Change Is Coming System Transformation Excellence and Performance

Change Is Coming: System Transformation, Excellence, and Performance (STEP-VA) Daniel Herr J. D. Deputy Commissioner Virginia Department of Behavioral Health and Developmental Services

Section One WHY CHANGE IS NEEDED: THE CONTEXT

Challenging Road to Reforming Virginia’s Behavioral Health System Funding Alignment 50% Have No Payor ADA/ Olmstead Lack of Primary Care CSB Variability Crisis Focus Burden and Cost of BH Care System of Pieces • 40 CSBs/1, 927 locations • 631 private providers/4, 131 locations Slide 3 CSB Variability • Funding amount and type • Population demographics • Local priorities • Service array Funding • 25% State General Funds • 23% Local Funds • 40% Medicaid Funds • 40% CSB clients lack payor source Crisis Focus • 30% of services delivered are crisis services

The Behavioral Healthcare (BH) Landscape • BH issues drive up to 35% of medical care costs. • Care for people with BH disorders costs up to 2 -3 times as much as those without such disorders. • State hospital capacity average: 15 beds per 100, 000 people. • National average of state spending on hospitals = 23% of overall BH budget. • National average of state spending on community = 75% of overall BH budget (~$89 per capita, 2013). • From 2009 -2012, 12 states closed 15 state mental health hospitals. Slide 4 • In 2013, VA was 31 st in non. Medicaid GFs for BH at $92. 58 person. Median (Ohio) was $100. 29 person. • Roughly 50% of GF dollars for BH supports 3% of persons served. • State Hospital Capacity: 17. 3 beds per 100, 000 people. • Virginia spending on hospitals = 49% of overall BH budget in FY 18. • Virginia spending on community = 48. 5% of overall BH budget, FY 18 ($47 per capita, 2013). • Average 200 individuals ready for discharge in VA’s mental health hospitals. • VA has never closed a MH hospital.

Virginia’s Behavioral Health Services (FY 2017) Individuals Served - Hospital & Community State Mental Health Hospitals, 6, 291, 2% CSB Substance Use Disorder Services, 30, 549; 10% Spending - Hospital & Community 400, 000 CSB Mental Health Services, 120, 751; 38% CSB Emergency Services, CSB Ancillary Services, 62, 391; 20% 93, 111; 30% 350, 000 300, 000 $60, 245, 340 $54, 353, 341 $293, 631, 499 $282, 629, 155 State Hospital Community 250, 000 200, 000 150, 000 100, 000 50, 000 0 General Fund Slide 5 Nongeneral Fund

State Hospital Changes Due To Last Resort Legislation 10000 State Hospital TDO Admissions 8000 6000 4000 2000 0 FY 13 FY 14 FY 15 FY 16 FY 17 FY 18 FY 19 FY 20 • Since “Last resort” legislation was passed, a bed was provided for everyone under a TDO who needed a bed since the law was implemented July 1, 2014. • Since FY 2013, TDO admissions have increased 294%. • Since FY 2013, medical care costs have grown by more than 90%. • In FY 2019, the trend continues as in prior years. Slide 6

Total TDOs and Hospital Admission Trends 30, 000 25, 000 20, 000 24, 889 22, 687 25, 798 22, 322 25, 852 21, 861 25, 576 20, 220 15, 000 10, 000 5, 000 0 Slide 7 2, 192 FY 15 3, 497 FY 16 4, 397 FY 17 5, 356 FY 18* Total TDOs Admitted to State Hospitals Total TDOs Admitted to Private Hospitals Total TDOs Issued

Extraordinary Barriers to Discharge List (EBL) In September 2018, there were 158 individuals in state hospitals who were clinically ready for discharge for more than 14 days but appropriate community services were unavailable to facilitate a safe discharge. This is 12 percent of the total statewide census. Because approximately 575 people are added every year, the EBL is increasing again. 250 Number of Individuals on the EBL 200 150 100 168 147 156 50 152 204 181 147 194 185 172 145 155 185 Slide 8 8 l-1 Ju 8 r-1 Ap 18 n. Ja 7 Oc t-1 7 l-1 Ju 7 r-1 Ap 17 n. Ja 6 Oc t-1 6 l-1 Ju 6 r-1 Ap 16 n. Ja 5 t-1 Oc Ju l-1 5 0

