By James C Sherlock
The supply cannot keep up with the demand.
In this case, the consequences concern personal well-being and public safety. And they can be terrible either way.
Governor Youngkin will propose additional funding and policies for the state mental health system to the 2023 General Assembly.
The state offers inpatient services, community-based government services, and Medicaid-funded services.
Medicare offers payments to participating hospitals. Private insurance offers protection.
I say “offer” because much of what the policy dictates has proven difficult in practice to deliver.
Virginia’s psychiatric system is in serious trouble due to a lack of staff and facilities to handle the very steep increases in the number of people needing help.
The staffing problems are twofold, affecting both government and private services.
- Key positions require trained specialists, whose shortage is felt nationwide; and
- Working conditions in mental health care are highly stressful, physically demanding and dangerous, driving away much-needed low-skilled workers who can easily find work elsewhere.
Medicaid programs offer services that private agencies and physicians facing the same labor shortages, in any combination, are unable or unwilling to offer Medicaid reimbursement rates. Government-sponsored Medicaid Managed Care Organizations (MMCOs) have not solved these problems.
So part of the answer is money, but we really don’t know how much. And in this case, money alone may not provide enough services to meet demand.
What follows is a summary of the issues.
Psychiatric Hospitals. Residential complexes are in the worst condition.
In addition to doctors, nurses and other skilled workers, they lack the minimum-wage workers who make up the majority of the labor force. These are the same workers needed by every small business and most large corporations, and inpatient psychiatric work is hard and dangerous. The supply does not meet the demand.
During the peak of the pandemic, Alison Land was Commissioner for the Department of Behavioral Health and Development said the general assembly
“Low pay, burnout and growing workloads are pushing employees out of the field. In many cases, shortages result in available staff struggling to respond to a high-need patient population. Assaults and injuries at facilities are commonplace, Land said — a difficult cycle that leads to increased turnover.”
Indeed common. As she spoke, injuries were indeed difficult. She went on to say that inpatient facilities across the state are operating with about 65 to 70 percent of the workforce with occupancy at or above the borders.
The overcrowding was caused in part by the 2014 law sponsored by Creigh Deeds in honor of his son who, in a mental crisis, injured his father and killed himself. Virginia psychiatric hospitals had to admit patients in crisis situations and under temporary warrants (TDOs) for whom a bed with qualified staff could not be found elsewhere.
Since then, TDOs have increased by 400%.
In mid-2021, more than half of Virginia’s state mental health facilities were temporarily closed to new admissions due to overcrowding.
Private providers face the same problems, highlighted by the growth of Medicaid-funded services, which have found few service providers to take on in some areas of the state.
The state called on general hospitals to admit more patients in mental health crises. The Virginia Hospital and Healthcare Association’s response was that general hospitals would do whatever they could, but they faced the same space and staffing problems as psychiatric hospitals.
Children’s Hospital for the King’s Daughters (CHKD) in Norfolk reported huge waiting lists for psychiatric services for children fueled by COVID.
hospital quality. The best source for reliable, quality information on Virginia’s nine psychiatric hospitals Medicare Comparison Click on the hospital name.
Use Dominion Hospital B. Falls Church, scroll down and click on Psychiatric Services. You’ll see that Dominion gets excellent marks for every measure of quality; the roundabouts Institute of Mental Health in Northern Virginianot nearly as good.
Petersburg Poplar Springs Hospital has a a lot of the work to be done across the board. Western State has serious deficiencies in patient safety.
For general hospitals with a psychiatric ward, you can do the same. Use August health as an an example.
So the Medicare comparison list is worth checking out.
Shortage of staff – example Eastern State. The Eastern State Hospital in Williamsburg, the largest in the state, is Looking for Workers for 44 job descriptions, for which they are usually looking for several workers.
It offers a benefits package that includes various health plans, paid life insurance, the Virginia Retirement System pension plan, 12 days of paid vacation, annual vacation, family vacation, and sick leave.
