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April 1, 2007
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Virginia's community-based service system finds opportunities during a budget crunch

Since 1975, legislative study after study has encouraged the downsizing, if not closure, of at least some of Virginia's 13 state facilities (both psychiatric and five training centers) and the development of a strong, stable, well-maintained community-based service system. While Virginia's community-based service system has made progress during the past 30 years, the array and capacity of community services remain uneven across the commonwealth, funding of local services varies greatly, and a frugal Medicaid system work against the robust community-based system envisioned in each of the studies and reports. But that's not to say that system transformation isn't happening.

System transformation in Virginia involves services for children and adults with mental illness, mental retardation, and/or substance use disorders. Virginia's community services boards (CSBs) and behavioral health authorities (BHAs) are responsible for community-based services for these populations. The Virginia Association of Community Services Boards (VACSB) represents the state's 40 CSB/BHAs. VACSB, consumers, families, and providers jointly advocate for mental health, mental retardation, and addiction services through the Coalition for Citizens with Mental Disabilities.

In October 2003, the state announced an initial across-the-board 10% budget reduction in all community programs. James Reinhard, MD, commissioner of the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services, his staff, state facility directors, and VACSB members came together two months later to present a plan to avoid additional reductions. This creative leadership team, working in regional arrangements, formulated a plan that would move funding from state psychiatric facilities (i.e., close beds) and reinvest that funding into community services. These community services would support individuals moving from state facilities and those at risk for state facility placement. The governor and the Virginia General Assembly approved the plan, and implementation began immediately.

Consistent hard work, public-private partnership development, and flexible, creative use of funds were essential in demonstrating the plan's successful outcomes before the next biennial budget both to avoid future funding cuts and to secure additional dollars. Outcomes included:

  • diversion of consumers to local hospitals instead of state facilities under partnership agreements;

  • creation of crisis stabilization units;

  • development of contractual housing and intensive services arrangements between CSB/BHAs and existing adult facilities;

  • expansion of assertive community treatment, including PACT;

  • reduced average lengths of stay from 67 days in a state facility to 7 days in a local hospital;

  • creative arrangements for service linkages; and

  • added depth and quality in utilization review and management.

As an example of the outcomes we achieved, the Richmond region, consisting of seven CSB/BHAs, closed 20 civil beds at the state facility, provided intensive services for 1,130 consumers (three times as many prior to reinvestment), created a Jail Team serving 67 consumers, and developed a regional behavior team for consumers with co-occurring disorders requiring specialized technologies.

These successful outcomes, coupled with a report on the enormous capital expenditures needed for outdated state psychiatric and mental retardation facilities, convinced then-Gov. Mark Warner that enhancing and expanding the plan's reinvestment strategy would begin to move Virginia to the long-desired consumer-focused, community-based system envisioned in the previous legislative studies. Warner included a major system transformation initiative in his outgoing 2006-08 biennial budget. The $160 million initiative included state facility downsizing and community services growth. One-third of the funding was to be captured through Medicaid reimbursement.