The Client Services Committee of the Hammond Commission met at the Hampton-Newport News Community Services Board located at 2501 Washington Avenue, 2^nd Floor, in Newport News. The meeting was called to order by the Chairman, James Stewart, at 10:20 A.M. Mr. Stewart introduced the Committee members, Jim Martinez, Director of Mental Health for DMHMRSAS and staff liaison to the Committee, and Dr. Lewis Gallant, Director of Substance Abuse Services for DMHMRSAS.

Members present were: James Stewart, Executive Director of Henrico CSB; Henry Altice, Blue Ridge CSB; The Honorable Thelma Drake, House of Delegates; Beverly Fleming, Shenandoah County Supervisor; David Martin, Pastor at First Baptist Church, Norfolk; and Anthony Vadella, Poplar Springs Hospital.

Chuck Hall, Executive Director for the Hampton-Newport News Community Services Board, welcomed the Committee. He said that they had closely followed the work of the Commission and looked forward to hearing the information scheduled to be discussed.

He introduced James Segall, CSB Board Chairman, who thanked the Commission for their work and wished them well in finding solutions to reform the system.

Mr. Stewart reviewed the Hammond Commission Work Plan for 1999, the Client Services Committee Work Plan, and the meeting agenda.

Mr. Martinez provided an orientation to the involuntary commitment process, including current legislation and information from the Institute of Law Psychiatry and Public Policy Civil Commitment Manual. There have been many changes to the law over the years and a major review and rewrite in 1995. Copies of these materials are filed with these minutes.

Mr. Martinez introduced the following panelists who discussed the process, transportation, consumer experiences, and their concerns:

Ms Marsh talked about how commitment is the most traumatic experience for consumers and their families. These experiences are largely responsible for the family movement. She feels that the main problem is the lack of community services. Ms Marsh offered the following recommendations:

• Increase preventive services - crisis stabilization units, mobile crisis and outreach (different from PACT), and access to psychiatrists – to avoid the necessity of involuntary treatment;
• If no TDO occurs, provide the family with supports to cope with the crisis;
• Offer continuing psycho-education for consumers to help develop insight and take responsibility for their health condition;
• Offer more training for law enforcement officials in mental illness, handling crisis situations and the family perspective (similar to what has been done in domestic violence);
• Offer training for magistrates regarding family and consumer views;
• Treat the family as a secondary client and partner and provide support, greater communication and helpful written information; and
• Increase the number of doctors in the community for medication and consultation.

Ms Engster has experience with the mental health system as a consumer, peer supporter, and provider. She has met with consumers in the Northern Virginia area and they would like to address these issues:

• She feels that emergency mental health services need improvement. Emergency service clinicians need to be the best and most skilled, but are not always properly skilled or trained, especially in the areas of negotiation and crisis resolution. The objective should be to engage consumers, not just move along in the process.
• Most consumers were satisfied with the treatment they received from law enforcement officers, but complained about the use of physical restraints. Local practice varies regarding the use of restraints when transporting individuals, and this issue should be reviewed. It was suggested that mental health professionals, consumers, and law enforcement officers develop a model training program for localities.
• Are TDOs always necessary, or are there alternatives that are less restrictive? Ms Engster would like to see a crisis intervention plan developed that would provide immediate intense services that could stabilize patients and may allow them to go home with caregiver support.
• More in-home services are needed with 24-hour access to outreach workers (including peers) and medication. This would help support families and other primary caregivers, who often have no other supports. This is more difficult to accomplish in rural areas.
• Many consumers were dissatisfied with the legal process and the representation they received from attorneys during commitment, which rarely played out as envisioned in the law. There should be more information for consumers about the process and their legal rights. In addition, a legal defense system similar to the public defender should be investigated for commitment hearings.
• Peer support for the consumer should be included in the process. Often, only blood relatives are recognized.

Lt. Barfield and Capt. Eaves discussed their departments' policies on transporting clients with mental illness and some of their experiences. They agreed that having policies on such issues as using restraints were for the protection of the consumer as well the public and the officers. They raised questions about how much discretion officers could use in enforcing the policies and whether someone could provide transportation other than a law enforcement officer.

Ms Romano discussed the role of the Community Services Boards in the involuntary commitment process, including many examples from the Prince William area. Although they are only one of the agencies included, CSBs are very involved in the process, even more so since 1995. CSBs are responsible for many things such as assessments, prescreening forms, advising the special justices, coordinating hearings and providing the inpatient beds. Their main concern is the welfare of the clients, and they help to coordinate all of the players in the process.