Workforce Challenges State Hospital Staffing Vacancy Rates – FY 18 • Direct care staff turnover CAT CSH CCCA ESH NVMHI PGH SVMHI SWVMHI WSH is the highest in 10 years, Direct 9% 1% a huge issue for state Care DSAs 20% 13% 22% 19% 6% 28% 18% Direct hospital census 14% 36% Care RNs 17% 29% 20% 54% 19% 44% 12% management. • The average salary trails the national market. Hospitals are facing staffing shortages and overtime is increasing as a result. • RN vacancy rate across nine hospitals is 28%; Direct care vacancy rate is 14. 0%. • CSBs are losing case managers to the Health Plans who are paying $10 -15, 000 more with other incentives. “Pay not equal to workload" was among the top five reasons cited for leaving a case management position. RN = Registered nurse DSA = Direct service associate Slide 9

What Virginia Must Solve ACCESS QUALITY • Over reliance on costly institutional care • Consistent implementation of best practices • Meeting Olmstead/ADA- Requiring integrated services CONSISTENCY ACCOUNTABILITY Slide 10 Must improve access to services across Virginia Over-reliance on crisis services ~50% of people served by CSBs lack coverage Health disparities (geographic, socioeconomic) • • • CSB services vary considerably across Virginia • Size, geography, local funding, reimbursement disparities, local priorities, etc. • Outdated data infrastructure and reporting • Variances in governance, related to funding streams • Quality/Performance/Engagement

Section Two THE CHANGES - STEP-VA - MEDICAID EXPANSION - FINANCIAL REALIGNMENT

Behavioral Health Services for Uninsured Virginians Three steps must be taken to transition Virginia’s public safety net services: 1) Build/expand the services, access, and measures incorporated into STEP-VA. Slide 12 2) Align DMAS managed care behavioral health programs with STEP-VA so the same metrics and standards apply to the care for both Medicaid members and the uninsured. 3) Address the bifurcated funding streams for CSBs and state hospitals to better align services with needs and achieve better cost efficiency.

System Transformation, Excellence and Performance in Virginia (STEP-VA) • Infuses the services to better manage symptoms, negotiate employment, manage time, develop and maintain relationships, and negotiate other real life problems in daily living. • Reduces the demand for psychiatric and medical hospitalization. • Addressing demand for state hospitals cannot be fully accomplished by implementing STEP-VA. • Through STEP-VA and by expanding housing to target discharge-ready individuals in state hospitals, Virginia’s imbalanced system shifts to stronger community services and more integrated housing and supports, more in line with other states. Slide 13

Implementation Dates for STEP-VA Services Required by VA Code (2017) STEP-VA Service Same Day Access Primary Care Integration Behavioral Health Crisis Services Outpatient Behavioral Health Psychiatric Rehabilitation Peer/Family Support Services Veterans Behavioral Health Care Coordination Targeted Case Management (Adults and Children) Slide 14 GA Implementation Code Requirement July 1, 2019 July 1, 2021 July 1, 2021 Funds Allocated 5. 9 2018: $4. 9 M / 2019 $5. 9 M 2019 $3. 7 M / 2020 $7. 4 2020 $2 M for detox 2020 $15 M – – –

Implementation of the First Steps Same Day Access By the end of 2018, all but 5 CSBs will have implemented Same Day Access. The remaining 5 will implement in early 2019. Slide 15 Primary Care Screening & Monitoring CSBs will begin providing or expand this service in early 2019. Outpatient Services The 2018 General Assembly provided $15 M in FY 2020 for outpatient counseling services to allow the majority of people requesting services to be seen within 10 business days of the SDA appointment. Build Out Crisis Services The 2018 General Assembly provided $2 M in FY 2020 for detoxification services to help divert individuals from state hospital admission under the influence of substances during emergency services evaluation.

Same Day Access (SDA) • A person calls or appears at the CSB and is assessed that day. Based on assessment is scheduled for appropriate treatment within 10 days. • Shifts care away from crisis response when people are more at risk for themselves and for others. • Requires a change in CSBs’ business practices, scheduling, documentation, caseload management, and utilization of more focused and practical therapies. • Best practice that virtually eliminates “no show” appointments, increases adherence to follow-up appointments, reduces the “wait time” for appointments, and makes more cost-effective use of staff resources. Average results seen by the National Council for Behavioral Health: o 60% reduction in wait times; greater engagement and reduced no-shows. o 39% reduction in cost of access to treatment process o 34% reduction in staff time needed per access to treatment event. o 9 hours per week in time saved per direct care staff on documentation. Slide 16

