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The System Transformation Initiative

The System Transformation Initiative
By Dr. James Reinhard
The following article was written for the Richmond Academy of Medicine quarterly newsletter “RAMifications”

On December 6, 2005, Governor Mark R. Warner announced an historic and unprecedented $460 million Transformation Initiative for Virginia’s Behavioral Health and Developmental services system. This initiative is a major infusion of resources for long overdue improvements to the Commonwealth’s system of residential and inpatient treatment. In addition, it continues and enhances critically important investments in the network of community-based services provided by 40 community services boards and their partners. The Governor’s proposals signal a multi-year commitment to transforming the services system to a state-of-the art system of community, residential and inpatient care. The Richmond Times Dispatch called the Governor’s Initiative a “Dream Scenario.”

When I learned of the Governor’s support for this initiative, I must admit that I expected to wake up from the dream at any minute to learn that it was truly just a dream. But the reality is that the Department, community services boards, consumers, advocates and providers have been working to shape this dream for the last four years. When I took office as Commissioner in 2002 we were operating within an inefficient structure of mental health and mental retardation services and supports. For decades, because of the lack of sufficient community alternatives, the Commonwealth has been forced to rely on what is usually the most expensive, the most restrictive, and most inefficient care-institutional care. Today, most of the state mental health and mental retardation facilities are in extremely poor physical condition and were built in an era when they were occupied by thousands of individuals. These facilities have significant health and safety risks for patients and residents and are inefficient to operate.

Through an effort that we called “Partnership Planning”, the Department and its partners (consumers, advocates, community services board representatives, private and public sector providers) worked together to develop first a Vision and then a Strategic Plan that articulates the need for new investments and specific steps for redirecting resources from institutional care to community-based services. The reforms that we propose in our Strategic Plan, if implemented, will bring Virginia into compliance with the United States Supreme Court “Olmstead decision” to provide services in the setting most appropriate for individual needs. In addition, we will be joining reforms occurring nationally to transform the services system to one that values recovery and the principles of self-determination. The primary goal of all of our planning efforts and the plan that we proposed to the Governor is to provide the services that individuals and families have been telling us they want and need.

The progress that we made in recent years began with the 2003 Community Reinvestment Initiative. This was a major effort in lean budget years to redirect the Commonwealth’s historic emphasis on institutionally based care to a focus on consumer-driven, community-based services. The General Assembly supported the initiative and funded projects in three regions of the state. These projects directed resources originally appropriated for facility programs to community programs. We redirected over $10 million to programs such as crisis intervention, discharge assistance, programs of assertive community treatment, jail services teams, and private inpatient bed purchase. We permanently closed over 100 beds at the 3 largest state hospitals.

The Reinvestment projects demonstrated to the Governor and General Assembly that when services are available in the community, the demand for facility care goes down. We have demonstrated that building community services is not only the right thing to do, but it allows us to use our resources more efficiently. In addition, we authorized regional management of service delivery and the utilization of state hospital beds. This regional focus strengthened existing partnerships with the community services boards and resulted in greater numbers of people being served in the community.

In 2004, working with the General Assembly, we funded 700 additional community Mental Retardation Waiver slots and 160 waiver slots for people in facilities who were ready for discharge. This investment began our progress toward Olmstead compliance, and allowed people for whom institutional care seemed a life-long destiny to leave the facility and to begin their lives in community home-like settings.

In 2005, the General Assembly funded $3.85 million to support 7 new crisis stabilization programs, and allocated $1.8 million for the purchase of local inpatient services from private providers. In addition, $400,000 was allocated for the establishment of regional community support centers at two additional training centers for persons with mental retardation. Now all 5 mental retardation facilities in the Commonwealth have the capacity to provide medical and dental resources to persons with mental retardation in their surrounding communities.

In concert with the 2003-2005 initiatives, the participants in the Partnership Planning Process undertook a comprehensive collaborative effort to develop local plans, as well as the Integrated Strategic Plan to recommend opportunities for restructuring and transforming the existing system of facility and community services. Over 500 people participated in this process.

The dedication of our services system partners fostered the creation of a Vision for the services system and the plan for implementing it. This shared Vision was adopted by the State Behavioral Health and Developmental Services Board as state policy on September 7, 2005. The Vision is:

We envision a consumer-driven system of services and supports that promotes self-determination, empowerment, recovery, resilience, health, and the highest possible level of consumer participation in all aspects of community life, including work, school, family, and other meaningful relationships. This Vision also includes the principles of inclusion, participation, and partnership.

Our Vision is responsive to the needs and preferences of consumers and families. It embodies best practices and state-of-the-art services and supports. It requires the most efficient and effective use of existing and future resources. It challenges us to change our service system’s culture, philosophy and values to embrace the concepts of self-determination, empowerment and recovery.

Today the Commonwealth is poised to transform the services system into one that has more choices and options for individuals to be served in more integrated community settings.

Governor Warner’s introduced budget proposes the redesign and replacement of four of the largest state-operated facilities, creating smaller, more efficient, state of the art buildings that provide new structures for programs as well as residential care that is safe and that meets today’s building codes. These four facilities are Western State Hospital in Staunton, Eastern State Hospital in Williamsburg, Central Virginia Training Center in Lynchburg and Southeastern Virginia Training Center in Chesapeake. The costs of facility replacements will be financed through the Virginia Public Building Authority or the Public Private Partnership Educational Facilities and Infrastructure Act of 2002. The estimated replacement costs represent about $290 million of the Governor’s Transformation Initiative. Each of the facility replacements include packages of flexible funding for community Behavioral Health and Developmental services in the region affected by the rebuilding of the state facility. Facility replacements will not mean layoffs in facility staff. We anticipate that the redesigned facility will allow us to meet the staffing standards that we have been working to achieve. In addition, any staffing changes will be managed through regular attrition and planned retirements.

