Supporting individuials by promoting recovery, self-determination, and wellness in all aspects of life
A life of possibilities for all Virginians
Focus First on Individuals Receiving Services
Our decisions and actions consider first the best interests of individuals who receive services and their families. We respect the potential and capacity of each individual who receives services. We value and support the healing and recovery process.
Accountability and Oversight
We take seriously our responsibility to provide oversight and accountability throughout Virginia’s public behavioral health and developmental system to ensure individuals receive timely access to quality, consistent services.
Responsiveness to External and Internal Customers
We seek input and involvement from our customers. We share ideas and remain open to different opinions. We listen to and respect what our customers say and respond promptly to their requests.
Partnership and Collaboration
We create opportunities for partnerships, encourage teamwork, and support each other to succeed. We accept shared ownership and seek win win (mutually acceptable) solutions. We communicate openly and clearly. We are willing to take risks as we look for creative solutions and new ways of solving problems. We make decisions and resolve problems at the level closest to the issue.
Professionalism, Integrity, and Trust
We recognize and celebrate individual and team successes. We use valid data that reflect best practices and positive results and outcomes. We take responsibility for ourselves, for our actions, and for how these actions affect others. We develop a supportive and learning environment and work continuously to improve the quality of the services we provide. We keep our word and deliver what we promise. We incorporate our values into everyday decisions.
We protect the assets and interests of the entire services system. We value and take care of staff. We use the Commonwealth’s resources in the most effective and efficient manner.
The Department of Behavioral Health and Developmental Services (DBHDS) central office is funded with 63 percent general fund dollars and 37 percent nongeneral fund dollars. Nongeneral fund dollars include 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 Early Intervention – Part C funds, and other funds received as generated by the Central Office by requesting reimbursement for allowable overhead costs related to Medicaid services in accordance with 2 CFR §200 Uniform Administrative Requirements, Cost Principals and Audit Requirements for Federal Awards.
(Changes to Initial Appropriation will be 0 when the plan is created. They will change when the plan is updated mid-biennium.)
|Initial Appropriation for the Biennium||57,364,221||33,519,772||56,541,355||33,642,691|
|Changes to Initial Appropriation||-2,277,913||0||2,101,468||200,000|
Anticipated Changes to Customer Base
Current Customer List
|Potential Number of Annual Customers|
|Consumer||Individuals receiving community services board services||219,924||292,786||Increase|
|Child||Individuals receiving infant and toddler early intervention services||16,200||24,828||Increase|
|Consumer||Individuals receiving state hospital services||4,506||4,639||Stable|
|Consumer||Individuals receiving training center services||817||617||Decrease|
|Consumer||Individuals receiving nursing home prescreening||818||923||Increase|
|Child||Juveniles requiring restoration to competency treatment services ||213||249||Stable|
|Civilly- Committed||Individuals receiving sexually violent predator determination ||134||150||Increase|
|Health Care||Community services boards and other public and private providers licensed by the Department ||933||950||Increase|
|Federal agencies||DBHDS receives grants from the Substance Abuse and Mental Health Services Administration (SAMHSA) in the U.S. Department of Health and Human Services to support community mental health and substance abuse prevention and treatment services and from the Office of Special Education Programs (OSEP) in the U.S. Department of Education to support Part C early intervention services for infants and toddlers and their families.|
|Local governments||Through its licensing function, DBHDS works with local zoning, fire, health, taxation, and social services departments to implement regulations and share information.|
|Individuals receiving services, family members, and advocacy organizations||DBHDS receives feedback from associations representing individuals receiving services, family members, and advocates on issues of mutual concern through their participation in policy, planning, and regulatory development activities and membership on the State Board and other advisory committees and councils.|
|Private providers (for profit and non-profit organizations)||DBHDS works with private providers to ensure that they meet licensing and human rights requirements and receives feedback on issues of mutual concern through their participation in policy, planning, and regulatory development activities.|
|Provider associations||DBHDS receives feedback from provider associations on issues of mutual concern through their participation in policy, planning, and regulatory development activities.|
|State agencies||DBHDS works with a number of state agencies that coordinate services or provide operational, financial, or workforce consultation and assistance to assure appropriate implementation of regulations and management requirements.|
|Commitment Review Committee (CRC)||DBHDS staff serves on the CRC committee, which is operated by the Department of Corrections.|
|Community services boards and behavioral health authority (CSBs)||CSBs function as the single points of entry into publicly funded behavioral health and developmental services, including access to state facility services through preadmission screening, case management and coordination of services, and discharge planning for individuals leaving state facilities. DBHDS funds, contracts with, provides consultation to, monitors, licenses, and regulates CSBs. CSBs participate in policy, planning, and regulatory development for the services system.|
|Virginia institutions of higher education (colleges, universities, and community colleges)||DBHDS collaborates with academic medical centers, academic programs of other colleges and universities, and community colleges to address workforce issues, promote the implementation of evidence-based and other promising practices, and to train the services system’s current and emerging workforce.|
|• ||Build and sustain services capacity necessary to provide person-centered services and supports when and where they are needed, in appropriate amounts, and for appropriate durations.|
This goal envisions statewide availability of a consistent array of individualized, person-centered, and family-focused behavioral health and developmental services and supports that enable individuals to participate as fully as possible in all aspects of community life. No matter where they live in Virginia, people will have access to quality, consistent behavioral health and developmental services that exemplify clinical and management best and promising practices. Services and supports are centered on the individual’s unique needs and strengths and provided as close to the individual’s home and natural supports as possible. This includes supports that incorporate the needs of the whole individual, from medical care to housing and employment.
