A new report released this week laid out the life-or-death issues facing the Virginia Board of Community Service’s (CSB) behavioral health services and the people who use those services, and laid out suggestions for fixes to address those issues .
The 136-page report by Virginia’s nonpartisan Joint Legislative Audit and Review Commission (JLARC), “CSB Community Service Board Behavioral Health Services,” describes organizational and financial problems facing the system, including a bed registry of the state, which is useless and obsolete.
State law requires each city or county to establish or join a CSB. Virginia’s 40 CSBs serve between one and 10 localities. Across the 40 boards, behavioral health services are provided in more than 500 offices, with each CSB operating between two and 34 service locations providing crisis services. Southwest Virginia CSB Region 3 covers Blue Ridge, Cumberland Mountain, Danville-Pittsylvania, Dickenson, Highlands, Mount Rogers, New River Valley, Piedmont, Planning District One and Southside.
The JLARC report highlights a variety of mental health issues facing Southwest Virginia:
- CSBs serve a greater proportion of adults with serious mental illness who live in the southwestern and northern Shenandoah Valleys than in other areas of the state.
- The number of fatal drug overdoses was highest in Southwest Virginia and the northern Shenandoah Valley in 2021.
- Between FY12 and FY22, the number of CSB users receiving behavioral health services increased by nearly 10 percent in Southwest Virginia.
The report quantifies that mental health needs have increased across Virginia, with admissions to the state’s nine psychiatric hospitals rising 68 percent from 2012 to 2021.
Shortage of beds for those in crisis
The document details the failure of the state’s psychiatric bed registry, which was intended to make CSB’s search for a psychiatric hospital bed more efficient.
“Useful real-time information on available psychiatric beds is lacking,” the report said. “Ninety-two percent of CSB staff surveyed with bed search responsibilities indicated that the bed registry was either not useful at all or was not used as part of the bed search process. A review by JLARC staff of the … bed registry in June 2022 showed that 13 of the 25 listed facilities had not updated their availability for at least two days, and some had not updated their availability for months.”
The JLARC report directly states that “Virginia’s psychiatric bed registry wastes limited time and staff resources.”
“There are only three [Residential crisis stabilization units] (RCSU) for Children and Adolescents in Virginia, which has a total of 25 beds. Additionally, not all licensed adult beds are staffed due to CSBs’ ongoing recruitment and retention challenges, and a large portion of Southern Virginia’s population does not have an adult RCSU within an hour’s drive. CSBs serving these areas have admission rates to state psychiatric hospitals significantly higher than statewide rates. Additional state resources may be allocated to fully staff existing RCSUs in the state and to develop additional RCSUs, particularly for children and adolescents and in underserved areas of the state.
Reports by JLARC, legislative committees, and studies by subject matter experts have concluded that Virginia’s CSB system has not been held accountable for providing high-quality services that lead to positive outcomes for people in crisis.
Staffing is also a problem. Planning District 1 CSB, which serves Lee, Scott, and Wise counties and the city of Norton in far southwest Virginia, has the fewest employees (four FTEs in FG21) and is all administrative staff. Planning District 1 CSB contracts with a non-profit organization to provide all behavioral health services.
With mental illness and suicide rates on the rise, the report raises the alarm that these structural problems need to be fixed and funded.
Proposals in the JLARC report include repealing the Code of Virginia requirement that every state facility, community service board, behavioral health authority and private inpatient provider licensed by DBHDS participate in the acute psychiatric bed registry.
The report says CSBs can help reduce pressure on state psychiatric hospital capacity by improving efforts to safely discharge state hospital patients. People who qualify for discharge stay in hospitals an average of 79 days waiting for paperwork.
The JLARC report details the challenges specific to Southwest Virginia: “Expansion of crisis stabilization units would help reduce inappropriate psychiatric hospital admissions and assist with patient discharges… A large portion of Southern Virginia’s population does not have an adult RCSU within an hour’s drive. CSBs serving these areas have admission rates to state psychiatric hospitals significantly higher than statewide rates. Additional state resources may be allocated to fully staff existing RCSUs in the state and to develop additional RCSUs, particularly for children and adolescents and in underserved areas of the state.
Governor’s Mental Health Overhaul Proposal
On Wednesday, Gov. Glenn Youngkin announced a $58 million behavioral health redesign plan, “Right Care, Right Now,” at Parham Doctor’s Hospital in Henrico County. The three-year plan aimed to close treatment gaps to address insufficient crisis care in the state as well as mental health workforce shortages.
