1. STEP VA: System Transformation, Excellence and Performance in Virginia Virginia’s pathway to excellence in behavioral healthcare and to a healthy Virginia
Thank you for the opportunity to present on the department’s strategies priorities for behavioral healthcare transformation in the Commonwealth.
Debra Ferguson, Ph.D.
Commissioner
Virginia Department of Behavioral Health
and Developmental Services

2. The National Healthcare Landscape
For context, I think it is important to begin with the national landscape for healthcare and the new interest in developing and promoting high-performing health systems.   To get there, the focus is on integrated approaches and targeting high risk, high cost populations with the ultimate aim of  improving care, improving population health and driving down the costs.  That’s the healthcare focus nationally, it’s our overarching goal in VA and it’s our goal for BH.
From the Institute for Healthcare Improvement

3. The Behavioral Healthcare Landscape
BACKGROUND:  
Primary factors contributing to EBL:  Delays in determining Medicaid eligibility= 28%;  Criminal justice involvement (NGRIs) = 28%; Lack of willing provider due to complex medical conditions, risk factors, or other intensive service needs = 19%; Need for guardianship = 11%
DAP Funding used to address lack of sufficient community infrastructure and supports
Comprehensive behavioral healthcare is essential to both population health and cost containment
Emphasis on prevention, early intervention and wellness
Bidirectional Behavioral Health and Primary Health Care Integration
Decreased reliance on institutional care
Increased focus on community-based services and supports
How does VA measure up nationally?
35th in BH funding in 2013
40th in consumers served per capita
15th in the nation in terms of expenditures per client.
Not maximizing our investment
50% of GF funding supports 3% of persons served
In BH, the national focus is on the ways in which comprehensive behavioral healthcare is essential to both overall population health and cost containment. There’s also a recognition that integrated care is a necessary component of improving health outcomes and patient satisfaction. There’s a huge emphasis on wellness, prevention and early intervention; and on moving away from a institutional behavioral healthcare model to a home and community-based system of services and supports.
In VA, our BH funding has been uneven and frankly anemic; we are not reaching enough consumers (our penetration rates are extremely low) and the funding that is provided is spent on more expensive inpatient services. This over-reliance on institutional care places us at great risk of DOJ finding that VA is failing to comply with the ADA and Olmstead. This is precisely the reason why DOJ is currently in 25 states due to failures in the BHcare system. Our year long transformation efforts are aimed at addressing these inequities. 
Medicare, Medicaid health plans and commercial health plans are understanding the importance of behavioral health to their bottom lines. All of the above are building high performing networks that include behavioral health providers. The behavioral health system in the US is moving from a fragmented 50 states 50 sets of rules, to one nationally-recognized, best practices framework for BH.
If we are going to serve more people and achieve better outcomes, we have to transform our BH service delivery system. And our transformed system must ensure quality, access and accountability across the lifespan and across the Commonwealth.

4. Behavioral and Primary Healthcare Link
Virginia (2013) (From the Kaiser Family Foundation)
Total number of SSI Beneficiaries=153,632
Number of SSI with disabilities= 135,238
135,238 x .5=  67,619+     (SSI beneficiaries in VA with likely with mental health diagnosis)
Prevalence of Behavioral Health Needs Among Medicaid-Only Beneficiaries with Disabilities
Our system transformation efforts must incorporate and address the demonstrated link between behavioral health and primary health conditions. Here you can see, the prevalence of BH conditions in Medicaid clients with disabilities. If you have a BH condition you are 2 to 3 times more likely to have a chronic health condition.
Data also demonstrate that the presence of a behavioral health condition is the major cost driver in the treatment of chronic conditions. For those with common chronic conditions, health care costs are as much as 75% higher for those with mental illness compared to those without a mental illness and the addition of a co-occurring substance use disorder results in 2- to 3-fold higher health care costs. A study in the New York Department of Health showed that for patients without MH/SA diagnosis, the cost for medical readmission was $149M; for patients with MH/SA diagnosis, medical readmission the cost was $395M, and for patients with MH/SA diagnosis, behavioral health readmission costs were $270M. We have no reason to believe that the data for Virginia would be any different.
Behavioral health and primary health are inexorably linked and so behavioral healthcare system transformation must reflect this reality.
For those with common chronic conditions, health care costs are as much as 75% higher for those with mental illness compared to those without a mental illness and the addition of a co-occurring substance use disorder results in 2- to 3-fold higher health care costs. – CMS
Source: Center for Health Care Strategies, Inc.

