Background and History
Agency Background Statement
Services System Direction and Oversight (Central Office)
The Department of Behavioral Health and Developmental Services (DBHDS) central office provides financial resources, policy direction, and programmatic and financial oversight of Virginia’s public behavioral health and developmental services system. The system includes nine state hospitals, a medical center, four training centers, and a treatment center for sexually violent predators (SVP) all operated by the DBHDS, and 39 nine community services boards and a behavioral health authority (CSBs) established by local governments.
Major Products and Services
The DBHDS central office performs a variety of administrative and oversight services for Virginia’s behavioral health and developmental services system, including financial management and controls, risk and quality management, behavioral health and developmental services program monitoring for children, adolescents, adults, and older adults, human resources development and management, information systems technology services, contracting, strategic planning, and architectural and engineering services.
As the lead agency for the Virginia Program for Infants and Toddlers with Disabilities (Early Intervention Part C), the central office manages a comprehensive interagency system of services and supports for at-risk children from birth to age three and their families to prevent or reduce developmental delay.
The DBHDS central office negotiates performance contracts with, partially funds, and provides technical assistance to CSBs. It licenses public and private mental health, developmental, and substance abuse services, developmental disability waiver services; and residential brain injury services to ensure that services providers adhere to basic standards of quality. The central office administers a statewide human rights program which protects individuals receiving public or private behavioral health or developmental services from abuse, neglect, or exploitation. It also operates programs for juvenile competency restoration, community-based conditional release of individuals found by courts to be sexually violent predators, and nursing home pre-admission screenings and resident reviews.
Customers Customer Summary
DBHDS central office customers include individuals who receive mental health, substance-use disorder, or developmental services and supports in community programs and state facilities. The customer base for publicly-funded behavioral health or developmental services frequently exhibit serious or complex needs or medical conditions requiring specialized services. Many have significant behavioral challenges or co-occurring combinations of mental illness, substance-use disorders, or intellectual or other developmental disability.
DBHDS expects the number of individuals seeking community-based services will increase as Virginia's population grows and coverage opportunities increase under the affordable health care act and other health reform measures. Expansion of service capacity to address this demand will increase the number of providers, services, and locations licensed by the DBHDS.
The 2014 session of the General Assembly amended the Code of Virginia to require state hospitals to accept civil temporary detention order (TDO) admissions if other alternatives were not identified within the new eight hour emergency custody order period. Based on data to date, this legislation has already resulted in a significant increase in TDO admissions to state hospitals. Admissions to state mental health facilities increased 20% in the second half of FY 2014 versus the first half.
As additional community services and supports required in the Commonwealth’s settlement agreement with the U.S. Department of Justice (DOJ) are brought on line and training center closures occur, the number of individuals remaining in training centers will decline significantly.
Finance and Performance Management
Finance Financial Summary
Funds depicted in the table include general fund dollars and nongeneral funds that include federal funds appropriated for administrative oversight functions within federal grants including the Substance Abuse and Mental Health Administration (SAMHSA) Community Mental Health Services (CMHS) and Substance Abuse Prevention Treatment (SAPT) block grants and Program for Infants and Toddlers with Disabilities (Early Intervention Part C) funds, and other funds received as fees from Medicaid, Medicare, private insurance, private payments, and Federal entitlement programs related to indirect services costs to support facility operations.
Financial summary tables for CSB and state facility services and activities are included in the following Executive Progress Reports – 790: Grants to Localities; 792: Mental Health Treatment Centers; 793: Intellectual Disabilities Training Centers; and 794: Virginia Center for Behavioral Rehabilitation.
|Fund Code||Fund Name||FY 2015||FY 2016|
|0275||Public-Private Education Act Fund||$155,000||$155,000|
|1000||Federal Trust||$10,862,433||$12,392,571|Revenue Summary
Revenue collections include federal grant funds and other funds received as fees related to indirect services costs to support facility operations. Non-general fund revenues serve to augment the central office general fund appropriation. Currently DBHDS is in the process of reviewing the cost allocation and is working with CMS on this. The amount of revenue in regards to indirect service costs could go up or down.
