A More Appropriate Management Model for State Mental Health Facilities

Central State Hospital Petersburg

by James C. Sherlock

I always find it disturbing when state agencies operate institutions that they are also responsible for regulating and inspecting.

It almost cannot work.

I have brought this up with regards to the VDOE operation of a virtual learning program when that same agency oversees private providers of the exact same services.

That is small ball compared to the issues at the state’s mental health facilities.

Now we have a very recent tragic example at Central State of decades-long problems at state-run mental hospitals including overcrowding and inadequate staffing.

A 2021 Associated Press article used Central State as the leading example of overcrowding. The reporter wrote, prophetically:

Virginia sheriffs are reporting being stretched thin after responding to psychiatric emergencies that require them to hold people and transport them for treatment.

‘I’ve had deputy sheriffs tied up for days at a time,’ John Jones, executive director of the Virginia Sheriffs’ Association, told the newspaper in an interview on Tuesday. ‘We’re at a crisis point.’

Now seven sheriffs deputies and three Central State staffers are charged with murder in that same scenario.

I view the current management model in which a single state agency oversees, operates and inspects its own facilities as untenable.

There is a proven alternative.

Current management organization. The Virginia Department of Behavioral Health and Developmental Services (VDBHDS) manages its own facilities and regulates and inspects private facilities.

The Commissioner has eight direct reports. Among them are:

  • A Deputy Commissioner for Facilities, who oversees eleven mental health facilities;
  • A Chief Clinical Officer responsible for case management, human rights management, clinical quality management, regulatory matters and licensing;
  • A Chief Administrative Officer, who manages the CFO (budgeting, financial), the human resources officer, and the CIO;
  • An Assistant Commissioner for Compliance, Risk Management and Audit.

To state the obvious, in that organizational structure the actual responsibility for the operation of state facilities resides in the Commissioner, not his Deputy for Facilities.

The ongoing transition to a broader system of mental health supports. Virginia has for more than a decade, in alignment with recommendations from the Centers for Medicare/Medicaid Services, been evolving its mental health system with increased emphasis on the establishment of community services and on the more effective and efficient use of state facilities.

The state facilities are now one of several resources in an overall continuum of care.

Patients are initially evaluated and referred to the mental health facilities by staff from Community Services Boards (CSBs). Pre-admission screening services are provided by CSBs on a 24 hours per day, 7-days-per-week basis.

The Governor’s plan increases funding for those systems dramatically.

I do not believe running state mental hospitals is the appropriate responsibility for a VDBHDS Commissioner who has far wider responsibilities.

It is also unnecessary.

An alternative management structure. I offer a model that will put the Commonwealth and VDBHDS in what I consider its proper position of policymaking, regulation, oversight and inspection, the role it fills for private mental health facilities, rather than operator of state mental facilities.

A Government Owned-Contractor Operated (GOCO) facility is a model used by the Army when it hires a privately owned company to operate a munitions production site that it owns.

The Radford Army Ammunition Plant is an example.

The Army owns it, but BAE Systems operates it under contract to the Army. The contract is re-bid every five years. If the contractor is unsatisfactory in his performance, he will be replaced sooner.

The applicability of that model to state mental health facilities is apparent. There is no lack of private operators of mental health facilities to compete for the contracts.

Bottom Line. This is not a partisan issue. Virginia has struggled with its dual role in its mental health facilities for as long as I can remember.

If a government employee owned stock in a private company for which he was in position to make oversight decisions, it would be deemed a conflict of interest and he would have to recuse himself.

That same conflict of interest is present here, and there is no way under the current management structure for the VDBHDS Commissioner to recuse himself – to put himself at arms length from oversight of his own operations.

I recommend the GOCO alternative as a more appropriate role for the state in state mental health facilities management and one more likely to produce the results we all seek.