Alternative Transportation for Virginians Experiencing Mental Health Crises

John (“Jack”) Hilles
ILPPP Research Assistant
University of Virginia
B.A. Candidate, Class of 2020

Elena Kruse
ILPPP Research Assistant
Washington & Lee University
B.S. Candidate, Class of 2020

The following post provides an overview of alternative transportation for individuals experiencing mental health crises in Virginia. It describes challenges the state faces and alternative transportation programs currently underway.

Subscribe to the Policy Blog to stay up-to-date on our upcoming posts!

---

The Context

In November of 2013, Virginia Senator Creigh Deeds’s son, Gus Deeds, was issued an Emergency Commitment Order during a mental health crisis. However, clinicians were unable to find the 24-year-old a hospital bed within the six hours allowed for evaluation, so Gus was sent home. The next day, Gus Deeds attacked his father and then killed himself. The tragic incident may have been avoided if clinicians had a better capability of finding a hospital bed for an individual suffering a mental health crisis. (1)

Virginia’s Response

In 2014, Senator Deeds established the Joint Subcommittee to Study Mental Health Services in the 21st Century to improve Virginia’s delivery of mental health services. More commonly known as the “Deeds Commission,” the committee extended the maximum time for clinicians to evaluate an individual from six to eight hours, and expanded the time that facilities could hold an individual under a Temporary Detention Order (TDO) from 48 hours to 72 hours. Also, the Deeds Commission established legislation that requires state psychiatric hospitals to admit individuals who meet the criteria for temporary detention if a private bed cannot be found before the eight-hour window ends. (1)

The Problem

While beneficial for ensuring a bed is available for anyone in need of care, this new law has led to an influx of people admitted to state hospitals under a temporary detention order, and therefore statewide bed shortages. Now, individuals issued a TDO in the midst of a mental health crisis are often transported long distances to a hospital that has a bed available. As a result, the manner in which these individuals are transported is more important than ever.

According to the Virginia legal code, a magistrate issuing a Temporary Detention Order (TDO) for a mental health patient must specify either a law enforcement agency or an alternative transportation service to transport the patient to a hospital (2). Historically, law enforcement officers (LEOs) are most frequently assigned to transport individuals in a mental health crisis, and alternative transportation providers are almost never utilized. In 2018, 99 percent of the 25,000 individuals issued involuntary detention orders were transported by LEOs (1). This is problematic. Primarily, transporting individuals in the back of a marked law enforcement vehicle, often handcuffed, intensifies the trauma associated with an already distressing mental health crisis (3). Additionally, treating people experiencing a mental health crisis as dangerous criminals undermines the mental healthcare community’s ongoing efforts to reduce the harmful stigma associated with mental illness. In addition, LEO transportation is costly and time-consuming for law enforcement agencies (3). The Arlington-based Treatment Advocacy Center notes that for law enforcement agencies across Virginia at least 10% of agencies’ budgets are spent on transporting individuals in mental health crisis (3). Law enforcement transportation also removes police officers from their shifts for several hours at a time, which is especially taxing for many smaller agencies, both financially and in terms of maintaining community safety (3).

Pilot Program

In 2015, new legislation expanded the capabilities for magistrates to consider alternative transportation for any TDO or civil commitment. Previously, a magistrate could not consider alternative transportation for individuals with a “substantial likelihood” to “cause serious physical harm to himself or others” (4). The same year, the Virginia Department of Behavioral Health and Developmental Services (DBHDS) funded a pilot program in the Mount Rogers Community Services Board (CSB) region for alternative transportation with the security firm Steadfast Investigations & Security. This security firm provided transportation for individuals in unmarked cars with non-uniformed drivers trained in Crisis Intervention Team (CIT) principles and Mental Health First Aid. As planned, the alternative transportation was not used in every TDO transport. For many individuals with a risk of elopement or causing harm to themselves or others, law enforcement officers, police cars, and handcuffs ensure the safety of everyone involved.

From November 2015 to July 2016, 27% of Mount Rogers individuals under a TDO were provided alternative transportation (5). The pilot was deemed very effective. Every one of the transports was considered successful, and there were no instances of elopement. Importantly, alternative transportation provided a more humane experience for individuals undergoing mental health crisis and relieved law enforcement resources. Furthermore, the successful rollout of alternative transportation in the Mount Rogers area suggested similar results could be obtained if the pilot was expanded to a larger area (5).

Statewide Rollout

Based on the success of the pilot program and recommendations of the Task Force on Alternative Transportation[1], DBHDS agreed to a two-year, $7 million contract with private security firm G4S Secure Solutions. G4S will provide statewide alternative transportation for patients requiring involuntary hospitalization. If the statewide rollout is successful, the contract can be extended.

The G4S drivers will undergo a background check and 80 hours of classroom and pre-assignment training, including CIT training and human rights training (3). Individuals transported by G4S will not be handcuffed, and will be driven in unmarked cars by non-police officers.  As in the pilot program, law enforcement agencies will still provide transportation in high-risk cases; however, G4S is expected to transport 50% of TDOs across the state, nearly doubling the proportion of alternative transports seen in the pilot program. The contract thus aims to keep LEO resources in the community and improve conditions and reduce stigma for thousands of individuals experiencing mental health crisis.

[1] The Task Force on Alternative Transportation was created by the 2017 General Assembly (HB1426 and SB1221). It was a multi-stakeholder group that put forth recommendations for a statewide model for alternative transportation for individuals under temporary detention in Virginia.

References 

1. Balch, B. (2019, May 07). Virginia to sign $7M contract with private security firm to transport mental health patients, freeing up law enforcement. Retrieved from https://www.richmond.com/news/virginia/virginia-to-sign-m-contract-with-private-security-firm-to/article_6ebc45b0-ebd2-5b4e-b7e7-51ca7c93ea7f.html

2. Va. Code Ann § 37.2-810 (2015)

3. Albiges, M., & Albiges/Staff, M. (2019, May 17). Thousands in mental health crisis are handcuffed by police. The state wants to cut that number. Retrieved from https://pilotonline.com/news/government/virginia/article_c728d742-78ab-11e9-a85c-a733fb0ae39a.html

4. Va.Code Ann. § 37.2-808 (2015)

5. Larsen, M. (2016). Alternative Transportation Pilot [PowerPoint slides]. Retrieved from http://jchc.virginia.gov/documents/2016/aug/2%20Alternative%20Transportation%20CLR.pdf

6. Sorrell, R. (2019, May 08). State approves contract for mental health transports in Virginia. Retrieved from https://www.heraldcourier.com/news/state-approves-contract-for-mental-health-transports-in-virginia/article_1a28d40a-0624-566b-8c1b-427f93c6ff17.html

Theory v. Practice, Managed Care, MCOs, and the Impact on Public Behavioral Healthcare

Kedar Dange, B.A.
ILPPP Research Assistant
MPH Candidate, Class of 2019

Kevin Farrelly, MPP
ILPPP Research Specialist

The following post provides an overview of managed care organizations and how they have been used in Virginia and in other states. It also describes concerns relating to the effect of managed care organizations on public behavioral healthcare, which have emerged in Virginia in the past year.

Subscribe to the Policy Blog to stay up-to-date on our upcoming posts!

---

Note: Much of the content for this blog entry is derived from interviews with CSBs. We acknowledge that other stakeholders may have viewpoints that contrast with those expressed here. We do not put forth specific policy recommendations in this post, but report stakeholder concerns as issues that bear further investigation by policymakers and administrators.

What is a Managed Care Organization?

A Managed Care Organization (MCO) is an entity that provides managed care health plans and delivers services via a provider network. Managed care is a system of health service delivery that is designed to control the costs of delivering services by limiting beneficiaries to a defined network of providers and by closely managing the utilization of services. MCOs are commonly used to administer Medicaid services. In such an arrangement, a state Medicaid agency contracts with an MCO, which is then responsible for reimbursing providers for services. A key advantage of Medicaid managed care is that it offers cost certainty. Medicaid agencies agree to pay MCOs a set monthly rate per beneficiary, known as a capitation rate. The MCO is then responsible for administering those funds, but should health care costs exceed capitation rates, those costs accrue to the MCO and not the state agency. As of July 1, 2017, 39 of 50 states had this type of risk-based arrangement with MCOs. (1) According to the Centers for Medicare and Medicaid Services (CMS), Medicaid managed care can help states reduce costs, manage utilization more effectively, and improve health care quality and outcomes. (2) 

The Commonwealth has a long history with Medicaid managed care, but recent significant changes to the program have brought new concerns to light in the area of behavioral health. Medicaid managed care in Virginia dates back to 1993 with the implementation of the Medallion primary care case management (PCCM) program. It covered elderly, blind, and disabled Medicaid beneficiaries alongside children and low-income adults and was expanded statewide in 1995. This was updated to Medallion II in 1996 with the addition of several other services, including behavioral health, and was further expanded in 2014 with Medallion 3.0, contracting with six health plans with upgraded enrollment processes. In December 2017, Virginia began to implement Medallion 4.0, which adds additional services and introduces flexible delivery systems and payment models. Implementation is expected to be completed in late 2018. (3)

A new managed care program, Commonwealth Coordinated Care Plus (CCC Plus) was launched in August 2017, and was designed to help coordinate care for dual-eligibles. “Dual-eligible” individuals receive both Medicare and Medicaid benefits, and in general, have more complex care needs and require more care coordination than a regular Medicaid beneficiary. CCC Plus is the second iteration of a program that began in 2014. Although MCOs are popular due to their potential to control costs and coordinate care, they have proven to be sources of major concern in recent years, especially for CSBs.

Medicaid and MCOs in Other States

State Medicaid managed care programs differ significantly in terms of total spending, the number of MCOs, and the jurisdictions of those MCOs. Two primary factors that drive Medicaid spending levels include 1) demand (i.e., the number of individuals who qualify for Medicaid in a given state), and 2) policy decisions, such as reimbursement rate setting and the scope of covered services. As of FY2014, North Dakota spent the most per Medicaid enrollee, at over $10,392. Virginia ranked 17th with $6,909, and Nevada ranked last at $3,620 per enrollee. (4)

In addition to spending levels, states also vary in terms of geographic coverage areas assigned to MCOs. In Virginia, all six MCOs contracted with the state are responsible for the entirety of the state. By contrast, in other states like Michigan, each MCO is given responsibility for a specific region, in which it is the sole provider of Medicaid managed care. Other states follow models similar to Virginia, in which multiple MCOs cover the entire state, and compete with each other for customers. Variations also exist in the number of MCOs; populous states like California, Texas, Florida and New York all have upwards of 10 MCOs, while the majority of the others have fewer than five.

Similar to Virginia, many states have experienced difficulties in implementing managed care programs. Nebraska, for example, experienced problems with slow authorization for Medicaid services. For this and other reasons, Nebraska’s Department of Health and Human Services has had to impose sanctions on private contractors at least eight times. (5)

Common CSB Concerns

Through communications with CSB executives and staff during the past year, the ILPPP has learned that many CSBs have experienced difficulties in doing business with MCOs. The most salient issues include delayed reimbursements, delayed authorization of service, increased competition for qualified staff, and administrative burdens.

As contractors of the Division of Medical Assistance Services (DMAS), one of the key functions of MCOs is to reimburse providers like CSBs for services provided to their beneficiaries. Many CSBs have reported significant delays in receiving reimbursements, with some owed into the hundreds of thousands of dollars for claims as old as 10 months. These reimbursement backlogs put some CSBs under significant financial strain.

Another common issue arises from competition for CSB staff. CSB executives report that many MCOs have hired away CSB clinical personnel because they are able to provide more competitive salaries, leaving many CSBs short staffed. CSBs have complained that MCOs are slow to provide authorization of services and are not transparent in denial of payment, which creates financial burdens that fall on CSBs and have some providers worried about being able to stay afloat financially. Denial of service authorization has also raised concern that some patients are not receiving adequate care, resulting in more crises, and costing more money in the long term.

