Martinez-2014

Virginia’s Public Behavioral
Health System:
Today’s Challenges & Opportunities
James M. Martinez, Jr., M.Ed.
Director, Office of Mental Health Services
DBHDS
Virginia Rural Health Association
December 11, 2014
Staunton, VA

Presentation Overview
• The Current Environment of
Behavioral Health (BH) and Reform in
Virginia
• New Laws Affecting Behavioral
Healthcare in Virginia
• DBHDS Vision, Mission, Core
Principles, and Transformation Process

The Current Environment
of Behavioral Health (BH)
and Reform in Virginia

Typical Driver’s of Mental Health Reform
• High profile violence
• Family & consumer experiences (e.g., suicide)
• Limited access to too few services
• Highly variable local practices
• Criminalization of persons with MI
• Stigma
• Court decisions
Virginia’s current situation reflects
these conditions

Current Virginia Context
• Deeds tragedy - difficulty accessing acute care from
community
• Individuals with MI and SUDs in jails
• Suicide (1,053 in 2012, vs 344 homicides in Virginia)
• Discharge–ready individuals in state hospitals
• Opiate drug use and deaths, SUDs seem overlooked
• BH funding instability, current state budget shortfall
• Debate about Medicaid expansion, “Obamacare”, etc.
• Ongoing Medicaid reforms BHSA (Magellan), CCC, etc.
• DOJ Settlement Agreement (ID/DS), etc. etc.

Current Sources of Demand
There are many…
CSBs and
State
Hospitals
NURSING
FACILITIES
DSS & CSA
CLINICS &
HOSPITALS
DJJ & DOC
LEAs
& JAILS
EMERG.
DEPTS.
SCHOOLS
COURTS
INDIVIDUALS
& FAMILIES

Individuals Served (DBHDS & CSBs) FY 2014
Community
Mental Health
Services
39%
State Hospital
Services
2%CSB Substance
Use Disorder
Services
11%
CSB Emergency
Services
22%
CSB Ancillary
Services
26%
33,035
76,034
115,452
4,506
*Note: FY 2014 numbers are now being validated and may change.
63,599

State Hospital Utilization
• From January 1 - June 30, 2014, overall admissions
increased by 24%.
– Adults: 18% increase,
– Child and adolescent: 46% increase
– Geriatric: 42% increase.
• Total admissions are trending higher for FY 2015:
• Due to robust treatment and rapid discharge, there has
been no commensurate increase in overall census, but
back up capacity has been established.
FY 2013 FY 2014 FY 2015 (thru 11/14)
3,959 4,275 2,090

Adult Civil TDOs to DBHDS Hospitals FY 2014
95 100
84 80
67
56
86
103
89
97
124
136
0
20
40
60
80
100
120
140
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

Recent Commissions and Task Forces
• 2006 – 2011 – Supreme Court Commission on
MH Law Reform.
• 2007 – Gov. Kaine’s Virginia Tech Review Panel.
• 2013 – Gov. McDonnell’s Taskforce on School and
Campus Safety (Mental Health Workgroup).
• 2013 – 2014 – Gov. McDonnell/Gov. McAuliffe’s
Taskforce on Improving Mental Health Services
and Crisis Response.
*Many others preceded these…….

New Developments This Year
• Significant changes in ECO and TDO laws, as of July 1
– 8-hour ECO period, “facility of last resort” procedures,
72-hour TDO maximum, etc)
• New Medical Screening and Medical Assessment
Guidance, April 1, 2014
• New Regional “Safety Net” protocols (as of June 13)
• TDO “Exception” Reporting (i.e., unexecuted TDOs)
• Psychiatric Bed Registry (operational March 3)
• Increasing demand on state hospitals

More New Developments
• Additional Crisis Intervention Teams (CIT), and
Therapeutic Assessment Sites for easy transfer of
custody from law officers to program
• Significant new requirements in Community Services
Performance Contract between DBHDS and CSBs
• Suicide Prevention and Mental Health First Aid
initiatives
• New Crisis Stabilization services for youth
• 8 Pilot programs to engage and serve older teens and
young adults (Coordinated Specialty Care).

New Laws Affecting
Behavioral Healthcare
in Virginia*
*Most of the slides in this portion of the presentation were prepared by Allyson K. Tysinger,
Senior Assistant Attorney General, Office of the Attorney General.

