State Mental Health Plan Too large, Complex to Succeed?

by James C. Sherlock

I really want Virginia’s mental health program to work. It looks like a major struggle, however.

I will recommend a major change: state control of the Community Services Boards (CSB)s.  I think that will be necessary for the plan to have any chance of succeeding.

I have just finished reading a draft 409-page report to the federal government that describes planned efforts to expand and improve the state’s mental health care system. It has been developed by the Virginia Department of Behavioral Health and Developmental Services (DBHDS) for the signature of the Secretary of Health and Human resources.

Three things jump off the pages — all of the hard things are to happen going forward, the complexity of the program will be enormous and the state will not have enough control to make it happen.

Some of the management obstacles I see:

  1. The draft plan requires what is frankly a series of miracles of management and coordination of organizations, their bureaucracies, IT systems, funding, hiring, building of facilities, training, operations and quality assurance between the state and federal government, within the state government, among state and local governments and between government agencies and the private sector across more programs than I can quickly count.   I participated as a contractor in the federal government reorganization after 9/11.  This plan is the most aggressive attempt to tackle this kind of an effort that I have seen at the state level.
  2. All of your efforts of course are governed by a list of federal and state laws and regulations longer than most citizens can possibly imagine.
  3. It is hard to understand the sources of all the properly trained and licensed people required even if we fully fund it.  Both physicians and nurses with the right specialties are already in very short supply.
  4. The Peer and Family support program in particular will need to be very well thought out, regulated and managed or it is at risk of turning into a series of nightmare headlines. Ditto the programs for Individuals with Criminal Justice Involvement.
  5. The core management design for the effort is in my view fatally flawed. The internal program management diagram. shows the problem.  When that is expanded to include all of the external government agencies like Medicaid, the Department of Corrections, the state and local police, the Department of Education and many others both state and local that have a big hand in this, it won’t fit on a chart.  The most vital and fixable disconnect is that the 39 Community Services Boards (CSBs) are not shown as under the operational control of the DBHDS. And all of them are understaffed.

Removing the last of those obstacles is possible but will require legislation. That will need to get that done if this is to work as well as we need it to, and even then it will be a major challenge.


Virginia, prodded by lawsuits filed by the Justice Department that the Commonwealth settled in 2012, has been studying the problems of mental health and their solutions since then. I introduced the subject in the column linked above.

First I thumbed through the pages of state certifications and assurances of compliance with federal laws and regulations governing mental health programs. Those included, first, 15 sections of Title XIX, Part B, Subparts II and III of the Public Health Service Act. Then 19 lines of specifications of other federal laws. Finally four pages of certifications of compliance with what appears to be a considerable chunk of the Federal Register.

Assessment and needs. The description of Virginia’s Public Behavioral Health System starts on page 62 of the online document.

The Department of Behavioral Health and Developmental Services (DBHDS) is tasked with providing public behavioral health (mental health and substance use disorders) as well as developmental and intellectual disability services in Virginia.

Virginia operates 12 facilities: eight behavioral health facilities for adults, one training center, a psychiatric facility for children and adolescents, a medical center, and a center for behavioral rehabilitation. State facilities provide highly structured, intensive services for individuals with mental illness, intellectual disability or are in need of substance use disorder services. The Commonwealth Center for Children and Adolescents (CCCA) in Staunton remains the only state hospital for children with serious emotional disturbance.

Community Services at the local level are provided by 39 community services boards and one behavioral health authority (referred to as CSBs). Local governments that provide services directly to consumers or through contracts with private providers across the Commonwealth have established these CSBs.

Long story short, it has not worked nearly well enough. The approach Virginia has laid out is named System Transformation Excellence and Performance (STEP-VA).  STEP-VA is supposed to result in a uniform set of required services, consistent quality measures, and improved oversight in all Virginia communities. But not unified control.

The goal of STEP-VA services is to focus on wellness among individuals with behavioral health disorders and prevent crises before they arise. As part of the changes, the projected result would be fewer admissions to state and private hospitals, decreased emergency room visits, and reduced involvement of individuals with behavioral health disorders in the criminal justice system.

Services include:

  • Same Day Access – (Phase 3, full implementation, began July 1, 2021)
  • Outpatient Services – (Phase 2 Initial Implementation initiated before July 1, 2020).

Outpatient service means treatment provided to individuals on an hourly schedule, on an individual, group, or family basis, and usually in a clinic or similar facility or in another location. Outpatient services may include diagnosis and evaluation, screening and intake, counseling, psychotherapy, behavior management, psychological testing and assessment, laboratory and other ancillary services, medical services, and medication services.

The outpatient mental health and substance use services are considered foundational services for any behavioral health system. Over 100 additional clinicians have been funded in the public system with STEP-VA outpatient funding ($15 million in state fiscal year 2021, increasing to $21 million in state fiscal year 2022).