Health & Family: Inspire and support Virginians toward healthy lives and strong and resilient families.
|» ||Expand the capacity of Virginia’s behavioral health and developmental services system to provide services and supports that will enable individuals to live full and productive lives in their communities.|
This objective builds and strengthens the capacity of Virginia’s behavioral health and developmental services system to respond to the needs of individuals with mental health or substance use disorders or developmental disabilities. Timely access to a consistent array of quality services will support individuals as they attain their highest achievable level of health and wellness, live as independently as possible, engage in meaningful activities that enable them to reach their potential, and participate fully in community activities.
• Work to achieve 75 percent substantial compliance with the DOJ settlement agreement by December 2017, to include work in the areas of case management, crisis services, quality and risk management, and the waiver management system (WaMS).
• Work toward a statewide training center census of 250 or less. SWVTC is planned to close by June 30, 2018. The CVTC campus will soon include no more than 120 individuals living on the “lower quad”.
• Implement strategies for managing the waiting list for the Medicaid waivers, including converting some slots to more appropriate waivers, thereby increasing the number of individuals served.
• Expand permanent supportive housing options for behavioral health and independent housing options for developmental disabilities.
• Implement “same day access,” the first step of System Transformation, Excellence and Performance in Virginia (STEP-VA), in the number of CSBs allocated by the 2017 General Assembly funding and develop a budget request to implement same day access in the remainder of the CSBs.
• Increase the statewide availability of behavioral health prevention and early intervention supports that are integrated with family, the community, and other human services supports.
• Develop a budget request for the next steps of STEP-VA, which may include primary care screening services and outpatient treatment services.
• Explore and develop plan and possible budget to include targeted case management services for children in STEP-VA.
• Work with consultant to develop comprehensive plan for statewide geropsychiatric services in Virginia.
• Develop, along with HHR, General Assembly required implementation plan for the financial realignment of Virginia public behavioral health system (Item 284 F).
• Continued implementation of SAMHSA’s Prescription Drug Abuse and Heroin Overdose Prevention Partnership for Success Strategic Prevention Framework in 12 Virginia.
• Increase SUD services such as acute detoxification, and medication assisted treatment.
• Establish a single standardized screening instrument being used by trained staff will be used for all individuals on intake to all jails.
• Employ measures to ensure that the jail waiting list will only exceed seven days if there is an exception based on unusual circumstances.
• Continue to expand Mental Health First Aid (MHFA)
• Strengthening, training and expansion of peer services.
|• ||Perform the core functions of the behavioral health and developmental services system in a manner that is efficient, effective, and responsive to the needs of individuals receiving services and their families. |
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. DBHDS 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. This goal envisions consistent implementation of clinical, administrative, and funding policies and practices that provide financial, administrative, and programmatic oversight of the public behavioral health and developmental services system; support and sustain service quality and appropriateness; protect individual human rights; and promote efficiency and costeffectiveness.
Government and Citizens: Be recognized as the best-managed state in the nation.
|» ||Perform central office leadership and administrative and support functions in a manner that is efficient, well managed, and responsive to the needs of individuals receiving services and their families.|
This objective implements finance, human resources, information technology, capital outlay, and other administrative and support functions that provide leadership to Virginia’s behavioral health and developmental services system and ensure compliance with state and federal statutes and regulations. Quality improvement processes use clearly defined performance and outcomes measures to demonstrate quality and track progress in achieving services system goals and priorities. Full advantage is taken of federal funding opportunities, including Medicaid, to implement recoveryoriented and personcentered services.
• Work with the CSBs and state hospitals to create appropriate discharge plans to decrease the extraordinary barriers list (EBL) by 100 people statewide.
