Supporting individuals 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.
State mental health facilities operated by the Department of Behavioral Health and Developmental Services (DBHDS) are funded with 79 percent general fund dollars and 21 percent nongeneral fund dollars. Nongeneral fund dollars are derived from the collection of fees from Medicaid, Medicare, private insurance, and private payments.
(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||294,023,194||78,512,458||294,270,242||78,531,714|
|Changes to Initial Appropriation||1,581,524||0||3,829,547||0|
Anticipated Changes to Customer Base
Current Customer List
|Potential Number of Annual Customers|
|Consumer||Individuals served in state hospitals||4,506||4,639||Stable|
|Consumer||Individuals served at Hiram Davis Medical Center||124||124||Stable|
| Local and regional jails||State hospitals work closely with local and regional jails to transfer inmates in need of inpatient forensic services.|
|Community services boards and behavioral health authority (CSBs)||State hospitals participate with CSBs in discharge planning.|
|Federal agencies||State geriatric centers and certain state hospital beds must be certified by the Centers for Medicare and Medicaid Services (CMS) to receive Medicaid reimbursement for services provided.|
|Pharmacy oversight agencies||State hospitals assure that its pharmacy operations meet regulatory requirements. |
|Individuals receiving services, family members, and advocacy organizations||State hospitals work closely with individuals receiving services and their families to assure their active and meaningful involvement in treatment and discharge planning and service provision. Peer providers and consumer-run organizations provide very valuable services and supports for individuals receiving services in state hospitals.|
|Private providers (for profit and non-profit organizations)||State hospitals purchase inpatient medical care for individuals receiving their services.|
|Private providers and vendors||State hospitals purchase or contract for a variety of services from private providers and vendors.|
|State agencies||State hospitals work with a number of state agencies that that coordinate services or provide operational, financial, or workforce consultation and assistance to assure appropriate implementation of regulations and management requirements.|
|State and Local agencies||State hospitals work with a number of state agencies that provide operational, financial, or workforce consultation and assistance to assure appropriate implementation of regulations and management requirements. Hospitals work with local health departments and fire marshals to assure compliance with applicable standards. |
|Virginia institutions of higher education (colleges, universities, and community colleges)||State hospitals collaborate 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.|
|• ||Implement self determination, empowerment, recovery, resilience, and person centered, trauma-informed, and strength-based core values at all levels of the behavioral health and developmental services system through policy and practices that reflect the unique circumstances of individuals receiving services and supports.|
Chapter 3 of Title 37.2 of the Code of Virginia establishes DBHDS and Chapter 7 of Title 37.2 authorizes DBHDS to perform certain functions related to the operation of state facilities. Additionally, the federal Centers for Medicare and Medicaid Services (CMS) establishes requirements for certified beds in state hospitals and the federal Individuals with Disabilities Education Act defines who receives special education services in state hospitals. DBHDS operates eight state hospitals for adults: Catawba Hospital (CH) in Catawba (near Salem), Central State Hospital (CSH) in Petersburg, Eastern State Hospital (ESH) in Williamsburg, Piedmont Geriatric Hospital (PGH) in Burkeville, Northern Virginia Mental Health Institute (NVMHI) in Falls Church, Southern Virginia Mental Health Institute (SVMHI) in Danville, Southwestern Virginia Mental Health Institute (SWVMHI) in Marion, and Western State Hospital (WSH) in Staunton. DBHDS also operates one behavioral facility for children with serious emotional disturbance: the Commonwealth Center for Children and Adolescents (CCCA) in Staunton. This goal incorporates core principles of recovery and resilience into state hospital services and supports to help individuals improve their health and wellness, learn to live selfdirected lives, and live productive lives in their communities.
Health & Family: Inspire and support Virginians toward healthy lives and strong and resilient families.
|» ||Continue progress in changing state hospital cultures to support recovery, self determination, empowerment, and person centered, trauma-informed, and strength-based service planning.|
This objective supports the realization in state hospitals of a more person centered, trauma-informed, and strength based system of developmental services and supports that build on the individuals’ strengths, preferences, and goals. This includes implementation of state hospital initiatives to establish and sustain recovery support services and increase use of peers in direct service roles.
• Integrate recovery principles in state hospital operations and implement strategies that increase the recovery experience for individuals receiving services, including peer to peer supports, treatment planning partnerships, and provision of educational, career development and job training opportunities.
• Incorporate recovery oriented peer supports and active treatment focused on discharge that includes wellness recovery planning and educational, career development, and job training programs.