The Challenge of Law Reform
• There are two ways to address people who don't
seek treatment:
1. coerce people into treatment by expanding coercive
treatment laws.
2. induce more people to seek treatment voluntarily
by offering better services.
• Reform cannot just be about making coercive
treatment laws “better”. It must also be about
reducing the need to use these laws.

The Challenge of BH Crisis Intervention
• Our goal is a person-centered, recovery-oriented
system of services and supports that helps
people get their lives back.
• Crisis contact and intervention, including the
involuntary admission process, is a critical point
of engagement – or not
• In crisis, what are we trying to do?
• For whom?

Psychiatric Bed Registry (SB260/HB1232)
• DBHDS to develop and administer web-based
acute psychiatric bed registry to contain
information about available acute beds in public
and private inpatient psychiatric facilities and
residential crisis stabilization units to facilitate
identification and designation of facilities for
temporary detention of individuals who meet the
TDO criteria

• Bed registry shall:
– Include descriptive information for each inpatient
psychiatric facility and residential crisis stabilization unit,
including contact information
– Provide real-time information about the number of beds
available and for each bed
• The type of patient that may be admitted
• The level of security provided
• Any other information to allow identification of appropriate
facilities for temporary detention

• Registry shall allow searches by:
–CSBs
–Inpatient psychiatric facilities
–Residential crisis stabilization units
–Health care providers working in an ER or
other facility rendering emergency medical
care

• Who is required to participate in the bed registry?
– State facilities
– CSBs
– Private inpatient providers licensed by DBHDS
• Participants must designate employees to submit
information to the system and serve as a point of
contact for requests for information

Emergency Custody (SB260/HB478)
• ECO valid for a period not to exceed 8 hours from
the time of execution
–8-hour period applies to paper ECOs and
“paperless” ECOs
–Old Law: 4 hours with possible 2-hour
extension
• Provision for extension has been removed
• 8 hours to execute an ECO from its issuance
–Old law: 6 hours

Emergency Custody (SB260)
• If the individual is detained in a state facility at the
expiration of the 8-hour period because a facility of
temporary detention could not be identified, the
CSB and the state facility may continue to attempt to
identify an alternative facility for an additional 4
hours
– This provision expires June 30, 2018
– Also see HB1172

• Law enforcement agency that executes the
ECO shall notify the CSB responsible for
conducting the evaluation as soon as
practicable after taking the person into
custody
–Applies to paper ECOs and “paperless” ECOs

• Any person taken into emergency custody shall
be given a written summary of the emergency
custody procedures and the statutory
protections associated with those procedures

Determining Temporary Detention Facility
(SB260/HB293)
• Upon receiving notification of the need for an
evaluation, the CSB shall contact the state facility
serving the area in which the CSB is located and notify it
that the individual will be transported to it upon the
issuance of a TDO if an alternative facility cannot be
identified by the expiration of the 8 hour emergency
custody period
• Upon completion of the evaluation, CSB shall provide
information about the individual to the state facility to
allow it to determine the services the individual will
require on admission

(SB260/HB293)
• Once notified, the state facility may conduct a
search for an alternative facility
–May contact another state facility if it is unable
to provide temporary detention and
appropriate care
• If state facility finds an alternative facility, it shall
notify the CSB and the CSB shall designate the
alternative facility on the preadmission screening
report

(SB260/HB293)
• A state facility shall not fail or refuse to admit an
individual who meets the criteria for a TDO
unless an alternative facility agrees to accept the
individual
• An individual who meets the criteria for a TDO
shall not be released

(SB260/HB293)
• If a facility of temporary detention cannot be
identified by the expiration of the 8-hour
emergency custody period, the individual shall
be detained in the state facility
• State facility shall be indicated on the TDO

Change of Temporary Detention Facility (HB1172)
• CSB may change the facility of temporary detention and
may designate an alternative facility at any point during
the period of temporary detention
– Must determine that the alternative facility is a more
appropriate facility given the specific security,
medical, or behavioral needs of the person
– CSB must provide notice to the clerk of name and
address of the alternative facility

Change of Temporary Detention Facility (HB1172)
• If facility of temporary detention ischanged,
transportation is provided in accordance with §37.2-810
– If law enforcement or an alternative transportation
provider has custody of the person when the change is
made, individual shall be transported to alternative
facility
– If individual has been transported to initial TDO facility,
CSB shall request the magistrate to enter an order
specifying an alternative transportation provider or, if no
alternative transportation provider, the local law
enforcement agency where the person resides or is
located if 50-mile rule is applicable

