State Mental Health Hospitals Under Pressuresfc.virginia.gov/pdf/retreat/2016...
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CITY AND COUNTY OF SAN FRANCISCO OFFICE OF THE CITY ATTORNEY JOANNE HOEPER TO: CC: FROM: DATE: RE: DENNIS J. HERRERA City Attorney Chief Trial Deputy DIRECT DIAL: (415) 554-3917 E-MAIL: [email protected] MEMORANDUM PRIVILEGED & CONFIDENTIAL DENNIS J. HERRERA TERRY STEWART JOANNE HOEPER Chief Trial Deputy Juiy 18, 2012 DRAFT REPORT OF INVESTIGATION In response to referrals from law enforcement, we undertook to investigate the City's payment of claims related to alleged damage to sewer laterals. This draft report summarizes our investigation and findings thus far. It incorporates the work of George Cothran, Dave Jensen, Blanche Blachman and Ron Flynn. There are a number of important issues that are unresolved and a significant amount of investigation that we could not complete before submitting this report. We therefore list additional investigation that could shed further light on this situation. We conclude by recommending changes that you may wish to consider in light of what has been uncovered thus far. INITIATION OF INVESTIGATION -- REFERRAL FROM LAW ENFORCEMENT In late December 2012, Jo Hoeper received a call from Bruce Whitten, Special Agent in charge of the public corruption unit in the FBI San Francisco Office. Whitten told Hoeper that the FBI had received reports of a possible scheme being perpetrated against the City involving fraudulent claims for sewers allegedly damaged by the roots of City owned trees. They discussed the general outlines of the scheme and Hoeper said she would make inquiries. On December 27, Hoeper sent an email to the Trial Team, the Claims Team (including Mike Haase) and the general counsel of the relevant departments. Brian Cauley responded and said that he and Haase were well aware of the scheme and that they took steps to identify and deny fraudulent claims. (The email and Haase's adoption of it is discussed on page 18). Also in late December, an investigator from the San Francisco District Attorney's Office mentioned to George Cothran that he had received a complaint about a scheme involving fraudulent sewer repair claims. Hoeper spoke to FBI Special Agent Katherine Klueber, who had been assigned by Whitten to investigate. In that conversation, Hoeper learned that the FBI had first received a tip about a possible sewer scheme involving the City in June 2007. That complaint apparently had been closed without action and the City had not been notified. In March 2011, the FBI received a second detailed complaint from an anonymous source. The source gave a statement to a retired prosecutor, who passed it on to the FBI. Cothran and Hoeper met with Klueber on February 23, 2012 and were given a copy of the 2011 statement (attached). HIGHLY CONFIDENTIAL Fox PLAZA . 1390 MARKET STREET, SIXTH FLOOR. SAN FRANCISCO, CALIFORNIA 94102-5408 RECEPTION: (415) 554-3800 · FACSIMILE: (415) 554-3837 n:\lit7\as2012\ 1200491 \00785328.doc SFCA000029427 Exhibit 23 Page 1 of 42 23
Transcript of State Mental Health Hospitals Under Pressuresfc.virginia.gov/pdf/retreat/2016...
SENATE FINANCE COMMITTEE
SENATE OF VIRGINIA
Senate Finance Committee
November 17, 2016
State Mental Health Hospitals Under Pressure:
Current Challenges and Future Role
SENATE FINANCE COMMITTEE
Presentation Overview
Topics covered in this presentation:
• Brief Background on Mental Health Care in America
• Background on the State Mental Health System
• Trends for the State Mental Health Hospitals in the Commonwealth and Challenges
• The Future Role of the State Mental Health Hospital in a Community-Based System
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SENATE FINANCE COMMITTEE
Virginia Built the First Public Psychiatric Hospital in America
• The first public hospital to care for the mentally ill was opened in October 1773, in Williamsburg.
• The facility had 24 beds and only admitted persons considered to be curable or dangerous.
• Prior to the creation of the hospital, mentally ill persons were typically confined to jail.