Additional CSB concerns stem from requirements to comply with regulations geared toward the private sector. Approximately 80% of Medicaid funds for mental health go to the private sector. Accordingly, regulatory changes are often made in response to instances of private sector wrongdoing. Providers in the private sector, however, often have the flexibility to discontinue offering services that become less profitable due to the accumulation of regulatory burdens. As safety net providers, CSBs do not have that same flexibility, often leaving them to bear a disproportionate share of regulatory burden and associated administrative costs.

DMAS does have some ability to hold MCOs accountable for the difficulties that many CSBs are reporting. The primary oversight mechanism appears to be a corrective action plan (CAP), which DMAS has issued to at least two of the six MCOs as of July 2018. A CAP, according to the CCC Plus contract, is devised and delivered as follows:

“The CAP gives the Contractor the opportunity to analyze and identify the root causes of the identified findings and observations, and to develop a plan to address the findings and observations to ensure future compliance with this Contract and State/Federal regulations. The Contractor’s first step in preparing a CAP is to review the specific findings/observations noted in the communication received from the Department and determine the root cause of the deficiency. CAPs must always include the necessary information and be submitted in the method as required in the CCC Plus Technical Manual. If a CAP does not contain the necessary information, an additional sanction or violation point value may be assessed.” (6)

It remains to be seen whether this method of contract enforcement will be effective in ensuring that beneficiaries receive timely and appropriate services and that providers receive timely and appropriate compensation for those services.

In the view of many CSBs, MCOs have caused significant administrative burdens and strained the ability of CSBs to deliver services. Although MCOs are intended to add efficiency and cost savings to the system, they appear to have thus far engendered inefficiency and financial uncertainty. Medicaid expansion and the associated reductions in state general funds have introduced another layer of uncertainty and, according to many CSBs, could pose further risks to the system.    

 References

1. Gifford, K., Ellis, E., Edwards, B. C., Lashbrook, A., Hinton, E., Antonisse, L., et al, 2017. (2017, October 19). Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 - Managed Care Initiatives. Retrieved December 6, 2018, from https://www.kff.org/report-section/medicaid-moving-ahead-in-uncertain-times-managed-care-initiatives/

2. Managed Care. (n.d.). Retrieved December 6, 2018, from https://www.medicaid.gov/medicaid/managed-care/index.html

3. Coming Soon: Medallion 4.0 Medicaid / FAMIS Health Care Coverage. (2018, July 19). Retrieved December 6, 2018, from https://www.virginiapremier.com/coming-soon-medallion-4-0-medicaid-famis-health-care-coverage/

4. Medicaid Spending per Enrollee (Full or Partial Benefit). (2017, June 9). Retrieved December 6, 2018, from https://www.kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee/

5. Nebraska’s new Medicaid system got off to a rocky start, but state says “growing pains” are healing. (2017, December 17). Omaha World-Herald. Retrieved from https://www.omaha.com/livewellnebraska/nebraska-s-new-medicaid-system-got-off-to-a-rocky/article_9f65fa24-bc59-5706-b5d7-a28e0d3e6464.html

6. Commonwealth Coordinated Care Plus MCO Contract for Managed Long Services and Supports. (2018, January). Commonwealth of Virginia, Department of Medical Assistance Services. Retrieved from http://www.dmas.virginia.gov/files/links/910/CCC%20Plus%20MCO%20Contract%20January%202018.pdf

Telemental Health Blog Series, Part 3 of 3: Spotlight on UVA’s Telepsychiatry Programs

A note from the blog manager:

Telepsychiatry and telemental health continue to be of importance to policymakers, as seen in the recently adopted Virginia State Budget, which includes for funds for general expansion of telepsychiatry within DBHDS, as well as funds for the development of the Appalachian Telemental Health Initiative. The following post is the third in a three-part series on telemental health in Virginia (click here for the first installment and click here for the second installment).

Subscribe to the Policy Blog to stay up-to-date on our upcoming posts!

Kathy Faris, B.A.
ILPPP Research Assistant
MPH Candidate, Class of 2019

---

UVA Psychiatry Department Interviews

In November of 2016, the ILPPP interviewed Dr. Larry Merkel and Dr. Zack Dameron of the UVA Department of Psychiatry and Neurobehavioral Sciences. This post summarizes the insights of Dr. Merkel and Dr. Dameron into the state of emergency telepsychiatry in Virginia, specifically in relation to the UVA medical network.

Dr. Larry Merkel – an associate professor of psychiatric medicine at the UVA Department of Psychiatry and Neurobehavioral Sciences

 Dr. Zack Dameron - an associate professor of psychiatric medicine at the UVA Department of Psychiatry and Neurobehavioral Sciences

UVA State Contracts and Payment Structures

At the time of the interview, UVA provided adult telepsychiatry services to Chesapeake Community Services Board (CSB), Federally Qualified Health Centers (FQHCs) in southwest Virginia, as well as child telepsychiatry services throughout the state. When speaking about CSB partnerships, Dr. Merkel said that sharing contracts is a possibility for CSBs, which may reduce concern about no-shows as this opens up the option to use timeslot sharing between CSBs. If this was the case, when a client did not attend an appointment at one of them, the other could use that timeslot. Mt. Rogers CSB and Southside CSB are currently in this type of shared contractual arrangement and they share psychiatry hours. All of these are contractual agreements; however, UVA does provide some fee-for-service work in southwest Virginia which is funded through an Anthem grant. This fee-for-service work is provided by assigning one resident to 3 or 4 clinics, creating a network.

Dr. Merkel spoke further on payment models by noting that in fee-for-service models, the patient site can bill Medicaid for facility fees but not the service. In contractual models, the patient site can bill for both facility fees and services provided. He suggests that contractual models incentivize a low no-show rate. This is because a contractual agreement, the time slot is already paid for on a monthly basis even if the patient does not show. This may encourage the patient site to be more vigilant in insuring that the patient attends the appointment. The provider also benefits from this model because they still receive payment for the time slot, even if the patient does not show up (unlike in the fee-for-service model). Dr. Merkel indicated that UVA has had problems with no-shows in the past when using the fee-for-service model. Dr. Merkel suggested that the employment of behavioral health managers may reduce the no-show rate for telepsychiatry services via a collaborative health model. (1) He further added that studies support this claim about the collaborative model when compared against the consultation model. Dr. Dameron adds that hiring behavioral health managers in Charlottesville is challenging due to competition with salaries for social workers providing outpatient therapy in the community. Another thing mentioned by Dr. Merkel that has helped UVA reduce the no-show rate is hiring a person specifically tasked with telepsychiatry scheduling at the Telemedicine Department. She is in frequent contact with the sites, reminding them and the patients of their appointments.

When asked about the potential for using telepsychiatry technology to improve the efficiency of the emergency evaluation process (2) for CSBs, Dr. Dameron reported that he thought utilizing telepsychiatry for prescreening would likely be met with resistance from emergency departments stemming from the lengthy time required for telepsychiatry. He pointed out that telepsychiatry would add up two hours to the emergency department workload. He conceded, however, that it might be beneficial in rural areas.

Details about implementing UVA’s telepsychiatry programs

UVA providers of telepsychiatry are primarily psychiatric residents with each one assigned a single region or network for their one year residency. Dr. Merkel compared UVA to private telepsychiatry providers concluding that there seems to be more dissatisfaction with private providers due mainly to inconsistency in psychiatrists. He further added that UVA’s model has the advantage of keeping one consistent provider assigned to a location for at least a year. However, at the time of the interview, UVA was at capacity for providing psychiatric services but looking to hire more providers. Dr. Dameron noted that critics of the physicians at UVA may believe capacity is stymied since they are not working nights and weekends but should be doing so to meet demand. However, these critics may not realize that nights and weekends are when physicians complete electronic recordkeeping.

Dr. Dameron acknowledged that the UVA residents who provide telepsychiatry services may not like it due to the additional time it takes to set up the equipment and communicate between the resident and patient site. He estimated that at some sites, what should take 1 hour in-person would take 3 to 4 hours over telepsychiatry. However, he also noted that some residents have more positive experiences and go into 100% telepsychiatry practices. Dr. Dameron provides about 4 hours of telepsychiatry services per week and finds it particularly rewarding to impact populations that have otherwise limited access to care. He also spoke about political pressure to expand into the western part of the state to provide telepsychiatry services. However, there is no capacity to bring on more work and the UVA residents are vehemently opposed to expanding into this area as they would view the expansion as motivated by profit only. The residents also find the electronic medical records (EMRs) to be cumbersome and time-consuming due, in part, to their poor design. Indeed, a “Time in Motion” study (3) indicated that for each 1 hour with a patient, physicians spend 2 hours with tech. Dr. Dameron expressed concern that the residents may leave this area for more affluent ones where they would receive “cash” for services and have less required use of EMRs (e.g., small, private practices). EMR systems may further complicate matters when granting access to lab results in telepsychiatry as the patient and provider site need to trust one another and have compatible EMR systems or information sharing agreements. For example, UVA and Sentara Martha Jefferson Hospital (MJH) both use EPIC but they are not the same system and are not compatible with one another without additional training. Dr. Dameron said that both engagement at an upper level (not just IT level) as well as communication between EMRs was necessary for this type of information sharing to work.

Dr. Dameron spoke at length about another UVA emergency telepsychiatry contract with MJH. The original contract addressed two problems: lack of psychiatric resources at MJH and overcrowding in the UVA emergency room. MJH was closing its original hospital which housed 20 of UVA’s psychiatric beds and UVA provided psychiatric consultation to MJH hospital and emergency room. Since UVA was no longer on site, telemedicine consultation allowed UVA psychiatry to continue to provide services and avoided having to send psychiatric patients to UVA’s overcrowded emergency room. Cost projections for the contract are based on historical precedent for number of consultations UVA made per month with value assigned to each consult. The monthly fee is then estimated from these numbers. The workload for UVA psychiatrists did not increase when this contract began as they were already providing services, it only increased payment (fee was charged regardless of insurance status). This type of contract, however, is only feasible in settings where residents are available 24/7. Dr. Merkel mentioned that it is a possibility for Region 10 CSB (the Charlottesville area’s CSB) to link with MJH in order to do emergency evaluations. Also, Dr. Merkel noted that despite their successful program, there are still several challenges with the MJH arrangement. The main issues seem to be transporting labs and other ancillary communications to UVA.

Dr. Dameron spoke about workforce issues in the field of psychiatry and telepsychiatry specifically. He first noted that training mid-level providers, such as nurse practitioners, is much faster than training physicians. However, there is a difference in expertise and experience between the two. He also pointed out that the differential in salaries is so narrow that there would be limited savings. There are also other considerations beyond cost for nurse practitioners at UVA because nurse practitioners cannot meet the teaching mission to UVA medical residents. For private facilities, substituting psychiatric nurse practitioners for physicians in emergency consults may partially reduce expenses due to increased discrepancies in salaries between the two groups. He indicated that psychiatric nurse practitioner’s may not be able to make inpatient admission determinations in psychiatric consultations, with inpatient psychiatric units being the most restrictive in terms of requiring a psychiatrist in order to admit patients. Physicians may be resistant to giving them this authority but he suggested that the initial decision could be made by the psychiatric nurse practitioner and a physician would be required to confirm the decision.