Performance Performance Highlights
One important measure of DBHDS central office performance is the ability of DBHDS licensing specialists to visit providers of behavioral health and developmental services. On-site inspection of providers is a key component of the state's strategies to ensure the public health and safety. In 2011, less than three-quarters (68%) of provider services were visited by a licensing specialist. Additional specialists have been added since then and the percentage of provider services that are inspected at least annually has risen to more than 90%. A measure of central office productivity involves the average number of days required to complete a licensing complaint investigation. Complaints come to the central office in a variety and each much be investigated to determine if a violation of DBHDS licensing regulations has occurred. This new measure tracks the days between the date a complaint is received and the date the investigation is closed without a corrective action plan (CAP) required or the date that a CAP is issued.
Key Risk Factors
Several factors will have a significant effect on DBHDS over the next four years.
- Mental health services system reforms: Virginia’s behavioral health services system is multifaceted, extremely complex, and can be difficult to navigate for individuals in crisis and families who are seeking assistance. It also is challenging for providers because it requires effective communication and collaboration among many partners, including CSBs and private hospitals, law enforcement, and the judicial system. The 2014 session of the General Assembly extended the emergency custody order (ECO) period from a maximum of six to a total of eight possible hours to give clinicians more time to locate an available psychiatric bed. The temporary detention order (TDO) period also was extended from 48 to 72 hours to provide additional treatment time for an individual to stabilize prior to the court hearing to determine whether involuntary admission to a psychiatric facility is required. A DBHDS online psychiatric bed registry is helping clinicians locate available beds in emergency situations and specific statewide expectations for securing a private or a state hospital bed when an individual qualifies for a TDO are in place. Additionally, the Governor’s Task Force on Improving Mental Health Services and Crisis Response is developing recommendations to improve the system and the Joint Subcommittee to Study Mental Health Services in the Commonwealth in the 21st Century created by the 2014 session of the General Assembly are currently studying Virginia's behavioral health services system. Potentially significant services system reforms resulting from these efforts may change how the current system operates.
- Inadequate behavioral health service capacity in the community: Although mental health is a crucial component of individual and community wellness, access to needed community behavioral health services varies significantly across the state. Service availability is limited by notable gaps in important basic services such as crisis, emergency, acute inpatient, outpatient, case management, and psychiatry services and recovery-focused housing and employment supports. In particular, the prevention and early intervention system is underdeveloped and very few targeted investments in recent years went to early intervention. Improving access to specialized services and community placements would provide safe and appropriate alternatives to state hospital forensic beds and expedite discharges of state hospital patients who are clinically ready for discharge. Despite the infusion of dollars after crises (around $34.5 million in new money over the past ten year period or under $23 million if adjusted for inflation), competing priorities and budget cuts in recent years resulted in significant set-backs that have made it difficult to maintain consistent and robust development of services. Even with funds provided by the 2014 General Assembly to expand crisis, local inpatient, assertive treatment, and other priority services, continued investments in innovative, evidence-based mental health and substance-use disorder services programs, particularly trauma-informed crisis management and interventions focused on prevention and early intervention, are needed to address capacity issues.
- Inadequate developmental service capacity: To meet the requirements of the Commonwealth’s settlement agreement with the U.S. Department of Justice (DOJ), major expansion of new or enhanced waiver slots, work and housing supports, and crisis services is required to support individuals who are living in the community and those who are transitioning from training centers to the community. As of July 2, 2014, there were 7,173 individuals on the community intellectual disability waiver waiting list and 1,481 individuals on the community developmental disabilities waiver waiting list.
- Implementation of Health Care Reforms: The DBHDS central office and the services system will be affected by implementation of Medicaid care coordination and managed behavioral care initiatives and associated service delivery requirements; potentially significant expansion in demand for community services resulting from newly insured enrollees seeking services and associated provider workforce capacity pressures; and potential changes to the arrays of federal mental health and substance abuse block grant services.
- Individual protections and oversight: Significant provider growth will increase demands on licensing and human rights to assure that individuals with extensive medical and behavioral challenges are receiving appropriate services in safe settings.
- Inadequate technical support capacity: As DBHDS expands use of electronic health records, implements health care reforms, improves central office and facility performance through technology improvements, and replaces aging, expensive technologies with more cost effective solutions, the organization’s reliance on technical support will increase. An increasing number of mission critical clinical and financial processes used by central office, state facilities, CSBs, and licensed providers rely on technology provided by a limited number of agency IT staff.