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The Public Hospital for Persons of Insane and Disordered Minds
SENATE FINANCE COMMITTEE
Timeline of Mental Health Care and Deinstitutionalization in America
1773 1825 - 1841 1954 1963 1965 - 1977 1999 2003 2016
First public hospital to treat the
mentally ill opened in
Williamsburg
Reform movement begins and Dorothea Dix begins
her advocacy
work
Introduction of new
drugs, i.e. Thorazine
Over
550,000 people in
state mental
institutions nationally
President Kennedy signs the
Community Health
Centers Act
Medicaid and SSI
programs begin
State
mental hospital
population drops to
160,000 by 1977
Supreme Count rules
in Olmstead Case on
Community Integration
and Choice
37,000 State
Mental Health
Hospital Beds
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President Bush’s New
Freedom Commission on Mental
Health
SENATE FINANCE COMMITTEE
Deinstitutionalization Impact
• Rapid deinstitutionalization of state mental health hospitals began in the 1960’s. In 1970, the average daily census was over 9,300, and is down to about 1,300 today.
• It is generally accepted that neither the federal government nor state governments provided adequate resources to fully develop the community capacity needed to treat individuals with serious mental illness as deinstitutionalization occurred.
• The resulting impact is high numbers of the mentally ill in jail and in the state correctional system, utilizing emergency rooms in crisis, and among the homeless.
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Virginia Mental Health Hospital Average Daily Census (1976 -2012)
SENATE FINANCE COMMITTEE
8 Major Virginia Mental Health Studies Since 1971
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1971 Hirst Commission Commission on Mental, Indigent and Geriatric Patients
1979 JLARC Report on Deinstitutionalization and Community Services
1980 Bagley Commission Commission on Mental Health and Mental Retardation
1986 Emick Commission Commission on Deinstitutionalization
1986 JLARC Report on Deinstitutionalization and Community Services
1997 Rhodes Commission Joint Subcommittee to Study the Effects of Deinstitutionalization
2000 Gartlan Commission
Joint Subcommittee to Evaluate the Future Delivery of Publicly Funded Mental Health, Mental Retardation and Substance Abuse Services
2014 -2017
Deeds Commission Joint Subcommittee to Study Mental Health Services in the Commonwealth in the 21st Century
SENATE FINANCE COMMITTEE
Why is the Public Mental Health Care System so important?
• In 2014, 18% of adults (over 1.1 million) in Virginia were identified as having a mental illness and about 3.8% or 240,000 Virginians had a serious mental illness.
• Estimates place the number of children and adolescents in Virginia with serious emotional disturbance at 100,000.
• Nationally, 24% (104,000) of homeless adults are considered seriously mentally ill.
• 6,554 (16.4%) inmates in local and regional jails have a mental illness.
• The cost to the state through the criminal justice system, along with the economic impact of mental illness on society, affects every Virginian.
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Sources: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013 and 2014; NIMH Data; and 2015 U.S. Housing and Urban Development Survey.
SENATE FINANCE COMMITTEE
What is the Public Mental Health System in Virginia?
• Nine state psychiatric hospitals (eight for adults and one for children) provide inpatient hospital care with a capacity of 1,491 beds.
• Community-based services are provided through a system of 39 Community Services Boards and one Behavioral Health Authority established in 1968. – Mandated to provide case management and emergency services. – Other services include outpatient services, day support, residential, and
employment services.
• Private providers, reimbursed through Medicaid, also play a major role in providing mental health services.
• State correctional facilities and local and regional jails hold several thousand offenders with serious mental illness.
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SENATE FINANCE COMMITTEE
The Public Mental Health System Serves Many In Need
• In FY 2015, 118,919 individuals received mental health services from Community Services Boards and 32,964 received substance abuse services. – 70% were adults and 30% were children.
• Of the adults, 65% had a serious mental illness and of the children,
77% had a serious emotional disturbance.
• About 68% of total CSB spending in FY 2015 was for mental health and substance abuse services ($720 million).
– Approximately 55% of the individuals receiving mental health services were
covered by Medicaid.
• In FY 2015, 5,814 individuals received services in state mental health hospitals, with annual expenditures of $341.2 million (total funds).
