Background and History
Agency Background Statement
The Department of Behavioral Health and Developmental Services (DBHDS) provides funding to the 39 community services boards and one behavioral health authority (referred to as CSBs), which serve as the single point of entry for public behavioral health and developmental services in Virginia. Although part of the DBHDS system of care, CSBs are established by the 133 local governments in Virginia and may serve single or multiple jurisdictions. CSBs are key operational partners in Virginia’s public behavioral health and developmental services system and their relationship with DBHDS is based on the community services performance contract, provisions of Title 37.2 of the Code of Virginia, State Board policies and regulations, and other applicable state or federal statutes and regulations. Services provided by all CSBs are licensed by DBHDS.
DBHDS contracts with CSBs to provide a core of comprehensive mental health, developmental, and substance-use disorder services. CSBs are mandated to perform emergency services, case management, subject to the availability of funds, and state facility preadmission screening and discharge planning for individuals leaving state facilities. CSBs may provide services and supports directly or through contracts with private providers, which are vital partners in delivering behavioral health and developmental services. Groups of CSBs may contract for services or provide them directly on a regional basis.
DBHDS funds other organizations or agencies to provide a variety of services and supports, including non-profit peer-run services; infant and toddler intervention (Part C) services provided through local lead agencies (most of which are CSBs); Department of Aging and Rehabilitative Services substance use disorder counselors in CSBs; and Individual and Family Support Program (IFSP) developmental services, supports, and assistance. Also funded are activities to assure delivery of appropriate specialized services for individuals with conditions related to intellectual disability in Medicaid-funded nursing facilities, Virginia Autism Resource Center operation, and community trust assistance to families for special needs children.
Major Products and Services
Community mental health, developmental, and substance-use disorder services provided by or through CSBs include:
- Emergency services;
- Acute psychiatric and substance use disorder inpatient services, including medical detoxification;
- Outpatient services, including counseling and psychotherapy, medication services, intensive outpatient substance-use disorder services, intensive in-home services, assertive community treatment, medication-assisted treatment, and behavior management;
- Case management services;
- Day support services, including day treatment or partial hospitalization, ambulatory crisis stabilization, rehabilitation, and habilitation;
- Employment services, including individual supported, group supported, and sheltered employment;
- Residential services, including highly intensive - residential treatment centers, residential detoxification, and intermediate care facilities for individuals with intellectual disability; residential crisis stabilization; intensive - group homes, primary care, intermediate rehabilitation, and long-term habilitation; supervised - supervised apartments, domiciliary care, emergency shelter or respite, and sponsored placements; and supportive - supported living arrangements and housing subsidies;
- Prevention services; and
- Ancillary services, including motivational treatment, consumer monitoring, assessment and evaluation, and early intervention services.
Most, but not all CSBs provide Medicaid waiver services, Part C services, and peer services.
The Individual and Family Support Program (IFSP) provides up to $3,000 per year to eligible individuals with intellectual or developmental disabilities on waiver waiting lists and their families to purchase a wide array of supports, services, and other assistance that enable individuals to continue to live at home.
Customers Customer Summary
Individuals who receive mental health, substance-use disorder, or developmental services and supports in community programs frequently exhibit serious or complex needs or medical conditions requiring specialized services. Many have significant behavioral challenges or co-occurring combinations of mental health or substance-use disorders, or intellectual or other developmental disabilities.
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.
|Predefined Group||User Defined Group||Number Served Annually||Potential Number of Annual Customers||Projected Customer Trend|
|Child||Infant and toddlers and their families served in Part C early intervention services||15,523||18,247||Increase|
|Consumer||Individuals receiving CSB developmental services||20,248||26,399||Increase|
|Consumer||Individuals receiving CSB mental health services||112,121||180,176||Stable|
|Consumer||Individuals receiving CSB substance-use disorder services||34,382||46,632||Increase|
|Consumer||Individuals receiving CSB emergency or ancillary services||126,035||130,152||Increase|
Finance and Performance Management
Finance Financial Summary
Funds depicted in the table below include general fund dollars and federal funds derived from the Substance Abuse Prevention and Treatment (SAPT) and the Community Mental Health Services (CMHS) block grants funded by the Substance Abuse and Mental Health Administration (SAMHSA); Part C Early Intervention grant funds for infants and toddlers with developmental delays; and other grants for SA and MH services.
