A new report out this week laid out the life-or-death problems facing Virginia’s Community Services Board’s (CSB) Behavioral Health Services and the people who use those services, and laid out suggested fixes to address those issues.
The Virginia nonpartisan Joint Legislative Audit and Review Commission’s (JLARC) 136-page report, “CSB Community Services Board Behavioral Health Services,” described organizational and funding issues facing the system, including a state’s bed registry that is useless and out of date.
State law requires every 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 delivered at over 500 offices, with each CSB operating between two and 34 service locations, providing crisis services. Southwest Virginia’s region 3 CSB encompasses Blue Ridge, Cumberland Mountain, Danville-Pittsylvania, Dickenson, Highlands, Mount Rogers, New River Valley, Piedmont, Planning District One and Southside.
The JLARC report highlighted distinct mental health issues facing Southwest Virginia:
- CSBs serve a greater proportion of adults with a serious mental illness who reside in Southwestern and the northern Shenandoah Valley 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 consumers receiving behavioral health services increased nearly 10 percent in Southwest Virginia.
The report quantified the fact that mental health needs have increased throughout Virginia with admissions at the nine state psychiatric hospitals up 68% from 2012 to 2021.
A shortage of beds for those in crisis
The document describes in detail the dysfunction of the state’s psychiatric bed registry, which was intended to make CSBs’ search for a psychiatric hospital bed more efficient.
“It lacks real-time, useful information about the psychiatric beds available,” the report said. “Ninety-two percent of surveyed CSB staff with bed search responsibilities indicated that the bed registry was either not at all useful or not being used as part of their bed search process. A JLARC staff review of the … bed registry in June 2022 showed that 13 of the 25 facilities listed had not updated their availability in at least two days, and some had not updated their availability in months.”
The JLARC report directly states 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 operate only 25 beds in total. Additionally, not all licensed beds for adults are staffed because of CSBs’ current recruitment and retention challenges, and a large portion of Southside Virginia’s population does not have an adult RCSU within a one-hour drive. CSBs that serve these areas have state psychiatric hospital admission rates significantly higher than the statewide rate. Additional state resources could be devoted to fully staffing the state’s existing RCSUs and to developing additional RCSUs, particularly for children and adolescents and in underserved areas of the state.”
JLARC reports, legislative commissions and studies from subject-matter experts have concluded that Virginia’s CSB system has not been held accountable for delivering high quality services that produce positive outcomes for people in crisis.
Staffing is also an issue. 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 FY21), and all its staff are administrative. Planning District 1 CSB contracts with a nonprofit to provide all behavioral health services.
With mental illness and suicide death rates rising, the report raises the alarm that these structural problems must be fixed and funded.
Suggestions in the JLARC report include repealing the requirement in the Code of Virginia that every state facility, community services board, behavioral health authority, and private inpatient provider licensed by DBHDS participate in the acute psychiatric bed registry.
The report said CSBs could help reduce pressure on state psychiatric hospital capacity by improving their efforts to safely discharge state hospital patients. People who were eligible for discharge remained in hospitals an average of 79 days because they were waiting for paperwork.
The JLARC report detailed challenges specific to Southwest Virginia: “Expanding residential crisis stabilization units would help reduce inappropriate psychiatric hospital placements and help with patient discharge…. A large portion of Southside Virginia’s population does not have an adult RCSU within a one-hour drive. CSBs that serve these areas have state psychiatric hospital admission rates significantly higher than the statewide rate. Additional state resources could be devoted to fully staffing the state’s existing RCSUs and to developing additional RCSUs, particularly for children and adolescents and in underserved areas of the state.”
Governor proposal mental health overhaul
On Wednesday, Gov. Glenn Youngkin announced a $58 million behavioral health redesign plan, “Right Help, Right Now,” at Parham Doctor’s Hospital in Henrico County. The three-year plan aimed at closing treatment gaps to address the insufficient crisis care in the state as well as mental health workforce shortages.
“We have a crisis, and our behavioral health system is not equipped 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 called 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 disorder and overdose prevention. The funding is aimed to relieve law enforcement’s load addressing people in crisis and reducing the criminalization of mental health. Youngkin also said he wanted to expand school-based treatment as concerns for youth mental health grows. The Governor referenced the two recent fatal shootings in Charlottesville and Chesapeake, but he did not bring up gun control.
Better technology, more capacity needed
In an emailed statement, Secretary of Health and Human Resources John Littel said a bed registry is just one part of better utilizing technology across the continuum of care and especially in crisis services. Littel said Youngkin’s plan strived to ensure same-day care for individuals experiencing behavioral health crises.
“One of the initiatives is to develop a Public Health Information Exchange with referral capability (e.g., automatic bed registry, mobile dispatch dashboard, ED interface),” Littel wrote in the email, referencing the Governor’s Behavioral Health Plan. “The potential impact is to increase in utilization of [the crisis phone line] 988 across crisis needs, including for Substance Use Disorders (SUD) 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 Department of Medical Assistance Services. Littel said he has “spent the last several months listening to stakeholders across the Commonwealth, including health care professionals, community services boards, law enforcement officials, the ARC of Virginia, those who serve individuals with Developmental Disabilities, people with lived experience, and many more, to understand where change is needed and how we can get there.”
In the JLARC report, Littel said the emphasis on the mental health workforce and the impact on law enforcement was important “because of a broken temporary detention order (TDO) process.”
“We must develop more capacity throughout the system, beyond hospitals, especially through community-based services,” Littel wrote, explaining the Governor’s plan aims to change up the current situation where on average, law enforcement officers spends 51 hours on a TDO, while the person in crisis is often not getting critical mental health treatment.
A personal mission
For State Sen. Creigh Deeds, D-Charlottesville, the issue of prompt mental health treatment is personal. A decade ago, Deeds’ son, who was going through a mental health crisis, stabbed his father and killed himself.
“I hear from CSB employees, from law enforcement, I hear from people all the time that [the bed registry is] not working, and that’s essentially what the JLARC report said, and it said we need to refigure it,” Deeds said in a phone interview. “We’re not retreating from the idea, we just want to make sure it’s working properly. The worst thing, I think, is to create an illusion that you’re doing something and have people around it when you’re not actually doing anything.”
Same day assessment for people going through a mental health crisis is another top priority for Deeds.
“The devil’s in the details with respect to anything we do legislatively,” said Deeds. “But I’m glad the governor’s at the table. I’m glad he’s engaged in this issue. It’s not a one-time problem and we’re not going to fix it with one-time 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 housing helps practitioners
Clinicians serving those who are experiencing mental health criseses say the ability to grow capacity to provide the needed care requires changing the fund and the salaries for those working in this field.
“It’s a very competitive market for all of us to recruit capable clinicians to deliver the care our communities need,” said Robert Trestman, professor and chair of Psychiatry and Behaviorial Medicine at Carilion Clinic and the Virginia Tech Carilion School of Medicine.
Carilion Clinic operates six hospitals and 250 locations of care on the western side of Virginia including two inpatient psychiatric hospitals. The system interfaces with numerous different CSBs. In Carilion emergency departments 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,” said Trestman. “We work closely when we hospitalize someone. We coordinate the aftercare for those with serious mental illness who are in ambulatory care in this space.”
Trestman said the coronavirus pandemic exacerbated issues brought out in the JLARC report.
“The biggest issues here are housing for people being discharged from acute care,” said Trestman. “Is there funding … to expand transitional housing with supervision and support for expansion of partial hospital programs within this space? [We need] things that will provide more intensive care with adequate transportation, which is a major challenge in Southwest Virginia for people to get to treatment.”