Emergency Psychiatric Consultations in the UVA system

Both Dr. Dameron and Dr. Merkel shared information about the emergency psychiatric consultation process and its barriers. Dr. Dameron noted that during an emergency consultation, the main focal areas are suicidal ideation, homicidal ideation, or altered mental states. He noted that altered mental states are the most difficult to parse as clinical expertise is necessary to rule out medical explanations, particularly delirium. Dr. Merkel added that UVA will not prescribe medication in emergency consultations except in very rare cases. If prescriptions are provided, they are very limited (for both telepsychiatry and in-person) as prescribing can be problematic due to potential for abuse by drug-seeking individuals who come to the emergency department. Dr. Merkel also noted that following up with the same provider seen during an emergency service is possible, however, it is more feasible within a network such as the one in southwest Virginia (see UVA State Contracts and Payment Structures section). Finally, Dr. Merkel mentioned that in-home evaluations are being done for non-psychiatric reasons by Program of Assertive Community Treatment (PACT) (4) teams therefore it may be possible to explore emergency telepsychiatry services via this route.

Both spoke about the new emergency department facility being built at UVA and how this may impact emergency psychiatric services. The goal is to have 8 psychiatric holding beds in a quiet, safe area of the facility. However, staffing has not yet been arranged for these beds as the planning is in early stages. These beds would hold patients for up to 23 hours and may provide an alternative to quickly making a disposition and putting patients under a Temporary Detention Order (TDO) (5) to a state hospital. Dr. Dameron suggests the beds may allow physicians to intervene with medication sooner or influence the emergency department’s willingness to extend the time the patient is there for medication to take effect. He pointed out that this may not have the same effect if the patient is currently under an Emergency Custody Order (ECO)[6]. Dr. Dameron also spoke about the psychiatric holding facilities in North Carolina in relation to the effectiveness of this strategy. He noted that these NC units could be seen as a success or a failure but seemed to think they were harmful. He added to this by saying that psychiatric patients would end up leaving these locations without treatment due to the long wait times. The facilities themselves were not treatment sites and merely served as a facility to alleviate emergency department pressure. He concluded by saying that patients in these 23-hour type beds should receive services and should not be kept in an environment where their condition may worsen.

 References

1. According to the American Psychiatric Association, the Collaborative Care Model is a well-researched model aimed at integrating behavioral health and general medical services (shown to improve patient outcomes, save money, and reduce stigma related to mental health). https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/get-trained/about-collaborative-care

2. See the ILPPP report“Telemental Health in Emergency Settings: ‘Smart Practices’ for Community Services Boards Learned from the Field” at https://uvamentalhealthpolicy.org/s/TPinES_SmartPractices_FINAL.pdf for more information about this topic.

3. Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. 2016;165:753–760. doi: 10.7326/M16-0961

4. Assertive community treatment is, “a team-based treatment model that provides multidisciplinary, flexible treatment and support to people with mental illness 24/7… ACT team members help the person address every aspect of their life, whether it be medication, therapy, social support, employment or housing.” (https://www.nami.org/Learn-More/Treatment/Psychosocial-Treatments)

5. A TDO is “a legal document requiring an individual to receive immediate hospitalization for further evaluation and stabilization, on an involuntary basis, until a commitment hearing can be arranged to determine their future treatment needs.” For more information, see the NAMI Virginia Guide to Psychiatric Crisis and Civil Commitment Process in Virginia at https://namivirginia.org/wp-content/uploads/sites/127/2016/03/GuidetoPsychiatricCrisisandCivilCommitmentProcessforWebsite-justlawscriteria2016.pdf.

6. An ECO is, “a legal order by the court authorizing the law enforcement agency to take a person into custody for a mental health evaluation performed by a qualified mental health clinician through the local CSB/BHA.” Based on her own observations or the reports of others, a law enforcement officer may also take an individual into “orderless emergency custody” and transport the individual for an evaluation if she has probable cause to believe that individual meets commitment criteria. More information about Virginia’s civil commitment laws may be found at http://dls.virginia.gov/GROUPS/MHS/CivilCommitmentLaws.pdf.

Mandatory Outpatient Treatment: An Overview of Virginia’s Law and Utilization

Sarah Leser, B.A.
ILPPP Research Assistant
MPP/MPH Candidate, Class of 2019

Context

Forty-six states, including Virginia, utilize a form of outpatient civil commitment to provide treatment to individuals in need of mental health care. (1) Though mandatory outpatient treatment (MOT) was authorized in Virginia in 1976, it was not until recently that the practice was implemented widely. (2) In 2008, the Virginia General Assembly established detailed procedures for ordering, delivering, and monitoring MOT, thus making it a feasible option for providing mental health treatment. (3)   

What is MOT?

Virginia Code § 37.2-817 authorizes judges and special justices to order mandatory outpatient treatment for individuals who are severely mentally ill and meet hospitalization criteria, but may be better served through a less restrictive alternative such as receiving services in their community. The Virginia Code authorizes two main types of MOT orders: direct and step-down. A direct MOT order is issued if an individual is not currently under a commitment order at the time of the commitment hearing but is found to meet commitment criteria and a less restrictive alternative to hospitalization is deemed appropriate. (4)

A step-down MOT order is issued to allow an individual who is hospitalized to return to their community and continue receiving ordered outpatient treatment. This form of MOT went into effect fiscal year (FY) 2011. (2) A step-down MOT order may be initialized upon discharge or at a new hearing. A discharge MOT order is initiated when a special justice orders MOT concurrently with inpatient treatment either at an initial commitment hearing or recommitment hearing (5). This means that after an individual has been hospitalized for a predetermined amount of time, they can be discharged to continue their commitment on an outpatient basis. (2) A discharge MOT order authorizes the physician in charge of an individual’s treatment to discharge the person for outpatient treatment under the MOT plan without an additional hearing. (5) MOT may also be initiated at a hearing not associated with an initial commitment or recommitment. In this case, a physician, family member, or the community service board may motion for a hearing to be held at any point prior to a person’s discharge from involuntary commitment or voluntary commitment following a TDO to determine if MOT should be ordered upon discharge. (5, 6). For either type of MOT, an initial commitment order cannot exceed 90 days (7). A summary of MOT types and a chart depicting the various pathways to MOT can be found below.

Summary of MOT Types
===========================
1. Direct: Issued to an individual not currently under a commitment order, at the time of the commitment hearing
2. Step-Down: Issued in order to allow an individual to “step down” from an inpatient hospitalization order to an order for MOT
• Discharge – Initial: Issued concurrently with a commitment order at the time of an initial commitment hearing
• Discharge – Recommitment: Issued concurrently with a recommitment order at the time of a recommitment hearing
• New Hearing: Issued at a standalone hearing motioned for by a treating physician, family member, or CSB

In addition to allowing individuals with severe mental illness to receive treatment in their communities, MOT also functions to enhance adherence to treatment and address revolving-door syndrome, a cycle in which people are hospitalized, discharged, and re-hospitalized soon after, often because they have discontinued their medication. (8) While any individual meeting commitment criteria may be given a direct MOT order, to qualify for step-down MOT, a person must have been hospitalized involuntarily or voluntarily following a TDO twice in the previous 36 months. (5)

MOT can only be ordered if the services a person requires are available in the community. (3) The Community Service Board (CSB) in the location in which the individual resides is responsible for developing a detailed MOT plan, though the services required may be provided by the CSB or a private mental health professional. (9) The individual to whom an MOT order is issued must agree to the treatment plan, and the plan must be approved by the court. (3) Regardless of who provides services, the local CSB is responsible for monitoring MOT compliance and reporting any non-compliance to the court. (10) If an individual is found to be non-compliant, the court can modify or withdraw the MOT order, or, if necessary, the person may be hospitalized under a TDO. (10)

MOT Use Across VA

General District Courts maintain records of civil commitment cases concerning adults using the General District Court Case Management System (GDC-CMS). This system is maintained by the Office of the Executive Secretary of the Supreme Court. (11) Using these records, the ILPPP is able to track the number of MOT orders issued each year. Generally, the number of MOT orders issued each year has risen since the practice was solidified in the Virginia Code, especially after step-down MOT was introduced in 2011. In FY 2017, a total of 238 MOT orders were issued. Figure 1, found below, depicts the annual frequency of MOT orders from FY 2010 through FY 2017. Figure 2 shows the frequency of the type of MOT orders issued quarterly from FY 2010 though quarter 2 of FY 2018. The most commonly issued type is direct MOT, followed by step-down MOT orders issued at new hearings.  

Evidence from other States: Benefits of MOT

Because MOT is still a fairly new practice in Virginia, it is too early to draw state-specific conclusions about effectiveness. However, in states that have longer-established MOT programs, there is strong evidence that this treatment option produces benefits. New York has one of the most well-established outpatient commitment programs in the country. Known as Kendra’s Law, legislation authorizing assisted outpatient treatment (an alternative name for MOT) was passed in New York in 1999, and the state’s programs have been evaluated many times since. A long-term evaluation of assisted outpatient treatment (AOT) in New York found that AOT is associated with increases of 89% in use of case management, 67% in use of substance abuse treatment services, and 106% in medication adherence. (12) Higher engagement with and adherence to treatment resulting from AOT was found to be associated with reductions of 87% in incarceration, 83% in arrest, 77% in psychiatric hospitalization, and 74% in homelessness rates. (12) Another study out of New York found that AOT is associated with significant decline in hospitalizations, and this decline was sustained over a three-year study period. (13) It is important to note that New York has seen such positive results largely because of the state’s financial investment in expanding mental health service availability that accompanied Kendra’s Law. While this expansion was associated with large upfront costs, reductions in medical and criminal justice expenses stemming from AOT were found to produce net cost declines of 49% in the first year and 27% in the second year after AOT began across New York. (13) Moving forward, as MOT becomes more established and widely used, the ILPPP hopes to conduct similar evaluations to identify benefits specific to Virginia.      

References

1. “Assisted Outpatient Treatment.” Treatment Advocacy Center, http://www.treatmentadvocacycenter.org/component/content/article/1336

2. Allen, AA. and TM Ko. Annual Statistical Report Adult Civil Commitment Proceedings in Virginia FY 2016, University of Virginia Institute of Law, Psychiatry and Public Policy, 2017

3. Hickey, J. and Allyson Tysinger. “New Era Begins: Mental Health Law Reform in Virginia.” Richmond Public Interest Law Review, 2008.

4. Virginia Code § 37.2-817(D)

5. Virginia Code § 37.2-817(C)

6. Virginia Code § 37.2-805

7. Virginia Code § 37.2-817(E)

8. “Report of the Task Force on Future Commitment Reforms.” Virginia Commission on Mental Health Law Reform, 2009.

9. Virginia Code § 37.2-817(F)

10. Virginia Code § 37.2-817.1

11. Faris, KM. Brief Report on Mandatory Outpatient Treatment for Adults, FY 2010 – FY 2017, University of Virginia Institute of Law, Psychiatry, and Public Policy, 2018.

12. Geller, J.L. “The evolution of outpatient commitment in the USA: From conundrum to quagmire.” International Journal of Law and Psychiatry, 2006.

13.  Swanson, J. W., Van Dorn, R. A., Swartz, M. S., Robbins, P. C., Steadman, H. J., McGuire, T. G., & Monahan, J. “The Cost of Assisted Outpatient Treatment: Can It Save States Money?” American Journal of Psychiatry, 2013.

Mental Illness Within the Criminal Justice System: An Overview

Luke Siebert, B.A.
ILPPP Research Assistant
MPH Candidate Spring 2020

The following post provides an overview of mental illness within the criminal justice system in jails throughout the nation and Virginia, in particular. It also covers outcomes of policy actions that have been enacted to address mental illness in the criminal justice system.

Subscribe to the Policy Blog to stay up-to-date on our upcoming posts!

---

Of note: It is important to understand that there is a distinction between jails and prisons. Jails typically house inmates for a short period of time whereas prisons house inmates for longer-term incarceration. The distinction is important to note, as the Virginia Department of Corrections (DOC) takes responsibility for managing prisons, whereas the Virginia sheriffs’ offices operate the local jails (regional jails include sheriffs on their boards). As such, the mental health services afforded and programs provided are different for prisons than jails. Prisons are not discussed in this post.

