The Client Services Committee of the Hammond Commission met at the Rappahannock Area Community Services Board located at 600 Jackson Street in Fredericksburg, Virginia on Friday, June 18, 1999. The meeting was called to order by the Chairman, James Stewart, at 10:05 A.M. Mr. Stewart introduced the Committee members, Jim Martinez, Director of Mental Health Services for the Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) and staff liaison to the Committee, Martha Mead, Director of Legislation and Public Relations for DMHMRSAS, Roscoe Roberts, Office of the Attorney General, and Ray Burmester, Hammond Commission member.

Members present were: James Stewart, Executive Director of Henrico Area Mental Health and Mental Retardation Services; Henry Altice, Director of PHASES for Blue Ridge CSB; David Carter, resident of Central Virginia Training Center; Beverly Fleming, Chairman of Shenandoah County Board of Supervisors; and Anthony Vadella, President and CEO of Poplar Springs Hospital.

Delegate Weatherholtz is a parent of a mental health consumer. He is also a retired law enforcement officer who transported many individuals with mental health problems. He is concerned about those consumers who receive services, then stop taking their medication and relapse, needing treatment again. Mr. Weatherholtz was informed about "first generation" studies in North Carolina that showed that mandatory outpatient treatment was correlated with reductions in hospitalization. Preliminary results from a "second generation" study suggest that mandatory outpatient treatment reduces hospital readmissions, especially among individuals at high risk for relapse. Delegate Weatherholtz introduced House Bill No. 801 in 1998 that would have added a new section to the commitment laws in Virginia relating to mandatory outpatient treatment. The bill would have established a pilot program of mandatory outpatient treatment in no more than three jurisdictions determined by the DMHMRSAS to have adequate and appropriate resources for such a program. It would have authorized treatment for persons in need of services who were previously hospitalized due to non-compliance with prescribed psychiatric treatment and who are unlikely to obtain this needed treatment without a court order. The Bill would have empowered the CSB to take custody of and deliver the individual to a treatment facility for persuasion and evaluation. HB 801 has not been voted on but was referred to HJR 225 who referred it to the Hammond Commission. A copy of the Bill is filed with these minutes.

Jim Martinez discussed the provisions of the Bill. He explained the criteria for the order, contents of the petition, hearing procedures, rights of the consumer, noncompliance options, and appeals. Mr. Martinez wondered whether the statute would be constitutional under the equal protection clause because of its limited applicability across the Commonwealth. Many states have mandatory outpatient treatment (MOT) laws, even Virginia although it is seldom used because of the practical difficulties in implementing it. Mr. Martinez said that most research shows a correlation between MOT and reduction in hospitalization, but it is impossible to rule out the effects of other factors on the outcome. There was a pilot MOT project at Bellevue Hospital in New York in 1995-98. Both the experimental and control subjects received intensive case management and service coordination, and a statistically significantly smaller proportion of both groups were rehospitalized during the follow-up as compared to the year preceding. There was no indication overall that the court order for MOT produces better outcomes for clients or the community than enhanced services alone.

Additional discussion concerned these issues:

• Budget implications would be modest. Transportation and hearings would involve additional costs. A continuum of basic services would need to be in place for the jurisdictions in the pilot, and most of the consumers involved would already be in the system.
• Coordination and collaboration among the CSB, providers, judiciary, and law enforcement would be necessary.
• Many consumers and advocates view MOT as punitive.
• The role of PACT teams was discussed as part of the service continuum in the MOT project or as an alternative to MOT. It is believed that the jurisdictions that have PACT teams available have an advantage over those areas where it is not available. Variable access to services in the system is an issue.

1. The major providers of SA services in Virginia, which includes the public and private treatment providers, the judiciary, and the criminal justice system, work together collaboratively to ensure that gaps and duplication of services are eliminated, and the best quality of care at the lowest cost for the taxpayer is available.
2. That the Hammond Commission explore a public managed care model for Virginia that includes SA and addictions.
3. Funding be provided for residential bed purchases from public and private providers of adolescent SA treatment.
4. Funding be continued for local and regional jail therapeutic community programs funded by Federal grants that are expiring.
5. Expanded Medicaid coverage for SA and addiction within FY 2000.
6. Funding the statewide implementation of the Healthy Communities / Healthy Youth Collaborative Prevention Initiative.
7. Expanding statewide case management services for substance abusing women who are pregnant or parenting.
8. Creating an adult and adolescent drug court in every judicial district in the Commonwealth.
9. Expanding adult and adolescent treatment services including intensive day treatment, intensive and regular outpatient services, case management and the expansion of current adult residential treatment beds and the purchase of adolescent treatment beds from the private sector.
10. Establishing additional detoxification and stabilization programs for adults and one for adolescents.