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SENATE FINANCE COMMITTEE
Map of the Community Services Boards
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1 Alexandria 11 Danville-Pittsylvania 21 Highlands 31 Prince William
2 Alleghany Highlands 12 Dickenson County 22 Loudoun County 32 Rappahannock-Rapidan
3 Arlington County 13 District 19 23 Middle Peninsula-Northern Neck 33 Rappahannock Area
5 Horizon Behavioral Health 14 Eastern Shore 24 Mount Rogers 34 Region Ten
4 Blue Ridge Behavioral 15 Fairfax-Falls Chruch 25 New River Valley 35 Richmond
6 Chesapeake 16 Goochland-Powhatan 26 Norfolk 36 Rockbridge Area
7 Chesterfield 17 Hampton-Newport News 27 Northwestern 37 Southside
8 Colonial Behavioral Health 18 Hanover County 28 Piedmont 38 Valley
9 Crossroads 19 Harrisonburg-Rockingham 29 Planning District One 39 Virginia Beach
10 Cumberland Mountain 20 Henrico Area 30 Portsmouth 40 Western Tidewater
SENATE FINANCE COMMITTEE
Current System of State Psychiatric Hospitals
Hospital Beds Location Eastern State Hospital 302 Williamsburg Central State Hospital 277 Petersburg Western State Hospital 246 Staunton Southwestern Virginia Mental Health Institute 179 Marion Northern Virginia Mental Health Institute 134 Falls Church Piedmont Geriatric Hospital 123 Burkeville Catawba Hospital 110 Catawba Southern Virginia Mental Health Institute 72 Danville Commonwealth Center for Children and Adolescents 48 Staunton Total 1,491
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SENATE FINANCE COMMITTEE
How is the Public Mental Health System Funded?
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Community Services Boards
43%
State Hospitals 19%
Central Office Support
3%
Medicaid* 35%
FY 2015 Total Public Funding = $1.75 billion (Does not include Dept. of Corrections or Jails)
*Excludes Medicaid Payments to CSBs and state mental health hospitals. Source: Data provided by DMAS and DBHDS.
SENATE FINANCE COMMITTEE
Virginia is Lagging the National Transition to Community Services
66%
51%
35%
29% 26% 26%
30%
46%
63%
69% 72% 72%
0%
10%
20%
30%
40%
50%
60%
70%
80%National % of State Mental Health Agency Expenditures by Setting
Hospital Expenditures
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Source: National Association of State Mental Health Program Directors
Virginia is currently about 50/50.
Community Expenditures
SENATE FINANCE COMMITTEE
State Support for Community Services Has Grown
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2007 2008 2009 2010 2011 2012 2013 2014 2015 2016Other $18.6 $22.3 $22.8 $25.7 $25.8 $21.8 $23.1 $23.1 $25.7 $27.2Federal $54.0 $53.8 $52.3 $53.5 $53.8 $55.5 $54.5 $53.7 $53.4 $54.9Fees $191.0 $212.7 $226.1 $236.7 $248.0 $254.4 $264.9 $251.6 $256.5 $267.1Local Funds $132.3 $143.7 $141.3 $144.1 $139.1 $150.3 $157.6 $161.8 $160.5 $164.2State Funds $193.0 $203.6 $210.1 $219.6 $227.2 $230.9 $231.5 $241.4 $251.6 $281.4
$0
$100
$200
$300
$400
$500
$600
$700
$800
$900
Mill
ions
Community Services Boards Mental Health and Substance Abuse Services Expenditures (Prior 10 Fiscal Years)
SENATE FINANCE COMMITTEE
State Hospital Spending
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$206 $220 $205 $201 $213 $212 $226 $229 $256
$281
$77 $88 $99 $88 $80 $77 $71 $70
$85 $77
$0
$50
$100
$150
$200
$250
$300
$350
$400
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Mill
ions
State Mental Health Hospital Expenditures By Funding Type
General Fund Special Funds
Note: Special funds are revenue from Medicaid, Medicare, commercial insurance and private pay.
SENATE FINANCE COMMITTEE
State Hospital Revenues and Expenditures
Note: Except for children and geriatric patients, Medicaid does not pay for inpatient psychiatric care for adults (IMD Exclusion).
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Medicaid 58%
Medicare 22%
Private Ins. 7%
Other Revenue
13%
FY 2016 NGF Revenue $55.6 million
Staffing Costs 77%
Operational 22%
Equipment and
Property 1%
FY 2016 Expenditures $358.2 million (All Funds)
SENATE FINANCE COMMITTEE
Hospital Cost per Bed Averages $237,000 Annually
Hospital Beds FY 2016 Cost /
Bed Eastern State Hospital 302 $236,282 Central State Hospital 277 $254,613 Western State Hospital 246 $245,626 Southwestern Virginia Mental Health Institute 179 $223,364 Northern Virginia Mental Health Institute 134 $236,420 Piedmont Geriatric Hospital 123 $248,462 Catawba Hospital 110 $216,436 Southern Virginia Mental Health Institute 72 $236,025 Commonwealth Center for Children and Adolescents 48 $270,726
Average $237,142
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SENATE FINANCE COMMITTEE
Issue for State Hospitals: 2014 Law Changes
• Bed of Last Resort (SB 260) – Changed the law to make state hospitals accept individuals under a
Temporary Detention Order (TDO) if no other willing facility is found.