INTRODUCTION

According to the National Alliance on Mental Illness (NAMI), between 25 and 40 percent of Americans with a mental illness will be jailed or incarcerated at least once in their lifetime. (5) The incarceration of these individuals can be attributed to a number of different factors and policies. Persons suffering from mental illness are frequently stereotyped as violent, dangerous, or “crazy” due to their portrayal in the mass media. Law enforcement officers serve as the primary responders to mental health crises, creating interactions between people with mental illness and law enforcement that otherwise may not exist. Many of these officers lack the mental health training necessary to work well with persons experiencing a mental health crisis. Out of 18,000 police departments across the country, only 3,000 have their officers undergo Crisis Intervention Team (CIT) training. (7) The lack of mental health services in the community also contributes to the rising number of mentally ill individuals that cycle through the criminal justice system. Even if mental health services are available, getting treatment is often complicated by issues related to transportation, both to and from treatment facilities, and inadequate staffing. The bottom line is this: Jails have effectively become the largest mental health treatment facilities in the United States. (2)

In this blog post I aim to provide an overview of mental illness within jails. To do so, I will provide statistical background on jail populations, discuss policies that currently exist within jails related to mental illness, and identify current shortcomings within the system. I will conclude with an overview of programs and initiatives that have been implemented, both in Virginia and elsewhere, that aim to reduce the prevalence of the mentally ill in jails.

STATISTICS ABOUT MENTAL ILLNESS IN VIRGINIA JAILS

            In 2017, the Compensation Board of Virginia published their annual report on the prevalence of mental illness in jails and the services provided to those with mental illness. (3, the 2018 report is expected in November) While jails have a higher number of mentally ill men than women, the proportion of female offenders suffering with a mental illness is much higher than the proportion of men. The number of inmates with a mental illness continues to rise as well, with Virginia experiencing a 15 percent increase in the mentally ill population in their jails from 2016 to 2017*. Of the 7,450 mentally ill inmates, 80 percent were charged with crimes that were considered to be non-violent. (3)

            Thus far, jails have been largely unable to accommodate the mentally ill properly. Per the Compensation Board’s report, only 21 out of 54 surveyed jails had mental health units or bed areas that were separated from general population areas. (3) Many jails also reported a severe shortage of beds available for inmates with mental illness. When asked, the majority of jails indicated that their greatest funding needs were related to staffing, medication, and jail expansion so as to include more mental health beds. (3)

POLICIES IN THE JAILS

            While issues of proper accommodation for mentally ill inmates remain unsolved, some progress has been made towards assessing the wellbeing of incoming inmates. As of July 1st, 2017, all local and regional jails within the state of Virginia are required to screen every booked individual for mental illness using either the Brief Jail Mental Health Screen (BJMHS) or the Correctional Mental Health Screen (CMHS) instrument. (3) While 49 out of the 54 jails participating in the Compensation Board survey reported screening for mental health prior to the implementation of this new mandate, the instruments used were not consistent from jail to jail. Considering mental health professionals do not always conduct these screenings, requiring consistent use of an easily understood and validated instrument is crucial for ensuring that jail staff can properly assess the mental health of incoming inmates. (3)

            In the event that an inmate screens positive for mental illness, a referral is supposed to be issued for a comprehensive mental health assessment (MHA). (3) Assessments differ from screenings in that they help inform treatment or case planning. Additionally, assessments aid in addressing an individual’s immediate need for services. (9) Contrary to mental health screenings, MHAs are conducted by mental health professionals. (3) Of the 54 jails surveyed, referral rates of positively screened inmates ranged from 1 to 45 percent. Per the Compensation Report, Virginia’s state average referral rate of positively screened inmates is 18 percent. The time from referral to MHA varied drastically per jail as well. While some jails were able to have an inmate’s MHA conducted within 4 hours of the referral, others sometimes took longer than 72 hours. (3)

            The utilization of MHAs is crucial, both for inmates dealing with mental illness and for the jails or correctional facilities housing them. MHAs can provide jail staff with information about an inmate’s condition that might not otherwise be known. (9) For example, inmates with suicidal tendencies can be identified ahead of time in order to ensure that proper arrangements are made to keep them safe. Medications can be organized by the jails to ensure that individuals suffering from mental illness keep their symptoms at bay. Furthermore, individuals who have an undiagnosed mental illness can receive a diagnosis and begin receiving treatment. (9)

SOME AREAS NEEDING IMPROVEMENT

Although mental health policy in jails, and in the state of Virginia generally, has seen improvements over the past few years, there are still plenty of areas in which the system could be improved. For example, solitary confinement is still utilized as a form of punishment for inmates who violate jail rules. Those sent to solitary are confined in a tiny cell for 23 hours a day. In prisons, inmates assigned to a solitary unit typically must stay there for at least 15 consecutive days, with many staying 30 days or more at a time. (8) No data on length of stay was found for inmates in jails.

Mentally ill offenders are disadvantaged by solitary confinement more so than other inmates. Several studies have found that inmates with mental illness are more likely to act out than others, thus subjecting them to potential placement in solitary confinement units. (2) Acts such as self-injurious behavior, which are more common amongst those with mental health problems, may be classified as forms of misconduct and punished**. The disproportionate placement of mentally ill offenders in solitary confinement is even more troubling when considering the number of negative psychological effects provoked by significant time spent in solitary. These effects include hallucinations, paranoia, and insomnia, all of which could be made worse should an inmate already have a pre-existing mental illness. Social segregation subjects individuals to stress, isolation, and conditions offering little to no structure, none of which mirror life outside of a jail cell. (2) In 2017, approximately 1,335 mentally ill inmates in Virginia were placed in solitary confinement. (3) Delegate Hope recently introduced HB795, a bill that would have reduced the amount of time an inmate belonging to a vulnerable population could spend in isolation to no more than 15 consecutive days, or 20 days in a 60-day period, except in the case of extenuating circumstances. This bill, which included mentally ill offenders as members of the “vulnerable population”, was left in the Militia, Police, and Public Safety Committee. (6)

Medications serve as another potential barrier to the wellbeing and success of an inmate during their time in jail. According to the 2017 Compensation Board’s Report, not all psychotropic medications are provided by jails***. (3) In the event that medication is not provided by the jail, it is the responsibility of the inmate to have a third party, such as a family member or physician, bring them their medication. (3) This is potentially problematic, as inmates may not have the insight into their illness necessary to make the effort to reach out, or they may not have any reliable third party contacts outside of the jail, particularly if they are homeless.

While inmates with mental illness experience a plethora of problems in jail, problems exist after inmates are discharged as well. Inmates discharged from jail are forced to reintegrate into a world that is drastically different from jail, all while trying to concurrently manage their illness. Jails often fail to provide mentally ill inmates with any type of assistance with arranging appropriate treatment upon their release, drastically increasing the likelihood of recidivism. For example, in Virginia, inmates are given only 15 days worth of medication and a prescription upon discharge (N. Goodloe, personal communication, July 23, 2018). Often times it takes much longer than 30 days to receive an appointment with a mental health provider. Individuals who fail to see a mental health provider may resort to self-medicating or may discontinue taking their medication altogether, worsening their symptoms. Mary Zdanowicz put it succinctly: “Non-adherence with treatment leads to relapsing symptoms in a mental health system that encourages choice until the person becomes dangerous. Then police are called and the cycle continues.” (12)

NEW POLICY EFFORTS AND PROGRAMS

 After examining the state of mental illness in jails, resources available to inmates, and areas in which the system needs reform, it is evident that there is much room for improvement with regards to the rights and treatment of these individuals. Below I will discuss a number of initiatives that have been implemented with the goal of keeping non-violent offenders with mental illness out of jails and connecting them with mental health services. The examples presented are illustrative and do not include a comprehensive review of efforts in every state.

VIRGINIA

            Virginia has implemented a number of programs and initiatives in the hopes of better treating offenders with mental illness. Seven mental health dockets have been created across the state with the goal of diverting some mentally ill offenders from the criminal justice system. (10) Several more are in the early stages of development. Mental health dockets are specialized dockets created within the court system that afford offenders with serious mental illness (SMI), specifically those who are charged with less serious crimes, treatment options so that they can better manage their illness. The docket aims to reduce the recidivism rate of offenders with SMI by treating them rather than simply incarcerating them. Mental illnesses considered to be “serious” include major depression, schizophrenia, bipolar disorder, and any other mental disorders causing serious impairment. Charges may be dropped altogether after completion of the mandated treatment, but sometimes they are simply reduced in severity. Although individuals participating in the program are not punished with time in jail, they must comply with a number of requirements, with failure to comply potentially resulting in re-incarceration. (10)

The utilization of mental health dockets is a somewhat new initiative that aims to increase public safety and treatment engagement, improve the quality of life for participants, and reduce costs. (10) Thus far, mental health dockets appear to be meeting those goals. Participation in the mental health dockets has been shown to decrease the number of new charges incurred by an individual and lower recidivism rates. Defendants whose cases went through a mental health docket were also able to gain access to treatment quicker than those not involved in the dockets. It should be noted that cost savings have yet to be determined, as results are not consistent. This is perhaps due to the different qualifications different mental health dockets have for participation, such as severity of illness and treatment required. (10)

            Virginia has also recently allocated new funding to several jails. In an effort to develop and better the quality of mental health services in jails for current inmates and recently released inmates, the Department of Criminal Justice Services (DCJS) allocated a total of $3.5 million to six regional and local jails as part of a pilot program. (11) Hampton Roads Regional Jail, Prince William Adult Detention Center, Middle River Regional Jail, Western Virginia Regional Jail, Richmond City’s Sheriff’s Office, and Chesterfield County’s Sheriff’s Office were the six jails chosen by the General Assembly. During the program’s first six months of operation, each pilot site saw an increase in the number of treatment plans administered, the amount of peer support and therapy provided during incarceration, and the number of inmates connected to post-release services. Although pilot sites have cited far more successes than challenges, this is not to say that notable challenges do not exist. The most common challenges across the six sites are the transient nature of the inmates (moving from jail to jail) and the difficulty experienced when trying to find suitable, affordable housing for recently released inmates. (11)

            The creation of Crisis Intervention Teams, or CITs, in Virginia and other states has proven highly effective as well. The program initially started in Memphis, Tennessee and has since then been implemented across the country. (1) The goal of CIT is to train officers on how to respond effectively to calls, either criminal or non-criminal, involving individuals with mental illness. Individuals experiencing a mental health crisis may have a difficult time thinking clearly, especially if confronted by police officers about a serious situation. It is here that CIT officers utilize techniques involving patience and shared understanding to help de-escalate situations, as opposed to more confrontational and directive strategies that they would typically use. With more officers trained to respond to calls involving individuals with mental illness, fewer of these individuals end up detained or arrested. (1)

            Lastly, the 2018 General Assembly recently approved a number of budget amendments to increase the amount of funding available to implement programs that could help keep individuals with mental illness out of the criminal justice system. Funding was allocated to establish new Crisis Intervention Assessment Centers in up to six un-served rural communities, Intercept 2 programs in up to three rural communities, and CIT training programs in up to six rural communities. Allocations were approved on a yearly basis. Under item 312(T.2), a total of $2,700,000 was approved for the establishment of Crisis Intervention Assessment Centers, with $900,000 set aside for the first year and $1,800,000 for the second year. Under item 312(T.3), $1,315,296 was approved for the establishment of CIT training programs, with $657,648 provided both years. Finally, under item 312(NN), $1,417,326 was approved for the establishment of Intercept 2 programs, with $708,663 to be used each year. 