5. Key Elements to Transformation
Goal of excellence in behavioral healthcare
Emphasis on population health and wellness
So how does VA get there? DBHDS transformation efforts have been designed to create the pathway to establishing a high-performing BHcare system. Our efforts are grounded in the goal of achieving excellence in BHcare in the Commonwealth, incorporating a population health model and priority on recovery and wellness; promoting, facilitating and incentivizing integration of primary and BHcare and making sustained and targeted investments in those home and community-based services that enable people to obtain treatment in their home communities, with families involved and integrated with primary care and other human services supports.
The Excellence in Mental Health Act provides an exciting opportunity to obtain federal funding for community-based BHcare treatment. The Act creates “Certified Community Behavioral Health Clinics” (CCBHCs; or FQHCs for BH) to serve people with SPMI and SUD with intensive, evidence-based, person-centered treatment services. The Act provides $25M in funding to 8 states for planning and demonstration projects of CCBHCs. In addition, the Act provides that these CCBHCs will be eligible for enhanced FMAP (65%) which would provide a powerful incentive for VAs CSBs to become CCBHCs. We are already working on developing our application and convening community partners to seize this opportunity for VA. CCBHCs create a pathway to excellence and DBHDS is committed to bringing excellence in BHcare to the Commonwealth.
Sustained, strategic investment in community services and supports
Integration of behavioral health and primary health

6. The Excellence in Mental Health Act
April 1, 2014 the Protecting Access to Medicare Act (PAMA) was enacted.
Section 223 of the Act established Demonstration Programs to Improve Community Mental Health Services
Collaboration between SAMHSA and CMS on implementation of Section 223
Establishes Certified Community Behavioral Health Clinics (CCBHCs)
There are two phases:
Phase 1: Provides up to $2M for CCBHC Planning Grants
Phase 2: Up to 8 CCBHC Planning Grant states will be selected to participate in the demonstration program

7. The EMHA Opportunity What EMHA Offers: What EMHA Solves:
System Transformation, Excellence and Performance (STEP Virginia) The Path to a Healthy Virginia
What EMHA Offers:
Same Day Access
Standardized core services
24/7 Mobile crisis
Veterans services
Robust child services
Connections to primary care
What EMHA Solves:
Access
Geographic disparities in service offerings
Inconsistent quality
Funding
Capacity
The EMHA is an unprecedented opportunity to create a 21st century behavioral health services system that is available to all Virginians. For years, we have been trying to fix our behavioral health system, but have been slowed by inconsistent funding and measures created in reaction to crisis and tragedies. The EMHA not only fixes what is wrong with our system, but is our opportunity to plan in a thoughtful and strategic way to implement a high performing, high value networks of service.

8. STEP VA Application and Objectives
Virginia’s application was submitted before the Aug. 5, deadline.
The objectives of STEP VA include:
Establishment of the CCBHC certification process,
Implementation of evidence-based practices in all CCBHCs,
Promotion of bidirectional primary health and behavioral health integration,
Provision of same day access,
Reduction in health disparities, and
Establishment of a Prospective Payment System (PPS) providing bonus payments for achieving quality outcomes.
SAMHSA is making a total of $24,635,000 available – Up to 25 states may receive grants of up to $2 million.
In addition, DBHDS is contributing $2 million of its own resources to ensure STEP VA’s success.