• Establish staffing ratio needed to support the number of licensed providers managed by The Office of Licensing.
• Continued maturity of data warehouse to provide data that guides policy and programmatic decisions for DBHDS as well as providers.
• Continue to promote and plan for expansion of OneMind electronic health records system.
• Promote need for major capital projects such as the VCBR expansion and the CSH rebuild.
• Work with Eastern State Hospital to restore acute psychiatric certification and improve on measures related to the “treatment corridor” of the ESH Plan of Improvement.
• Workforce Development for DSAs, CNAs, and LPNs (Create our own- educational assistance and collaboration with educational institutions).
• Broad, up to date, statewide toolkit established for recruitment and retention of physicians, RNs, and Direct Support Staff.
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.
Making Improvements to the Mental Health System
- Since 2014, no person has been turned away from a state psychiatric hospital bed when needed.
- In 2017, began implementation of Same Day Access in the first 18 of 40 CSBs.
- Since 2015, DBHDS has received $9.1 million in permanent supportive housing funds to serve over 691 individuals.
Launching Medicaid Waiver Redesign for Individuals with Developmental Disabilities
- Launched Medicaid waiver redesign on September 1, 2016 to better ensure services meet the needs of the 12,700 individuals with developmental disabilities receiving the waivers.
- Trained over 3,450 stakeholders on the amended Medicaid waivers which enabled the waivers to launch without disrupting services for providers and individuals.
Implementing the Department of Justice Settlement Agreement
- As of January 2017 (for FY 2018), an additional 1,804 additional waiver slots were approved for a total of 4,074 additional slots; this is 1,164 slots more than what the settlement agreement requires.
- By March 2017, 12,706 referrals had been received and 8,111 applications had been funded for the Individual and Family Support Program, which is required by the settlement agreement.
- The adult developmental services crisis program showed an increase in referrals from 472 adults referred to the program in FY 2014 to 958 adults referred during first three quarters of FY 2017.
- The children’s developmental services crisis program started collecting data in October 2015 and showed an increase in referrals to the program from 384 children in FY 2016 to 691 children referred during first three quarters of FY 2017.
Expanding Substance Use Disorder Services
- On April 24, 2017, DBHDS received a $9.7 million federal grant to improve access to prevention, treatment and recovery services for individuals with opioid use disorder, and to reduce the deaths of individuals from opioid overdoses.
- In April 2017, Virginia’s REVIVE! Program has trained about 5,500 lay rescuers and about 60 local law enforcement agencies to use naloxone, a medication that reverses the effects of overdoses.
Strengthening Wellness Programs
- As of April 2017, Virginia has a total of 30,283 citizens trained in mental health first aid (MHFA), including teachers, law enforcement, first responders, health care workers, military and veterans, service organizations, clergy, family members and other interested members of the public.
- Virginia now has the 6th highest number of instructors for MHFA in the country:
- Since January 2014 to present, Virginia has added a total of 327 adult MHFA instructors and 298 youth MHFA instructors.
- Currently, Virginia has 595 certified MHFA instructors: Of these, 367 are certified as adult MHFA instructors and 325 individuals certified as youth MHFA instructors, with many being dual certified.
Working to Improve Licensing Capabilities
- 45 percent increase in providers since 2012.
- DBHDS Licensing Specialists’ average case load is 280 -350 locations each above national recommended average of 90 facilities per regulator.
|Authorized Maximum Employment Level (MEL)|| ||423|
|Wage Employees|| ||17|
|Contracted Employees|| ||0|
Several factors pose substantial risk and will have a significant impact on DBHDS over the next several years.
- Significant Strain on State Psychiatric Hospitals: Virginia’s nine state mental health hospitals are under tremendous strain as they are weathering a 157 percent increase in temporary detention order (TDO) admissions and a 54 percent increase in total admissions since FY 2013. This follows “last resort” legislation passed in 2014 requiring state hospitals to accept admissions of individuals under a TDO if no alternate treatment location is found within the eight hour emergency custody order period. Such high admissions, along with with the large number of individuals unable to be discharged from state hospitals due to a lack of appropriate community placements and services, create an unsustainable utilization rate for the state hospitals. This significantly high utilization rate places both staff and patients alike in potentially unsafe conditions, and has led to increases in turnover rates among critical staff. State hospitals maintain extraordinary barriers to discharge list (EBL) for people who are clinically ready to discharge from a state hospital, but cannot leave because the right community services, such as appropriate housing, are not available. In March 2017, there were 205 individuals on the statewide EBL. This is difficult for individuals who are waiting in jail, individuals waiting to get out of hospitals, and for the hospitals who are struggling with staffing issues and trying to maintain a manageable census.
