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RICHMOND \u2014 Virginia\u2019s state-run psychiatric hospitals have been in crisis mode for years. But the last nine months have brought a series of new emergencies, from the\u00a0July decision<\/a>\u00a0to temporarily close to new admissions to a\u00a0recent lawsuit against the state<\/a>\u00a0for failing to admit a juvenile patient going through a mental health crisis.<\/p>\n The turmoil has brought renewed scrutiny to the agency charged with running the facilities.\u00a0Legislation filed this year<\/a>\u00a0by Sen. Siobhan Dunnavant, R-Henrico, proposed removing the state\u2019s nine hospitals from under the authority of the Department of Behavioral Health and Developmental Services and establishing an independent body to oversee them.\u00a0<\/p>\n The bill didn\u2019t pass, but legislators did add\u00a0budget language<\/a>\u00a0directing Virginia Secretary of Health and Human Resources John Littel to convene a workgroup focused on potential restructuring. While the final budget agreement\u00a0is still being debated<\/a>, the language \u2014 if included \u2014 specifically tasks the group with evaluating whether certain services should be shifted to another state agency, or if hospitals should be managed under a different model or structure.<\/p>\n \u201cI knew this would be a shot across the bow \u2014 a conversation starter,\u201d Dunnavant said. \u201cBut we need to rethink what we have. Because I think we can all agree that we haven\u2019t done a very good job of addressing our mental health crisis so far.\u201d\u00a0<\/p>\n It\u2019s not the first time that a Virginia lawmaker has suggested changing the model for state-run psychiatric hospitals. More than a decade ago, then-Gov. Tim Kaine\u00a0proposed closing and potentially privatizing<\/a>\u00a0several state facilities, including Virginia\u2019s only publicly run mental hospital for children and adolescents. Dunnavant amended her bill to leave the model open-ended, but her\u00a0original legislation<\/a>\u00a0proposed creating a hospital authority operated by a chief executive officer and board of directors.<\/p>\n In a committee hearing on the bill, Sen. Janet Howell, D-Fairfax, said shifting the facilities from state control would be a \u201cprecipitous\u201d change for Virginia, which founded the nation\u2019s first public institution for patients with mental illness in 1773. But proponents argue that state oversight has compounded problems at the hospitals, making it harder for them to respond to challenges in a timely way.<\/p>\n Dunnavant pointed to\u00a0severe understaffing<\/a>\u00a0that prompted former DBHDS Commissioner Alison Land to halt new admissions at five state facilities last July. The agency had spent months warning lawmakers that burnout and low pay, combined with the ongoing COVID-19 pandemic, were driving employees out of the field. At the time, salaries for direct care staff started at $11 an hour, and most hospitals were operating at 100 percent of their patient capacity with around 65 to 70 percent of the needed staff.<\/p>\n Land was able to divert some emergency funding to hire contract workers and offer bonuses to remaining staff. But the agency had to wait another month for the\u00a0General Assembly to allocate federal rescue dollars<\/a>\u00a0toward more permanent pay increases. Even now, it\u2019s unclear how much state funding will be directed to further raise salaries and whether it will be enough to recruit more workers to the facilities.<\/p>\n \u201cFor these hospitals to be accountable to the process of state appropriations \u2014 that\u2019s an almost insurmountable challenge,\u201d Dunnavant said. Keeping them under DBHDS authority is another concern.\u00a0<\/p>\n Even lawmakers who were skeptical of the proposal acknowledged that running state facilities has always been a heavy lift for the agency. Over the years, DBHDS has been tasked with licensing and overseeing both state and private behavioral health services, along with residential substance use disorder treatment and services for Virginians with developmental disabilities.<\/p>\n \u201cThey have so much to say grace over that someone is going to feel like they\u2019re getting left out constantly,\u201d said Sen. Creigh Deeds, D-Bath. \u201cAnd it might be time to reorganize the department and separate those functions.\u201d<\/p>\n When it comes to privatization, though, Deeds isn\u2019t convinced. While current budget language would allow the administration to study a range of options, it specifically lists public-private partnerships as a model for the state to consider.\u00a0<\/p>\n Under the authority model proposed in Dunnavant\u2019s original legislation, oversight of the facilities would be outsourced to a CEO and nonlegislative board of directors confirmed by the General Assembly. While it wouldn\u2019t completely remove state control, she suggested it would function more like a private health system, drawing from industry expertise and potentially contracting out state bed space to private hospitals.<\/p>\n While there was little outright opposition to the suggestion, some lawmakers and mental health advocates said it wouldn\u2019t address the root causes of Virginia\u2019s ongoing bed crisis.\u00a0<\/p>\n \u201cIt could be helpful in certain instances, but I just don\u2019t see this as a situation where if we just change who\u2019s in charge, that alone will fix this problem,\u201d said Del. Mike Mullin, D-Newport News. \u201cBecause it is really an issue of lack of access to care at the appropriate level.\u201d<\/p>\n Problems within Virginia\u2019s mental health system have spanned decades. According to a\u00a02014 policy paper<\/a>\u00a0by Mira Signer \u2014 now a chief deputy commissioner for DBHDS \u2014 the U.S. Department of Justice began investigating state-run hospitals in the 1990s for inadequate care that, in some cases, led to patient deaths. The department pushed the state to deinstitutionalize, leading to a more than 600-bed reduction at state facilities over an eight-year period.