The Management and Operations Committee of the Hammond Commission met at the Northwestern Community Services Board in Front Royal on Friday, June 4, 1999. In the absence of the chairman, Senator Emmett Hanger called the meeting to order at 10:25 A.M. and introduced the members of the Committee. Those present were: The Honorable Emmett Hanger, Senate of Virginia; The Honorable Charles Colgan, Senate of Virginia; and Vickie Fisher, Mental Health Association of Virginia. Senator Hanger also introduced Charline Davidson, Director of Planning and Regulations for the DMHMRSAS, Mr. Beverly Fleming, Hammond Commission member, and Garland Bigley, Office of the Attorney General.

David M. Ziegler, Executive Director of Northwestern Community Services Board

Mr. Ziegler welcomed the Committee, distributed a brochure and other information about Northwestern CSB, and presented an overview of the programs and services provided there. Northwestern serves about 5,000 individuals annually from the City of Winchester and the Counties of Clarke, Frederick, Shenandoah, Page, and Warren. Mr. Ziegler believes that his CSB represents many of the strengths and values of the community services system. He feels that they are responsible for and responsive to the needs of the citizens and have built a great team. They integrate care and blend resources and have the largest homeless program in rural Virginia. He spoke to a pending grant application for Virginia Health Care Foundation funds to integrate primary and behavioral health care services at the center. Mr. Ziegler urged the Hammond Commission members to step back and look at the positive areas of the system and give guidance to make improvements. A copy of information about Northwestern CSB is filed with these minutes.

Beverly Fleming, Shenandoah County Board of Supervisors Chairman, Northwestern CSB member, and Hammond Commission member, welcomed the Committee on behalf of the CSB Board. He was proud of the accomplishments of the CSB, the services provided, and the new buildings to house them.

Ms Bennett is the parent of a disabled daughter. She complimented the Commission on the readability of the interim report and looked forward to the next one. She offered the following points for consideration:

• PAIR is concerned that managed care organizations (MCO) will deny access to services for severe and profoundly disabled people who are considered too expensive and difficult to serve. They request that the residents of Virginia’s 5 training centers be exempt from MCO controlling.
• PAIR is concerned that CSBs are discouraged from training center placements when they are appropriate for some clients. Training centers provide integrated services that are cost-effective and easily monitored. The level of expertise in providing quality care for fragile patients in training centers is not yet available in the community.
• Proximity of services and easy accessibility should be two of the primary objectives of the system in order to increase consumer and family involvement.
• PAIR raised a number of issues related to contracting certain nursing services. How are cost savings to be measured against access to quality services? Who mediates in disagreements concerning access? How is access maintained if service is reduced to cut costs? Will minimum wage and no benefits attract skilled staff?

Ms Bennett is concerned that in the urgency to save funds, the heart will be cut out of human services. A copy of Ms Bennett’s remarks is filed with these minutes.

Mr. Ziegler said that training centers should be part of the continuum of care for MR consumers. Individuals with complex medical and behavioral issues are best served there, medically and economically.

Mr. Winburn expressed concern about losing trained, experienced staff due to salaries that are not competitive. Patients often become attached to their care providers.

Mr. Ziegler stated that the General Assembly had provided funds for a 4.5% salary increase for CSB employees, but the Medicaid match was not included in the formula. This cut the amount of the increase provided to the CSBs. Senator Hanger responded that the Committee would investigate this issue.

Mr. Peachey talked about the census reduction project with Western State Hospital that he feels is very successful. Northwestern CSB interviews patients to inform them about the community and to find out about their needs and interests prior to their being discharged. The staff are selected for their understanding of the consumers and their sensitivity to basic rights and respect. Mr. Peachey thinks that this personal care would not occur with an MCO. Mr. Fleming recommended that this program be considered for a statewide model.

• Ms Beall expressed her concerns about accessibility to care for mental health consumers. She said that they are basically divided into two groups:

1. Those who develop illness after they have some employment background may qualify for Medicare (SSDI). Many are not being served because providers cannot get federal reimbursement. CSBs have no incentive to enroll Medicare clients and
2. Those who have early onset of mental illness, have not been employed and may qualify for Medicaid (SSI). Federal reimbursement enables these individuals to access more community services, but prescriptions are not covered.

• Ms Beall believes that consumers are not always given the most appropriate services because therapists employed by CSBs are not receiving specialized training. The field has become more complex, with specific treatments designed for each mental disorder. Medical advancements and new drugs have provided more hope for consumers, if they are able to access the care they need. Academic linkage would help public providers stay current with treatments and training.
• Ms Beall thinks that a central data system is needed to measure outcomes, track funds, evaluate performance, and aid in planning. The state should have access to the data, and because it is owned by the provider and considered to have value, should address this issue in contracts with providers.