– Since July 1, 2014, no individual has gone without a bed.
• Emergency Custody Orders (ECO) and TDO Timeframes (SB 260) – Extended the maximum period of a TDO from 48 to 72 hours.
– Extended the maximum length of time an ECO is valid to eight hours, up from six hours.
• Acute Psychiatric Bed Registry (SB 260) – Required the creation of a web-based psychiatric bed registry to facilitate
the identification and designation of facilities for the temporary detention.
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SENATE FINANCE COMMITTEE
Increase in Emergency Evaluations
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83,701 96,041
22,804 25,816
010,00020,00030,00040,00050,00060,00070,00080,00090,000
100,000
FY 2015 FY 2016
EmergencyEvaluationsTDOs
FY 2015 27.2% of Emergency Evaluations resulted in TDOs
FY 2016 26.7% of Emergency Evaluations resulted in TDOs
In FY 2016, an average of 263 emergency evaluations and 71 TDOs were issued daily.
SENATE FINANCE COMMITTEE
State Hospitals Took 66% of the Increase in TDOs in the Past Year
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0
5,000
10,000
15,000
20,000
25,000
30,000
FY 2015 FY 2016
State Hospitals
Private Hospitals
FY 2015 22,804 TDOs - 21,263 went to private hospitals (93%)
FY 2016 25,798 TDOs - 22,321 went to private hospitals (86.5%)
Private hospitals cite: Behavioral and medical acuity, and clinically inappropriate.
SENATE FINANCE COMMITTEE
Admissions Have Increased for All Hospitals
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0-49% 50-99% 100%+
FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 % Increase Since FY 2012
Catawba 223 249 244 345 456 104% Central 545 514 521 620 799 47% CCCA 775 691 833 931* 1,018* 31% Eastern 248 242 569 628 766 209% NVMHI 763 693 546 822 1,059 39% Piedmont 62 59 74 115 105 69% SVMHI 287 261 310 282 374 30% SWVMHI 756 720 772 730 931 23% Western 585 530 671 786 832 42%
TOTAL 4,330 3,959 4,275 5,087 6,340 46%
* Includes admissions to contracted beds at Popular Springs Hospital.
SENATE FINANCE COMMITTEE
Hospital Bed Utilization Capacity is Routinely Above 85%
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Facility Beds Aug. 23, 2016
Catawba Hospital 110 98.2
Central State Hospital 277 88.4
Eastern State Hospital 302 99.7
Northern Virginia Mental Health Institute 134 90.3
Piedmont Geriatric Hospital 123 99.2
Southern Virginia Mental Health Institute 72 93.1
Southwestern Virginia Mental Health Institute 179 96.6
Western State Hospital 246 96.7
Source: Department of Behavioral Health and Developmental Services
SENATE FINANCE COMMITTEE
Short-Term Challenges for State Hospitals
• Bed of Last Resort Legislation – Has resulted in increased admissions and, combined with an increase in
TDOs, has pushed the capacity of the state hospitals beyond best practices.
– In addition, much of the capacity is being used for TDOs rather than the typical use of state hospital beds (civil and geriatric commitments).
• Extraordinary Barriers to Discharge List – State hospitals maintain a list of patients that have been clinically ready for
discharge for 30 days but lack the family and community supports to be discharged.
– The list typically has from 150 to 180 individuals on it at any onetime.
– Typical barriers to discharge are lack of housing and guardianship.
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SENATE FINANCE COMMITTEE
What Are the Short-Term Options to Handle These Challenges?
• Rebalance TDO admissions with Private Hospitals – Fully understanding the reasons why private hospitals are not able to handle the
increase in TDOs is critical. The Virginia Hospital and Healthcare Association recently surveyed members to
get more data to better understand the issue. – The Department of Behavioral Health and Developmental Services is working with
private hospitals to provide short-term assistance to secure more beds for TDOs in private hospitals.
– If funding is an issue, the state could explore higher rates for TDOs (currently paid at Medicaid rates) to incentivize private hospitals.
– Provide additional funds for Local Inpatient Purchase of Service (LIPOS) program to facilitate private hospital admissions.