- Inadequate behavioral health service capacity in the community: While immense efforts went into reducing Virginia’s jail waiting list and shoring up the emergency mental health system, significant challenges remain because the system is thinly stretched and underfunded such that it is unable to focus in every area of risk that needs attention. Although mental health is a crucial component of individual and community wellness, access to needed community behavioral health services varies significantly across the commonwealth. 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, severely limiting Virginia’s ability to treat mental health issues earlier when symptoms tend to be more manageable and psychosocial consequences are less likely to have occurred. Improving access to specialized services and community placements would provide safe and appropriate alternatives to state hospital beds and expedite discharges of state hospital patients who are clinically ready for discharge. In truth, it is not possible to produce the array of community services needed while Virginia lags so far below the rest of the nation for spending on community behavioral health services. Governors and the General Assembly have added funding to the system in the recent past, but there has been a lack of both consistent funding and action to produce a consistent, accessible array of services for people who to have their needs met before crises arise. The system will be reformed when it has the capacity in its community mental health and substance-use disorder services for children, adults and geriatric individuals to treat disorders before they become crises, which are far more difficult to manage and far more expensive.
- The U.S. Department of Justice (DOJ) Settlement Agreement: Virginia has steadily moved forward with implementing the DOJ settlement agreement, which requires individuals with developmental disabilities to be served in the most integrated settings appropriate to their needs. The initial challenges associated with this effort included expanding community capacity to support individuals through the development on non-congregate services in integrated settings, improving the discharge process of individuals from training centers into the community, and developing a quality management system. Strategies adopted from the beginning focused upon redesigning the Medicaid Developmental Disability waivers to provide the resources to support individuals in inclusive community settings and creating a quality management system to ensure the quality of services. Multiple steps must still be taken to achieve full compliance with the agreement, including:
- Enhancing case management through additional guidance and tools for case managers;
- Increasing child crisis capacity, including adding respite services and opening crisis therapeutic homes for children and youth;
- Increasing provider capacity and competency to serve individuals in integrated, non-congregate settings including those with intense medical and behavioral support needs;
- Expanding opportunities for individuals to access competitive employment and independent housing;
- Enhancing data collection, reporting capabilities, and use of data to strengthen the system;
- Improving risk management capabilities;
- Developing and improving quality improvement mechanisms which improve outcomes for individuals living in the community; and
- Improving consistency in the availability and quality of services across the state.
- Inadequate developmental service capacity: To meet the requirements of the commonwealth’s settlement agreement with the U.S. Department of Justice (DOJ), a major redesign was implemented in September 2016 of Virginia’s Medicaid waiver program for individuals with developmental disabilities with the approval of the U.S Centers for Medicare and Medicaid Services of major amendments to the three waivers. The redesign included the addition of waiver services to help support individuals secure employment and access community housing. Crisis transition services are being expanded to address the needs of individuals who require more intense behavioral supports post crisis stabilization and to allow time for providers to develop community services. Over the next two years, further development of providers and services that address those with more intense support needs will support individuals currently living in the community and those who are transitioning from training centers to the community. The settlement agreement requires the steady addition of waiver slots over the course of the 10-year agreement to ensure adequate capacity is available to serve individuals in integrated, community settings. Fortunately, current and former Governors and the General Assembly have added 4,074 new Waiver slots since 2012, far more than the 2,910 new slots required by the agreement to help reduce the waiver waiting list. However, as of March 2017, there were over 11,300 individuals with developmental disabilities who choose to receive services in their own communities instead of training center care and were therefore on the waiting list to receive waiver services. To facilitate planning on how to address needs, DBHDS implemented a three tiered prioritization grouping of the waiting list: Individuals in priority one are projected to need services in a year; those in priority two are expected to present in 1-5 years; and those in priority three are not expected to need a slot for five years or more. As of April 2017, 2,802 individuals had a priority one ranking, 4,728 priority two and 3,840 a priority three. In order to support the move of individuals from the training centers to the community and to further reduce the waiting list for community services, additional resources are required. The average cost of supporting individuals in training centers in FY 2016 was $343,267 per person, per year, up from $301,663 in FY 2015. The cost per person is projected to continue to increase due to the fixed costs allocated to a declining census in the training centers as well as discharges and natural deaths. The average cost of supporting former training center residents who have moved into community homes since 2011 is currently $141,559.
