal introduced during the 2021 session to fund overtime costs for localities associated with lengthy delays in mental health transports.

For the workgroup’s next meeting, which is expected to be held in early June, stakeholders were requested to provide information on where admission delays are occurring (and whether they are more concentrated in certain parts of the state), and how a proposal to fund private hospital staffing to enable currently un-staffed beds to be opened would be structured.  Staff were asked to provide some information on potential uses for American Rescue Plan Act dollars in addressing these issues, to include expansion of telemedicine services for emergency departments.  The workgroup also expressed interest in revisiting a recent report on the use of Crisis Intervention Team Assessment Centers to relieve pressures on law enforcement.

VACo Contact:  Katie Boyle

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