Sampling of Same Day Access Initial Results CSB Initial Results for Same Day Access Chesterfield Eliminated wait-lists. Has zero no-shows for assessments (means staff spend less time doing outreach and rescheduling people who do not follow through with services). Improved (lower) drop-out rates from assessment to admission. Blue Ridge Decreased intake time from 3 -3. 5 hours to 1. 5 -2 hours. Henrico Engagement improved with a substantial increase in the show rate to the program (2016: 56% show rate; 2017: 77% show rate). Large increase in clients entering into services compared to 2016. New River Valley Wait time for initial intake has gone from almost 4 -6 weeks to 0 days; No show rate for first appointment from assessment has decreased from over 40% to 18%. Hanover Slide 17 Launched December 1, 2017. From Dec. 1 – Dec. 29, there were 81 people who walked in for services.

Primary Care Screening and Monitoring • In 2017, the General Assembly required all CSBs to provide outpatient primary care screening and monitoring services by July 1, 2019. • Primary care screening and monitoring for individuals seeking services from CSBs will increase the likelihood of those at risk of physical health issues getting preventative and primary care for physical health conditions. • Care coordination is vital to ensure individuals are linked with health care providers and follow up is done to address any barriers to services to address health risks. “People with severe mental illness (SMI) have an excess mortality, being two or three times as high as that in the general population. This. . translates to a 13 -30 year shortened life expectancy in SMI patients…About 60% of this excess mortality is due to physical illness. ” - Journal of World Psychiatry (Feb. 2011) Slide 18

Behavioral and Primary Healthcare Link Prevalence of Behavioral Health Comorbidities Among Medicaid-Only Beneficiaries with Disabilities Slide 19 Source: Center for Health Care Strategies, Inc.

Behavioral and Primary Healthcare Link Impact of Behavioral Health Comorbidities on Per Capita Costs Among Medicaid-Only Beneficiaries with Disabilities Slide 20 Source: Center for Health Care Strategies, Inc.

Re-envisioning the Future of Crisis Services Comprehensive Array of Services • Prevention Services • Mobile Crisis Stabilization • Children’s Crisis Therapeutic Homes • Provider Development Slide 21 Lifespan Support • Children • Adolescents • Adults Cross Disability • Behavioral Health • Developmental Disability

Outpatient Mental Health and Substance Use Services • • Includes individual, family, and group psychotherapy and competent use of evidence based practices. Evidence based practices include but are not limited to: o o o o o Slide 22 Trauma Informed Care Foundation for all Person and Family Centered Care services provided by the agency Recovery Oriented Care Motivational Interviewing Cognitive Behavioral Therapies (Trauma informed CBT for children) Prescription long-acting injectable medications for mental and substance use disorders Tobacco Cessation American Society of Addiction Medicine ASAM Criteria Medication Assisted Treatment

Targeted Case Management • Assisting individuals in sustaining recovery, and gaining access to needed medical, social, legal, educational, and other services and supports. • Supports for persons deemed at high risk of suicide, particularly during times of transitions such as from an ED or psychiatric hospitalization. • Identifying and reaching out to individuals in need of services, • Assessing needs and planning services, • Linking the individual to services and supports, • Assisting the individual directly to locate, develop, or obtain needed services and resources, • Coordinate services with other providers, • Enhancing community integration, • Making collateral contacts, • Monitoring service delivery, and • Advocating for individuals in response to their changing needs. Slide 23

Psychiatric Rehabilitation Services • Psychiatric Rehabilitation Services provide: o o o o Assessment, Medication education, Opportunities to learn and use independent living skills Enhance social and interpersonal skills, Family support and education, Vocational and educational opportunities, Advocacy to individuals with mental health, substance use, or co-occurring disorders in a supportive community environment focusing on normalization. • It emphasizes strengthening the individual’s abilities to deal with everyday life rather than focusing on treating pathological conditions. • Specific services to be provided include Mental Health Skill Building Services, Psychosocial Rehabilitation Services, and Intensive In-Home Services as defined in the current Virginia State Medicaid Plan. Slide 24