• Continue to expand peer provided recovery supports and use of peer mentors in state hospital programs.
• Train and support staff in the integration of recovery values, principles, concepts, and language into hospital processes and practices.
• Expand opportunities for individuals and their families to participate as partners in state hospital service planning, delivery, and evaluation.
• Implement wellness programs designed to lower obesity, hypertension, diabetes, and heart disease and facilitate exercise and other healthy lifestyle choices.
• Participate in the Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TCS) process to bring peers, advocates, families, providers, state agencies and other stakeholders together to monitor and report on progress in achieving a recoveryoriented system of care.
|• ||Build and sustain services capacity necessary to provide person centered, trauma-informed, and strength-based services and supports when and where they are needed, in appropriate amounts, and for appropriate durations.|
This goal envisions state hospital services and supports that are flexible, are appropriately tailored to the needs of individuals receiving services, and exemplify clinical and management best and promising practices.
Health & Family: Inspire and support Virginians toward healthy lives and strong and resilient families.
|» ||Provide high quality state hospital services that efficiently and appropriately meet the needs of individuals receiving services.|
This objective implements highly structured intensive inpatient services, including a range of psychiatric, psychological, psychosocial rehabilitation, nursing, support, and ancillary services, that prepare individuals to participate as fully as possible in all aspects of the most-integrated community life possible upon their discharge.
• Maintain sufficient numbers of trained staff and equipment at each state hospital to provide services that are appropriate to the populations served and sufficient to assure quality and safety of individuals receiving services.
• Serve as the “safety net” for TDO admissions when alternate facilities in the community are determined to be unavailable.
• Improve state hospital bed utilization through aggressive monitoring of service plans and discharge efforts such as targeted discharge assistance that reduce lengths of stay and enable individuals to be integrated more quickly into the community.
• Use the results of Annual Consultation Audits and other hospital surveys to improve state hospital service delivery through adoption of best practices and operational efficiencies, standardize hospital procedures, as appropriate, and reduce duplication.
• Provide training to enhance the use of best practice guidelines and evidence based approaches in the treatment and care of individuals receiving state hospital services.
• Offer or arrange for medical care appropriate to the particular needs of individuals receiving services in state hospitals.
• Provide inpatient pharmacy services to individuals receiving services and supports in state hospitals that comply with state requirements and federal programs.
• Coordinate with local school divisions to provide education services that address the educational needs of children and adolescents are met while they are receiving inpatient psychiatric services.
• Continue work with the regions to implement best practices for regional management of inpatient resources.
• Operate state geriatric treatment centers that provide treatment and rehabilitation services that promote selfdetermination, recovery, and community participation.
• Implement a career path for direct service associates to improve recruitment and retention efforts.
• Provide funds to assure medical care and special hospitalization needs are met for individuals receiving services in state hospitals.
|» ||Provide sufficient secure inpatient forensic evaluation, competency restoration, and treatment services that meet the demands of jails and courts.|
This objective implements effective and efficient secure inpatient forensic services.
• Strengthen state and local behavioral health and criminal justice partnerships and collaborative programs to reduce or divert forensic admissions from state hospitals and increase conditional releases and discharges to the community.
• Continue to take affirmative efforts to reduce current waiting list of persons in jails referred for restoration of competency and ensure individuals ordered for inpatient restoration of competency to stand trial are admitted with 10 days from receipt of the court order.
• Implement changes in DBHDS policy regarding Not Guilty by Reason of Insanity (NGRI) acquittee management to allow temporary custody of new insanity acquittees to be implemented in state hospital civil beds whenever possible based on clinical and risk status.
• Improve the flowt hrough of NGRI acquittees by placing acquittees into the least restrictive settings necessary as quickly as possible and providing enhanced access to expert consultation to assist services providers address treatmentrecalcitrant and institutionalized patients.
• Improve oversight to reduce unnecessary admissions for pretrial evaluation, competency restoration, and treatment of NGRI acquittees.
• Focus provision of inpatient pretrial evaluation and treatment to persons who meet emergency treatment criteria
• Evaluate the size of the CSH maximum security unit and explore opportunities to improve its safe and secure management.
• Improve the DBHDS Forensic Information System (FIMS).
|• ||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.|
This goal envisions consistent implementation of state hospital administrative and support services that support and sustain service quality and appropriateness, protect individual human rights, ensure compliance with federal and state requirements, and promote efficiency and cost effectiveness. Affirmative actions are taken to identify and eliminate unnecessary variability in state hospital practices and procedures.