- Major Opioid Epidemic: Virginia is facing an opioid epidemic that places urgency on substance-use disorders and addiction recovery services. In 2015, there were 1,028 fatal drug overdoses in Virginia. Of these, 811 were the result of opioids – this is a 60 percent increase in opioid-related deaths since 2007, and the number of deaths from heroin has more than tripled in this time. In recent years, drug overdoses have exceeded motor vehicle accidents and gunshots as a cause of death. According to the National Survey on Drug Use and Health, more than half a million (585,000) Virginians need treatment for a substance use disorder and are not able to get it. Part of the reason is that Virginia does not have enough capacity to treat individuals with substance-use disorders. The public system of treatment for substance use disorders is implemented largely by a system of 40 locally-run community services boards (CSBs) that provides services to about 30,000 individuals with substance-use orders each year. Increasingly, their treatment needs are becoming more complex: About one-third have an opioid use disorder; about half are struggling with an alcohol use disorder; and about 60 percent have some type of co-occurring mental illness.
- The Virginia Center for Behavioral Rehabilitation to Soon Reach Capacity: The Virginia Center for Behavioral Rehabilitation (VCBR) is Virginia’s only facility designated for the treatment of individuals committed as sexually violent predators (SVPs). These individuals have completed their prison sentences but have been tested to present a danger to the public with a substantial risk to reoffend and court-ordered to additional treatment and secure confinement. VCBR has a maximum bed capacity of 450. One of the most pressing issues is the availability of beds at VCBR to provide secure confinement and treatment for individuals committed to the custody of DBHDS. DBHDS’ 2016 VCBR forecast anticipates that maximum census at VCBR will be reached in 2019. The General Assembly has been aware of the need to expand VCBR and approved planning funds in 2014. The capital building funds have not yet been approved. At this point, VCBR will reach capacity before construction on the expanded facility can be completed. It is anticipated that the census at VCBR will reach 502 (50 individuals over capacity) during FY 2022 and will reach nearly 550 by FY 2024. As a result, DBHDS is developing contingency plans for up to 100 beds. Among the options is to reopen and renovate a closed building at another DBHDS facility that was previously used for maximum security. This option will only accommodate about 65 beds on a temporary basis. Also, this option will require a general fund appropriation to renovate and fully secure the space and staff the building. DBHDS is developing contingencies for the remainder of anticipated new admissions. In fact, planning funds will soon be necessary for the third expansion of VCBR to plan appropriately for increased census growth of individuals civilly committed to VCBR in the coming years.
- 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 information technology staff.
General Information About Ongoing Status of Agency
A key priority of the DBHDS central office is improving services system transparency, oversight, and accountability. In addition, 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:
- Continue working towards compliance with the Department of Justice (DOJ) Settlement Agreement: This initiative, required by the federal government, is an immediate vehicle to achieve long-term transformation of Virginia’s developmental disabilities system into one that integrates (rather than segregates), individuals with developmental disabilities into community life. Virginia is at the midpoint of implementing the 10-year settlement agreement and is on track to complete implementation before June 2021. However, experience in other states has shown that a period demonstrating maintenance following implementation is required before the state is considered by the court to be in full compliance.
- Virginia has embraced the goal of providing services for individuals with developmental disabilities in the most integrated care settings appropriate to their needs. Critical system elements have been created to expand community capacity to ensure people have access to quality services provided in safe, appropriate, inclusive settings.
- Fully implement Medicaid waiver redesign management elements: Virginia has implemented the amended developmental disability home and community-based waivers with the approval of the Centers for Medicare & Medicaid Services (CMS). The amended waivers added services and supports that are individualized, integrated and strength-based. The amended waivers became effective September 1, 2016. As a result of the redesigned waivers, more service options are available to assist individuals be better connected and involved in their communities. The challenge is to fully implement all aspects of the waiver redesign which includes the interactive web-based individual service plan; a planning calendar to assist case managers to have critical conversations on accessing community resources, employment and community inclusion with individuals and their families; and service packages to better align level of need with allocated resources to meet the needs of all individuals who move from the waiting list into services.
- Continue on path to close two of Virginia’s training centers: At this time, DBHDS continues to move forward with creating a single system of services, rather than a dual one of Medicaid Waiver supported services and state operated ICF facilities. Southwestern Virginia Training Center closes by June 2018 and Central Virginia Training Center by June 2020. Southeastern Virginia Training Center will be Virginia’s only remaining state operated ICF facility at that time. Since 2012, as individuals with mild to severe and profound disabilities have moved successfully from training centers to new community homes, the statewide training center census has decreased over 70 percent. Virginia will be able to meet the needs of all current residents in community settings by January 2020.