FLORIDA

            In Miami-Dade County, Florida, officials have implemented a diversionary program that includes mental health training for both police officers and 911 dispatchers. (4) The goal of this training is to help better prepare first responders to recognize and act in the case of a mental health emergency. Thus far results have been positive, as jail populations have declined by over 2,000 inmates in the past five years. (4)

Florida also recently changed its data management system with the hopes of increasing data sharing so as to prevent people from falling through the cracks of the criminal justice system. (4) In 2012, Otsuka partnered with IBM and the South Florida Behavioral Health Network to try and find a way to integrate criminal justice, mental health, substance use, and social support services data. Research found that case management after incarceration was crucial for the rehabilitation process, as individuals who had access to case management were 50 percent less likely to recidivate than those that did not. (4)

ILLINOIS

            Chicago, Illinois is home to the Cook County Jail—the largest jail in the United States. The Cook County Jail is also effectively the country’s largest mental health treatment center. (5) The jail has put into place several new measures with the intention of improving the quality of life for individuals with mental illness who are facing charges. If eligible, inmates are signed up for CountyCare during intake. CountyCare is a health insurance program designed to help low income inmates pay for prescriptions and mental health care. Additionally, Cook County has a new building called the Mental Health Transition Center that focuses on preparing inmates for their transition back into the community. Individuals work in a group setting to learn how to cope with their mental illness and successfully reintegrate into society. (5)

CONCLUSION

Mental illness in the criminal justice system is a complicated issue. Although the criminal justice system has implemented several programs and policies that are working well, there is still much to be done. Virginia continues to make improvements, and there is reason for continued optimism, as mental health has risen to the forefront of issues targeted by policymakers in the state, as well as the country at large. It is important to continue following the progress made within Virginia’s criminal justice system. It may also be beneficial to look to other states, such as those mentioned above and others, in order to learn from their challenges and successes.  

Notes:
*Each year, LIDS requests that Virginia jails fill out a survey. This survey is typically dispersed in June, data is collected by July, and then a report is created summarizing the findings. The data submitted by the jails is self-report. As such, data counts may not always be completely accurate. It should also be noted that not every jail opts to participate in the survey. 
**Even if self-injurious behavior is not viewed as a form of inmate misconduct, solitary may be seen as the only “safe” housing option because it removes mechanisms for self-harm.
***While jails are the only place that people have a constitutional right to health care, jails are only required to buy necessary items to provide such care at the cheapest cost available. For example, although jails may have some antipsychotics available in their formulary, they may not have the antipsychotic an inmate is accustomed to taking, or even a generic variation of their standard prescription.

References

1. CIT International. CIT is More Than Just Training...It’s a Community Program. Retrieved from http://www.citinternational.org/Learn-About-CIT
2. Clark, K. (2018). The Effect of Mental Illness on Segregation Following Institutional Misconduct. Criminal Justice and Behavior, 1-20.
3. Compensation Board. (2017). Compensation Board Mental Illness in Jails Report. Retrieved from http://www.scb.virginia.gov/docs/2017mentalhealthreport.pdf
4. Docherty, J. P. (2017, October 20). Creating New Hope for Mental Illness and The Criminal Justice System. Retrieved from https://www.nami.org/Blogs/NAMI-Blog/October-2017/Creating-New-Hope-for-Mental-Illness-and-the-Crimi
5. Ford, M. (2015, June 8). America’s Largest Mental Hospital Is a Jail. The Atlantic. Retrieved from https://www.theatlantic.com/politics/archive/2015/06/americas-largest-mental-hospital-is-a-jail/395012/
6. HB795, 2018 Session. (Virginia 2018). Retrieved from http://lis.virginia.gov/cgi-bin/legp604.exe?181+sum+HB795
7. Madhani, A. (2016, October 2). Police departments struggle to get cops mental health training. USA Today. Retrieved from https://www.usatoday.com/story/news/nation/2016/10/02/police-departments-struggle-cops-mental-health-training/91297538/
8. Nolan, D. & Amico, C. (2017, April 18). Solitary by the Numbers. Frontline. Retrieved from http://apps.frontline.org/solitary-by-the-numbers/
9. Substance Abuse and Mental Health Services Administration. (2015). Screening and Assessment of Co-occurring Disorders in the Justice System. Retrieved from https://store.samhsa.gov/shin/content/SMA15-4930/SMA15-4930.pdf
10. Virginia Department of Behavioral Health and Developmental Services. (2016). The Essential Elements of Mental Health Dockets in Virginia. Retrieved from http://www.dbhds.virginia.gov/library/forensics/ofo%20-%20mental%20health%20docket%20report%20final.pdf
11. Virginia Department of Criminal Justice Services. (2017). Report on the Virginia Department of Criminal Services Jail Mental Health Pilot Programs. Retrieved from https://www.dcjs.virginia.gov/sites/dcjs.virginia.gov/files/publications/corrections/dcjs-jail-mental-health-pilot-program-full-report.pdf
12. Zdanowicz, M. (2007). Mental Health Polices Are Cause for Alarm in the Corrections Community. Sheriff Magazine, 7-10. Retrieved from https://mentalillnesspolicy.org/wp-content/uploads/sheriffs-forensics.pdf

Trends for House and Senate Bills Passed During the 2018 General Assembly Session

Luke Siebert, B.A.
ILPPP Research Assistant
MPH Candidate Spring 2020

The following post describes the various house and senate bills related to mental health that were passed in the 2018 General Assembly session. For more information about these bills, check out our recent DMHL publication here or click on the links below to go to the Virginia Legislative Information System page for each bill.

Subscribe to the Policy Blog to stay up-to-date on our upcoming posts!

---

Trends for House Bills

15 House bills were passed during the 2018 General Assembly session. Representatives Hope (3) and Bell (2) were the only Representatives to have more than one bill passed.

Of the 15 bills passed, several encompassed similar issues. Four addressed issues related to the ongoing opioid and substance abuse epidemic, two addressed policies regarding the location of mental health evaluations, specifically sanity and competency, two addressed policies for the administration of TDOs, and two addressed hospital policies and procedures.

Bills concerning mental health education in schools, sentencing policies for those declared NGRI, the disclosure of health records, the definition for a qualified mental health professional, and a mandated annual suicide prevention report were also passed.

Of note, HB842 was made effective immediately upon being signed by the Governor. All other bills are effective as of July 1, 2018.

Trends for Senate Bills

12 Senate bills were passed during the 2018 General Assembly session. Senators Deeds (3), Dunnavant (3) and Barker (2) were the only Senators to have more than one bill passed.

Of the bills passed, three addressed policies regarding research and data sharing and two addressed individuals who had been subjected to involuntary mental health treatment. Other bills addressed topics including the location of opioid treatment clinics, ECO protocol, training firefighters and EMS personnel on mental health awareness, the definition of a licensed mental health practitioner, the assessment of sexually violent offenders prior to their release, substance abuse education, and the employment of convicted criminals with a history of mental illness and/or substance abuse.

Of note, SB 669 was made effective immediately upon being signed by the Governor. All other bills are effective as of July 1, 2018.

---

Summary of House and Senate Bills Passed During the 2018 General Assembly Session

Opioid and Substance Abuse (5)

HB322 (Bourne) – Possession and administration of naloxone This bill adds Department of Corrections employees, designated as either probation and parole officers or correctional officers, to the list of individuals permitted to possess and administer naloxone following completion of a training program. A signed version of the bill, effective July 1st of 2018, is available here.     

HB842 (LaRock) - Possession or distribution of controlled paraphernalia; hypodermic needles and syringes; naloxone As originally proposed, this bill would have authorized certain licensed medical professionals, as well as individuals certified by DBHDS, who are authorized to possess and administer naloxone to individuals experiencing overdose to also possess hypodermic needles and syringes, and to a) use them to administer naloxone to individuals in the midst of an opioid overdose and b) dispense them to individuals who have completed training in administering naloxone. These needles and syringes would be used solely for the purpose of administering naloxone to a person experiencing an opioid overdose. An amended version of the bill, available here, added language to clarify that the authorized distribution of needles and syringes is solely for injecting naloxone. The final version of the bill, available here, became effective immediately upon being signed by the Governor.

HB1173 (Pillion) - Limits on prescription of controlled substances containing opioids This bill eliminates a current exception to a requirement in the Virginia Code which states that a prescriber is not required to request certain information from the Prescription Monitoring Program (PMP) for opioid prescriptions of up to 14 days to a patient as part of treatment for a surgical or invasive procedure. Previously, the Code required that a prescriber must request certain information from the PMP when initiating a new course of treatment that includes prescribing opioids for a human patient for more than 7 days. This bill’s elimination of the exception expires July 1, 2022. A final version of the bill, effective July 1st of 2018, is available here.

HB1194 (Garrett) - Schedule I controlled substances This bill adds a number of drugs to the list of Schedule I controlled substances. The final version of this bill, effective July 1st of 2018, is available here.

SB329 (Dunnavant) - Clinics for the treatment of opioid addiction; location As originally proposed, this bill would have provided the following exception to the statutory prohibition on locating clinics for the treatment of persons with opiate addiction through the use of methadone or opioid replacements within one-half mile of a public or private licensed day care center or a public or private K-12 school: licensure may be available for an applicant to operate in its current location or to relocate an existing facility when the facility is currently located within one-half mile of a public or private licensed day care center or a public or private K-12 school in the City of Richmond, and when the clinic has been licensed and operated as a facility to provide treatment for persons with opiate addiction through the use of methadone or other opioid replacements by another provider immediately prior to submission of the application for a license, and, upon issuance of the license, will be operated by a behavioral health authority.

The Senate passed a substitute to this bill that allowed an existing opioid clinic in both Richmond and Henrico County to continue operating in its current location despite being within a half-mile of a school or daycare facility. A similar bill, SB455, was incorporated into this bill. The final version of the bill, entitled SB329ER, became effective July 1st of 2018

---

Data Sharing/Research (4)

HB569 (Gooditis) - Department of Behavioral Health and Developmental Services; report on suicide prevention activities This bill requires the DBHDS Commissioner to report annually, by December 1st, to the Governor and the General Assembly on the Department’s activities related to suicide prevention across the lifespan. A final version of the bill, effective July 1st of 2018, is available here.

SB719 (Dunnavant) - Data sharing; substance abuse data As originally proposed, this bill would have established a Substance Abuse Data Sharing and Analytics Clearinghouse, administered by the Secretary of Health and Human Resources in consultation with the Substance Abuse Data Sharing and Analytics Advisory Committee that would also be created by the bill. The purpose of the Clearinghouse would be to share or disseminate data related to substance abuse among and between involved agencies, with a focus on opioid addiction and abuse, in order to, among other things, conduct research and apply data analytics to identify the most efficient and efficacious treatments and to streamline administrative processes and reduce burdens on persons being served. Under this bill, the Secretary of Health and Human Resources would also have the authority to enter into agreements with private entities and public institutions of higher education to further the goals of the Clearinghouse. Additionally, the Secretary would be required to report annually to the Governor and the General Assembly regarding the results achieved through the use of the Clearinghouse, including cost savings and policy recommendations. The bill would also specify that data sharing among state and local agencies in certain circumstances was a proper use of personal data.

The Senate Committee on General Laws and Technology incorporated this bill (and three others) into SB580 (Hanger). A final version of the bill, effective July 1st of 2018, is available here. 

SB728 (Dunnavant) - Prescription Monitoring Program; prescriber and dispenser patterns As originally proposed, this bill would have required the Director of the Department of Health Professions to annually review controlled substance prescribing and dispensing patterns through adding a new subsection to the Virginia Code. The review would have been conducted in consultation with an advisory panel consisting of representatives from relevant health regulatory boards, the Department of health, the Department of Medical Assistance Services, and the Department of Behavioral Health and Developmental Services. Additionally, the bill would have required the Director to make any changes to the criteria for unusual patterns of prescribing and dispensing and to report any findings and recommendations for best practices to the Joint Commission on Health Care by November 1st of each year.