Ms Romano recommended that the following issues be considered:

• In many areas, written information is provided by CSBs to consumers and their families, but it should be available statewide;
• There should be a chief special justice to help with coordination and communication among judicial officers;
• Commitment laws for juveniles are very complicated and should be revised;
• Commitment hearings should be held in the same jurisdiction as the consumer’s home, and in the hospital used for temporary detention if possible. This would maximize family participation and decrease transportation needs;
• Prince William CSB provides in-home assessment only for the elderly. Mobile teams for additional in-home assessments and services are needed. The WINTEX project in Northern Virginia has been helpful in keeping consumers near home and hospitalization to a minimum. In Prince William, patients may be admitted directly to psychiatric units rather than going through emergency rooms, if no medical issues are involved; and
• Data on hearings and commitments statewide is not readily available or useable, and better data would be helpful.

Ms Minton served on the Hospital Association and CSB task force that reviewed the TDO process in 1995. She addressed many of the issues that had been raised and commented that regulatory guidelines (e.g., EMTALA) and confidentiality laws often handicap private providers in seeking ways to expedite or assist in the process, and often leave families out of the process altogether. She urged that:

• There be continued collaboration between the public and private sectors;
• Parents, peers and significant others be allowed to become more involved in the process to enhance communication among providers, CSBs, and family members or others providing support to consumers; and
• Judges consider consumers’ capacity more thoroughly.

Derek Curran, Emergency Services Director for Hampton-Newport News CSB and

Nora Butler, Western Tidewater CSB also provided comments and perspectives during the above discussions.

1. Programs aimed at preventing crises should be expanded. Creative crisis stabilization alternatives, mobile teams (not the same as PACT), and increased use of the private sector are warranted;
2. Access to physicians, during both the emergency/crisis phase and throughout treatment, should be increased;
3. Collaborative training efforts should be undertaken among public and private providers, judicial officers, law enforcement officers, attorneys and others involved in the process;
4. Families should receive more support in times of crisis through telephone access to service providers, in-home mobile teams, etc. Information-sharing among involved providers and other officials, to families and significant others, should be standardized;
5. Juvenile involuntary commitment laws should be reviewed and revised as necessary;
6. CSBs should put their most clinically skilled, compassionate, problem-solving staff into emergency service positions, then support them in this role through compensation and other supports. CSBs should solicit consumer and family member feedback about emergency services and ES staff, and use this information to improve clinician skills and emergency services;
7. A system should be developed to train and monitor the practices of special justices, attorneys and independent evaluators in the involuntary commitment process. The system should ensure consistency of quality and practice across the Commonwealth. [Note: A suggestion was made for the Supreme Court and State Bar to develop such a system. Delegate Drake volunteered to investigate this issue and report to the Committee]; and
8. More emphasis should be given to consumer and family education, including psycho-education for consumers regarding self management of their condition.

1. Citizens of the Commonwealth who abuse, are addicted to, or are at risk to abuse or be addicted to drugs and alcohol, should be able to access the appropriate level of services;
2. The publicly funded SA services system will provide fully funded SA services that are effective, based on best practices, and maintained at a level that addresses documented need. The Governor’s Council on Alcohol and Drug Abuse should monitor and report annually; and
3. Providers will evaluate and monitor service delivery to ensure accurate data is available for the ongoing provision of quality care and services.

1. The major providers of SA services work together collaboratively to avoid gaps and duplications of services and to ensure the best quality of care at the lowest cost;
2. The Hammond Commission explore a managed care model for Virginia that includes SA and addiction and allows the purchase of services from the private sector;
3. Funding for residential bed purchases from public and private providers of adolescent SA treatment should be considered;
4. Continuation of funding for local and regional jail therapeutic community programs funded by federal grants that are expiring;
5. Request that DMAS provide Medicaid coverage for SA and addiction within FY 2000;
6. Support the statewide implementation of the Healthy Communities / Healthy Youth Collaborative Prevention Initiative;
7. Expand statewide case management services for substance abusing women who are pregnant or parenting;
8. The Supreme Court should conduct a research project and consider expanding the availability of adult and adolescent drug courts to every judicial district in Virginia;
9. Expand adult and adolescent treatment services that include intensive day treatment, intensive and regular outpatient services, case management, and residential treatment beds; and
10. Establish additional detoxification and stabilization programs for adults and adolescents to help divert clients from psychiatric facilities to the community.

The next meeting will be on June 18, 1999 at the Rappahannock Area Community Services Board in Fredericksburg. The topics for discussion will be Delegate Weatherholz’ proposal on mandatory outpatient commitment, residential placements and supports, and the role of Virginia’s academic medical centers.

The meeting was adjourned at 3:00 P.M.