Additional community resources will provide Mental Retardation Waiver rate increases. A 10% increase is proposed for providers of congregate living services and 5% for providers of other support services, such as in-home supports or day treatment. Additional Mental Retardation Waiver slots for diversion from institutionalization as well as for discharges from training centers are provided in the budget. In addition, the Governor’s budget provides funding for discharge assistance for patients who are ready to leave state mental health facilities and for community-based recovery initiatives to keep people out of state hospitals.

Services for children and adolescents will be increased, including funding for two additional systems of care projects that provide wrap-around community services for children and adolescents. In addition, funding is provided for treatment for children and adolescents in the juvenile detention centers. Funding is also included for extending services to 1,430 children from ages 0-2 who benefit from the Part C Early Intervention Services for Infants and Toddlers.

Of critical importance is proposed funding for crisis stabilization services for persons with mental illnesses and with substance use disorders. These programs, already up and running in some communities provide community alternatives to prevent hospitalization, and also may provide step-down services for the transition from the facility back into the community. The department realizes that there is ongoing concern about the adequacy of the number state operated inpatient mental health beds. Inpatient psychiatric treatment will always be a critical component of a spectrum of care provided in the Commonwealth. Bringing more, appropriate, and state of the art resources to the current array of community services will allow us to better determine what the “right size” of state institutions will need to be.

It is important to note that the Governor’s budget includes community resources directed to all regions to increase community capacity for existing and expanding populations in need of services. On-going investments in community alternatives will avoid future facility costs.

This historic and unprecedented investment in Behavioral Health and Developmental services will transform our services delivery system to one that truly embraces the concepts of recovery, self-determination and empowerment. We will finally be able to move the Commonwealth toward becoming a national standard for state-of-the art, consumer-driven community-based care.

The following table presents a summary of the major community initiative items included in the Governor’s introduced budget.

MHMRSAS System Transformation Community Initiatives FY 2007 FY 2008 Biennium
Medicaid MR Waiver Rate Increases: 10% for congregate living services, 5% for other services1 $34,710,014 $34,710,014 $69,420,028

Community Medicaid MR Waiver Slots: 80 slots in FY 2007 and an additional 69 slots in FY 20081

$4,972,250 $9,260,816 $14,233,066
Community Medicaid MR Waiver Slot Start Up: $4,000 per slot for one-time start up costs $320,000 $276,000 $596,000
MR Guardianship Services for individuals residing in or at risk of placement in state training centers $720,000 $1,341,000 $2,061,000
Part C Early Intervention Services for Children: Funds to serve additional infants and toddlers $4,078,366 $4,078,366 $8,156,732
Community MH Discharge Assistance: Fund plans for civil and NGRI state hospital consumers $2,880,000 $2,880,000 $5,760,000
MH Services for Children and Adolescents: $1 M for two system of care projects, $1 M for expanded services in juvenile detention centers $2,000,000 $2,000,000 $4,000,000
MH Community-Based Recovery: Increase availability of targeted community-based services statewide2 $3,750,000 $3,750,000 $7,500,000
SA Crisis Stabilization Services: Expand existing sites and establish additional crisis stabilization units $4,678,568 $4,678,568 $9,357,136
Eastern State Hospital: Community-based services for individuals otherwise served by the hospital3 $4,796,640 $6,928,480 $11,725,120
Western State Hospital: Community-based services for individuals served in HPR I and II3 $6,575,000 $6,575,000 $13,150,000
Southeastern Virginia Training Center: MR waiver slots for 28 discharges in FY 2007, an additional 24 in FY 20081 with $4,000/slot for start up costs $2,678,928 $4,863,152 $7,542,080
Central Virginia Training Center: MR waiver slots for 52 discharges in FY 2007, an additional 45 in FY 20081 with $4,000/slot for start up costs $4,975,152 $9,072,572 $14,047,724
DBHDS Central Office Licensing Positions (3) $248,128 $248,128 $496,256
DBHDS Central Office Architecture & Engineering Positions (3) $285,5411 $285,541 $571,082
Total Community General Funds $54,126,191 $62,098,136 $116,224,327
Total Community Non-general (federal Medicaid) Funds $23,542,396 $28,849,501 $52,391,897
Total Community Funds $77,668,587 $90,947,637 $168,616,224

1 Includes 50% federal financial participation and 50% state matching funds.
2 Services include discharge assistance planning, inpatient MH treatment, in-home residential support, jail-based hospital diversion projects, psychiatric evaluation and crisis counseling, and expanded case management services.
3 Services: discharge assistance planning, inpatient MH treatment, in-home residential support, crisis stabilization and other related MH services to delay or deter state hospital admission.

Other Investments

Community Resource Pharmacy $2,031,325 $3,782,139 $5,813,464
State Facility Pharmacy $4,240,088 $4,950,771 $9,190,859
Medicare Part D Implementation $759,000 $759,000 $1,518,000
State Facility Direct Care Aide Career Ladder $148,658 $811,861 $960,519
Total Other Investments $7,179,071 $10,303,771 $17,482,842


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