• Provide Additional Community Supports to Reduce the Extraordinary Barriers to Discharge List
– Provide additional funding for permanent supportive housing. – Explore options in Medicaid to cover supportive housing services. – Fund additional public guardianships. – Provide additional Discharge Assistance Planning funds.
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SENATE FINANCE COMMITTEE
State Hospitals Have a Future Role in a Community-Based System
• The need for state mental health hospital beds will continue. The role of the state hospital should be limited to being the system’s safety net.
– Future advancements in behavioral health drugs and a robust community services system may minimize the need for state hospital psychiatric beds.
• The Commonwealth needs to balance psychiatric hospital care with the capabilities of the community system.
– As the community-based mental health system develops overtime we will be able to better determine the appropriate number of state hospitals/beds needed at any onetime.
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SENATE FINANCE COMMITTEE
Virginia Has a High Number of Mental Health Hospitals
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SENATE FINANCE COMMITTEE
Virginia has a High Number of Beds per 100,000 Population
State Beds per 100,000 Rank
Wyoming 34.3 1 North Dakota 18.5 2 Virginia 18.2 3 New Jersey 17.2 4 Connecticut 17.1 5 Montana 16.8 6 New York 16.3 7 Mississippi 16.2 8 Oregon 16.2 9 Maryland 15.8 10
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State Beds per 100,000 Rank
Utah 8.4 41 Texas 8.1 42 Wisconsin 7.9 43 Alabama 7.9 44 Arkansas 7.5 45 Michigan 7.3 46 Arizona 4.4 47 Vermont 4.0 48 Minnesota 3.5 49 Iowa 2.0 50
10 Lowest States 10 Highest States
National Average = 11.7 Source: Treatment Advocacy Center
SENATE FINANCE COMMITTEE
What are the Long-Term Challenges for State Hospitals?
• Size of the Hospital System – Funding for hospitals versus community services. – How many hospitals does the Commonwealth need? – How many beds are necessary?
• Aligning Financial Incentives for the Use of State Hospitals
– The Community Services Boards determine admissions to the state hospitals and there is no cost to the community.
• Capital Needs – The current system of nine hospitals has significant capital needs totaling
over $235 million. – Replacement of Central State Hospital is the highest priority.
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SENATE FINANCE COMMITTEE
Long-Term Challenges for State Hospitals (continued)
• Workforce – The state hospitals compete with the private sector for nurses and mental
health professionals.
– Shortages of professionals along with state pay practices make it harder for the state hospitals to compete and retain staff.
• Management and Operations – Ensuring that the hospitals operate as a system rather than individual
hospitals.
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SENATE FINANCE COMMITTEE
Long-Term Options to Consider
• Conduct a Comprehensive Review of the State Hospital System – Evaluate both the number of hospitals and bed capacity the system needs.
– Evaluate financial incentives related to the use of state hospital beds versus other community options.
– Determine the appropriate management and operational structure for the system of hospitals.
– Develop outcome measures for the system.
– Develop a plan for meeting the capital needs of the future system.
– Consider options to improve workforce issues.
• Develop a caseload forecasting capability for the entire mental health system – This tool would allow policymakers to better understand the demand in the
system and develop appropriate plans to better meet community needs.
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SENATE FINANCE COMMITTEE
Long-Term Options to Consider (continued)
• Evaluate the Effectiveness of Discharge Assistance Planning (DAP) funding – Nearly $21 million a year is spent on DAP, which is used to pay for
supports in the community to discharge individuals from state hospitals. – One option to explore is using some of the funding to support certain
initiatives (i.e. group homes) that assist more than just one individual.
• Explore creating a stand-alone mental health agency – An agency dedicated to only mental health and substance abuse may
provide greater focus on the issues facing the system. – Developmental services could be moved and combined with other
agencies to create a larger agency focused on services for individuals with disabilities.
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SENATE FINANCE COMMITTEE
Conclusions
• Virginia’s Mental Health System must continue moving toward a more robust community-based system to ensure treatment of the mentally ill in appropriate settings.
• In the short-term, Virginia needs to maintain the current level of state mental health hospital beds due to the increase in TDO admissions until such time that the demand for beds has lessened.
• In order to relieve the pressure on the state mental health hospitals, Virginia should incentivize private hospitals to handle more TDOs and provide alternative placements in discharging patients on the Extraordinary Barriers Discharge List.
• In the longer-term, as Virginia continues to invest and develop a consistent and robust community system of care, the size of the mental health hospital system could be downsized commensurate with the need.
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