• Ms Marsh reported that one of NAMI’s initiatives is pharmacy benefits.
• Priority populations is also a very important issue because in order to plan services and allocate resources, it is necessary to know who will be served. Currently, the State Board of Mental Health, Mental Retardation, and Substance Abuse Services has a policy on priority populations, but she feels that the priority population of the individuals with the most serious mental illnesses (SMI) should be specified in the state code as many other states do.
• Ms Marsh believes that the community services system is inadequately funded and that many of the services provided don’t fit the needs of those who require services. Current data shows that less than half of the mental health services provided by CSBs are for people with SMI. This means that only 14% of the people with SMI in Virginia, as estimated by the federal government, are being served. The others are at home, in shelters, in jail, or on the street. Ms Marsh distributed a New York Times Magazine article concerning a mentally ill man who pushed a woman to her death in front of a train. He had a history of violent behavior and mental health treatment. She said that it highlighted the problem of people who needed an effective continuum of services but were unable to obtain them.
• Ms Marsh believes that eligibility criteria for Medicaid are a barrier to service and should be changed. Many SMI consumers are left out. Some CSBs are not financially able to accept clients unless they are eligible for Medicaid reimbursement. She thinks that MCOs will address only those 38% of consumers already in the system on Medicaid.
• New changes in treatment require significant retraining of staff. Ms Marsh believes that psychosocial services should be provided in public facilities. She thinks the PACT team should be a system wide model for mobile accessibility.

Mr. Peachey said that he believes that the current services system is based on an ineffectual 1960s model. He wants it changed with the necessary retraining to a wrap-around service system for the people with SMI.

Mr. Speidel discussed his concerns about seriously emotionally disturbed children and youth (SED).

• The MHA of Virginia is concerned that increasing numbers of SED children are being relegated inappropriately to the Juvenile Justice System in detention and correctional facilities. Approximately 60% of the youth in the justice system suffer from at least one mental disorder, and many have committed only minor, nonviolent and status offenses.
• The MHA is convinced that many of these youth could have been successfully diverted from the justice system if there had been adequate resources to provide professional prevention and early intervention services in the community. The needs of at-risk children and their families are best met through a system of collaborative community-based services involving the school, mental health, and child welfare officials.
• The Comprehensive Services Act (CSA) for At-Risk Youth and Families provides funding and resources to a select group of children. Currently, juvenile offenders and those with mental health problems are not mandated for services. The Joint Legislative Audit and Review Commission suggested in 1998 that these children, estimated at about 20,600, be afforded the same services.
• The MHA is against the use of the "Handle with Care Plus" program implemented in the Department of Juvenile Justice. The techniques used have the potential to injure and would not be tolerated in the public mental health service system.

• Mr. Waldron said that the new funding approved by the General Assembly will allow for more individualized mental retardation (MR) service plans to be developed, but there will still be a waiting list.
• Because MR is a condition and not a disease, the MCO medical management model does not apply. However, these individuals have a greater chance of developing mental illness than the general population, and consumers with dual diagnoses (MR & MI) are more difficult to serve.
• Mr. Waldron believes that Virginia is behind other states in providing long-term services and supports. Medicaid should cover dental services in the community, and reimbursement rates for services are too low, which affects availability.
• Mr. Waldron thinks that children are underserved in the system, and more could be identified for the Medicaid MR Home and Community-Based Waiver. A large number of developmental disabilities are excluded because they are not labeled as MR, and DMAS is investigating the creation of a new waiver to cover them.
• He thinks that self-determination is the philosophical direction the system is headed, and it will be a challenge.

Ms Wilson said that she understood many of the problems in the system, having served as a case manager on call in the evenings and on weekends. Many staff members have heavy loads and responsibility.

• She believes that the Early Intervention System, birth to 3 years, is one of the best programs in Virginia. She recommends using those federal regulations as guides when planning programs for adults. Families are supported and included as equal partners with providers, and services are delivered in the natural environment whenever possible.
• Ms Wilson would like for family members to be provided with resources and support for the purposes of caregiver training, education, and to work with boards and commissions.
• She said that ARC has a 5-year plan to eliminate waiting lists.

The minutes from the May 20 meeting in Burkeville were approved.

The next meeting will be on July 12 in Charlottesville. The topic of "Sustaining Awareness" will be discussed for half of the meeting, and the remainder will be used to formulate the Committee’s recommendations for the Executive Committee. Senator Hanger reviewed the areas from the May 20 meeting to be considered and the issues raised in today’s meeting will be added. A suggestion was made to invite Ann Lucas from DMHMRSAS to present information on family involvement aspects of the Part C early intervention program, and also Michael Shank and Shirley Ricks to discuss the Consumer and Family Involvement pilot.

The meeting was adjourned at 1:50 P.M. Mr. Zeigler gave Committee members and guests a tour of the Northwestern Community Services Board facility.