Virginia
Departments of Mental Health Mental Retardation and Substance Abuse Services and Veterans Services Proposal for Veterans Behavioral Healthcare
Briefed to JLC on 12 Oct 2007
David L. McGinnis, Decision Support Manager, DMHMRSAS
Martha J. Mead, EO 19 Project Manager, DVS
Objective:
Active Partnership between the Virginia Department of Veterans Services, the Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services and the Commonwealth’s Community Service Boards to improve access by Virginia’s veterans to behavioral health services and supports.
Facts:
Veterans Needing Care Are Coming and In Large Numbers.
A range of indicators demonstrate that demand for behavioral health services from veterans of post-9/11 military deployments and their immediate families will grow dramatically. While the behavioral health effects from recent combat exposure receives ongoing examination, returns show that they are significant. Studies of those seeking treatment through the U. S. Department of Veterans Affairs (VA) demonstrate that at least one-third of the more than one million men and women who have served in Iraq and Afghanistan are in need of some form behavioral health services. History assures us on-set triggers may come long after discharge.
A recent highly publicized Department of Defense (DoD) study of the mental health needs of returning personnel finds that these behavioral health challenges come from two “emerging” signature injuries: post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). A growing cluster of associated surveys, studies and professional writings reveal that half of our contemporary military veterans are candidates for related behavioral health issues.
Recent sports medicine studies reveal that women have a third higher probability of sustaining serious brain injury than men from the same trauma encounter. Women make up a significant proportion of the forces deployed since 9/11.
Capacity of our Community Based System is already consumed
The collective waiting lists for behavioral health services among the Community Service Boards in Virginia approach 6,000 residents. The recently released draft report of the Joint Legislative Audit and Review Commission on Access to State-Funded Brain Injury Services in Virginia indicates that services for persons with traumatic brain injury (TBI) are severely limited. As referenced earlier, TBI has been recognized by federal agencies as a “signature wound” of the wars in Iraq and Afghanistan. Based on current rates of diagnosis reported by the VA and continuing trends in the Virginia’s veteran population, the Commonwealth should expect a 15 to 20 percent surge in behavioral health consumers from the new veteran cohort, quadrupling current waiting lists. A similar rise in persons needing treatment and rehabilitation services for TBI should be anticipated.
Most Are Not Going to Be Identified Prior to Discharge.
Unless veterans are identified as having behavioral health issues prior to discharge–or they are astute enough to seek evaluation at the time of discharge or within the timeframe for healthcare coverage thereafter–they will not have access to VA services at the onset of behavioral deterioration. Historically, this has been the case and we currently see nothing to convince us otherwise. In many instances, behavioral healthcare issues do not manifest symptoms until months or years after exposure to trauma. In addition, military personnel may seek services from other sources than the VA to avoid the stigma of a diagnosis of mental illness.
Initial identification of need will likely come through existing portals including law enforcement, emergency services and family services. Initial response will come from emergency service capabilities of Community Service Boards and other community providers, placing demands on their resources and those of the Commonwealth.
Families Are Not Part of the Veterans Care Taxonomy but Are Also Victims of Post-9/11 Service-Connected Behavioral Issues.
Indicators and experience on the collateral effects of these behavioral health issues on family members point toward the growing need for family services in proportion to the veteran spouse/parent. This requires special attention as (1) the family is where first adverse effects of behavioral health deterioration have human impact, (2) these services remain outside the service definitions for veterans’ services and (3) family services are a sensor for No Wrong Door.
Virginia Veterans and their Families will not go from “the End of the Line at VA to the End of the Line at the CSB.”
Governor Kaine’s Executive Order 19 (2006) calls on each agency to identify opportunities for improving services and addressing the continuum of care needs of disabled veterans. In pursuit of this objective, the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) is forming a strong partnership with the Virginia Department of Veterans Services (DVS). This includes the DVS initiative for a “No Wrong Door” for veterans and an extensive safety net for their immediate families.
The Commonwealth will not let these citizens down, will pursue adequate resources to make this happen and will get all those identified the status and support that they deserve.
Among the first steps on this journey is scoping a Commonwealth-wide support system, characterized by proactive, encompassing care and resources dedicated to the healing of veterans and their families. That is the purpose of this paper.
Concept:
This would be addressed through three operational components: (1) State-level coordination, (2) community coordination activities, and (3) behavioral health and rehabilitation services. These elements bring into focus, through training, orientation and coordination all of the agencies in the Commonwealth to meet the objective. Through service expansion and coordination we will provide the level of care required to restore and sustain the behavioral health of our veterans.