CSBs also receive funds from other sources such as local funds, Medicaid, other fees, and other revenues. These funds are not appropriated by the Commonwealth and are not included in the Appropriation Act and, therefore, are not included in the following table.
Revenue collections are from various federal grant funds including the Substance Abuse Prevention and Treatment (SAPT) and the Community Mental Health Services (CMHS) block grants funded by the Substance Abuse and Mental Health Administration (SAMHSA); Part C Early Intervention grant funds for infants and toddlers with developmental delays; and other grants for SA and MH services.
Performance Performance Highlights
Important measures of performance of community behavioral health and developmental services involve the intensity of case management services and the retention of individuals in SA services.
- Active engagement of individuals in case management services allow case managers to observe and assess individuals’ needs and preferences; ascertain if supports and services are being implemented appropriately; and determine if supports and services remain appropriate or should be changed.
- Intensity of engagement by adults with serious mental illness in mental health case management services is measured by the percentage of individuals during the past year who received at least six hours of services within three months.
- Provision of in-home developmental case management services to specific groups receiving face-to-face visits under the settlement agreement with the U.S. Department of Justice reflects the degree to which individuals are actively engaged.
- One of the principles of effective treatment of substance-use disorders is that an individual's involvement in on-going treatment significantly reduces or stops drug use and that the best outcomes occur with longer durations of treatment. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment. Retention in services is measured by the percentage of individuals during the past year who remain engaged for at least five months.
- DBHDS is using two measures of the ability of CSBs to implement new requirements related to civil temporary detention orders (TDOs). These measures specifically track the number of temporary detention orders (TDOs) for which state facilities served as the last resort because a community facility was not found at the end of emergency custody order (ECO) period, and the rate of state hospital civil TDO admissions. The 2014 General Assembly amended the Code of Virginia to require state hospitals to accept civil TDO admissions if other alternatives have not been identified within the 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.
A measure of productivity for this service area involves the DBHDS labor cost per CSB payment. Payments to CSBs are made on a bi-weekly basis. This measure will track the average cost of staff time to process a payment to a CSB.
Key Risk Factors
Several factors will have a significant effect on community services providers over the next four years.
- Mental health services system reforms: The services system is multifaceted, extremely complex, and may 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 Governor’s Task Force on Improving Mental Health Services and Crisis Response is currently developing recommendations for system improvement 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 is currently studying the Commonwealth’s behavioral health services system. Implementation of potentially significant system reforms emanating from these efforts may change how the current system operates.
- Inadequate behavioral health service capacity: 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. 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: Increasingly, CSBs and private providers are being affected by new service delivery requirements associated with Medicaid care coordination and managed behavioral care initiatives. The low income threshold for Medicaid presents challenges for providing services for uninsured and underinsured individuals. Changes resulting from potential health care reforms include the loss of CSB general fund dollars that now support services to individuals who would become eligible for Medicaid services if coverage were expanded; provider workforce capacity pressures resulting from increasing demands for services by newly insured enrollees and Medicaid enrollees; and potential changes to the arrays of federal mental health and substance abuse block grant services.