Temporary Detention Written Summary
(S260/HB478)
• Person detained shall be given a written
summary of the temporary detention
procedures and the statutory protections
associated with those procedures

Length of Temporary Detention (SB260/HB574)
• Commitment hearing shall be held within 72
hours of execution of the TDO
• If 72-hour period ends on a Saturday, Sunday,
legal holiday, or day on which the court is
lawfully closed, person may be detained until
COB on the next business day when the court is
open
–Old Law: 48 hours

Commitment Hearing Procedure (SB260/SB439/HB574)
• When judge informs the individual of his right to
apply for voluntary admission and advises him
that if he chooses to be voluntarily admitted he
will be prohibited from possessing or purchasing
a gun, the judge must now advise the individual
that he will also be prohibited from transporting
a gun.
–Consistent with § 18.2-308.1:3

Filing Commitment Orders with Court Clerk
(SB576/HB743)
• Judge or special justice shall file orders from a
commitment hearing for involuntary admission,
MOT, or voluntary admission after a TDO with
the clerk as soon as practicable but no later than
COB on the next business day following
completion of the hearing

Mandatory Outpatient Treatment (SB439/HB574)
• CSB must acknowledge receipt of an MOT order
to the clerk within 5 business days
• CSB shall acknowledge receipt of an order
transferring jurisdiction of an MOT case within 5
business days

Treatment of Minors (SB260/HB478)
• ECO period increased to 8 hours (was 4)
– Provision for extension removed
– 8 hours to execute an ECO (was 6)
– TDO period unchanged for minors (96 hours)
• Law enforcement agency that executes the ECO shall
notify the CSB responsible for conducting the evaluation
as soon as practicable after taking the person into
custody.
– Applies to paper and “paperless” ECOs

Treatment of Minors (SB260/HB293)
• Provisions for determining the facility of temporary
detention are the same as for adults
– State facility if an alternative facility is not identified
before expiration of the ECO
• If the individual is detained in a state facility at the
expiration of the 8 hour period because a facility of
temporary detention could not be identified, the CSB
and the state facility may continue to attempt to identify
an alternative facility for an additional 4 hours
– Expires June 30, 2018
– HB1172 only applicable to adults

Annual Report Required (SB260/HB293)
• DBHDS must submit an annual report on June 30 of
each year to the Governor and Chairmen of House
Appropriations and Senate Finance
– Number of notifications of individuals in need of facility
services by CSBs
– Number of alternative facilities contacted by CSBs and
state facilities
– Number of temporary detentions provided by state
facilities and alternative facilities, the lengths of stay, and
the cost of the detentions

Governor’s TF Study Use of Law Enforcement
(SB260/HB478)
• Governor’s Task Force on Improving Mental Health Services
and Crisis Response shall identify and examine issues related
to the use of law enforcement in the involuntary admission
process
– Consider options to reduce the amount of resources
needed to detain individuals during the ECO, including
the amount of time spent transporting. Options shall
include:
• Developing crisis stabilization units in all regions
• Contracting for retired officers to provide
transportation
• Report of findings and recommendations to Governor and
General Assembly by October 1, 2014

Study of CSB Evaluators (SB261/HB1216)
• DBHDS shall review the requirements related to
qualifications, training, and oversight of
individuals performing preadmission screening
evaluations
• Make recommendations for increasing
qualifications, training, and oversight
• Report findings to the Governor and General
Assembly by December 1, 2014

Disseminating Info on Effective Crisis Strategies
(HB1222)
• Secretaries of Public Safety and HHR shall encourage the
dissemination of information about specialized training
in evidence-based strategies to prevent and minimize
mental health crises. Strategies shall include:
– CIT training
– Mental Health First Aid
• Information disseminated to law enforcement, first
responders, ER personnel, school personnel, and other
interested parties

Joint Subcommittee to Study Mental Health Services
(SJR 47)
• 12 legislative members (Sen. Deeds, Chair; Del. Bell, Vice-chair)
• Review and coordinate with work of Governor’s Task Force
• Review laws governing the provision of mental health services,
including civil commitment laws
• Assess the systems of publicly funded mental health services
(emergency, forensic, long-term, and services in jails and juvenile
detention facilities)
• Identify gaps in services and types of facilities and programs
needed
• Recommend statutory or regulatory changes to improve access to
services, quality of services, and outcomes for individuals
• Interim report by December 1, 2015; final report by December 1,
2017