State-Level Coordination:
State-level coordination would occur through a senior-level executive in the Department of Veterans Services. The coordinator will need a fully-resourced team to support the responsibilities of the office. The following outlines the broad concepts of the duties of this office. The specific requirements will depend upon the level of funding and further research with DVS regarding its establishment. The coordinator’s office would work to:
ü Ease the transition from active service for Virginia’s wounded or disabled veterans through coordination, training and cooperation with federal, state and local agencies.
ü Oversee and implement a system of case management through the DVS Benefits Offices, local Community Services Boards and local vocational rehabilitation field offices to ensure that wounded or disabled veterans and their families receive the federal, state, and private benefits and services to which they are entitled.
o The case management system would assess their needs with respect to benefits and services and coordinate their referrals to services and supports, including behavioral healthcare, rehabilitation, employment services such as job placement and job training, social services and family supports.
ü Develop, in cooperation with the Community Services Boards, training and resource coordination programs for agencies and organizations that comprise the “front lines” of contact with wounded or disabled veterans and their families, including faith-based organizations, primary medicine, fire, rescue, law enforcement, social services, family services and others as identified and appropriate.
ü Monitor and research issues relevant to “wounded warriors”.
ü Perform outreach to improve wounded or disabled veterans' awareness of eligibility for federal, state, and private wounded or disabled veterans' services and benefits.
ü Coordinate service provision through charitable organizations such as the resources of the American Legion, VFW Wounded Warrior project, the Families of the Wounded Fund, the Military Family Support Center, Denbigh House, Family Assistance Centers, the retired Army Chaplains Spiritual Program, churches, etc.
ü Recommend funding priorities for the Veterans Services Foundation.
ü Review programs, research projects, and other initiatives that are or may be designed to address or meet the needs of Virginia’s wounded or disabled veterans; or unresponsive or insensitive to the needs of wounded or disabled veterans.
ü Recommend changes, revisions, and new initiatives to the Commissioner, the Governor and the General Assembly to:
o Address deficiencies;
o Improve benefits and services; and
o Incorporate wounded or disabled veterans' issues in strategic planning for all relevant state and local agencies in the Commonwealth.
Administered in the Community
Community coordination activities will be accomplished by the regional and benefit services offices of the Virginia Department of Veteran Services. This will include outreach, benefits counseling and capabilities to qualify and register veterans and their families for assistance and benefits at a higher level than now available.
Behavioral health services will be provided by the Community Services Board operations through a cooperative case management system under existing statues and policies as amended for this purpose. The CSB’s will be reinforced and supported as necessary by the DMHMRSAS and its facilities.
Centered on Four Core Behavioral Health Services
Beyond Emergency Services, four community behavioral health services will be essential to treating individuals experiencing the effects of post traumatic stress disorder, traumatic brain injuries and other behavioral healthcare disorders, their families and the essential continuity of care for both:
Case Management
Inpatient Treatment
Crisis Stabilization
Veteran Proactive Assessment and Care Teams (VETPACT)
Size and capacity of these services would vary based on the density of the veteran populations within each CSB area. But as existing resources are consumed by current demands, dedicated and focused capacity, in terms of individuals, beds, and teams, will have to be added to each affected Board.
This added capacity, fully resourced, will require time to develop – depending on the level of funding available. Once established (after 24 months) each of these capabilities would be supported on a reimbursement for services basis as addressed below.
Established with Federal Funds
State and local reserves or operating funds are not available to support expansion of projected capabilities. A Federal Grant or Grants would be required to support this expansion of services. However, recognition of this need or the availability of these grants has yet to be established.
Maintained with Federal Reimbursement at Sustainable Rates
A separate and more flexible reimbursement process would be necessary to sustain these dedicated and expanded capabilities. This is necessary for several reasons in addition to the need to incorporate the veterans’ family into the services definitions and recognizing the fact that many individuals entering this services system will not initially have priority status within the Federal Veterans’ care system.
In addition, two separate Federal systems would be required: one to reimburse the CSB for services to Veterans no longer on active duty and another to reimburse the CSB for services to members of the Virginia National Guard who have returned from operational deployments and their families as well.
Start with Ten CSB’s
It is our vision to begin by expanding behavioral healthcare capabilities in ten CSB’s initially and apply the lessons from this process across the Commonwealth. We believe this gives us the best opportunity to meet this sustained need as efficiently and economically as possible.
The ten CSB’s in no particular order (except alpha) in which to initiate this program would be:
Blue Ridge (Roanoke Area)
Central Virginia (Lynchburg Area)
Colonial (Williamsburg)
Cumberland Mountain (Far Southwestern Virginia)
Fairfax-Falls Church
Hampton – Newport News
Norfolk
Portsmouth
Richmond
Virginia Beach |