<\/p>\n Virginia\u2019s investment in community mental health services, though, didn\u2019t keep pace with the reduction in beds. Deeds described funding as a yo-yo, pointing to the 2007 Virginia Tech shooting as an example.\u00a0<\/p>\n In the months following the massacre, perpetrated by a student with mental illness who then took his own life, state legislators allocated $42 million to the state\u2019s community service boards \u2014 publicly funded agencies that offer safety net services for behavioral health and developmental disabilities. Described as a \u201cdown payment\u201d for better mental health services, the funding was almost entirely eliminated over the next four years during the Great Recession.<\/p>\n \u201cThere was this grand study and those recommendations have basically gathered dust on a shelf,\u201d Deeds said. Then, in 2014, he spearheaded what\u2019s now known as Virginia\u2019s \u201cbed of last resort\u201d law, which requires state hospitals to admit patients after an eight-hour period if a bed can\u2019t be found at another facility \u2014 including private hospitals with behavioral health units.\u00a0<\/p>\n The legislation originated from personal tragedy. In 2013, Deeds\u2019 son, Gus, seriously injured Deeds and then killed himself during a\u00a0mental health crisis<\/a>\u00a0after state officials were unable to find him a psychiatric bed.\u00a0<\/p>\n Deeds described it as a necessary policy, but it\u2019s also led to unintended consequences, including a\u00a0steady reduction<\/a>\u00a0in the volume of involuntary psychiatric admissions accepted at private hospitals. Anna Mendez, executive director of the Charlottesville-based nonprofit Partner for Mental Health, said Virginia\u2019s problems stem from a slew of cascading effects \u2014 underfunding of existing state hospitals, a lack of investment in community-based services and continued tension between DBHDS and the state\u2019s private hospitals, along with a\u00a0broad shortage of mental health professionals<\/a>.<\/p>\n \u201cWe\u2019ve just created this perverse feedback loop,\u201d she said. \u201cSo I\u2019m not at all opposed to the idea of creating a hospital authority, but I think its ability to really improve outcomes is going to be fairly limited if we\u2019re continuing to work with insufficient resources.\u201d<\/p>\n Dunnavant\u2019s legislation didn\u2019t address a funding mechanism for the authority, though she suggested that the state could allocate even more money in the beginning to get the concept off the ground. Four of the state\u2019s nine hospitals have also lost accreditation from the U.S. Centers for Medicare and Medicaid Services over the years, and Dunnavant said an agency solely focused on running the facilities could expedite the re-accreditation process, allowing Virginia to leverage more federal funds.<\/p>\n Experts say the billing issues are much more complicated. Lauren Cunningham, a spokesperson for DBHDS, said the agency didn\u2019t take a position on the proposed legislation. But federal laws exclude state-run psychiatric facilities from traditional Medicaid reimbursement, and Virginia\u2019s public health plan doesn\u2019t typically cover forensic patients who enter state hospitals through the criminal justice system and often have long-term needs that should be managed by community providers.\u00a0<\/strong><\/p>\n \u201cWe are planning to look into additional programs and different structures the system can take to enhance public hospital operation, build community service access and accountability, stimulate private provider development, and enhance private hospital engagement,\u201d Cunningham said in a statement. Some legislators are also hopeful that proposals for the state\u2019s next budget cycle will lead to gradual improvements in the system.<\/p>\n While the House and Senate have yet to come to an agreement, both chambers are suggesting around $50.5 million to fund the final three services in\u00a0STEP-VA<\/a>, a statewide program intended to ensure that each of the state\u2019s community service boards offer the same options for mental health treatment. In late 2021, Virginia also\u00a0expanded Medicaid coverage<\/a>\u00a0to six new behavioral health services, and both budget proposals include at least a one-year increase in reimbursement rates to providers.<\/p>\n \u201cI think we need to move forward and see what happens with that,\u201d said Del. Mark Sickles, D-Fairfax, who \u2014 like Deeds \u2014 hoped a steady expansion in outpatient services would gradually reduce the need for psychiatric hospitalizations. But it\u2019s still an open question whether the incremental increases in funding will be enough to meet local needs.\u00a0<\/p>\n The state has been gradually funding services in STEP-VA since the program was codified in 2017. But community service boards are also facing major workforce challenges, and it\u2019s not clear whether every agency is truly capable of offering all nine treatment options.\u00a0<\/p>\n \u201cPrudence dictates that we\u2019d want to circle back around to the first few services to ensure the original funding is still adequate,\u201d said Jennifer Faison, executive director of the Virginia Association of Community Service Boards. One of the very first steps requires the agencies to offer same-day assessments. But Mendez said one of her recent clients approached his local board for a substance use assessment and was told he couldn\u2019t be seen until June.<\/p>\n \u201cThere\u2019s this history in Virginia of being unwilling to make a real investment,\u201d she said. \u201cSo even fully funding STEP-VA is going to leave us well short of where we need to be.\u201d<\/p>\n This story is brought to WYDaily readers courtesy of \u201cVirginia<\/a> Mercury.\u201d<\/a><\/em><\/p>\n<\/div>\n![\"\"](\"https:\/\/d2unfigtnsklzd.cloudfront.net\/wp-content\/uploads\/2022\/03\/senate-retreat-4-450x300.jpg\")
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