Peer and Family Support • Peer Support and Family Support, including parent peer support for children, provides access to: o Peer specialists o Recovery coaches, o Peer counseling, o Family/caregiver supports including parent peer support partners. • Peers will be certified through the DBHDS certification process. • WRAP (Wellness Recovery Action Plan) or equivalent planning will be provided through peer and family support services. Recovery support services include: 1. Emotional support – Includes peer mentoring, peer coaching, and peer-led support groups; 2. Informational support – Includes peer-led life skills training, job skills training, citizenship restoration, educational assistance, and health and wellness information; 3. Instrumental support – Includes connecting people to treatment services, providing transportation to get to support groups, child care, clothing closets, and filling our applications or helping people obtain entitlements; and 4. Affiliational support – Offers the opportunity to establish positive social connections with other recovering people. Slide 25

Armed Forces and Veterans • Intensive Community-Based Mental Health Care for Members of the Armed Forces and Veterans are not always easily accessible. • Services are to be informed by SAMHSAs 10 guiding principles of recovery: o o o Hope Person-driven Many pathways Holistic Peer support o o o Relational Culture Addresses trauma Strengths/responsibility Respect • Work to identify members of the armed forces and veterans upon intake to be sure they receive appropriate support and services. Slide 26

Care Coordination • Care coordination includes but is not limited to: o o o Department of Social Services Physical health care providers Schools Employment and Housing resources • Care coordination for youth in the CCBHC model is crucial given the many different entities serving children and adolescents and their families including physical health providers. The intensity of care coordination should be appropriate to the level of need and include High Fidelity Wraparound model when needed. Slide 27

Care Coordination Four key activities will be included in care coordination: 1. Assume accountability including a referral and transition tracking system. 2. Provide individual and family support during the referral and transition process. 3. Build relationships with community providers serving the same population and develop formal care coordination agreements with those providers. 4. Develop connectivity wherever possible for ease in exchange of medical information. Slide 28

Person-Centered Treatment Planning • Engages the individual and family through emphasizing the uniqueness of each person and his or her right to self determination. • Is based on principles of wellness, recovery, and hope and seeks to discover strengths that each individual possesses. • Is the road map for the work done by the individual, family, and provider and addresses: o o o o Slide 29 Strengths, Needs, Abilities, and Preferences of the individual. Balancing strengths with barriers. The Individual’s life vision by incorporating his/her hopes, dreams, and goals. The Integration of prevention, medical and behavioral health needs. Safety and crisis planning. All services required to help meet the identified goals Individual’s advance wishes related to treatment and crisis management

Permanent Supportive Housing Institutional Use • Chronic housing instability and homelessness are correlated with high health, behavioral health, and Housing Instability criminal justice system costs. • Permanent Supportive Housing (PSH) combines affordable rental housing with supportive services to address the treatment, rehabilitative, and recovery support needs of adults with serious mental illness. • Studies have found PSH effectively improves participants’ housing stability and reduces emergency department and inpatient hospital utilization. • From FY 2015 – FY 2018, DBHDS has received $9. 3 M for PSH. • Approximately 391 individuals are currently housed and 310 additional individuals will be housed this fiscal year. • Once the leases are completed, DBHDS will house and serve 700 people with serious mental illness through PSH funding. Slide 30

DBHDS PSH Providers by CSB Catchment Slide 31

What STEP-VA Addresses ACCESS QUALITY CONSISTENCY ACCOUNTABILITY ü Regardless of ability to pay (sliding scale fees) and place of residence ü At convenient times & places ü Prompt intake & engagement in services ü Crisis management 24/7/365 ü Prioritizes children, Veterans, SED, SUD, SMI ü Evidence-based practices ü Improved coordination and integration ü EHR/Data-quality improvement, reducing disparities & research ü Person/family centered, trauma informed, ü Culturally competent ü Recovery oriented care ü Specific required services ü Uniform definition of services ü Full array of services for mental health & substance abuse needs ü Basic primary care assessment and linkage ü Important support services ü Know what we are paying for, services provided, number of individuals served ü Expanded and improved data collection ü Uniform metrics, outcomes ü State certification required Slide 32

The Opportunity for Medicaid Redesign $$$ 28% Slide 33 Medicaid is the largest payer of behavioral health services in Virginia 40 th in the county for overall mental health outcomes th in the country for 47 of Medicaid members had either children’s mental health a primary or secondary outcomes behavioral health diagnoses

Farley Center’s work in Virginia: Key Findings 28% Medicaid members with behavioral health diagnoses had 1. 34+ million visits across multiple care settings Slide 34 In FY 17, 28% of Medicaid members had either primary or secondary behavioral health diagnoses Among Medicaid community -based mental health services mental health skill building accounted for nearly 40% of the total expenditure, therapeutic day treatment for 29% and intensive inhome for 20%.