- Reform Virginia’s community behavioral health system: Over the past three years, Virginia has made significant improvements in the quality and accountability of community services through legislative and administrative efforts. These accomplishments have ensured that no person has been turned away from a psychiatric hospital bed when needed, increased qualifications of emergency custody and preadmission screening evaluators, updated communications infrastructure between the courts and behavioral health care providers, improved key outcome and performance measures, and strengthened community services board (CSB) performance contracts by increasing administrative requirements and outcome and performance measures. To truly strengthen the system across the lifespan, DBHDS developed System Transformation Excellence and Performance (STEP-VA) based on a combination of extensive stakeholder feedback and on a national best practice model for behavioral health. STEP-VA features a uniform set of required services, consistent quality measures, and improved oversight in all Virginia communities. Notably, STEP-VA services are intended to foster wellness among individuals with behavioral health disorders and prevent crises before they arise. The result would be fewer admissions to state and private hospitals, decreased emergency room visits, and reduced involvement of individuals with behavioral health disorders in the criminal justice system. The 2017 General Assembly implemented the first step of STEP-VA, “same day access,” as well as funds for medication assisted treatment to combat substance-use disorders. The next steps are full implementation of same day access, primary care coordination, outpatient services and targeted case management for children. DBHDS is now working closely with the Administration, the General Assembly and system stakeholders to move Virginia’s system forward in a cohesive, strategic manner.
- Strengthen Substance-use Disorder (SUD) Treatment Capacity: Infrastructure is lacking to combat Virginia’s opioid epidemic. Additional resources are needed to improve Virginia’s SUD system of care, especially for non-disabled, non-pregnant adults who are not eligible for Medicaid. In addition, the administration has initiated efforts to address Virginia’s opioid crisis and SUD challenges and improve its coverage of substance use disorders. As a result, Virginia is now one of three states approved to expand SUD treatment, as well as to dramatically improve the rates it pays for treatment. This initiative, Addiction Recovery and Treatment Services, or “ARTS,” went live April 1, 2017. DBHDS has also applied for a $9.7 million federal grant that focused on reducing the deaths of individuals from opioid overdoses and which also provides funds for Medicated Assisted Treatment, a STEP-VA service to help combat Virginia’s opioid epidemic. Together with the DBHDS-sponsored REVIVE! program, which trains people with no medical or health background to use naloxone to reverse the effects of an overdose, Virginia hopes to reverse Virginia’s tragic opioid epidemic.
- Addressing Behavioral Health Services in Jails: Virginia’s progress reducing the waiting list for admission to a state hospital for mental health treatment stalled under pressure on state hospitals as a result of last resort legislation starting July 2014. However, DBHDS is making concentrated efforts to ensure the jail waiting list remains low and manageable. Since September 2015, DBHDS has reduced the jail waiting list from 85 (with 75 waiting longer than seven days for admission) to 36 (with only 15 waiting longer than seven days for admission). In 2016, DBHDS changed its own jail waiting list policy so that anytime someone is waiting for hospital admission more than seven days there must be an exception based on unusual circumstances. DBHDS has been successful in reducing the jail waiting list to no more than seven days throughout the Virginia except in the eastern region which produces two times more cases per capita than the rest of the state. Beginning July 1, 2017, a bill passed by the 2017 General Assembly will require that a defendant who has been court ordered to inpatient treatment to restore competency to stand trial must be admitted to a hospital no more than 10 days from the date of receipt of the court order. DBHDS has contracted with Western Tidewater CSB to provide placements for 25 long term geriatric individuals who can be safely served in the community in order to convert one geriatric unit at Eastern State Hospital to an adult unit. This action will increase the capacity we need most to meet the obligations of new legislation that takes effect July 1. In addition, DBHDS is currently working on a General Assembly requirement due by November 1, 2017, to develop a comprehensive plan for the provision of discharge planning services at local and regional correctional facilities for persons who have serious mental illnesses who are to be released from such facilities.
- Continue to develop the quality improvement system: DBHDS has been actively building a greatly needed quality management system. As these project activities are becoming operational, the focus of quality management (QM) is shifting to measure our effectiveness in meeting improvement goals and expanding QM across DBHDS. Then, efforts will focus on building quality improvement functions and activities within all community providers. DBHDS is working to utilize new data warehouse capabilities to identify common trends, risk, triggers, and threshold. Using this data and information will help DBHDS provide technical assistance, training, and guidance to the providers, as well as develop processes and metrics to anticipate and correct problems early on. As a result, CSBs and private providers will understand and become aware of the expectation to have and implement quality improvement systems including measures and risk management. The quality improvement system is critical to exiting the DOJ settlement agreement. With the commonwealth moving to a private provider system, a robust system that allows providers the flexibility to be innovative in meeting the needs of citizens who depend upon the public system of care, appropriate means of oversight that ensures individuals are receiving high quality, outcome focused services are delivered that respects the rights of all. This quality assurance system is the means by which DBHDS will assure that the monitoring and oversight provided protects the rights of those served.