Mr. Shank explained that residential services are divided into "housing" (the place to live) and "supports" (the services needed to live successfully in the community).

• He distributed copies of the Interim Report on Senate Joint Resolution No. 159 prepared by the DMHMRSAS, Housing and Community Development, and Virginia Housing Development Authority (VHDA). SJR 159 requested a study of the feasibility of creating a residential alternatives capital fund to meet the housing needs of persons with mental disabilities and SA problems. A choice of stable, affordable housing is a priority for these consumers, who are often reliant on public assistance. A housing finance strategy should include a combination of grants to spur development, very low interest rate loans, and rental assistance to bridge the gap between the consumer's ability to pay and the actual debt costs. Funding for the production of affordable rental units for special needs housing has decreased as the need in this area has increased.

• CSBs reported for the Comprehensive State Plan that about 12,000 individuals were on a waiting list or known to be in need of residential services. Most people with disabilities live with family members, but will need services when caregivers are no longer able to provide them. Another group are those who are expected to be discharged from public facilities.
• Funding for residential services increased by more than $13 million from FY 97 to FY 98. The largest and fastest growing funding source is fees for MR, mostly generated through Medicaid and matched by state general funds.
• There are four residential service models:

1. Highly intensive has the smallest census and provides the individual with 24 hour supervision and is usually inpatient;
2. Intensive can be provided in the community with appropriate services;
3. Supervised is under the control of the CSB and assistance is given with basic community living skills; and
4. Supportive is living with others or alone with some support services available and includes the largest number of consumers.

• Mr. Shank said that a team approach to providing residential services, like PACT, can be very effective in ensuring flexible, responsive staff coverage and helping the disabled to live in the community. One approach is the "Village" Integrated Service System in Los Angeles.
• The projected caseload for residential services in 2004 is estimated by the CSBs to be 60,000 consumers, and would require the number of housing units to more than double to 20,000. Increased reliance on Medicaid would require an alternative source to fund room and board expenses.
• Most CSB clients are unemployed, receive SSI or SSDI, and have very low incomes and cannot pay for their housing costs. Many CSBs have a housing program that provides rental assistance from state general funds to cover the difference between 30% of their monthly income and the actual cost of the housing unit. HUD Fair Market Rents vary across the state with Northern Virginia being the highest.
• Virginia provides monetary supplements called Auxiliary Grants for individuals with mental disabilities who live in Adult Care Residences (ACRs). Other states fund a variety of housing models with Auxiliary Grants. Some Committee members expressed serious concern about the quality of care found in some ACRs and how they are licensed.
• A publicly funded housing capital fund could underwrite the difference between a mortgage and 30% of the individual's monthly income in those cases where ownership is preferable to renting. The average single unit of multifamily housing costs approximately $50,000.
• Mr. Shank said that the goal was to develop a more flexible approach to financing that would allow consumers some choice in housing. Housing requires a dedicated long-term financial commitment.
• He suggested that additional housing might be provided through loan requirements for multifamily low-income housing projects that would set aside a certain percentage of units for persons with mental disabilities.

Ms Schiff believes that a multi-path approach to housing is needed, with consistent funding and the necessary services provided.

• She believes that a dedicated residential development staff should be employed by each CSB. This staff would provide linkage and liaison between the disabilities and service programs and technical knowledge in the housing area.
• She has found that the federal housing law makes it easier to work with the community and makes housing more available and accessible. The Fairfax - Falls Church (FFC) CSB offers a full continuum of housing options based on individual need and choice.
• Ms Schiff believes that appropriate wrap around services are just as necessary as housing for consumers and are usually more costly.
• FFC CSB has developed a strategic housing plan to maximize funding for capital and rental subsidies. The CSB is included in the counties' capital improvements program and will receive bond funding for approved projects. They are partners with the local housing authority and work with nonprofit and faith organizations.

• Ms Schiff is involved with several collaborative efforts with HUD:

• A significant number of the homeless population in shelters are identified as SMI and SA. They are developing both transitional and permanent housing and supports for those individuals; and
• The supportive housing options program is a public-private partnership involving HUD funded rental subsidies and providing some residential options.