Government and Citizens: Be recognized as the best-managed state in the nation.
|» ||Provide efficient and effective administration and support services at each state hospital.|
Efficient and effective administration and support services must be in place if state hospitals are to provide quality services in a safe, secure, and healthy environment. This objective implements general management, computer services, food services, housekeeping, linen and laundry services, and physical plant services that support the effective and efficient operation of state hospitals and the implementation of an electronic health record.
• Adhere to all safety regulations as prescribed by the Department of Environmental Quality pertaining to boiler inspections.
• Adhere to all safety regulations as prescribed by the local Fire Marshall pertaining to building safety.
• Adhere to Virginia Department of Health regulations pertaining to state hospital food services operations, overall sanitation, and cleanliness.
• Comply with the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rule requirements.
• Continue to adhere to Prompt Payment Act, small purchase charge card usage, Payline participation, direct deposit participation, and other regulatory compliance requirements.
• Continue to assess opportunities to improve the effectiveness and efficiency of facility administrative services.
• Implement an electronic health record system of clinical treatment/medical record, pharmacy, ancillary, and accounts payable modules at each state hospital.
State hospitals provide highly structured intensive inpatient services, including a range of psychiatric, psychological, psychosocial rehabilitation, nursing, support, and ancillary services. Specialized programs are provided to older adults, children and adolescents, and individuals with a forensic status.
Hospital forensic services include inpatient pretrial evaluation, competency restoration, and a variety of clinical and inpatient interventions. At CSH, a maximum security forensic unit has perimeter and internal security and security staffing equivalent to a medium security correctional center and an intermediate security unit has a medium correctional center level of perimeter security. Three hospitals have medium security units or programs, ESH, SVMHI, and WSH, with specialized staff and a minimum of two levels of locked security to prevent escape. Adults with a forensic status also receive services on state hospital civil units.
Geriatric centers at SWVMHI, CH, and PGH provide a variety of specialized clinical and inpatient interventions in areas of behavioral management, cognition, interpersonal skills, self-care, and leisure time development that are specifically designed to address the unique and complex recovery, treatment, and support needs of older adults (65 years and older).
An important measure of state hospital performance is readmissions of individuals within 30 days of discharge. This measures the effectiveness of hospitals in addressing the treatment needs of admitted individuals completely, working with the individuals’ case managers at local community services boards (CSBs) on discharge planning, ensuring applications for any necessary benefits (e.g., Medicaid or SSDI) have been applied for, preparing the individuals for discharge, and maintaining effective working relationships with the CSBs they serve to avoid unnecessary readmissions soon after discharge. As a result of the dramatic increase in admissions for individuals in a behavioral health crisis under a TDO, the state hospitals are now serving a much more clinical, medically, and behaviorally acute population, with a shorter length of stay and a higher readmission rate. A measure of productivity for state mental health facilities is hospital clinical costs per patient day. Clinical costs include medical and nursing staff, psychologists, social workers, therapists, and other staff and activities that are directly associated with the provision of care to individuals receiving hospital services This measure tracks the overall productivity of its clinical service staff and its ability to identify and address staff capacity issues across hospitals.
|Authorized Maximum Employment Level (MEL)|| ||4425|
|Wage Employees|| ||671|
|Contracted Employees|| ||0|
- State hospitals as facilities of “last resort:” The 2014 General Assembly amended the Code of Virginia to require state hospitals to accept civil temporary detention order (TDO) admissions if other alternatives have not been identified within the eight hour emergency custody order period. CSBs must notify the primary state hospital serving the CSB’s area when an emergency custody evaluation is needed. State hospitals are required to admit any individual for temporary detention who is not admitted to an alternative treatment facility prior to the expiration of the emergency custody period. As noted above, as a result of the change in the civil commitment laws, state hospitals have experienced a 157 percent increase in TDO admissions and a 54 percent increase in total admissions since FY 2013.
- Lack of community alternatives: Delayed discharges from state mental health hospitals increase pressure on local private hospital emergency departments, law enforcement, and individuals who would benefit from state hospital services. In FY 2015, there was an average of 152.5 individuals who were clinically ready for discharge but who experienced barriers to discharge that extended their hospitalization over 30 days because appropriate community supports and housing arrangements were not available. In FY 2016, there were an average of 184.2 individuals who were found to be clinically ready for discharge for more than 14 days. In FY 2017, DBHDS changed the criteria for individuals to be added to the EBL to those who have been clinically ready for discharge for more than 14 days. So far in FY 2017, there has been an average of 185 individuals on the list each month.
