We have experienced an increase in the population of individuals with mental illness since the 1980’s without a commensurate growth in services provided to meet their needs. In part, that is due to the lack of insurance coverage in both the private insurance market and from public funds. It is important that we expand the capacity of Virginia’s mental health safety net.
Between 70-85 percent of primary care doctor visits have a significant psychological or behavioral component to the diagnosis. Patients with mental health conditions are more commonly seen in primary care facilities than other facilities. Anxiety and depression are among the top three diagnoses, after hypertension and diabetes.
Most primary care providers (physicians, nurse practitioners, or physician assistants) are not fully trained to diagnose or treat individuals with mental health illnesses. They often refer these individuals to community mental health providers, but there is a shortage of these professionals. Hence, many mental health disorders are undiagnosed or inadequately treated. Often, inappropriate psychotropic drugs are prescribed with little monitoring for adverse effects.
Today, we have approximately 9,045 licensed mental health professionals in the mental health workforce. Forty percent are Licensed Clinical Social Workers, 28 percent are Licensed Professional Counselors, 20 percent are Clinical Psychologists, 11 percent are Psychiatrists, and 1 percent are Psych-Mental Health Nurse Practitioners. (Only 133 out of 7,023 Nurse Practitioners in Virginia are Psych-Mental Health Nurse Practitioners). Nearly 2/3rds of Virginia’s counties have a shortage of mental health services. Most professionals are located in the northern, central and Hampton Roads areas of the state.
Most behavioral health services are delivered in Community Health Clinics or Free Clinics. . Many behavioral health practices are small with less than 500-1000 patients. Those organizations that do not offer behavioral health services cite affordability, lack of space and availability of mental health professionals in their locations. Many organizations have vacant positions and it can take up to 8 months to find a mental health professional to fill the vacancy.
In my view, the best way to deliver services is locally, through the Community Services Boards with standards of high quality of care, and low regulatory barriers to access treatment.
We need more child psychiatrists and counselors and better coordination with pediatricians in the community. It’s important to leverage primary care doctors and nurse practitioners already in the community.
The first thing to do is work with our higher education community and identify incentives, expedited admissions, and scholarships for anyone willing to pursue a degree in mental health medicine, nursing, or counseling services.
The best force multiplier for mental health services is to increase the volume of psychiatrists and Psych-Mental Health Nurse Practitioners. There are 4 programs available at VCU, UVA, Radford/Shenandoah, and George Mason through masters, post-masters, or doctoral programs in nursing. These programs can be funded with tuition assistance through STEM-H (See Higher Education Plan).
We need to streamline the process for licensing. We have many spouses of military servicemen and women who reside in Virginia that may be licensed to provide child psychiatric services, nursing, or social services in other states and should be given a temporary or provisional license to work here in Virginia.
We need to work together to find ways to help families with adolescents who upon their 18th birthday lose access to pediatric services, often have a new diagnosis, and are still struggling to determine the best treatment modality.
Often, these individuals fall through cracks until a crisis in the college setting, or they are unable to find work and act out in the community. Too often, they enter the criminal justice system, when they should be accessing treatment or counseling to prevent acting out with criminal behavior.
Strong public-private partnerships that utilize local support organizations and the faith-based community to assist with treatment, training, and housing are necessary to do everything we need to do for mental health in Virginia, but we can start with some basic reforms that will help fix the problem.
The reforms after the VA Tech massacre did not go far enough to address the glaring problems with the emergency commitment laws currently on the books. Right now we hospitalize only individuals with the most serious conduct resulting from their mental illnesses, who have tried to commit suicide, tried to harm others or are living in horrid conditions. Otherwise, the law does not allow people who need mental health treatment to be hospitalized or ordered to receive out-patient mental health treatment.
Virginia needs an “in need of treatment standard.” This would allow commitment of individuals with mental illness on a basis that there is clear and convincing evidence they need mental health treatment.