Agency Statistics Statistics Summary
The following statistics provide a snapshot of DBHDS central office operations during FY 2013:
General Information About Ongoing Status of Agency
A key priority of the DBHDS central office is improving services system transparency, oversight, and accountability. The central office is working to strengthen its financial services accountability, performance contract oversight, and auditing capability; to identify and implement facility operational efficiencies; to increase clinical and program oversight; and to plan and manage capital projects that address facility needs. The central office is implementing information technology solutions, including an electronic health record (EHR) system and a data warehouse and is developing quality improvement processes and data analysis and performance measurement tools such as data dashboards that support data-informed and evidence-based interventions and solutions.
In addition to improving services system oversight and accountability, the DBHDS central office is working aggressively to achieve a truly community-based and person-centered system of high-quality behavioral health and developmental services provided in the most integrated settings appropriate to individuals' needs and consistent with their preferences and choices. This includes initiatives to improve service access by:
Expanding community-based mental health services through successful implementation of new secure therapeutic assessment centers, additional assertive community treatment teams, children’s mental health crisis services, and additional local inpatient bed purchases and discharge assistance plans funded by the 2014 General Assembly;
Improving the services system’s responsiveness to individuals who are experiencing a behavioral health crisis and their families and supporting the work of the Governor’s Task Force on Improving Mental Health Services and Crisis Response and the legislative joint subcommittee studying mental health services;
Bringing new Medicaid waiver slots on line for the 8,500 Virginians who are waiting for ID and DD services in their communities;
Assisting with the transition of individuals currently residing at the Northern Virginia Training Center to an integrated community environment with bridge funds provided in the 2014 Appropriation Act;
Developing Developmental Disability Health Support Networks to provide medical assistance, especially dental support, to those individuals residing within the community;
Developing, supporting and expanding recovery support services that implement the principles of recovery, resiliency, and self-determination through a newly established Office of Recovery Support in the central office;
Investing in programs that work and provide positive outcomes by:
teaching family members, health care and school employees and others how to respond to an escalating mental-health crisis,
diverting people experiencing behavioral health crises from jail and into needed services, and
providing supportive employment and supported housing programs that facilitate stability and self-sufficiency in the community;
Improving substance abuse services capacity to address increasing opioid abuse and overdoses that too often have fatal consequences;
Strengthening partnerships with key system stakeholders, including CSBs, law enforcement, the court system, primary health care providers, landlords, and advocates, and with the persons served and their family members to help ensure the best outcomes for individuals with mental health or substance use disorders or developmental disabilities; and
Using technology, such as telepsychiatry, to increase access to care in under-served areas, particularly, the southwestern and rural portions of Virginia.
In collaboration with state and community partners, the DBHDS central office is working to develop a flexible and individualized system of developmental services and supports, as required by the Commonwealth’s settlement agreement with the DOJ by:
Enhancing intellectual disability and developmental disability waiver services through the redesign of the existing waivers;
Transitioning individuals out of state training centers and other institutions to the community and closing three of the four remaining training centers by 2020;
Providing individual and family supports that help individuals remain in the community;
Implementing crisis services for adults and children and adolescents with developmental disabilities;
Expanding integrated housing and competitive employment opportunities;
Enhancing case management services and strengthen case manager competencies;
Conducting enhanced licensing visits of certain providers; and
Improving critical incident reporting and risk management processes.
The DBHDS Information Services and Technology (IS&T) office provides coordination, guidance, oversight, and support to information systems affecting the central office, state facilities operated by DBHDS, CSBs, and licensed private providers. These services include information technology (IT) security, Commonwealth IT standards compliance, web and application development and support, and data management. IS&T provides technical support for 28 applications in addition to the OneMind Electronic Health Records System (EHRS). Support for the OneMind EHRS is considered separate because it is an ongoing implementation project (through FY 2016) and the technology requires assignment-dedicated, highly trained staff. As noted in the Key Risk Factors, there has been a significant increase in agency and non-agency demand for implementation and support of DBHDS-managed technology and related services.