Agency Statistics Statistics Summary
The following statistics provide a snapshot of CSB operations:
General Information About Ongoing Status of Agency
DBHDS is working with CSBs and other community service providers to:
Implement principles of recovery and resiliency principles and recovery support services across Virginia;
Expand access to behavioral health care, including trauma-informed crisis stabilization and related services for adults and children and adolescents, comprehensive and integrated children’s programs, community-based services to individuals residing in state hospitals who have been determined clinically ready for discharge, additional drop-off centers to provide an alternative to incarceration for individuals with serious mental illness, new Programs of Assertive Community Treatment (PACT) teams and additional mental health inpatient treatment purchased in community hospitals, and to expand telepsychiatry services;
Provide flexible and individualized developmental services and supports that keep families intact and reduce the need for costly out-of-home placements, including enhanced case management/care coordination, crisis services for adults and children and adolescents with developmental disabilities, and expanded opportunities for integrated housing and competitive employment;
Implement improvements to the civil commitment process and new state hospital admission protocols based on new laws passed by the 2014 session of the General Assembly; and
Improve service provider transparency and accountability the CSB-DBHDS performance contract and finance and program audits, DBHDS licensing of services and human rights protections, risk management and quality improvement processes, monitor outcomes, and document the effectiveness of their services.
In addition, oversight and accountability of CSB services include certification of Medicaid services by the U.S. Centers for Medicare and Medicaid Services (CMS), accreditation by national agencies, and investigations by the Virginia Inspector General’s Office.
The 40 CSBs maintain many of their own information technology (IT) systems. However, they do rely on DBHDS central office for core systems such as the Community Automated Reporting System (CARS) to provide semi-annual reporting on performance contract financial metrics, the Community Consumer Submission (CCS3) system to report basic demographic and services data monthly on individuals served by the CSBs, and the Intellectual Disabilities Online System (IDOLS) for waiver enrollments, service authorizations, and determinations regarding retaining slots.
CSBs have purchased electronic health record information systems from various vendors; Credible (14), Unicare (10), and Anasazi (8) have the greatest presence. Almost all CSBs have implemented certified EHRs, and the remaining CSBs are in the process of doing so. CSBs are also in varying stages of pursuing meaningful use certification and funding.
While all large and many medium budget size CSBs have in-house IT staff, some medium and most small CSBs do not. This poses challenges to those CSBs, particularly regarding data quality and using data for management purposes. The added data reporting requirements associated with the DOJ settlement agreement are imposing significant workload burdens on CSB IT systems as well as service staff.
Given the variety of IT system platforms and the difficulties CSBs have in sharing data among themselves, statewide service and financial data is not readily available to CSBs, and the absence of a statewide data warehouse hosted by DBHDS and accessible to CSBs only exacerbates this situation.
Operating CSBs and the BHA maintain their own human resources management and development systems, while administrative policy boards are part of their local government systems. Many CSBs, especially those not part of local governments, face continuing challenges in attracting and retaining well-qualified staff due to lack of resources for adequate compensation. Additionally, some rural CSBs face special challenges in attracting staff to their areas. CSB recruitment and retention issues are further exacerbated by the lack of state funding for salary increases in recent years.
All CSBs will face challenges in adapting to and complying with their employer responsibilities under the Affordable Care Act related to health insurance. While all large and many medium size CSBs have in-house HRM staff, some medium and most small CSBs do not. This poses challenges to those CSBs in effectively managing their human resources.
Operating CSBs and the BHA maintain their own buildings. Ownership and leasing arrangements vary for the 13 group homes funded through DBHDS and constructed in Health Planning Region V (Eastern Virginia) for individuals with intellectual disabilities who are leaving Southeastern Virginia Training Center. Similarly, DBHDS has approved funding of 13 homes for individuals who are leaving Central Virginia Training Center. Eight of these homes have been constructed; one is in the final design with construction to begin in the summer. No additional state funded and managed projects are planned at this time. The use of remaining funds to provide additional housing in the community utilizing alternative methods is ongoing.
NOTE: This is one of five DBHDS Executive Progress Reports. See Department of Behavioral Health and Developmental Services (720); Mental Health Treatment Centers (792); Intellectual Disabilities Training Centers (793); and Virginia Center for Behavioral Rehabilitation (794).