“We have a crisis and our behavioral health system is not prepared to deal with it,” Youngkin said at the event.
Youngkin’s proposal pledged $230 million in his new budget, announced Thursday, for behavioral health. The plan calls for fully funding more than 30 new mobile crisis teams and providing better pay for workers, while increasing the mental health workforce. It also develops community-based services and targeted substance abuse and overdose prevention. The funding is aimed at easing the burden on law enforcement in dealing with people in crisis and reducing the criminalization of mental health. Youngkin also said he wants to expand school-based treatment as concerns about youth mental health grow. The governor mentioned the two recent deadly shootings in Charlottesville and Chesapeake, but did not raise the issue of gun control.
Better technology, more capacity needed
In an emailed statement, Health and Human Resources Minister John Littell said the bed registry is just one part of better use of technology across the continuum of care and particularly in crisis services. Littel said Youngkin’s plan seeks to provide day care for individuals experiencing behavioral health crises.
“One of the initiatives is to develop a referrable public health information exchange (eg, automated bed registry, mobile dispatch board, EMS interface),” Littell wrote in the email, referring to the Behavioral Health Plan. health of the governor. “The potential impact is an increase in the use of [the crisis phone line] 988 in crisis needs, including for substance use disorders (SUDs) and other behavioral health crises in addition to suicide prevention.”
Youngkin’s proposal was created in partnership with the Department of Behavioral Health and Developmental Services and the Division of Medical Assistance Services. Littell said he has “spent the last several months listening to stakeholders across the Commonwealth, including health care professionals, community service boards, law enforcement officials, the Virginia ARC, those who serve people with developmental disabilities, people with living experience and much more to understand where change is needed and how we can get there.”
In the JLARC report, Littel said the focus on the mental health workforce and the impact on law enforcement are important “due to a broken Temporary Detention Order (TDO) process.”
“We need to develop more capacity across the system, outside of hospitals, especially through community-based services,” Littell wrote, explaining that the governor’s plan aims to change the current situation, where law enforcement officers spend an average of 51 hours in TDO, while the person in crisis often does not receive critical mental health treatment.
For state Sen. Creigh Deeds, D-Charlottesville, the issue of rapid mental health treatment is a personal one. A decade ago, Deeds’ son, who was going through a mental crisis, stabbed his father and killed himself.
“I hear from CSB officials, from law enforcement, I hear this from people all the time [the bed registry is] it’s not working and basically that’s what the JLARC report says and it says we need to reconfigure it,” Deeds said in a phone interview. “We’re not backing away from the idea, we just want to make sure it works properly.” The worst thing in my opinion is to create the illusion that you are doing something and have people around it when you are not actually doing anything.
Same-day assessment for people going through a mental health crisis is another top priority for Deeds.
“The devil is in the details with everything we do legislatively,” Deeds said. “But I’m glad the governor is at the table.” I’m glad he’s engaged with this issue. The problem is not a one-time thing, and we will not fix it with a lump sum of money. We have chronically underfunded mental health services.’
Deeds points to a crisis response program in Charlottesville that was completely shut down due to lack of funds and staff.
Coordination, funding and accommodation help practitioners
Clinicians serving those experiencing mental health crises say the ability to increase capacity to provide needed care requires a change in funding and salaries for those working in the field.
“It’s a very competitive market for all of us to recruit capable clinicians to provide the care our communities need,” said Robert Trestman, professor and chair of the Department of Psychiatry and Behavioral Medicine at Carilion Clinic and Virginia Tech School of Medicine. Carillion.
Carilion Clinic operates six hospitals and 250 treatment sites in western Virginia, including two inpatient psychiatric hospitals. The system connects to many different CSBs. In Carilion’s emergency rooms, CSB assessors determine whether people in crisis need acute psychiatric hospitalization. (Disclosure: Carilion is one of our donors, but donors have no say in news decisions; see our policy).
“We have to coordinate that,” Trestman said. “We work closely together when we hospitalize someone. We coordinate follow-up care for those with serious mental illness who are in outpatient care in this space.”
Trestman said the coronavirus pandemic has exacerbated the problems identified in the JLARC report.
“The biggest issues here are housing for people discharged from acute care,” Trestman said. “Is there funding … to expand transitional housing with oversight and support to expand partial hospital programs in that space? [We need] things that will provide more intensive care with proper transportation, which is a big challenge in Southwest Virginia for people to get to treatment.