DBHDS IS&T goals and priorities are included in the Health and Human Resources Technology Investment Management Strategic Plan for the Secretariat and include:
Implementing OneMind EHRS clinical and financial modules and providing 365/24/7 support. This includes support for a wide variety of state facility functions beyond clinical and financial technologies—for example: food service, health information management, and off-hours vendor pharmacy;
Implementing a DBHDS-wide data warehouse;
In coordination with DMAS, integrating processing functionality for the DD waiver and ID waiver (now supported by the Intellectual Disabilities Online System or IDOLS) into a new consolidated waiver system;
Providing a new data exchange to eliminate CSB double entries into the Infant and Toddler Early Intervention Services System (ITOTS);
Providing video conferencing and telepsychiatry services to the central office, state facilities, and local magistrates;
Training and management of regional Information Security Officers (ISOs) for state facilities;
Migrating DBHDS servers to the Commonwealth Enterprise Solutions Center (CESC);
Supporting non-technical projects initiated under the DOJ Settlement Agreement;
Replacing the current Online Licensing System (OLIS) with a system that meets the organization’s need for enhanced licensed provider data collection and performance tracking;
Implementation of mandated requirements for ICD-10 codes and integration of DSM-5 codes applicable to behavioral health care;
Improving monitoring and reporting on CSB performance by providing integrated data exchange between CSB Automated Reporting System (CARS) and the Community Consumer Submission system (CCS3);
Upgrades for server hardware and software to remain current with vendor application requirements and COV/VITA infrastructure software requirements; and
End-user technical support for all applications.
The DBHDS central office faces a number of recruitment and retention challenges, especially in the IS&T area where there is intense competition for individuals with specialized EHRS skills. The central office turnover rate in FY 2014 was 6.6% and 35 positions are currently being recruited. This has helped the DBHDS to recover from budget cuts over the last ten years when about one-third of the central office staff was eliminated.
The average age of DBHDS central office staff is 51.9 years old and the average work tenure is 15.2 years. During the next five years, 39% of central office staff will be eligible to retire with unreduced benefits. Comprehensive workforce succession planning and systematic training and workforce development strategies are essential if the central office is to successfully transfer responsibilities from retiring to new employees and support advancement of staff through successively higher levels of competencies.
DBHDS has developed SystemLEAD, a long-term leadership development initiative designed to give participants broad exposure to the competencies necessary for leadership in the services system. SystemLEAD will be piloted with central office staff, in a state hospital and a training center, and in partnership with neighboring CSBs. The SystemLEAD curriculum will focus on leadership competencies, including knowledge, skills, abilities, and behaviors, that staff who aspire to leadership roles in the service system must possess. It includes an individualized assessment and development plan, training and group projects, coaching and mentoring, and special work assignments and cross training. SystemLEAD goals are to prepare qualified internal candidates to assume leadership positions; retain superior performers; and reduce turnover rates among high-performing employees. The first phase of the program, which includes creating the core and site committees and communicating the initiative to the work force, is set to begin in 2015.
As the central office assumes additional quality management and oversight responsibilities, workforce development priorities will include training to develop new skill sets, including project management, proficiency with new reporting and informatics, quality management, and EHRS and other new IT systems.
The DBHDS central office occupies 13 floors of the Jefferson Building, a 15-story state structure located at the edge of Capital Square in Richmond at the intersection of Bank and Governor Streets. The building was constructed in 1956 and the interior was renovated in 1999 at which time the exterior envelop was upgraded. The building has been equipped with WIFI in nearly all locations which allows staff to move readily throughout the spaces and remain connected to the central servers. Window replacement is planned for fall 2014.
A study has been commissioned to improve building space utilization and accommodate increasing and changing central office staff requirements resulting from electronic health records and changes in the manner in which central office services are being delivered. Spaces have been rearranged for greater efficiency by congregating similar functions in contiguous spaces and efforts are underway to better quantify the number of central office staff who are regularly out of the office and could share space. Additional space has been obtained on two floors and the area previously serving as a computer room has been converted to offices, which largely serve the information technology function.
Several conference rooms and the main board room are being equipped with technology to hold meetings with facilities around the state and other entities. Antiquated equipment and furniture is being replaced with appropriate equipment and furnishings that will support a more efficient operation.
Note: This is one of five DBHDS Executive Progress Reports. See Grants to Localities (790); Mental Health Treatment Centers (792); Intellectual Disabilities Training Centers (793); and Virginia Center for Behavioral Rehabilitation (794).