- Forensic pressures on state hospital bed capacity: With adult civil beds increasingly occupied by adults with a forensic status, fewer state hospital beds are available for civil patients. Even with a statutory preference for outpatient competency evaluations and competency restoration whenever possible, many persons who could be served on an outpatient basis are instead referred to state hospitals. Continued investment in community-focused forensic services such as outpatient and jail-based evaluations, restoration of competency, and treatment for persons found not guilty by reason of insanity (NGRI) and ongoing diligence and aggressive utilization management of hospital jail inmate admission waitlists are required to offset the increasing demand for state hospital beds by adults with a forensic status. In FY 2018, the forensic pressures on the system will increase as a result of the change in law which requires individuals in jail must be admitted within 10 days of receipt of a court order for restoration to competency to stand trial.
- Geriatric pressures on state hospital bed capacity: Virginia serves many older adults with psychiatric needs in its state hospital geriatric centers (representing 12 percent of total hospital bed days for FY 2014) rather than in the community. This rate is among the highest in the nation, in large part because the Commonwealth lacks adequate community alternatives that provide specialized programs and providers trained to address the specific needs of older individuals with mental health or substance use disorders. Following the change in the civil commitment laws in 2014, the geriatric hospitals experienced an even more dramatic increase in admissions than the adult hospitals. Piedmont Geriatric Hospital experienced a 78 percent increase in admissions. Specialized crisis response services for older individuals with behavioral health disorders are not widely or routinely available across Virginia. Demand is expected to increase as this population group increases. DBHDS is working closely with health and long-term care partners to strengthen the availability of community services and supports for these individuals, including emergency and crisis response services.
- Facility capital requirements: With the completion of the new Western State Hospital, the average age of state hospital buildings is nearly 50 years old. Many of these older buildings have significant physical plant problems requiring major renovation. Central State Hospital is in critical need of being replaced. A recent survey found that the deferred maintenance needs at state mental health facilities exceeded $294,573,930.
- Inadequate technical support capacity: As the mental health treatment centers expand use of electronic health records, implement health care reforms, improve performance through technology improvements, and replace aging, expensive technologies with more cost effective solutions, reliance on technical support will increase. An increasing number of mission critical clinical and financial processes rely on technology provided by a limited number of facility and central office information technology staff
General Information About Ongoing Status of Agency
State hospitals have made significant progress changing their cultures to support recovery, self-determination, and empowerment. Recovery-oriented, person-centered, and trauma-informed principles are now increasing the recovery experience for individuals receiving services through peer-to-peer supports, treatment planning partnerships, and educational and career development and job training opportunities.
State hospitals continue to focus on improving bed utilization through aggressive monitoring of service plans and discharge efforts that reduce hospital lengths of stay and enable individuals to be integrated more quickly into the community. In addition, Discharge Assistance Program (DAP) funds are supporting creation of of individualized services and supports for individuals residing in state hospitals who are clinically ready for discharge but have significant barriers to their discharge. Local Inpatient Purchase of Service (LIPOS) private hospital bed purchase funds are being used by CSBs to ensure treatment is provided in the community rather than in more restrictive settings. In FY 2018, both programs received additional funds from the General Assembly. To offset the increasing demand for state hospital beds by individuals with a forensic status, ongoing efforts continue to improve forensic patient management, review, and oversight processes and to safely and appropriately divert forensic admissions when possible. Although the Code of Virginia expresses a preference for outpatient competency evaluations and restoration whenever possible, many persons who could be served on an outpatient basis are instead referred to state hospitals. DBHDS is working to develop community-focused forensic services, including jail evaluations and treatment and outpatient competency restoration services in either the community or jail, to safely and appropriately divert forensic admissions to community alternatives.
DBHDS has implemented annual consultative audits (ACAs) to improve state hospital service delivery. ACAs use a peer-review process involving colleagues from other state hospitals, individuals receiving services, and central office staff to review and provide feedback on facility operations and compliance with oversight and accreditation requirements and offer consultative suggestions to improve service delivery. ACA results are being used to facilitate adoption of best practices and operational efficiencies; standardize procedures, as appropriate; and reduce duplication. Operational efficiencies also should result from the implementation of the electronic health record system (EHR) clinical treatment/medical record, pharmacy, ancillary, and accounts payable modules. DBHDS has also retained nationally recognized experts to conduct mock compliance and quality of care surveys and to provide technical assistance and consultation for areas of identified need in the state hospital system.