• Ms Schiff cautioned that there is growing competition for HUD dollars, and Virginia CSBs may need to look for alternative funding sources.

Mrs. Burmester presented a summary of the VACSB budget proposal for the 2001-2002 Biennium.

• The priority for mental health is to build community services and reduce the use of state facilities. The total budget recommendation is $110.7 million and includes $37.7 million for housing and supports for about 2000 people. Also included in the budget are PACT teams, job placement, use of local hospitals, and medications, psychiatrists, nurses, and case managers.
• The priority for mental retardation is to relieve elderly caregivers and families with emergencies and to support special education graduates. The total budget recommendation is $177.8 million and includes $93.5 million for residential supports for 2,300 identified individuals and $11.6 million for 200 residents who are leaving training centers. Also included in the budget are employment and day support, family support, and a waiver for autism.
• The priority for substance abuse is to promote safe communities and healthy families, treat addiction, and prevent substance abuse. The total budget recommendation is $75.8 million and includes $8 million to establish five regional crisis stabilization facilities and $8 million to establish five regional adolescent treatment facilities. Other budget items include treatment for pregnant women and mothers and offenders.
• The priority for children and family services is to build community services for troubled and disabled children and their families. The total budget recommendation is $66.3 million and includes $13.6 million for residential services for 400 children. Other budget items include crisis intervention, psychiatric services, day treatment, and intensive in-home services.

A panel consisting of William Shelton, Director of the Virginia Department of Housing and Community Development, and Valerie Moore and Barry Merchant of the Virginia Housing Development Authority continued the discussion on residential placements and supports.

Important issues concerning housing in Virginia were discussed. There is a shortage of low cost housing units in the state, and capital is needed to create more units. Funds from the federal government are decreasing, and competition for available funds has increased.

• Mr. Merchant said that there existed a revolving capital fund program in Virginia structured around the use of tax-exempt bonds. It faltered during the period when interest rates were very high, requiring even greater subsidies, and the state and federal budgets experienced severe cutbacks. No recent allocations have been made for this program.
• He said that a major constraint in many areas of the state is the lack of a delivery system for housing. There are not enough sponsors interested in providing housing for the disabled population.
• Mr. Shelton emphasized the areas that he believes are necessary to address in a housing solution:

1. An income stream is necessary to support the debt required to build units and pay fair market rents.
2. Providers need assurance that the stream is dependable and available for the term of debt.
3. Capital will be required to fill the market gaps. Finding affordable housing is a challenge in many areas of the state.
4. Any successful solutions must be jointly planned and implemented by the different agencies that have a stake in this issue.

• He cautioned that HUD is now using a more restrictive definition of homeless programs that precludes using federal funds for individuals discharged from mental health facilities.
• Ms Moore reminded that any start up costs and predevelopment costs need to be included in the financial planning. She believes that education for all of the parties involved, including elected officials, is key to any successful program.

1. A dedicated residential developer for each CSB or combination of CSBs. Ms Schiff was asked to help develop a job description, and the DMHMRSAS was asked to recommend how the CSBs might be grouped;
2. A reliable stream of state funding for rental subsidy should be considered;
3. The Commonwealth should target areas where housing is unavailable, and encourage providers through a capital-funding program. The program could include grants for down payments or low interest loans. The amount of money involved needs to be determined as well as how to ensure its long term availability;
4. Accessibility assistance grants are needed for in-home modifications;
5. Adequate funding is desired for the service supports necessary for living in the community. The following funding options were discussed:

• MR Medicaid waiver;
• Medicaid reimbursable residential service for SMI;
• Psychiatric services; and
• PACT wrap-around services, including Medicaid reimbursement for PACT;

1. Create state and local councils or task forces, including public and private agencies, to address collaboratively the housing and support needs of MI, MR, and SA populations. These task forces could develop strategic plans and identify resources;
2. Providers (vs. facilities) of residential services for the mentally disabled should be licensed by the DMHMRSAS. ACRs serving persons with mental disabilities should be licensed by DMHMRSAS in order to receive auxiliary grants.

