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Differences in Civil Commitment Practice in Virginia

This article explores the variations in the civil commitment process in Virginia, focusing on disparities in hearing outcomes, dismissal rates, involuntary hospitalization rates, and the use of mandatory outpatient treatment. The goal is to promote fairness and improve access to mental health services.

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Differences in Civil Commitment Practice in Virginia

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  1. Differences in Civil Commitment Practice in Virginia James M. Martinez, Jr. Department of Behavioral Health and Developmental Services June 2010

  2. Goals of MH Law Reform • “Reducing the need for commitment by improving access to mental health, mental retardation and substance abuse services” • “Reducing unwarranted criminalization of people with mental illness” • “Redesigning the process of involuntary treatment so that it is more fair and effective” [R. Bonnie, Remarks to CMHLR, Oct. 6, 2006]

  3. Goals of Law Reform (cont) • “Enabling consumers of mental health services to have more choice over the services they receive, and” • “Helping young people with mental health problems and their families before these problems spiral out of control.” [R. Bonnie, Remarks to CMHLR, Oct. 6, 2006]

  4. Promoting “Fairness” Goal 3……. Redesigning the process of involuntary treatment so that it is more fair and effective

  5. Promoting “Fairness” What makes a system “fair”? The system responds the same way to everyone… • A common understanding of law and procedure (across individuals, agencies, communities) • Consistency in practice (application of law) • Uniformity of services and supports • Equitable access to care

  6. Promoting “Fairness” (cont) What has Virginia done in these areas? • CMHLR Task Forces coordinate statutory reform and implementation • Uniform training of CSBs, courts, law enforcement, other partners & stakeholders • Cross-agency collaboration on policy and solving operational problems • Shared technical assistance resources • Targeted funding for new services

  7. Fairness: How are we doing? Despite extraordinary effort to promote consistency, there are significant differences in the civil commitment process throughout Virginia, and in the experiences of service recipients and families with that process. For example…

  8. Hearing Outcomes Statewide Of 15,196 initial commitment hearings July 2009 - March FY 2010, statewide outcomes were: • dismissal = 19.0% • involuntary hospitalization = 57.1% • voluntary admission = 23.4% • mandatory outpatient tx = <1%

  9. Variations Between Courts • 33 District Courts conducted 100 or more initial hearings • All data that follows is from these District Courts…….

  10. Dismissals Regarding dismissals, state avg. = 19.0% • 4 District Courts had dismissal rates more than twice the state average, ranging from 39.8% to 87.4%, and • 7 District Courts had dismissal rates less than 5%, ranging from 0% to 3.9%, with two courts having zero dismissals.

  11. Highest Dismissal Rates District Courts with Dismissal rates more than twice state average: • Galax (361/413) 87.4% • Fredericksburg (233/438) 53.2% • Charlottesville (140/340) 41.2 % • Hampton (432/1086) 39.8%

  12. Lowest Dismissal Rates DCs with Dismissal rates less than 5%: • Danville (21/539) 3.9% • Roanoke (26/816) 3.2% • Salem (16/635) 2.5% • Dinwiddie (3/198) 1.5% • Hopewell (4/320) 1.3% • Bristol (338) and Norfolk (180) had 0%

  13. Involuntary Hospitalization Regarding involuntary hospitalization (state average = 57.1%): • 8 District Courts had involuntary hospitalization rates higher than 70%, ranging from 73.5% to 98.5%, and • 9 District Courts had involuntary hospitalization rates lower than 35%, ranging from 4.4% to 33.1%

  14. Highest Involuntary Commitment Rates District Courts with rates > 70% (state avg = 57.1%) • Dinwiddie (195/198) 98.5% • Hopewell (305/320) 95.3% • Chesapeake (406/489) 83.0% • Petersburg (719/870) 82.6% • Richmond (1324/1620) 81.7% • Augusta, Norfolk, Va Beach all above 70%

  15. Lowest Involuntary Commitment Rates District Courts with Rates < 35% (state avg = 55.2%) • Galax (18/413) 4.4% • Winchester (15/238) 6.3% • Montgomery (110/487) 22.6% • Russell (43/171) 25.1% • Prince Wm, Mecklenberg, Fairfax County, Fredericksburg, Bristol, all below 35%

  16. Mandatory Outpatient Treatment Regarding Mandatory Outpatient Treatment: • Only 56 MOT orders were issued statewide July 2009 - March 2010 • Only 11 District Courts had MOT orders • 33 of 56 total MOT orders were from one jurisdiction - Prince William

  17. Courts with MOT Orders • Prince William (33/452) 7.3% • Augusta (3/153) 2.0% • Alexandria (2/154) 1.3% • Lynchburg (3/564) 0.5% • Smyth (5/950) 0.5% • Fairfax County (2 orders), Roanoke (3), Rockingham (1), Salem (2), Danville (1), and Montgomery (1) all < 0.5%

  18. Voluntary Hospitalization Excluding dismissals and MOTs, there were 12,232 hospitalizations • About 70% of these were involuntary and 30% voluntary (i.e., person accepts court offer of voluntary admission) • In District Courts with 100+ hearings, an average of 29.0% of hospitalizations were voluntary

  19. Highest Voluntary Rates 11 District Courts with 100+ hearings had 50% or more voluntary hospitalizations, ranging from 50.7% to 91.9% • Winchester (of 186 total hosp) 91.9% • Montgomery (of 381 total hosp) 71.1% • Russell (of 146 total hosp) 70.5% • Bristol (of 338 total hosp) 66.9% • Mecklenberg, Galax, Prince William, Fairfax County, Danville, Loudoun, Rockingham all above 50%

  20. Lowest Voluntary Adm Rates 6 District Courts with 100+ hearings had less than 10% voluntary admissions, ranging from 0.0% to 9.9% • Smyth (of 724 total hosp) 9.9% • Charlottesville (of 200 total hosp) 9.5% • Chesapeake (of 438 total hosp) 7.3% • Lynchburg (of 358 total hosp) 7.3% • Hopewell (of 316 total hosp) 3.5% • Dinwiddie (of 195 total hosp) 0.0%

  21. Some Thoughts on Variance • Variance in dismissal rates may indicate criteria are interpreted differently (e.g., by CSBs, examiners, court officials) • Variance in voluntary admission rates may indicate different views about threshold for voluntary admission (e.g., Winchester). • MOT usage in Prince William, and dismissal rate in Fredericksburg, is related to using full 48-hour TDO period, and second CSB eval prior to hearing.

  22. Other Sources of Variance? • Different perspectives among CSB staff and IEs • Variations in hearing process (evidentiary and procedural rules, attorney role, etc.) • Hospital admission criteria • Payment options (e.g., LIPOS), etc. Note - Differences may be more or less explainable or acceptable (e.g., availability of alternatives to hospital vs widespread differences in statutory interpretation) • What are your thoughts on this?

  23. Strategies to Reduce Variance • Training, technical assistance, oversight • A minimum core array of services? • Uniform eligibility and admission criteria, and consistent utilization management processes? • Consistent payment to providers to support desired outcomes? • What else?

  24. In Closing…… • Consistency is toughest goal to achieve • Data just beginning to illuminate variations and possible problems • All communities & all cases are different • State, regional and local interests are different • Commission on MH Law Reform is setting up workgroup to address these issues.

  25. In Closing…… What are your ideas for making the civil commitment process more consistent and fair?

  26. Thank you! James M. Martinez, Jr. 804-371-0767 (office) 804-786-4837 and 804-786-5927 (main) jim.martinez@dbhds.virginia.gov

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