Transportation for Temporary Detention (HB323)
• In determining the primary law enforcement
agency to provide transportation, magistrate
shall specify in the TDO the law enforcement
agency of the jurisdiction where the person
resides or any other willing law enforcement
agency that has agreed to provide transportation

DBHDS Vision, Mission,
Core Principles, and
Transformation Process

Our Vision and Mission
• DBHDS has adopted a new Vision:
A life of possibilities for all
Virginians
• We also have a new Mission:
Supporting individuals by promoting
recovery, self-determination, and
wellness in all aspects of life

Process of Recovery in People
Person
Illness
Illness
Person

Process of Recovery (cont)
Friends
Person
Illness Employment
Leisure
Activity
Family

Slide Source: Recovery-Oriented Practice by Pat Deegan, Ph.D.
The Disease-Centered Model
Professional Role
1. Hierarchical
2. Paternal
3. In-charge
4. Holds the important
knowledge
5. Responsible for
treatment
6. Disease is focus
Patient Role
1. Subservient
2. Obedient
3. Passive
4. Recipient of
knowledge
5. Responsible for
following treatment
6. Host of disease

Slide source: Recovery-Oriented Practice by Pat Deegan, Ph.D.
The Person-Centered Model
Person’s Role
1. Personal power
2. Personal knowledge
3. Personal responsibility
4. Person in context of
life is focus
5. Person is self-
determining
Professional Role
1. Power sharing
2. Exchange information
3. Shared decision-
making
4. Co-investigator
5. Professional is expert
consultant on journey

DBHDS Core Principles
• Individuals can and do recover from mental illness and
substance use disorders.
• Across the entire Commonwealth, Virginians should
have access to quality mental health services.
• Interventions should be focused on prevention and early
intervention.
• Services must be individualized, consumer-driven and
family-focused.
• To best promote recovery, interventions should be
holistic, and include necessary primary health care,
housing and employment supports.

What This Means
• All of our services and supports are grounded in
principles of recovery and resiliency.
• Our system delivers well-functioning and responsive
emergency services.
• Our services reflect a commitment to prevention and
early intervention.
• Individuals with mental illnesses are deflected from
inappropriate service systems (like criminal justice).
• We increase our emphasis on children's behavioral
health, particularly for transition age youth.
• With these principles in mind, we are asking ourselves
what are we trying to do? For whom?

DBHDS Transformation
• Commitment to Best Practices Implementation
 Calling on national expertise
 Incorporating lessons learned from other states
 Utilizing previous data, studies, and recommendations from former and
current task forces and commissions
• Accountability
 New Performance Contract Addendum
 Bed registry implementation and monitoring
• Transparency
 Information available on new DBHDS website
• Communication
 Commitment to regular communication with stakeholders about changes in
practice and policy
• Collaboration
 Working with system partners to incorporate their input

Transformation Approach
• Commissioner-convened small transformation teams
focused on four areas (initially):
 Adult behavioral health,
 Adult developmental services,
 Children’s behavioral health, and
 Justice-involved behavioral health and
developmental disability services.
• Identify structures and processes to aid, enhance and
expand services delivery.
• Report on key deliverables in 6, 12, 18 and 24 months.

We are ALL IN!
• ALL IN! is the name of our newsletter. What does it mean?
• ALL IN! speaks to our level of commitment and sense of urgency.
• ALL IN! acknowledges that transformation requires broad
partnerships - with those we serve, their families, advocates,
state agencies and community partners.
• ALL IN! commits to inclusiveness. We are dededicated to a life full
of rich possibilities for everyone.
• ALL IN! recognizes our responsibility to all of Virginia, from the
Shenandoah Valley to the Eastern Shore; from Coeburn to
Fairfax. Virginia deserves the most robust, comprehensive service
system we can provide. We believe we can have a model system.
• Everyone can be a part of this process.
• Although we face challenges, we also have a unique opportunity
to truly transform our system for those we serve. We are ALL IN
and we are counting on you being ALL IN! too.

Thank you,
for all you do,
every day!

My Contact Information
James M. Martinez, Jr.
804-371-0767 (office)
804-786-4837 (OMH main)
jim.martinez@dbhds.virginia.gov

Martinez-2014

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