A workgroup created by language in the 2021 Appropriation Act and directed to review existing services for individuals living with dementia and to recommend ways to improve access to evidence-based and evidence-informed services for this population has held four meetings and is preparing recommendations in advance of its November 1, 2021, report deadline. The workgroup was inspired in part by the challenges facing Virginia’s state hospital system, which has been operating with critically high census levels, particularly in geriatric hospitals and units. Individuals with dementia who experience behavioral health crises are being hospitalized because their behaviors are challenging to manage and there are sometimes few alternatives to the state hospital system, but state hospitals are not well-suited to provide appropriate care for this population.
At the workgroup’s first meeting, staff from the Department of Behavioral Health and Developmental Services provided information regarding state hospital care for individuals with dementia, noting that the average length of stay for an individual with dementia in FY 2020 was 167 days – far longer than the 67.3-day average length of stay for all patients, a situation attributed to challenges in finding supports in the community to enable individual with dementia to be discharged. Department staff pointed out that state hospitals are generally intended to treat serious mental illness, which is not a classification under which a primary diagnosis of dementia would fit. State hospitals typically rely on pharmacological treatments, which are not recommended for individuals with dementia, and the evidence-based treatments that are indicated are difficult to provide within state hospitals due to space and staffing limitations. The Department currently funds a pilot project at the Mount Rogers Community Services Board through which the CSB provides support to a nursing facility to enable that facility to serve individuals with dementia, a program that has been successful in avoiding further hospitalization and one the Department is seeking to replicate in other parts of the state.
The Appropriation Act language instructed the workgroup to consider the Regional Older Adult Facilities Mental Health Support Team (RAFT) program, which operates in northern Virginia, as a possible model. Currently this team is the only program of its kind in Virginia; its mission is to support the discharge of older adults with serious mental illness or dementia with behavioral problems from state hospitals to assisted living facilities or nursing facilities, and to divert older adults from hospitalization by providing support in the community. RAFT provides intensive mental health services to older adults, including within assisted living facilities or nursing facilities, and also provides training and consultations to facilities and crisis intervention to enable individuals to stay in their places of residence.
At its fourth and final meeting, the workgroup considered a series of potential recommendations, which include the following:
- Integrating dementia specialists into the system of care: The Department is working to develop teams within CSBs similar to the RAFT model to support older adults with mental illness, and there is interest in integrating dementia specialists into those teams.
- Enhancing workforce development: Some suggestions included cataloging existing training programs and partnering with schools of social work and health care training to offer specialty training. The workgroup discussed the importance of a unified statewide strategy for workforce development for behavioral health practitioners.
- Awareness, education, and training: Members discussed improving training for specific professions, such as law enforcement (perhaps through the incorporation of dementia-specific training into Crisis Intervention Team training) and primary care physicians, as well as working with local health departments on public awareness of dementia-related issues.
- Crisis Stabilization Units or respite centers: Members discussed the creation of temporary options for individuals experiencing behavioral health crises who cannot remain in their residences.
- Exploration of funding streams and reimbursement opportunities: Members were supportive of exploring potential Medicaid coverage for the services of dementia specialists or similar programs. It was noted that such a review should include the managed care organizations who are part of the Virginia Medicaid program.
- Collaboration among state agencies: Members discussed potential partnerships among state agencies, to include agencies outside the human services secretariat, such as the Department of Veterans Services and the Department of Criminal Justice Services, as well as with interested stakeholders such as the Alzheimer’s Association. One potential opportunity would be the creation of a dementia services task force.
VACo Contact: Katie Boyle