The DBHDS Central Office Information Services and Technology (IS&T) team provides coordination, guidance, oversight, and support to information systems affecting the central office, state facilities operated by DBHDS, community service boards (CSBs), licensed private providers, and the public. 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 39 applications: 22 are specifically for the central office and 17 are used across the DBHDS enterprise by facilities, CSBs, providers, and the citizen customers of the agency. 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.
The business goals prioritized by DBHDS leadership for IS&T include:
- Comply with Audit Requirements: Comply with the requirements as identified in the Corrective Action Plans for the APA FY 2014 and FY 2015 audits. Each contains repeat findings from the 2013 audit.
- Improve Application Configuration Management Capabilities: Evaluate methodologies, assign resources, and execute the documentation of security baseline configurations for information systems in compliance with industry best practices and the Commonwealth Security Standard.
- Increase Oversight over Third-Party Providers: Evaluate methodologies, assign resources, and execute a formal process for gaining assurance that third party providers have secure IT environments to protect sensitive data.
- Ensure the Physical Security of People in our Facilities: DBHDS hospitals and training centers need comprehensive physical security systems in order to ensure staff, family, and individual safety at our facilities. Security systems can include, but are not limited to, duress systems, door access systems, and overhead enunciators.
- Support Consolidation of Waivers: Virginia has three waivers supporting people with developmental disabilities that were launched on September 1, 2016. The implementation of the new Waiver Management System (WaMS) has occurred in three phases, with a target completion date of September 30, 2017. WaMS tracks essential steps and processes related to the waiver program including enrollment, waiting list management, and service authorizations. Additional planned functionality includes a calendar and service packages—these functions are necessary to support case managers in their critical conversations with clients about aligning services with needs. The challenge of aligning the business processes of case managers, providers, and DBHDS pre-authorization staff is slowing, but not preventing, the full implementation of WaMS. This delays the desired result of managing the waivers with real time data.
- Increase Frequency and Quality of Licensing Specialist Visits to Providers: Upgrade or replace the current DBHDS licensing system with a system that will be used by DBHDS for licensing specialists and providers. DBHDS has a Va. Performs key measure to increase the percentage of licensed service providers that receive a visit from a licensing specialist per quarter and per year. The new system will also deliver improved functionality for performance reporting and data mining, event tracking, public-facing search options, and integration between other state agencies that use provider data.
- Align with the Commonwealth Plan to Replace CIPPS: DOA is replacing the statewide payroll system, CIPPS--a mainframe/COBOL application, with sole-source PeopleSoft product provided by Accenture. DBHDS will have to modify existing interfaces with CIPPS according to DOA's timeline (an approach similar to their implementation of Cardinal Financials). Currently our legacy financial application FMS, and KRONOS, our timekeeping application, interface with CIPPS.
- Ensure Financial Technology Remains Supportable: Replace the Financial Management System (FMS) application with modern technology that is cheaper to support, provides more robust reporting and analysis functions, and more easily integrates with Commonwealth partner financial applications such as Cardinal, Performance Budgeting, and the future CIPPS replacement.
- Mobile Remote Access Services (MRAS): As the organization transitions to community based care, Mobile Remote Access Services (MRAS) will be required for high-speed mobile access to the COV network and DBHDS business infrastructure in even the most remote parts of the state, thereby enabling employees, CSB staff, and providers to access DBHDS and vendor-hosted applications and data with mobile devices.
- Enable Efficient Data Retention, Exchange, Analysis, and Reporting: Enable efficient data retention, exchange, analysis, and reporting from agency facilities, CSBs, and private providers in support of existing programmatic requirements related to provision of quality care to individuals with behavioral health and developmental needs. This includes program area data and financials.
- Support Business Process Re-Engineering Efforts: Implement a system-wide (CO and facilities) collaboration system that provides a single integrated location where employees can streamline business processes, efficiently collaborate, find organizational resources, and manage content.
- Improve Performance of Information Security Functions: The current infrastructure of DBHDS’ Information Security Office does not have the necessary tools to implement the access and application controls, vulnerability scanning, application and administrator audit logging, or the ability to monitor data and network activities required by VITA in the COV ITRM SEC501-09 Information Security Standard. These regulations are also tied to Virginia Code Title 2.2 Chapter 20.1 § 2.2-2009.
- Expand Effort to Automate and Streamline Hospital Clinical Workflow: Expand use of the OneMind Electronic Health Record System (EHR), a suite of 29 applications that provides an electronic record of patient health information for DBHDS hospitals, including patient demographics, progress notes, clinical assessments, medication orders, past medical history, laboratory data and therapy reports. The OneMind EHR automates and streamlines the clinician's workflow, and has the ability to generate a complete record of any clinical patient encounter.
