SWVMHI

1. SWVMHI Adolescent Unit Overview Presented to the Child & Adolescent Mental Health State & Community Consensus Planning Team June 22, 2009, CCCA, Staunton

2. SWVMHI Adolescent UnitMarion Serving Youth ages 13 though 17 • Unit staff include: • Child & Adolescent-trained psychiatrist • Ph.D. psychologist • 2 Clinical Social Workers • Recreational Therapist • 7 RNs • 20 Psychiatric Aides

4. Part of the larger SWVMHI facility 172 Beds 60 Acute Admissions 50 Long Term Adult 40 Geriatric 16 Adolescent 6 Infirmary SWVMHI: Promoting mental health in southwest Virginia by assisting people in their recovery

5. SWVMHI catchment area Adolescent 9 CSBs, 23 western counties Planning District I – Lee, Scott & Wise Highlands – Washington Cumberland Mtn.-- Tazewell, Russell & Buchanan Dickenson County Mt. Rogers – Smyth, Wythe, Grayson, Carroll & Bland New River Valley -- Pulaski, Giles & Floyd Blue Ridge – Roanoke, Botetourt & Craig Danville-Pittsylvania Piedmont – Franklin, Henry & Patrick

7. Admission Process Virginia Code Section 16.1-335 “The Psychiatric Inpatient Treatment of Minors Act” “Inpatient Treatment” means placement for observation, diagnosis, or treatment of a mental illness in a psychiatric hospital or in any other type of mental health facility determined by the DMHMRSAS to be substantially similar to a psychiatric hospital with respect to restrictions on freedom and therapeutic intrusiveness. “Least restrictive alternative” means the treatment and conditions of treatment which, separately and in combination, are no more intrusive or restrictive of freedom than reasonably necessary to achieve a substantial therapeutic benefit or to protect the minor or others from physical injury.

8. Admission Process • Virginia Code Section 16.1-339 Parental admission of an objective minor 14 years of age or older (excerpt): • Because of mental illness, the minor (i) presents a serious danger to himself or others to the extent that severe or irremediable injury is likely to result, as evidenced by recent acts or threats or (ii) is experiencing a serious deterioration of his ability to care for himself in a developmentally age-appropriate manner, as evidenced by delusionary thinking or by a significant impairment of functioning in hydration, nutrition, self-protection, or self-control; • The minor is in need of inpatient treatment for a mental illness and is reasonably likely to benefit from the proposed treatment; and • Inpatient treatment is the least restrictive alternative that meets the minor's needs. The qualified evaluator shall submit his report to the juvenile and domestic relations district court for the jurisdiction in which the facility is located.

9. Admission Process • Decisions regarding admission are based on the criteria in Adolescent Commitment Laws: • Initially made during preadmission screening; • If meet criteria, referral first made to private sector facilities*; • Then referral to state operated facilities (SWVMHI & CCCA). *May not occur in cases where travel distance is prohibitive

10. Admission Process • Referrals tend to be highest in behavioral acuity, medical complexity, and typically lacking reimbursement resources. • Referrals also may, because of the complexity of issues, have complicated barriers to discharge that will delay discharge and result in “uncovered days.”

11. Denials of Admission • Relatively infrequent. • Denial of admission is most often the result of the need for medical stabilization or, secondarily, a lack of bed space.

12. Census Management • For each referral, the CSB is informed of remaining bed space. This allows for regional triage. • Priority is given to individuals who are most at-risk and not already in a safe treatment environment. • Transfers from private facilities receive lower priority. These transfers make up 20 - 25% of admissions to the unit. • In calendar year 2009 all individuals initially denied admission were currently receiving services from private sector facilities or were in detention centers awaiting Court-related evaluation.

13. Referral Source Approximately 20-25% of admissions have been transferred from private inpatient facilities 5% admitted for Court Ordered evaluations, 5% admitted from Detention Centers 65-70% admitted from community-based settings* Legal Status 20-25% admitted to other facilities first, then committed to SWVMHI 5% admitted on Judicial Order for Court related evaluation 65% admitted on TDO Admissions by: *family home, group home, foster home, residential treatment center, etc.

14. Admission by CSB • New River Valley 92 • Mt. Rogers 78 • Planning District I 67 • Blue Ridge 43 • Highlands 30 • Danville-Pittsylvania 22 • Cumberland Mtn. 19 • Piedmont Regional 14 • Dickenson County 11

16. Capacity • SWVMHI Adolescent Unit reaches 75% of total capacity for approximately 1/3 of each year. • Admission rates peak in Spring and Fall. • These peaks are mirrored at other treatment facilities. • The demand across the system rises and falls as a whole. • This results in system-wide scarcity of beds during peak demand periods.

17. Average Length of Stay • For Fiscal years 2007, 2008, 2009: • Mean length of stay is 14 days • Range is 2 to 173 days • In FY 08: 47 youths stayed 20 days or more • Of those 47, 33 stayed 30 days or more • Of those 33, 9 stayed 60 days or more • Of those 9, 4 stayed 90 days or more, 2 stayed 120 days or more and 1 stayed more than 150 days

19. Optimal Capacity? • Costs at SWVMHI do not vary significantly based on capacity. • What is the value of public’s expectation that a bed could be obtained should the need warrant? • For private sector to meet this need, would have to forgo right of refusal of any given admission or the ability to transfer individuals for any given reason.

20. Reimbursement • For FY 2008 • 233 adolescents served at SWVMHI • Medicaid only: 144 (62%) • Private Insurance only: 36 ( 15%) • Medicaid + Private: 20 ( 9%) • Without Coverage: 33 (14%)

21. Reimbursement Cont. • CCCA/SWVMHI Child & Adolescent bed days: • FY08 Total: 15,558 • Total reimbursed: 4,094 • Total Non-reimbursed: 11,464 • Note: Despite approximately 70%-80% of admitted individuals having payer source, only 26% of bed days reimbursed.

22. Educational Considerations • Information presented by the Inspector General on May 14, 2009, did not include costs of educational services. • Educational programs are State Operated Programs (SOP). • The Department of Education (DOE) compensates local school divisions for the costs of these programs.

23. Educational staff are employees of the local school division (Smyth County). The amount & type of educational services required for inpatient facilities is a function of length of stay. Shorter lengths of stay eliminate the need for a full-day educational program. Longer lengths of stay require a full range of educational services to comply with State and Federal Regulations (Special Education/IEP). Educational Considerations

24. What additional data would be helpful in determining where we go from here? “The future belongs to those who believe in the beauty of their dreams.” ~ Eleonor Roosevelt