Dr. Bentley said that there is a shortage of mental health professionals who are trained to work with persons with severe mental disabilities, and this could affect the quality of care. Virginia needs to address this problem by developing and using all of its resources, including higher education. Dr. Bentley made the following recommendations to the Committee:

• Deliberately recruit individuals from the academic community to participate in the system and work with the universities to get mental health professionals involved in higher education. Dr. Bentley believes this could best be accomplished through joint projects.
• Bring back and expand specialized training grants, especially for social workers because they are the primary providers of professional mental health services. She recommends the development of a certificate program in MR and SMI, and possibly have financial aid tied to service in a public facility.
• Expand dissertation research funding for doctrinal students. This can provide valuable information at a low cost.
• Revive the Galt Scholar program. Dr. Bentley envisions this individual from academia serving in many roles, including chairing a statewide academic advisory committee and coordinating regional conferences for professionals, academics, and students.

Dr. Pandurangi serves as a clinical consultant to Central State Hospital and is the Director of the Schizophrenic Program at MCV. He is concerned that of the 160 medical students at MCV only eight are exposed to Central State and none are exposed to a CSB. These future doctors are unfamiliar with the public mental health system and will be serving patients in their practice with mental disabilities. General practitioners who are not informed about the latest specialized treatments in mental disorders will delay in seeking consultation and referrals to specialists. Psychiatry interns receive one month of experience in a facility and in their last year three months working in a community program. He would like to see a curriculum change to include more public system exposure. Dr. Pandurangi informed the Committee that MCV was conducting research in mental issues, especially biological areas, and the results should be used to benefit the public system. He believes that there should be more collaboration between the public facilities and the academic medical centers.

Dr. Pandurangi recommended to the Committee that the Commonwealth of Virginia take the following actions:

• Encourage and support the state medical schools to develop a strong curriculum on chronic mental illness and public psychiatry with more exposure to the public system;
• Encourage and support academic medical centers to develop a public psychiatry tract within the residency training program;
• Develop and support fellowships in the public system in the areas of SMI, forensic psychiatry, SA, and Child and Geriatric Psychiatry as a part of training;
• Encourage and support applied research pertaining to public psychiatry by providing grants to medical faculty;
• Form regional consortia of CSBs, facilities, and academic medical centers to develop Drug Trial Centers for near-approval medications. The public system should take advantage of this source of advanced treatment and revenue;
• Encourage and support long term contracts for psychiatrists employed or contracted by the public system; and
• Establish an Institute for the Study and Treatment of Serious Mental Illness to serve clients and develop models of treatment.

• Dr. Merwin said that there is a major challenge maintaining a constant work force of competent nurses. The country is beginning another shortage of nurses that she expects to be severe for psychiatric nurses. For example, graduate preparation of psychiatric nurses declined from 1400 in 1980 to less than 500 in 1996. She recommends a long-range plan for recruitment and retention of nurses and nursing staff, incorporating input, collaboration, and active participation from academia.
• She reported that a current positive trend in psychiatric nursing is to add training for the qualifications of family nurse practitioner. The nurse practitioner provides for physical health care needs and psychiatric care and also is able to provide clinical supervision. This field can help improve health care in areas where good primary care is limited. Dr. Merwin recommends that a plan be developed to identify and recruit people for this program of study.
• Dr. Merwin believes that a coordinated statewide plan for continuing nursing education should be developed that integrates the DMHMRSAS and the academic centers.
• She believes that research is an important tool in improving health care. The Southeastern Rural Mental Health Services Research Center is a public academic center that conducts research studies that contribute to the mental health service delivery system. It involves many disciplines and hires students to help with data collection, interviewing, and writing. Most of the studies are externally funded and involve collaboration with DMHMRSAS providers: additional collaborative studies should be considered. The quality improvement efforts of the DMHMRSAS could be integrated with generating research problems, and interdisciplinary academic research teams could be involved in developing research based solutions to the problems.

Dr. Farrell discussed the use of Information Technology in the mental health field. The Center has conducted studies to systematically determine the impact of telemedicine and other technology, and how it can be used to improve patient care. She believes that distance learning as currently being used for nurse practitioners could become a continuing education model for mental health and interdisciplinary training.

Ms Wilson had two recommendations for the Committee:

• The need for accurate diagnosis of mental illness occurring concurrently with mental retardation; and
• The need for nursing services to individuals with severe developmental disabilities in the community.

The next meeting will be in Henrico on July 8, 1999. The Committee will develop the final recommendations for the Executive Committee. The meeting was adjourned at 4:00 P.M.