A workgroup convened to evaluate and recommend alternative options for individuals with neurocognitive disorders and neurodevelopmental disabilities who may otherwise be admitted to state psychiatric hospitals continued its discussions last week.
Legislation considered by the 2024 General Assembly directed the establishment of this workgroup; these companion bills (HB 888 (Watts) and SB 176 (Favola)) stemmed from a 2023 Joint Legislative Audit and Review Commission (JLARC) study of the state hospital system, which found that individuals with neurocognitive disorders (such as dementia or traumatic brain injuries) or neurodevelopmental disorders (such as autism) were not well served by state hospitals. JLARC’s report recommended that behaviors and symptoms that are solely the result of these disorders be excluded from the definition of “mental illness” for the purposes of temporary detention orders (TDOs) and civil commitments, and that state hospitals be allowed to deny admission to an individual under a TDO or civil commitment whose behaviors resulted solely from these disorders. However, JLARC staff suggested that such a policy change be enacted with a delayed effective date, due to concerns about the lack of alternative placements for individuals with neurocognitive or neurodevelopmental disorders who are in crisis. In keeping with this recommended delay in implementation, HB 888 and SB 176 would stipulate that behaviors or symptoms that manifest from a neurocognitive disorder or a neurodevelopmental disability are not sufficient, in themselves, to constitute mental illness, but the bills must be passed again in 2025 in order to take effect; the bills also contained language directing the convening of the workgroup.
As directed by the legislative language, the workgroup is required to:
- evaluate the current availability of placements for individuals with neurocognitive disorders and neurodevelopmental disabilities who would otherwise be placed in state psychiatric hospitals;
- identify and develop placements and services other than state psychiatric hospitals that would better support such individuals, especially individuals whose behaviors or symptoms are solely a manifestation of such disorders and disabilities, including through enhanced Medicaid reimbursements and a Medicaid waiver for individuals with neurocognitive disorders;
- specify any additional funding or statutory changes needed to prevent inappropriate placements of such individuals in state psychiatric hospitals; and
- provide recommendations for training of magistrates and community services boards.
A report is due by November 1, 2024.
The August 29 meeting featured perspectives from various stakeholder groups. Rebecca Morgan, President of the League of Social Services Executives, noted that social services directors were considering the workgroup’s charges as they related to adult protective services cases as well as to the challenges experienced by local departments of social services in finding placements for children in foster care with intense needs, many of whom have co-occurring mental health and other diagnoses, including autism, and many of whom also have experienced trauma from past abuse and neglect. She encouraged the workgroup to look at ways to build provider and community capacity to meet these children’s needs.
Staff from the Department of Behavioral Health and Developmental Services (DBHDS) presented information on current efforts to enhance community options for individuals leaving state hospitals and being served by assisted living facilities or nursing facilities, as well as an overview of the variety of services licensed by DBHDS that are intended to provide alternatives to inpatient hospitalization. A representative of the Virginia Hospital and Healthcare Association addressed the specialized treatment needs of individuals with neurocognitive or neurodevelopmental disabilities and the challenges experienced by hospitals in serving these individuals. He encouraged additional support for specialty hospital units, as well as support for specialized community providers, nursing facilities, and group homes to reduce the need for hospitalization.
The Virginia Health Care Association, which represents assisted living facilities and nursing facilities, discussed pilot projects in two localities that assist nursing facility staff in serving individuals with neurocognitive and neurodevelopmental disorders, and encouraged workgroup members to consider enhancements to reimbursement rates to reflect the costs to serve residents with behavioral health needs.
Jonathan Green, who coordinates magistrate services through the Office of the Executive Secretary, explained the process by which a magistrate issues a temporary detention order. Mr. Green explained that if the changes to the definition of mental illness included in HB 188/SB 176 were to be enacted, it may be challenging for magistrates to make a determination that actions and behaviors are the result of a neurocognitive or neurodevelopmental disorder, rather than a co-occurring mental illness, since magistrates are not clinicians and are generally relying on information from the Community Services Board and the treating physician in a fluid, time-constrained process in determining whether Code criteria have been met.
Jennifer Faison, Executive Director of the Virginia Association of Community Services Boards, echoed the diagnostic challenges articulated by Mr. Green, noting that CSB staff are often evaluating individuals they have only just met, and expressing concern about the lack of alternative options for individuals who would be barred from state hospitals under the legislation. She encouraged the workgroup to support recommendations that would assist caregivers, both paid and unpaid, in crisis situations; build out levels of care associated with crisis receiving centers; support workforce development; and ensure that funding levels keep pace with increases in caseloads.
At its next meeting, the workgroup will hear presentations from the Department of Medical Assistance Services, as well as from family members of individuals with neurocognitive or neurodevelopmental disorders. Preliminary themes discussed for potential recommendations included the importance of diversion and evidence-based models of care; the need to enhance supports for caregivers; the importance of improving workforce training; the importance of improving communication among service providers; and the need to build a continuum of services.
VACo Contact: Katie Boyle