The Senate passed a substitute to the original which implements the same requirements by amending an existing subsection of the Virginia Code rather than adding a new subsection. The final version of the bill, effective July 1st of 2018, is available here.

SB804  (Carrico) - Reporting, collection, analysis and dissemination of controlled substance overdose data As originally proposed, this bill would have required the Office of the Chief Medical Examiner, state and local law-enforcement agencies, emergency medical services agencies, and hospitals to report information about overdoses of controlled substances within 120 hours of receiving such information to the Office of the Secretary of Health and Human Resources, and for the Secretary to establish a system to collect and analyze such data and make such information available to public health, law-enforcement, emergency medical service agencies, fire departments and companies within 120 hours of receiving the information. The Senate Finance Committee incorporated this bill into SB580, which is available here.

---

ECOs and TDOs (3)

HB364 (Rush) – Execution of temporary detention orders; inmates in local correctional facilities This bill states that when a magistrate issues a TDO for an inmate at a local correctional facility, a deputy sheriff or jail officer employed by that facility may be authorized to serve the TDO. A final version of the bill, effective July 1st of 2018, is available here. 

HB1355 (Hope) - Designating an alternative facility for placement of a minor under a temporary detention order This bill establishes the same procedure and discretion for minors as adults in regards to magistrates ordering the transfer of an individual under a TDO from one facility to another. The final version of this bill, effective July 1st of 2018, is available here. 

SB673 (Deeds) - Emergency custody; time period As originally proposed, this bill would have repealed the enactment that put a June 30th, 2018 “sunset” on a subsection in the Virginia Code which provides that when a person is being held under an ECO, the local CSB and the state hospital, to which the person would otherwise be placed under a TDO, may continue attempting to find a facility other than the state hospital that is both able and willing to accept the individual for up to 4 hours after the 8-hour period of the ECO has run.

The Senate passed a substitute that accomplishes the same thing by amending the Virginia Code rather than repealing subsections of it. The final version of the bill, effective July 1st of 2018, is available here. 

---

Hospitals, Emergency Services, and Respective Personnel (3)

HB886 (Stolle) - Admissions for mental health treatment; toxicology As originally proposed, this bill would have required the Board of Health to include a requirement in its regulations that every hospital providing inpatient psychiatric services must establish a protocol for cases in which the hospital refuses to admit a patient on the grounds that the patient’s toxicology report raises a question of medical stability or medical appropriateness for admission. As a part of this requirement, the on-call physician in the psychiatric unit would be required to participate in direct verbal communication with a clinical toxicologist or certified poison specialist in order to review the results of the toxicology screen and determine whether a medical reason for refusing admission to the psychiatric unit related to the results of the toxicology screen exists.

An amended version of the bill, named HB886E, provides that the conversation with the toxicologist must occur only if the referring physician requests it. The final version of the bill, effective July 1st of 2018, is available here.   

HB1088 (Boysko) - Hospitals; security and emergency department staff; mental health training As originally proposed, this bill would have required that the Virginia Department of Health include a requirement in their regulations that licensed hospitals have their security staff and ED staff receive training in identifying and safely addressing situations involving patients and others experiencing a mental health crisis.

An amended version of the bill, HB1088ER, requires that the training be based on a trauma-informed approach and that the training address behaviors arising from substance abuse as well. A final version of the bill, effective July 1st of 2018, is available here. 

SB 670 (Deeds) – Mental health awareness training; firefighters and emergency medical services personnel This bill, identical to HB 1412, requires fire departments and emergency medical services agencies to a curriculum for training their personnel on mental health awareness. This training would qualify for continuing education credits. A final version of the bill, effective July 1st of 2018, is available here. 

---

Definitions (2)

HB1375 (Tyler) - Definition of qualified mental health professional This bill expands the definition of “qualified mental health professional” to include employees and independent contractors of the Department of Corrections who are professionally qualified and registered by the Board of Counseling to provide collaborative mental health services. A final version of the bill, effective July 1st of 2018, is available here.

SB762 (Barker) - Board of Behavioral Health and Developmental Services; definition of "licensed mental health professional" This bill directs the State Board of Behavioral Health and Developmental Services to include behavior analysts and assistant behavior analysts as those who qualify to be and those who may be licensed as licensed mental health professionals.

The Senate passed an amended version of the bill, titled SB762ER, which removed assistant behavior analyst from the list of titles qualified enough to be considered licensed mental health professionals. A final version of the bill, effective July 1st of 2018, is available here.

---

Sentencing and Releasing of Insane or Sexually Violent Offenders (2)

HB1193 (Bell) - Persons acquitted by reason of insanity; commitment; sentencing As originally proposed, this bill would have amended sections of the Virginia Code to provide that if a person is convicted of one offense and acquitted by reason of insanity for another offense in the same proceeding and the court finds that the person is in need of inpatient psychiatric hospitalization, the court must order the person’s commitment to inpatient hospitalization. The time that the person is committed would not be deducted from the length of their sentence. This bill would have also provided that the person in charge of a correctional facility must file a petition for the hospitalization of any person incarcerated in their facility should the court determine that such person requires inpatient hospitalization after being acquitted of an offense by reason of insanity.

A substitute to the bill, found here, essentially mandated the opposite. Under the substitute, a person convicted and sentenced for a criminal offense who is also acquitted of another offense by reason of insanity must serve their criminal sentence before being transferred to DBHDS. The bill also requires that if a person has already been committed to DBHDS following a finding of NGRI and is later sentenced to prison for a separate offense, the person must be transferred from DBHDS to Corrections to serve the criminal sentence. The final version of this bill, effective July 1st of 2018, is available here. 

SB267 (Howell) - Sexually violent predators; assessment protocol As originally proposed, this bill would have required the Director of the DOC to review monthly a database of prisoners convicted of sexually violent offenses who are scheduled for released within 24 months of that review and identify those who appear to meet the definition of a sexually violent predator through the use of an assessment protocol that has been approved by both the Director and the Commissioner of DBHDS.

The Senate passed an amended version of the bill, available here, with the amendment providing that the assessment protocol be “evidence based.” The House approved the bill after amending it with language (found here) requiring the DBHDS Commissioner to report annually to the key House and Senate Committee chairs on the protocol adopted to identify violent sexual predators and the numbers of prisoners so identified, with comparisons to findings in previous years.

The Governor recommended several changes to the bill, including language requiring that the DOC Director’s review include “defendants” as well as “prisoners” in DOC custody. A final version of the bill, effective July 1st of 2018, is available here. 

---

Location of Mental Health Evaluations (2)

HB52 (Hope) - Competency and sanity evaluations; location of evaluation As originally proposed, this bill would have required that competency and sanity evaluations be conducted on an outpatient basis at a mental health facility or in jails and would have removed the court’s authority to order hospital-based evaluations.

An amended version of the bill, passed as HB52ER, requires competency and sanity evaluations to be performed on an outpatient basis at a mental health facility or in jails unless 1) the outpatient evaluation finds that a hospital-based evaluation is needed to “reliably reach an opinion,” or 2) the defendant is already in the custody of DBHDS through an involuntary commitment order. A final version of the bill, effective July 1st of 2018, is available here. 

HB53 (Hope) - Persons acquitted by reason of insanity; evaluation As originally proposed, this bill would have authorized the Commissioner of DBHDS to determine where the evaluation of an insanity acquittee will be conducted on an outpatient basis or in a hospital setting.

An amendment in the nature of a substitute, available here, was passed which provides the trial court the ability to authorize whether or not the evaluation of an insanity acquittee is to be conducted on an outpatient basis. If the evaluation is permitted to be conducted on an outpatient basis, it is then up to the discretion of the Commissioner to determine whether or not the evaluation will occur in an inpatient or outpatient setting. The amendment also provides that in the vent an evaluation recommends release of a hospitalized acquittee, the discharge plan will be prepared by both DBHDS and the appropriate CSB. A final version of the bill, effective July 1st of 2018, is available here.

---

Involuntary Mental Health Treatment (2)

SB392 (Barker) - Involuntary commitment of a juvenile; notification of parents As originally proposed, this bill would have required that a petition for the involuntary commitment of a minor not be dismissed for failure to immediately serve both parents with a copy of the petition and notice of the hearing as long as one parent is present at the hearing and the judge deems that a reasonable effort was made to notify the other parent.

The Senate passed a substitute providing that the court may proceed with the hearing in instances where both parents cannot be notified if the court makes the determination that a reasonable effort was made to serve the petition and notice of the hearing to both parents. The House approved a substitute to the Senate’s substitute, SB392H1, which provided that the hearing may proceed if the court finds that one parent was served with both a copy of the petition and notice of the hearing and that reasonable efforts were made to serve both parents. The final version of the bill, effective July 1st of 2018, is available here. 

SB669 (Deeds) - Involuntary mental health treatment; minors; access to firearms As originally proposed, this bill would have made it illegal for an individual to possess, purchase, or transport a firearm if, as a minor age 14 or older, they had a) previously been ordered to involuntary admission to a mental health facility or to mandatory outpatient treatment or b) previously been subjected to a temporary detention order (TDO) and then agreed to voluntary admission. These restrictions would have applied to the individual both as a minor and as an adult. Affected individuals would still have the right to utilize the current statutory procedure for petitioning for the restoration of their firearm rights. The bill also would have required that the minor be advised that their firearm rights will be revoked if they are involuntarily admitted or consent to admission. Lastly, the bill would have set forth procedures for the submission by the court clerk to the CCRE of involuntary admission orders and consents to admission following temporary detention.

An amendment was made to the bill to correct an unintended wording error. The final version of the bill, available here, was made effective upon the Governor’s signing. 

---

Education (2)

HB1604 (Bell) - Health instruction; mental health This bill requires that public schools incorporate mental health and the relationship of physical and mental health into existing health instruction. The bill also directs the Board of Education to review and update the health Standards of Learning for students in 9th and 10th grade to include mental health. A final version of the bill, effective July 1st of 2018, is available here. It should be noted that this bill is identical to SB953  (Deeds). 

SB120 (Favola) - Alcoholic beverage control; substance abuse prevention; Virginia Institutions of Higher Education Substance Use Advisory Committee established As originally proposed, this bill would have amended directed the Virginia Alcoholic Beverage Control Authority Board to establish and appoint members to the Virginia Institutions of Higher Education Substance Use Advisory Committee, which would develop and update a statewide strategic plan for substance use education, prevention, and intervention at Virginia's public and private institutions of higher education.

 The Senate passed a substitute that directs the ABC Board to establish the same advisory committee, but with the more specific task of advising the Board regarding the Higher Education Alcohol Drug Strategic United Prevention (HEADS UP) program to ensure that the program utilizes best practices, collects meaningful data, and assists institutions of higher learning with their strategic plans. The Advisory Committee, which shall include representatives of public and private institutions of higher learning, students, directors of student health and others, must report to the Governor and General Assembly by December 1st of each year. SB120ER, passed by both houses, broadens the Advisory Committee’s role, giving it a goal of developing a comprehensive strategic plan for substance abuse education, prevention and intervention at Virginia’s institutions of higher learning. A final version of the bill, effective July 1st of 2018, is available here. 

---

Miscellaneous (2)

HB301 (Watts) - Disclosure of health records; state and local correctional facilities As originally proposed, this bill would have mandated that the standard requirements for disclosing health records not apply to the release of health records to a state correctional facility or to a local or regional correctional facility.

An amendment in the form of a substitute was approved which included the provisions noted above while adding amendments to the Virginia Code which provide that when an individual is committed to one of these facilities, the person in charge of the facility (or a designee) is entitled to obtain medical records concerning the individual from a health care provider. A final version of the bill, effective July 1st of 2018, is available here.