  • Primary Care Integration- (Phase 2/3 as of July 1, 2021; data requirements modified during COVID-19)
  • Care Coordination- (Assessment phase started in early 2019, not yet funded)
  • Peer and Family Support- (Phase 1 of Planning and Preliminary Implementation initiated July 1, 2019; first funding begins July 1, 2021). Peer Supporters have lived experience with mental health and/or substance use challenges and recovery from these challenges.
  • Psychosocial Rehabilitation/Skill Building – (Assessment phase started in early 2019, not yet funded)
  • Targeted Case Management – (Assessment phase started in early 2019, not yet funded)
  • Veterans Services (Phase 1 of Planning and Preliminary Implementation initiating Fall of 2019); first funding begins July 1, 2021
  • Mobile Crisis Services – (Phase 2 initial implementation for Child Mobile Crisis started July 1, 2020; first funding for adult mobile crisis services begins July 1, 2021)

Project BRAVO/ Medicaid Behavioral Health Enhancement. 

Medicaid is the largest payer of behavioral health services in the Commonwealth, and nearly a third of all Medicaid members have a behavioral health diagnosis.

On July 1, 2021, Virginia began[ implementation of the transformation of the community based behavioral health services offered through Medicaid. This initial phase of this implementation will include high quality, evidence based services that divert from inpatient psychiatric care. A number of these services are already available in Virginia but are not accompanied by a Medicaid rate that incentivizes evidence based practice. The services to be implemented this year are Partial Hospitalization Programs, Intensive Outpatient Programs, Assertive Community Treatment, Multisystem Therapy, Functional Family Therapy, and Comprehensive Crisis Services.

Behavioral Health Needs Assessment. 

The state paid a contractor to do a needs assessment of Virginians for publicly funded behavioral health services, to assess current capacity to meet the behavioral health needs of Virginian’s for community based, crisis and facility care including prevention, treatment and recovery.

The final report was provided to DBHDS in March 2020 immediately prior to COVID. In general, the report highlighted the needs for further system integration and an update to data infrastructure both at DBHDS central office and at the CSBs.

The coordination needed crosses many boundaries: Medicaid; Social Services; Housing; Primary Health Care; Employment Services and Supports; Criminal Justice and Juvenile Justice Services; Education; rights advocacy; CSBs; local agencies including school systems, social services, local health departments and area agencies on aging.

Five regional partnerships including one region with two sub-regional partnerships (Region 3) have been established to facilitate regional planning for services system transformation and promote regional utilization management. These partnerships provide forums to address regional challenges and service needs and collaboratively plan and implement regional initiatives. Partnership participants include CSBs, state facilities, community inpatient psychiatric hospitals and other private providers, individuals receiving services, family members, advocates, and other stakeholders.

Each regional partnership has established a regional utilization review team or committee to manage the region’s use of inpatient beds and funds allocated to purchase local inpatient psychiatric crisis care and residential substance abuse treatment, including state general funds as well as federal Community Mental Health Services (CMHS), and Substance Abuse Prevention and Treatment (SAPT) block grant monies.

Other initiatives that must be managed include partnerships with private providers, peer/recovery support services.

The impact of COVID

While evidence indicates the need for support and services is increasing, Virginians will be faced with a damaged behavioral healthcare system. Increased costs from personal protective equipment (PPE) and telehealth equipment, paired with reduced revenue and cancelled services during the initial months of the pandemic, have forced many behavioral health providers to furlough or layoff staff, close services, and reduce access.

Community Services Boards (CSBs) have been particularly hard hit as behavioral health providers who also offer the public a behavioral health safety net for individuals who cannot access care through other pathways.

Then follow sections on:

  • Intersecting Pandemics: Racial Injustice and Need for Community Based Crisis Care;
  • Cultural, Racial/Ethnic and Language Minorities;
  • Military Personnel and Their Families
  •  the homeless;
  • homelessness prevention for veterans;

Individuals with Criminal Justice Involvement. Recommendations for criminal justice improvement include:

  • Crisis Intervention Teams for mental health responses that are “that are interdisciplinary, collaborative, and community based.”
  • Jail Diversion Programs;
  • Mental Health Screening in Jail;
  • Behavioral Healthcare Standards for Jails:
  • Forensic discharge planning (turning persons over to the mental health system).;
  • Problem Solving Dockets
  • Programs for Sexual Minority Groups

Other specialized services:

  • Services for pregnant and parenting women
  • Services for Individuals who Inject Drugs
  • Services for persons at risk of tuberculosis
  • Services for Individuals in Need of Primary Substance Abuse Prevention
  • Support services for children
  • Services for Military Service Members, Veterans, and their Families (SMVF)

Transforming the Behavioral Healthcare System

DBHDS began a transformation process in 2014 that included a comprehensive review of the state behavioral health and developmental services system. Today this process continues to focus on access, quality, stewardship of resources, equity, and accountability. Virginia’s behavioral health system faces many challenges. These include:

  •  insufficient service capacity coupled with high demand;
  • inconsistent access to best practices;
  • inadequate integration of care for individuals with behavioral health (BH) and substance use disorder (SUD), consumers with complex, co-morbid health and behavioral health care needs, and/or behavioral health and criminal justice involvement;
  •  Need for increased peer and family involvement and support;
  • Criminalization of individuals with BH and SUD; and fragmentation of services due to lack of care coordination.
  • Ongoing workforce issues exacerbated by the impact of the COVID-19 pandemic across both community based and facility based services.
  • Suicide prevention.