Of course, there are multiple positions for Registered Nurses (US and International), Licensed Practical Nurses, Psychologists, Psychologists, Crisis Prevention Team Members, Nutritional Technologists, Clinical Nursing Technicians, Healthcare Technicians, Environmental Services Technicians, and Clinical Social Workers. They are also looking for a psychiatrist and a general practitioner. Sign-on bonuses are offered for almost every full-time position.
Among the jobs is one for a pharmacy courier, for which the minimum qualifications are a high school diploma, driver’s license and background check. This is a full-time position with a $7,500 joining bonus for those new to government employment with a one-year written agreement.
Community-Based Government Services. The state has been trying to move mental health care to the communities since 2017 by giving the 40 Community Services Boards (CSBs) more funding.
In 2017, then-Governor McAuliffe signed a bill requiring CSBs to provide Same Day Access (SDA) to individuals who need mental health support.
In 2019, Governor Northam announced that the goal had been met. The program offered triage. After an initial assessment, the goal was to supply those who needed it within 10 days of making an appointment.
The CSBs Crisis Services strive to incorporate a team of clinicians who are available 24/7 for crisis response to individuals experiencing a mental health or substance use crisis. They offer crisis intervention assessment, counseling and referral. They are responsible for pre-admission screening for hospitalization and court liaison services for individuals subject to involuntary placement procedures.
Crisis intervention teams include law enforcement, behavioral health professionals, and those experienced with close family members with mental illness. The CIT training is a 40-hour curriculum taught by specialists from these communities.
The training addresses common signs and symptoms of mental illness and co-occurring disorders; recognize when signs and symptoms indicate a crisis situation; safely de-escalate a crisis; and use of community resources to provide support.
CSBs also typically offer a Crisis Intervention Team Assessment Center (CITAC), which provides a safe space for those experiencing a behavioral health crisis. Crucially, CITAC relieves law enforcement agencies of maintaining custody of anyone who has a mental illness of sufficient severity to be under TDOs.
A crisis center provides a safe and less restrictive environment for people in crisis.
In practice, CSBs struggle with the same resource constraints as the rest of the system. In some cases, the full services described above are policy, but remain desirable in practice.
Medicaid. In July 2021, Virginia Medicaid, by far the largest insurer for mental health services in the Commonwealth, began operations offer finance:
- Assertive Community Treatment (ACT), a “coordinated set of services provided by a team of community medical, behavioral and rehabilitation professionals working to meet the complex needs of people with severe and persistent mental illness”
- Mental Health Partial Hospitalization Program (MH-PHP), a “combination of interventions and services similar to an inpatient program but lasting less than 24 hours.”
- Intensive Outpatient Mental Health Program (MH-IOP): “Clinical programs designed to provide a combination of interventions that are less intensive than partial hospitalization programs but more intensive than traditional outpatient mental health services.”
In December 2021, just before the Youngkin administration took office, six more Medicaid-funded services were offered.
Contractually, MMCOs are required to provide these nine services to their patient populations, but in many parts of the state, adequate care simply doesn’t exist. And yes, they are doing what they can with telemedicine.
In short, the Commonwealth cannot provide the government services required by law and offers to pay for more services through Medicaid than are available in the private sector.
Even the funds currently provided are being temporarily augmented by federal Covid funds.
The first thing any government would rightly do in this situation is dial down its programs because of the pervasive staffing shortage that money alone may not solve. Which are the most important?
The Department of Medical Assistance Services has floated the idea of having MMCO’s screen demand, but this is dismissed as not being timely enough.
The political problem is that any reduction in services due to a lack of skilled labour, and not just the price of those services, is labeled ‘cuts’ by the political opposition. Throwing granny in the snow, kind of commercial. Even if many officially “offered” services are no longer available in practice in many parts of the country.
Because skilled workers in the current market go where they want to go, not necessarily where they are needed, some services that are available in wealthier counties may not be in poorer counties, regardless of funding.
But to rule is to choose.
Governor Youngkin will have his administration’s estimates of what can be done with the money available and how much money that is. And how much can not be done.
This is exactly the problem the governor has taken on with the general assembly to help Virginians deal with.