With increasingly complex caseloads, state hospitals must maintain sufficient numbers of staff trained in best practice guidelines and evidence-based approaches in the treatment and care of individuals receiving state hospital services. Hospitals are working to improve staff cultural and linguistic competence so they can better address the recovery and communication needs of individuals and families in a culturally relevant manner.
Mental health treatment centers maintain small teams of information technology (IT) staff to support locally developed application systems and their local information technology infrastructure environments. The DBHDS central office Information Services and Technology (IS&T) office provides coordination, guidance, oversight, and support to ensure that these local systems comport to Commonwealth of Virginia (COV) security requirements and to enable required data integration with central office provided systems.
Although many of the central office (720) IT goals are intended to support the mental health treatment centers, two are of particular importance. First, the reduction of the Facility Application Inventory, will have the most significant impact on mental health technology operations. A reduced facility application inventory and increased central office support for agency-wide applications will allow facility IT staff to focus on the specific needs of their facility’s clinical staff.
Second is the expanded use of the OneMind Electronic Health Record System (EHR). OneMind is a suite of 29 applications that provides an electronic record of patient health information, including patient demographics, progress notes, clinical assessments, medication orders, past medical history, laboratory data and therapy reports. The OneMind EHR is currently in use at three mental health treatment centers to automate and streamline the clinician's workflow, and generate a complete record of any clinical patient encounter. Extending the OneMind EHR to the facilities that do not have it is the agency’s highest clinical technology priority.
Estimate of Technology Funding Needs
State hospitals operate 24 hours a day, seven days a week and depend on a cadre of skilled and dedicated employees in a wide variety of classifications. Most provide direct care or support facility infrastructure. Among the human resource challenges hospitals face are workforce aging; competition for psychiatrists, occupational and physical therapists, nurses, pharmacists, and direct care staff; and turnover due to the difficult nature of the work.
The hospital workforce average age is 45.6 years old and average work tenure is 9.1 years. The direct care turnover rate is 20 percent and the turnover rate for security positions is 19.6 percent. During the next 5 years, 22.7 percent will be eligible to retire with unreduced benefits. Additionally, overtime continues to increase due to higher acuity of patients, increased admissions and the high amount of turnover. The mental health facilities overtime grew by $2 million from fiscal year 2015 to fiscal year 2016.
Additionally, graduates of nursing programs have never used paper records, and some are turning down positions in part because six of the nine hospitals use paper records instead of an EHR. Some doctors also have expressed their concerns of the liability that comes with paper records. This is contributing to an already high vacancy for these skilled positions.The new EHRs and increasing service demands will require skilled staff with cultural and linguistic competence to serve an increasingly diverse population. Technical or clinical expertise, communication and analytic skills, ability to create and apply sophisticated new technologies, and reasoning and problem-solving capabilities will be needed. A variety of classes in performance management, computer skills, linguistics, and use of interpreters are provided to enhance workforce competence.
DBHDS is responsible for the operation of nine state-owned mental health facilities. The state hospitals, have approximately 3,000,000 square feet of building with an average age of nearly 50 years. Lack of adequate maintenance reserve funding continues to present problems with reference to these older structures.
These facilities consist of over 200 individual buildings served by a variety of mechanical heating and cooling systems ranging from central plant distribution systems to individual package heating and cooling units and in some instances makeshift systems. Replacement of these systems based on age and physical condition has typically been deferred due to an uncertainty of the long-range need for continued use of the buildings. Many buildings are anticipated to remain in use for a defined duration have reached the point of requiring an investment to maintain reliable systems for the remaining duration of their use. Buildings that may reach surplus status require conditioned environments to prevent deterioration, therefore enhancing possible future utilization. Although substantial critical system improvements have been achieved in recent years, a substantial backlog of potential system failures and system inefficiencies remain.
More than 400 acres of the current ESH campus have been declared surplus and will be advertised for sale by the Department of General Services. WSH construction is completed and the building is fully occupied. The old WSH campus has been sold.
The DBHDS six-year Capital Outlay Plan includes the following:
- Replacement of CSH,
- Expansion of WSH,
- Renovation of PGH,
- Improvements at ESH to create a safe adult mental health environment,
- Major system renovations for greater security, and
- Major renovation projects for roofs, infrastructure, abatement of hazardous materials, and HVAC/boilers repairs and replacement.
DBHDS is assessing ways to make facilities more efficient. This includes an examination of food service and laundry operations.
Note: This is one of five DBHDS Executive Progress Reports. See Department of Behavioral Health and Developmental Services (720); Grants to Localities (790); Intellectual Disabilities Training Centers (793); and Virginia Center for Behavioral Rehabilitation (794).