SB555 (Mason) - Barrier crimes; adult substance abuse and mental health treatment providers As originally proposed, this bill would have allowed DBHDS-licensed substance abuse or mental health treatment providers to employ persons who have been convicted of burglary to work in adult substance abuse or mental health treatment programs if the hiring provider determines that the criminal behavior was substantially related to the individual’s substance abuse or mental illness. The hiring provider must also determine that the person has been successfully rehabilitated and is not a risk to individuals receiving services.

The Senate passed a substitute that added local CSBs to the list of potential employers for these individuals. A final version of the bill, effective July 1st of 2018, is available here. 

Telemental Health Blog Series, Part 2 of 3: Takeaways from the Brief Survey of CSB Use of Telemental Health

A note from the blog manager:

The following post is the second in a three-part series on telemental health (click here for the first installment). This post covers points of interest from a 2016 brief survey of telemental health services in Virginia Community Services Boards (CSBs). The final post will be an in-depth look at emergency telemental health programs across the country with a spotlight on interviews with telemental health experts from the University of Virginia. 

Subscribe to the Policy Blog  stay up-to-date on this series as well as our other upcoming posts!

---

Kathy Faris, B.A.
ILPPP Research Assistant
MPH Candidate, Class of 2019

This report is informed by a brief survey on CSB telepsychiatry activities conducted by researchers at the ILPPP in late 2016 as a follow-up to interviews with CSB Executive Directors.  Note that some of these figures may have changed since administration of the survey. 26 CSBs out of 40 total CSBs participated in the survey.

---

How many CSBs use telemental health for clinical services?

CSBs Using Telemental Health for Clinical Services

• Of the 26 CSBs who completed the survey, 24 reported that they have telemental health equipment. 

• At the time of the survey, 10 CSBs were planning on expanding their telemental health services.

  • Additionally, 3 CSBs would like to expand pending overcoming barriers such as finding willing providers and prescribing laws. 

For what service types do CSBs use telemental health?

Services for which CSBs use telemental health

• "Other" responses include primary care, providing psychiatric services to other CSBs, and intra-agency services. 

• General clinical services include case management, medication management appointments, therapy sessions

• Mental health emergencies include TDO evaluations, emergency mental health
  intervention

Who provides telemental health services?

CSB Providers of Telemental Health

• 3 are currently looking for new providers of telemental health services

Why do CSBs use telemental health?

Reasons CSBs use telemental health

• "Other" reasons CSBs use telemental health include increasing efficiency of the provision of services in jails/prisons, to communicate with magistrates/special justices for ECO/TDO processing, and to communicate with private and state hospitals.

Why do CSBs use telemental health services?

• 12 CSBs use telemental health services to supplement their own resources with private providers or public mental health resources

• 13 CSBs use telemental health to make resources more available (e.g. psychiatrists can meet with outlying clinics)

What are the challenges of increasing the usage of telemental health services?

Challenges of Telemental Health

Example Challenges

• Connectivity: Connecting between sites, particularly rural areas

• Staffing: Not enough providers and site-specific staff to manage telemental health appointments.

• Resistance/Reluctance: Providers and site-specific staff reluctant to use telemental health

• Equipment/Technology: Costly upgrades to equipment and equipment malfunctions

• Prescribing Laws: These laws restrict the ability of psychiatrists to prescribe medications via telemental health

• Billing: Billing for these services may be challenging or unavailable for some payers

• Cost of Services: Loss of money on each visit that is not compensated for by payer reimbursement

---

*Glossary of terms
LCSW: Licensed Clinical Social Worker
LPC: Licensed Professional Counselor

Certified Community Behavioral Health Clinics: Model Overview and Virginia Adaptation

CCBHC Model Overview

Kedar Dange, B.A.
ILPPP Research Assistant
MPH Candidate, Class of 2019

Context

Following enactment of the Protecting Access to Medicare Act in 2014,** new mental health treatment programs were developed. Eight states across the US have adopted Certified Community Behavioral Health Clinics (CCBHCs) in order to reform the structure of their behavioral health systems. Virginia has begun implementing an adaptation of the CCBHC structure in its STEP-VA program.

Certified Community Behavioral Health Clinics

CCBHCs are centers designed to provide a variety of mental health and substance-use disorder services using the framework of a trauma-informed approach to mental health. This concept revolves around empowerment, fostering trust and transparency, and recognizing social factors in the treatment of mental illness. These programs were defined in the Protecting Access to Medicare Act, and in 2016 the Substance Abuse and Mental Health Services Administration (SAMHSA) selected eight states to participate in the program. (1)

Oversight of these operations is done by Designated Collaborating Organizations (DCO). These are external providers, private or public, which are contracted by the CCBHC to ensure that all nine essential services are provided and paid for, several of which may be provided by the overseeing DCO itself:

• Emergency mental health services, including 24-hour mobile support, intervention, and stabilization*

• Screening, assessment, and diagnosis*

• Treatment planning*

• Outpatient care for mental health and substance use patients*

• Primary care screening and monitoring

• Case-management

• Psychiatric rehab

• Peer and family counseling/support services

• Services for members or veterans of the Armed Services

• Connection with other providers and systems (hospitals, criminal justice, child welfare, etc.) via partnerships and collaborations
  *Must be provided by CCBHC itself, not contracted from DCO

Emphasis is put on rehabilitation, outpatient care, and behavioral elements of health, as well as offering early and cost-irrelevant care to vulnerable populations (particularly military members) without interruption (24/7/365). (2)

As a provider under Medicaid, CCBHCs are eligible for unique payment plans, covering a range of addiction and mental health services. The Prospective Payment System (PPS) allows CCBHCs to receive Medicaid reimbursements based on anticipated costs of the expanded service range, guided by SAMHSA-issued quality measures and the CCBHC cost report template released by the Center for Medicare and Medicaid Services (CMS). (3) This allows CCBHCs additional funding to invest in new hires, additional programs, and new technologies that were previously ineligible for reimbursement. (4)

Seven of the eight CCBHC states have reported results: New York, Minnesota, Missouri, New Jersey, Oklahoma, Oregon, and Pennsylvania. Each CCBHC was surveyed to measure how well service capacity and quality has improved. Metrics of success range from hiring new employees, particularly psychiatrists and other specialized staff members, to services offered, such as Medication-Assisted Treatment, opioid recovery initiatives, and screening programs. An extended glossary of quality measures was released by SAMHSA and can be found below. (5,6)

Table 1: Quality Measures for measuring CCBHC effectiveness (5)

Individual states, such as Pennsylvania and Minnesota, report successes in providing better and more integrated care, hiring qualified medical professionals, facilitating communication between CCBHCs and hospitals, and providing same-day care access to consumers. (1)

Benefits

The primary benefit of this style of program is its designation as a special provider under Medicaid, which enables qualifying programs to receive additional funding to cover expanded services via PPS, which is defined by anticipatory cost reports provided by the CCBHCs themselves. Oversight by DCOs enables participating organizations to be uniform in services offered and streamlines communication, particularly billing, for CCBHCs, and provides flexibility for states that have pre-existing CCBHC-like programs to integrate into the new framework without having to completely restructure. All CCBHC services, and by extension DCO-provided services, report through SAMHSA’s Uniform Reporting System, which collects information on a large variety of demographic and service usage information.7 These report National Outcome Measures (NOM) which have been developed by SAMHSA in collaboration with NRI. (8)

STEP-VA

Virginia’s analogous program, launched by the Virginia Department of Behavioral Health and Development Services (DBHDS) called STEP-VA (System Transformation Excellence and Performance) is built on the same framework. STEP-VA will provide a more comprehensive and standardized array of services at all 40 CSBs, and is slated to be implemented in phases over the next several years. To date, DBHDS has funded and begun to implement the first two phases: same-day access and primary care screening. (9) The goals of STEP-VA are largely similar to those of the national program, using the same essential services. (10) Once STEP-VA is fully implemented, the following services will be provided at all 40 CSBs (11):

• Same Day Access

• Outpatient Services (including MAT and improved in-home services for children)

• Primary Care Integration

• Detoxification

• Care Coordination

• Peer and Family Support

• Psychosocial rehabilitation/Skill Building

• Targeted Case Management

• Veterans Services

• Person-Centered Treatment

• Mobile Crisis Services

STEP-VA will build off of the current set of services already being provided by CSBs while adding new services to in an effort in increase access, quality, consistency and accountability. (12)

CCS 3 Outcomes Data

Beginning in July, 2017, CSBs have been submitting the following six outcome measures to DBHDS as part of regular CCS 3 reporting. (13) Most of these outcomes map onto similar CCBHC quality measures that are reported by the CCBHCs as part of the CCBHC demonstration program. The CCBHC demonstration program also requires that a number of other quality measures are tracked, most of which do not appear to be tracked by DBHDS. ILPPP staff do not currently know if DBHDS plans to adopt more of the CCBHC quality measures as part of implementing STEP-VA and plan to research this further.

* Denotes 1 of the 9 required measures to be reported by the CCBHCs as part of the CCBHC demonstration program.

** The Protecting Access to Medicare Act was an expansion bill signed in April 2014 to extend expiring programs implemented in several previous bills, notably preventing a 24% reduction in reimbursement rates for physicians through Medicare. Among the extension of Medicare programs, grant provisions were created, allocating $27 million to new programs to improve community mental health, which became the test runs for the CCBHC model. (14)

References

1. “Certified Community Behavioral Health Clinics.” National Council, www.thenationalcouncil.org/topics/certified-community-behavioral-health-clinics/

2. Miskowiec, Don, and Linda Rosenberg. CCBHC Demonstration. CCBHC Demonstration, National Council for Behavioral Health, 2017.

3. “Section 223 Demonstration Program to Improve Community Mental Health Services.” Medicaid.gov, 2017, www.medicaid.gov/medicaid/finance/223-demonstration/index.html.

4. “Getting Paid as a CCBHC” National Council, https://www.thenationalcouncil.org/topics-a-z/getting-paid-ccbhc/

5. “Glossary of CCBHC-Related Quality Measure s and Acronym.” SAMHSA, 17 Apr. 2017. https://www.samhsa.gov/sites/default/files/programs_campaigns/ccbhc-glossary.pdf

6. “Questions-Clarifications-about-Qms-Ccbhcs.pdf.” SAMHSA, 2016. https://www.samhsa.gov/sites/default/files/questions-clarifications-about-qms-ccbhcs.pdf

7. “2016 URS Output Tables.” SAMSHA: Uniform Reporting Service, 2016. https://wwwdasis.samhsa.gov/dasis2/urs.htm

8. “Uniform Reporting System and Mental Health Client-Level Data.” Uniform Reporting System and Mental Health Client-Level Data | NRI: No Person's Life Will Be Limited by Mental Illness or Addiction, NRI, 2017, www.nri-inc.org/our-work/projects/uniform-reporting-system-and-mental-health-client-level-data/

9. “Joint Subcommittee to Study Mental Health Services in the 21st Century Adopts Final Recommendations for 2017.” VACO, 2017. http://www.vaco.org/joint-subcommittee-study-mental-health-services-21st-century-adopts-final-recommendations-2017/

10. Herr, Daniel. “DBHDS Updates and STEP-VA: System Transformation, Excellence and Performance in Virginia.” 2015. http://dls.virginia.gov/groups/mhs/Step_VA.pdf

11. “DBHDS Comprehensive State Plan (2016-2022).” DBHDS, 2016. http://www.dbhds.virginia.gov/library/quality%20risk%20management/dbhds-comprehensive-state-plan-2016-2022.pdf

12. Barber, Jack. “DBHDS Budget and Policy Overview.” 2017. http://hac.state.va.us/subcommittee/health_human_resources/files/1-24-17/DBHDS%20Presentation.pdf

13. Gilding, P. “Community Consumer Submission 3 Extract Specifications: Version 7.3.3” Virginia Department of Behavioral Health & Developmental Services, 1 July, 2017. http://www.dbhds.virginia.gov/library/community%20contracting/ccs3extractspecificationsversion733may2017finalver4.pdf

14. Wilson, Joy Johnson. “The Protecting Access to Medicare Act: In Brief.” NCSL, National Conference of State Legislature, 15 Apr. 2014, www.ncsl.org/research/health/protecting-access-to-medicare-act-of-2014.aspx.