DBHDS/DMAS Vision of Redesign: A comprehensive spectrum of behavioral health services • In collaboration with stakeholders’ clinical input, our goal is to develop recommendations for a comprehensive system redesign plan for Medicaid behavioral health services • Our vision for this system: § Improved behavioral health outcomes for members § A shift in our collective energies § Manifestation of trauma-informed principles across member, provider, and system § Reflective of the evidence for what works in community mental health § Mindful of the evolving needs for members across the lifespan

DBHDS/DMAS Work Process 1. 2. 3. 4. 5. 6. Review best practices for Medicaid mental health services across the lifespan from research literature and state case studies Analyze service gaps for the Virginia Medicaid population Identify individual and population level metrics and quality outcomes Assess DBHDS licensing and regulations to ensure quality and accountability Enlist stakeholders’ input throughout process to shape recommendations for a continuum of care and next steps Develop recommendations for a continuum of evidencebased, trauma-informed, and preventive-focused Medicaid community mental health services

Anticipated Outcomes • • • Alignment: Recommendations to align Medicaid behavioral health services with DBHDS licenses to create a continuum of evidence-based, trauma-informed, prevention-focused and cost-effective service options for members across the lifespan Accountability: Recommendations on outcome measures that incentivize high quality services in least restrictive environments Access: § Recommendations to expand access through a “no wrong door” approach for members across a full array of services delivered in settings where they naturally present for support. § Recommendations to expand access to service types and therapeutic interventions that are best practices and well-matched to members’ level of impairment / support need.

General Assembly Requirement for Financial Realignment Plan This plan shall include (Item 284 E. 1. ): i. ii. iii. iv. v. vii. a timeline and funding mechanism to eliminate the extraordinary barriers list and to maximize the use of community resources for individuals discharged or diverted from state facility care; sources for bridge funding, to ensure continuity of care in transitioning patients to the community, and to address one-time, non-recurring expenses associated with the implementation of these reinvestment projects; state hospital appropriations that can be made available to CSBs to expand community mental health and substance abuse program capacity to serve individuals discharged or diverted from admission; financial incentive for CSBs to serve individuals in the community rather than state hospitals; detailed state hospital employee transition plans that identify all available employment options for each affected position, including transfers to vacant positions in either DBHDS facilities or CSBs; Legislation/Appropriation Act language needed to achieve financial realignment; and matrices to assess performance outcomes. Slide 38 The plan is due December 1, 2017

Cost of Business as Usual Census* Utilization FY 2018 FY 2019 FY 2020 Maintain Current 1418 Beds 1347 95% Staffing Cost Discharge Assistance Planning (DAP)/Local Inpatient Purchase of Services (LIPOS) Cost Staffing for 56 -Bed WSH Permanent Supportive Housing (PSH) Cost 1375 97% 1404 99% FY 2021 FY 2022 Add 56 Beds at Western State Hospital (WSH) 1432 1460 97% 99% FY 2023 1474 Beds 1489 101% 1516** 103% $5. 8 M $6. 2 M $4. 9 M $9. 8 M $14. 7 M $19. 6 M $24. 5 M $29. 4 M $1. 4 M $3 M (1. 5) $6. 2 M $6 M $8. 3 M $9 M $8. 3 M $12 M $8. 3 M $15 M $8. 3 M $18 M (2. 3 +1. 8) * Census projections are based on the 2% per year growth experienced since “last resort” legislation went into effect in FY 2014: FY 2014 = 87% utilization; FY 2017 = 93% utilization. ** FY 2024: Demand decreases IF outpatient services, permanent supportive housing and crisis services for STEP-VA are all fully implemented. Slide 39 FY 2024*

Age of Facility Structures Slide 40

Useful Life Analysis Slide 41

The Structural Problem & Realignment Concept Current $200, 000 Realignment $200, 000 $0* $400, 000 State Hospital CSB NO CONNECTION Slide 42 CSB Pays Hospital for Bed Days CSB Funds Alternatives to Hospitalization *These are not real dollars in this concept example. The $0 would reflect only a determined amount of non-fixed hospital expenses, not the hospitals’ entire budgets.