9. 9 (plus 1) Components of Excellence
Crisis Services; 24 hour mobile, crisis intervention and stabilization
Targeted Case Management
Outpatient mental health and substance abuse services
Patient-centered treatment planning
Screening, assessment and diagnosis (including risk assessment)
Psychiatric Rehabilitation Services
Peer support and Family support
Care for members of the Armed Forces and veterans
Outpatient clinic; primary care screening and monitoring
There are 9 (plus 1) component services for CCBHCs which you see depicted here. The additional “plus one” is care coordination which is seen as a critical and necessary component of any high value, high performing behavioral health services system.

10. Virginia’s Eight CCBHCs
Rappahannock Area CSB
Harrisonburg-Rockingham CSB 4 5
Richmond BHA
New River Valley CSB
Cumberland Mountain CSB 6 3 7 1
Colonial BH 2 8
Mt. Rogers CSB
Chesapeake CSB
Cumberland Mountain CSB
Mt. Rogers CSB
New River Valley CSB
Harrisonburg-Rockingham CSB
Rappahannock Area CSB
Richmond Behavioral Health Authority
Colonial Behavioral Health
Chesapeake CSB

11. Key Community Services Investments
Comprehensive Outpatient Services
Robust Crisis Services; 24 hour mobile, crisis intervention and stabilization
Permanent Supportive Housing
Supported Employment
Children’s Mental Health/Trauma Services
Transition Age/First Break
Geropsychiatric Care
Jail Diversion & Community Re-entry
Behavioral Health Services to Veterans
Acute Detoxification
Prevention and Early Intervention
Key Services
Community
Transformed, High Performing Behavioral Healthcare System
In order to maximize the benefit from CCBHCs VA needs to invest in several key services in order build the necessary infrastructure for a robust home and community-based BHcare system. These key investments will decrease our reliance on high cost, institutional care by enriching the community-based service system. It also moves our BHcare system, and our healthcare system more generally, closer to the goal of becoming a high value, high performing system focused on population health and wellness.

12. What EMHA and CCBHCs Can Achieve in Virginia$
Bending the Cost Curve
Reduce hospitalizations
Reduce ER visits
Reduce psychiatric hospitalizations
Wellness
Improved health outcomes
BH and primary health integration
Patient Experience
How does DSRIP fit? It an unprecedented opportunity to dramatically rebalance the system and improve quality, outcomes and patient experience. Through DSRIP, along with CCBHCs, investments in behavioral healthcare will reduce general and psychiatric hospitalizations and ER visits. Other benefits will be increased wellness, improved health outcomes, greater integration of behavioral and primary healthcare, and an improved patient experience. It will enable the Commonwealth to build a system of home and community-based services that will effectively serve people in the community, all while driving down cost.
Using the framework of excellence in behavioral healthcare, DSRIP enables us to achieve improved outcomes and wellness for all Virginians…and these investments in behavioral health will bend the cost curve throughout healthcare.

13. THE VISION: A Life in the Community
Virginia as the Healthiest Nation
Focus on wellness and integration
A Life In the Community
Population Health
Community-based model of care
Virginia as the model for excellence in behavioral health across the lifespan
Improved quality, access and outcomes
DBHDS’s goal for everyone we serve is a life in the community. In order to provide and support this life for people, we have to shift our investment from institution-based care to making key, strategic investment in the community that best promote integration, wellness, self-determination and recovery…and people with SPMI and SUDs can and do recover. Our job, is to create a high-performing BHcare system that best enables them to do just that.
DBHDS is ALL IN with Commissioner Levine’s commitment to population health and making Virginia the healthiest state in the nation. We want the Commonwealth to achieve health and maintain wellness. Excellence in behavioral healthcare is the way to get there.

14. Destination Wellness and a Healthy Virginia
The Goal
There Is No Health Without Behavioral Health
Destination Wellness and a Healthy Virginia
To conclude, DBHDS is working to help realize the goal of making Virginia the healthiest state in the nation.
This involves making significant changes in delivery, integrating care and expanding the infrastructure that will truly allow Virginia to achieve health and maintain wellness.
Transformative efforts to reach excellence in behavioral healthcare is how we will get there.