- Improve Reporting and Analytic Performance in OneSource: The OneSource Data Warehouse is a critical component of the agency's analytic capabilities. In FY 2017, DBHDS will be operating at or beyond the capability of our current technical infrastructure. DBHDS recommends migrating OneSource to a new infrastructure, and leave the other applications in the current OneSource environment.
- Implement a Consolidated Critical Event Tracking System: DBHDS collects individual and facility level data regarding critical events along with triggers and thresholds data. Currently, the MS Access-based event reporting software that is used by state hospitals and training centers is not centralized and doesn't permit the Central Office (CO) to capture system-wide data related to risk-management. Consolidating these systems into an agency-wide critical event reporting platform will allow DBHDS to retire/eliminate costs for 16 individual Event Tracking applications and Access databases, the Seclusion & Restraint application and database, portions of the Forensics Information Management System (FIMS), the PAIRS application and database, and to enhance or eliminate the current CHRIS application and database. The initiative is tentatively titled All Critical Events System (ACES).
- Reduce the Cost to Support Facility Dev/Test/Prod Environments: Move hospital and training center applications from their geographically and organizationally scattered locations to a central office managed development, test, and production environment stack while supporting individual facility needs for unique applications.
- Reduce the Facility Application Inventory: DBHDS facilities pay to maintain an inventory of over 450 unique applications. Duplication of functionality and inconsistent use of technology platforms and data storage architectures are costly. Shortfalls in facility IT staffing support has led to non-compliance with COV/CSRM mandated security requirements. By using Central Office IT Staff to support agency-wide, cross-facility applications, existing facility IT staff would be able to focus on facility unique applications that support clinicians and the individuals in their care.
- Align Early Intervention Programs with Federal Outcome-based Results Requirements: Currently, the Infants and Toddlers Online Tracking System (ITOTS) does not comply with the U.S. Dept. of Education (DOE) newly-revised accountability system under the Individuals with Disabilities Education Act (IDEA). The new Results Driven Accountability (RDA), developed by the Office of Special Education Programs (OSEP), shifts the department’s accountability efforts from a primary emphasis on compliance to a framework that focuses on improved results for children with disabilities, while continuing to ensure the Commonwealth meets IDEA requirements. RDA emphasizes improving child outcomes and DBHDS needs to move in a direction that stresses improvement over mere compliance.
- Integrate EHR with Billing and Registration: The OneMind EHR system does not have full integration with the patient billing and registration systems at the facilities. While some integration exists, to date integration has been set aside in favor of expanding the use of the EHR to new facilities.
- Preserve or Improve Technology Services through the Transition to New Infrastructure Service Providers: The Commonwealth contract with Northrop Grumman (NG) for infrastructure services will end in 2019. Some DBHDS technologies will have to transition to a new service provision model.
Estimate of Technology Funding Needs
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 current turnover rate for FY 2017 is 4.7 percent and 48 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 49 years old and the average work tenure is 10.2 years. During the next five years, 27 percent 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 involves central office staff, staff in state hospitals and training centers, and now includes 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 program is currently in its third year, and experienced much success in the previous two years.
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 Department of General Services’ space in 14 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. Windows were replaced in 2015. More recent discussions have begun to address HVAC systems for fresh air and ventilation and to provide HVAC for the Upper Basement (UB). Previously, the Upper Basement has been occupied as a computing center with some office space; however, the transfer of computing elsewhere and conversion of the space to office space has reduced the heat generated on the floor. The UB now requires supplemental heat in winter, proper ventilation and an alternative cooling strategy to free up more usable floor space. Once the windows were replaced, air infiltration and energy efficiency were increased. However, occupants now report stale air and lack of adequate ventilation on all floors. The Department of General Services is investigating fresh air ventilation settings and is reportedly working to improve indoor air quality in the Jefferson Building.
Space planning studies have been commissioned to improve building space utilization and accommodate additional office space. Space standards have also been established to guide assignments and advise staff regarding space types and sizes for position types including: permanent, contractor, part-time and DBHDS employees that only visit the Central Office occasionally. Based on the studies and standards, moves are underway with a goal of group functional teams together on the same floors where reasonable. Other space saving strategies are also being explored.
An active dialogue has been opened with the Department of General Services to improve the quality of services in the building. Addressed items include: Poor quality work when making repairs and installing new items, lack of heat in the Upper Basement areas, necessary changes to door locking schemes, space refresh schedule addressing recarpeting and repainting. DGS has tentatively agreed to an 8 year refresh schedule and is considering the request for HVAC in the UB.
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).