Telemental Health Blog Series, Part 1 of 3: An Overview of Elements of Telemental Health in Crisis Settings

A note from the Blog manager: 

The following post is the first in a three-part series on telemental health. This post will give an overview of the elements of emergency telemental health. Future posts will include results from a brief survey on telemental health in Virginia's Community Services Boards conducted by the ILPPP in 2016 and an in-depth look at emergency telemental health programs across the country with a spotlight on interviews with telemental health experts from the University of Virginia. 

Subscribe to the Policy Blog  stay up-to-date on this series as well as our other upcoming posts!

---

University of Virginia Institute of Law, Psychiatry, and Public Policy

KM Faris and AA Allen
February, 2018

Background and methodology

TMH in Emergency Settings: “Smart Practices” for Community Services Boards Learned from the Field

jchc Report: Options for Increasing the Use of Telemental Health in the Commonwealth - Interim Report

The following research was conducted to support “SJ-47” – the Joint Subcommittee to Study Mental Health Services in the Commonwealth in the 21st Century, specifically, the work of the Emergency Services Expert Advisory Panel. Telemental health[*] has been frequently discussed by the panel as a way to enhance emergency services. Researchers from the ILPPP have been looking closely at existing emergency telemental health practices and their current and potential use in emergency departments and other emergency settings. Note that the ILPPP has also published an in-depth report on the use of telemental health in emergency settings by Community Services Boards (CSBs) statewide, which can be found at https://uvamentalhealthpolicy.org/s/TPinES_SmartPractices_FINAL.pdf. Another report for a related subgroup of SJ-47, the Telemental Health Workgroup, was published in November 2017 by the Joint Commission on Health Care, which can be found at http://jchc.virginia.gov/CompleteTelemental%20Health%20RD509-%20Interim%20Report%20.pdf . This “interim” report describes findings and recommendations for the Telemental Health Workgroup (a sub-group of SJ-47). The final report which will investigate additional options for telemental health in Virginia will be submitted by November 2018.

This post does not make recommendations regarding what emergency telemental health and telepsychiatry programs Virginia should pursue, but rather exists in order to educate policymakers regarding the array of programs that exist, including considerations that must be made when adopting any such program.

ILPPP staff gathered information through literature reviews, interviews, and surveys. As part of a separate report[†] on telemental health in emergency settings at CSBs, researchers interviewed CSBs and two CSB telemental health partners (two local hospitals) on their current practices. Literature reviews were conducted on current trends in emergency telemental health and specific programs to provide a wider view of telemental health in the U.S.

---

Goals of emergency telemental health

Emergency telepsychiatry has been described as “psychiatric care delivered over live interactive videoconferencing to assess and treat patients experiencing potential imminent dangerousness to themselves (suicidal or grossly disturbed behavior) or dangerousness to others (homicidal or other violent behaviors).”(7) This can also describe emergency “telemental health” services, a term that encompasses all emergency mental health services provided via videoconference. Telemental health in acute or emergency situations has become more common in recent years and addresses an important need for many individuals and health providers. Telemental health has been shown to be safe and effective for emergency assessments. A 2014 study found that there were no differences between face-to-face and telemental health assessments in disposition determination and the two were similar on measures of suicidality, dangerousness, and diagnostic category.(6)

Many patients lack access (due to geography or excessive wait times) to necessary mental health care. In emergency situations, many hospital emergency departments are not prepared to address the needs of psychiatric patients which can lead to lengthy patient wait times and improper diagnosis.(11) Through telemental health, emergency department providers can connect with psychiatrists or other mental health professionals for treatment, consultation, and/or evaluation services in a timely manner. This can have significant impact on patient length of stay or the need for inpatient admission.(11) While emergency telemental health is used for treatment in some cases, the most common use appears to be consultation or evaluation services. The setting for emergency telemental health is typically a structured one such as hospital emergency departments and specialized mental health centers. A small portion may occur in the patient’s home if the patient is already engaged in telemental health service from their home during which the patient experiences a mental health crisis.(8,10)

Program structure and linkages

Networks/Health Systems

The structure of programs for telemental health in emergency settings has been largely neglected in literature and studies of telemedicine. The available literature indicates that emergency telemental health networks are largely structured as hub-and-spoke sites centered around the patient site (e.g., emergency department) of a local hospital or specialized facility with a telemental health program through which the patient receives consultation services, usually via videoconferencing, from a psychiatrist or other licensed mental health professional located at the “hub” site (e.g., a large, in-network hospital).(10) The telemental health services may be provided by a health facility in the same network as the spoke sites or the services may be procured through a membership with an external network of providers through a formal arrangement. A telemental health network may provide the added benefit of administrative support for spoke sites.(2)

Free-standing sites

While the telemental health network structure seems to be the most popular for emergency telemental health, there are also free-standing psychiatric facilities that do not belong to larger health networks. These sites work with private companies which provide telemental health services directly to facilities on a monthly or appointment-based fee schedule rather than through a network membership.(1,10) In fee-for-service models for the provision of telemental health, the telemental health professional bills the third-party payers (e.g. Medicaid, private insurance) per appointment. In the contractual model, telemental health professionals are paid a negotiated fee or wage for specified periods of time when they are on-call and the patient site bills third-party payers for telemental health services.(3) Contracting for these services must be arranged with the providers of telemental health services, including any necessary administrative services.(2)

State or Regional Public Networks

States or regions looking to address mental health needs of their communities may be interested in providing telemental health services to a network of community-based agencies. The South Carolina Department of Mental Health has such a program where the state telemental health providers connect to emergency facilities around the state for consultation.(4) The network provides telemental health to Medicaid populations via the pool of psychiatrists and other mental health professionals employed by the state. The capitated payments for services provide enough revenue to employ providers for this population without concerns about patient location.(2)

Primary Responsibility for the Patient

The determination of which party assumes the primary responsibility for the patient is complex and should be established prior to implementing telemental health services.  Many factors can affect which party holds primary responsibility such as the type of patient site and even the time of day. If, for example, the patient site is a specialized mental health crisis center, the relationship between the patient site providers and the telemental health providers will typically be a collaborative one. In freestanding clinics or hospitals with no psychiatric/mental health crisis team, the telemental health providers will assume primary responsibility for patient mental health decisions. Another issue to consider in responsibility is the time of day in which the evaluation takes place. After hours, there may be fewer on-site mental health resources or staff available and thus, the telemental health providers hold primary responsibility.(7)

If the telemental health provider is a psychiatrist (telepsychiatrist), they may partner with patient site prescribers who will write the prescription recommended for the patient. Alternatively, the telepsychiatrist may write the prescription and email or fax it to the patient site.(3)

Funding and Costs

In recent years, the costs for implementing telemental health have been dropping due to the lower cost of purchasing equipment. However, purchasing equipment is still an initial investment estimated at roughly $7,000 per site.(10) Depending on existing internet infrastructure, facilities may also need to invest in increased bandwidth in order to provide continuous encrypted videoconferencing. Another financial concern involved in implementing a telemental health program is the cost associated with paying for telemental health services in addition to the staff member(s) who facilitates the telemental health appointment. Although there may be an initial increase in overall costs, telemental health in emergency situations often reduces the patient wait time, especially in rural situations.(9) Calculating the relative cost of telemental health in emergency situations is therefore fairly complex and may lead to a reduction in overall costs incurred by patient boarding[‡] or transport in the long term.

As mentioned above, billing for telemental health services is dependent upon the arrangement in each location with either the patient site or the telemental health provider billing third-party payers. Medicaid will not reimburse for technology costs for purchase of telemental health equipment but this funding has been acquired internally or via grant funding for many telemental health programs.(10) However, grant funding does not allow for a sustainable program and thus determining the reimbursement policies and procedures for Medicaid and private insurance providers is a necessary part of program planning. While most states have Medicaid programs that will provide some degree of reimbursement for telemental health, policies of private health plans vary more widely. Some telemental health programs have raised concerns that, even if payers will provide reimbursements, they may not be adequate to sustain programs without supplemental funding.(2)  

Emergency telemental health in Virginia

In Virginia, telepsychiatry and other telemental health services are used by the majority of Community Services Boards (CSBs), however, as of September 2016, only 5 are currently using emergency telemental health and of these 5, there are 4 currently using it for prescreening clients. CSBs have a variety of partnership arrangements for telemental health services including different levels of care collaboration as well as billing models (e.g., contractual and fee-for-service models). More in-depth information is needed from stakeholders, specifically, CSBs, telemental health providers, hospital emergency department staff, law enforcement, and community leaders. Particular topics of interest for stakeholder discussions are how telemental health is being used in emergency situations, the different providers of telemental health in Virginia, and the different types of billing and care models used by CSBs across the state.

---

References

1.     Burke Mental Health Emergency Center. Prepared for 2014 ATA Innovation in Remote Care Award Nominee.Print.

2.     Lambert, David, et al. "Understanding the Business Case for Telemental Health in Rural Communities." The journal of behavioral health services & research 43.3 (2016): 366-79. Web.

3.     Myers, Kathleen, and Carolyn Turvey. Telemental Health: Clinical, Technical, and Administrative Foundations for Evidence-Based Practice. Newnes, 2012. Web.

4.     Narasimhan, Meera, et al. "Impact of a Telepsychiatry Program at Emergency Departments Statewide on the Quality, Utilization, and Costs of Mental Health Services." Psychiatric Services 66.11 (2015): 1167-72. Web.

5.     Nicks, BA, and DM Manthey. "The Impact of Psychiatric Patient Boarding in Emergency Departments." Emergency medicine international 2012 (2012)Web.

6.     Seidel, Richard W., and Mark D. Kilgus. "Agreement between Telepsychiatry Assessment and Face-to-Face Assessment for Emergency Department Psychiatry Patients." Journal of telemedicine and telecare 20.2 (2014): 59-62. Web.

7.     Shore, Jay H., Donald M. Hilty, and Peter Yellowlees. "Emergency Management Guidelines for Telepsychiatry." General hospital psychiatry 29.3 (2007): 199-206. Web.

8.     Shore, Peter, et al. "Meeting Veterans Where they'Re @: A VA Home-Based Telemental Health (HBTMH) Pilot Program." Int J Psychiatry Med 48.1 (2014): 5-17. Web.

9.     Southard, Erik P., Jonathan D. Neufeld, and Stephanie Laws. "Telemental Health Evaluations Enhance Access and Efficiency in a Critical Access Hospital Emergency Department." Telemedicine and e-Health 20.7 (2014): 664-8. Web.

10.  Williams, Mike, MM Pfeffer, and Donald M. Hilty. "Telepsychiatry in the Emergency Department." California HealthCare Foundation (2009)Web.

11.  Yellowlees, Peter, et al. "Emergency Telepsychiatry." Journal of telemedicine and telecare 14.6 (2008): 277-81. Web.

Footnotes

[*] There are many terms used to describe teleconferencing for mental health services such as telemental health or telepsychiatry. In this report, the term “telemental health” will be used to describe all types of telemental health activities including psychiatric (i.e., provided by a psychiatrist) services. 

[†] https://uvamentalhealthpolicy.org/s/TPinES_SmartPractices.pdf

[‡] “Patient boarding” can be defined as “holding a patient in an ED [emergency department] bed while awaiting an inpatient mental health bed” and is a common occurrence in emergency departments.(5)