These challenges continue to be compounded by broader, external factors including an aging workforce, inadequate resources, regulatory stressors, complexities with system-wide implementation of electronic health record technology, and lack of access to critical support services such as transportation, employment, and affordable housing. Throughout 2020 and 2021 these preexisting issues were compounded by an abrupt shift to telehealth statewide in response to the COVID-19 pandemic. Community based partners lacked resources and training to fully engage with the individuals they serve. The individuals seeking/receiving services were often confronted with barriers to include the fiscal impact of job loss, poor reception for the use of telehealth at their residence, and increased need to care for children/other family members.

I’d like to believe this plan by the state has some chance of working as designed, but experience makes me doubt it.

I would doubt the state’s ability to staff and manage an enterprise of this scale and complexity if it ran the entire thing. It won’t under the current plan. It needs to fix that.

But whatever they do I wish them Godspeed. It is important work.

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6 responses to “State Mental Health Plan Too large, Complex to Succeed?”

  1. Dick Hall-Sizemore Avatar
    Dick Hall-Sizemore

    The basic flaw in the Commonwealth’s mental health services system are the community mental services boards (Chapter 10 boards). They are not run by the state mental health agency, but by local or regional boards or agencies. State statutes set out minimum standards and requirements, but the implementation is up to the Chapter 10 boards. And there is no uniformity in their operations. For example, in my experiences as the DOC analyst at DPB, I quickly learned that some Chapter 10 boards had good working relations with local probation and parole offices in providing mental health services to offenders on probation, while other Chapter 10 boards were largely uncooperative.

    Furthermore, there is little accountability for all the state appropriations to the local Chapter 10 boards. At DPB, several of us came to the conclusion that putting more money into those entities was like pouring money into a black hole.

    In recent years, there has been movement toward making the system more accountable. It is called STEP-VA. JLARC has specific responsibiity for analyzing these efforts. There is a series of JLARC reports which will probably be more useful to you than that gigantic report to the feds.

    1. James C. Sherlock Avatar
      James C. Sherlock

      Thanks, Dick.
      The program I assessed is STEP-VA.

      There is a big hole in the middle of STEP-VA.

      My professional opinion is that unless legislation brings the Community Services Boards (CSB’s) under the operational control of the DBHDS, there is no chance or the “plan” to work.

      That is an old government hand and enterprise architect talking. I respect your more specific experience with the players here. It seems we are in violent agreement.

      1. Dick Hall-Sizemore Avatar
        Dick Hall-Sizemore

        Yes, we agree.

  2. Jim Loving Avatar
    Jim Loving

    As someone whose family has worked with this system for 35+ years from the role of supportive family members of a client/constituent/patient of this system, as well as occasional testifier to the legislature (sibling of mine), I can attest to the complexity and challenges of the system. And, we mostly have worked with the Central VA CSB for Henrico/Richmond and Harrisonburg.

    I used to work with many Enterprise Architects, and I have always appreciated their work because as James knows, before you can design IT systems that are efficient and optimal, you must first understand mission and business processes.

    This is an attempt to do this and not surprisingly, you have layers upon layers of government agencies-programs at multiple levels (local, state, federal) with differening programs and NGOs also included in the mix.

    I’m glad I am not attempting to “fix” this, just learning how to navigate it for a loved one is enough of a challenge.

    Thanks for the post.

    1. James C. Sherlock Avatar
      James C. Sherlock

      Thank you. We both wish them well.

      Your point about using a systems engineering approach to describe an architecture for this entire enterprise is on point. After reading 409 pages of program description, I found no evidence of it. If they had done that work, they would have proudly claimed and published it.

      The systems engineering can be done retroactively and the plan changed as necessary. That would mean admitting that DBHDS had spent 9 years not doing it right. That realistically can only happen under a new administration.

      I have forwarded to both DBHDS and Secretary Carey my suggestion for the state to take operational control of the CSBs. My assessment is that the plan has no chance of broad success without that. You can open the diagram linked in the column and see it with your own eyes. That is a copy of DBHDS’ own diagram.

      Currently, of course, the state – DBHDS in this case – has no experience in operations management. That is why they could not see the problem presented by their own program description.

      They will have to build an operations center and hire experienced ops managers to staff it. Then all of those dashed lines in the diagram will turn to solid lines.

      Only then can they face the other monumental challenges with some hope of success.

      If you want to weigh in with DBHDS and the Secretary, let me know with an email to Jim Bacon and I will sent you the contact addresses. With your personal experience, your input would be valued. After all, the 409-pager is labeled a discussion draft.

  3. Robert Gluck Avatar
    Robert Gluck

    Completely agree with your point about the CSBs. My adult son has lived in Fairfax, Loudoun, and Prince William counties over the past few years. Not surprising considering his poor track record of complying with rental housing rules and the difficulty of finding affordable housing in the greater DC area. He’s worked with the CSB in all 3 areas and each one requires a separate enrollment process, different treatment approaches, and different levels of service. And each is more than happy to pass responsibility (i e. the cost) for his care to the other. The result is a lack of seamless care for someone who desperately needs it.

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