We need to ensure that when someone is released from a hospitalization for such treatment or court-ordered into outpatient treatment, there is actual follow through with mental health professionals. Right now there are loopholes in the law which allows local Community Services Boards to decline to provide outpatient treatment even when a Court commits the person to outpatient care. HB 475 closed one of the loopholes effective July 1, 2012.
Plus, the Community Services Board is required to come up with a treatment plan in an extremely short period of time before outpatient care can happen. The preliminary treatment plan must be presented at the time of the commitment hearing which – in at least two jurisdictions (Roanoke and Richmond) are routinely less than 12 hours from execution of the order.
We need to ensure that the treatment is being provided, as well as provide a more comprehensive mechanism for enforcement and continuity of care. The best approach is to integrate primary care and behavioral health as a “best practice”. This will improve access to behavioral health services and decrease the stigma attached to mental health illness. With better coordination of care we can improve patient outcomes and lower system costs.
There are many areas throughout the Commonwealth where faith-based organizations and secular groups work successfully with local governments to identify affordable housing for vulnerable populations.
The Auxiliary Grant is an appropriate financing tool. The Auxiliary Grant program was established as a state supplement to SSI in 1973. Under current Virginia law, you can only get it if you reside in an assisted living facility or adult foster care home. It is used to help pay for room and board and can include a personal needs allowance. As Governor, I will push to make the grant “portable,” meaning the grant money would go with the person instead of to the assisted living facility or adult foster care home. We should not have to force these individuals into group homes or adult foster care assisted living, unless it is determined to be absolutely necessary for their own health and wellbeing.
It’s important that we look for some of the root causes or stressors that can affect families with young children. Unemployment and poverty is the primary reason for food insecurity in young children, lack of access to primary care, or for attending preschools should the family choose formal early childhood education opportunities. The number of children with single parents continues to grow. Virginia funds many programs that address these problems, but there are cracks in the system.
I have an economic plan to reduce the tax burden on families and promote job growth throughout Virginia. I have an education plan for K-12 that has a focus on workforce readiness. But for those families who are lacking and show signs of mental stress that effect young children, we can do more.
The commitment process for juveniles is much more comprehensive than that for adults and parents have control over their children such that they can hospitalize them or compel treatment when there are problems.
We need to ensure that the local Community Services Boards and Family Assessment and Planning Teams (FAPT) are given the funding to refer children into treatment when needed.
I think we should recognize the particular importance of leveraging and collaborating with primary care pediatricians in developing alternatives for our youngest children. We need to ensure that local Community Service Boards and FAPT are given funding to refer children into treatment plans when needed. I support pre-school vouchers for low-income children, which will facilitate emotional development. There are many federal programs that address early childhood development at the local level, but coordination throughout the network can be improved at the state level to assist these families in accessing those support services.
Virginia’s families need to have a mechanism to seek treatment of individuals with mental illness even when it is not an emergency situation.
As Governor, I would support funding localities for providing mental health services in junior high and high schools through a staff psychologist or LCSW.
Virginia families should be able to petition a court in cases that are not necessarily emergencies to at least get outpatient treatment for their loved ones. We could reform the guardianship process to assist these families, who have no other alternatives to help their young adult family members access treatment..
We need to actually commit to spending money on mental health reform. This is an area where I am willing to invest funds to develop a high quality care program for this population at the community level. We can use savings obtained through our Waste, Fraud and Abuse programs and direct those funds toward mental health services. We should look at the issue of tort reform and the cost of liability insurance to provide protections for lawsuits against mental health professionals. We need to work with the private sector and with our own state agencies on finding ways to provide the appropriate coverage for mental health services.
In the meantime, it’s imperative that we improve the coordination and communications in the primary care system. We can work to integrate primary care with behavioral health care through a best management practice model. Many physical and behavior health conditions occur together.
In order to make it work, we will need to rethink the roles of primary care providers, provide retraining, and add counseling visits that can last 15-30 minutes for well checks or “brief intervention” visits, with increased coordination between physical health and behavioral health providers. And finally, we must reduce the regulatory barriers to open beds in facilities that have them, and work with the Community Services Boards to increase treatment options.