CSB Summary of Identified Needs In July 2017, DBHDS requested that CSBs identify strategies and resources for reducing state hospital utilization. Crisis Services Housing Services and Supports Crisis stabilization and detoxification units, mobile crisis teams, expanded contracts with private hospitals Slide 43 Permanent supportive housing, transitional supervised living homes, intensive residential settings, assisted living facilities In-home supports, jail based services, clinical support for nursing homes, discharge planning for private hospitals, increased use of peer support services, case management, outpatient therapy, PACT teams, psychosocial programming, and increased access to outpatient psychiatry

Year One – Community Integration Plan Year One Goal – Build alternatives to state hospital placement. Projected Results – 178 discharges; Reduce the EBL from 170 to 117. Implement a community integration plan to prepare for financial realignment: • Develop new supervised living homes and assisted living facilities attached to permanent supportive housing. This facilitates transitions to integrated placements and makes room for more discharges. Leads to 104 discharges. • 50 additional discharge assistance slots (DAP) leads to 50 discharges. • Develop four safe and appropriate transitional supervised living homes specifically for the individuals who have been found Not Guilty by Reason of Insanity (NGRI) and are court-determined to be ready for discharge. Leads to 24 discharges. • Begin a standard utilization review process to ensure that individuals in state hospitals who no longer meet continued stay criteria are promptly identified. Slide 44

Year Two Goal: Finalize bed utilization targets and funding distribution. Projected Results – 144 discharges; Reduce the EBL from 117 to 88. • Continue community integration plan: leads to 70 discharges through supervised and assisted living, 24 through NGRI homes, 50 more through DAP • Transition to continued stay criteria from EBL. • Complete implementation of standardized reporting related to utilization. • Bed reduction targets will be based on factors including the utilization of state hospitals per 100, 000 population, ADC, access to private hospitalization, regional/geographic factors, and judicial practices. • DBHDS approval of community capacity options developed by CSBs or regions. • Finalize reimbursement/refund procedures based on bed utilization. • Finalization of any further Code/regulatory changes required for financial realignment to include precluding local funds from being used to support state hospital care. Slide 45

Year Three End of Year Three Goal – Reduce the state hospital average daily census (ADC) by 80. • Community integration plan is ongoing. • Financial Realignment Start-Up: Based on plans approved by DBHDS in FY 2020, CSBs and/or Regions begin building needed services, may include: o new assisted living facilities, o crisis stabilization units, o contracting with private providers when necessary. • Standardized utilization review and monthly report processes will continue. • Census reduction achieved by end of fiscal year. Slide 46

Year Four Goal – Implement full realignment. Projected Results – Reduce and maintain census at ADC of 1, 280 vs current projection of 1, 460 for FY 2022. • Bed utilization targets established for each CSB. Targets will be converted to a monthly utilization target for each CSB. • The payment for bed day based on non-fixed costs of hospital care. • Bed utilization above the monthly target will result in the CSB being billed for the days utilized above the target. Bed utilization below the monthly target will result in a “refund” from the state hospital. • Add provisions to the performance contract between DBHDS and the CSBs to preclude local funds from being used for state hospital bed purchase. Slide 47

Cost of Financial Realignment vs. Business as Usual $80, 000 $70, 000 $60, 000 $50, 000 $40, 000 $30, 000 $20, 000 $10, 000 $0 FY 2019 FY 2020 FY 2021 FY 2022 FY 2023 FY 2024 FY 2025 FY 2026 Financial Realignment New GF Business as Usual GF Realignment GF Slide 48 FY 19 $12. 0 M $24. 2 M FY 20 $22. 2 M $30. 4 M FY 21 $29. 2 M $41. 8 M FY 22 $38. 3 M $41. 2 M Business As Ususal New GF FY 23 $47. 3 M $43. 5 M FY 24 $56. 4 M $45. 8 M FY 25 $65. 7 M $48. 0 M FY 26 $74. 8 M $50. 3 M

Financial Realignment Impacts Business as Usual • Reduces the number of individuals no longer needing a hospital level of care and decreases the amount of time individuals wait on the EBL. • Helps build placement and support capacity in the community system, and addresses infrastructure critical to making STEP-VA services successful. • Reduces state hospital utilization closer to best practice rate of 85%. • Changes the determination of the number of beds required in state hospitals to be by actual need rather than history or estimates. • Avoids spending similar amounts of money over the next 5 -6 years on more hospital beds/staff to the impediment of building community capacity. • Introduces managed care principles: financial support of appropriate service/cost, utilization review with continued stay criteria, multiple data points to monitor performance/make adjustments. Slide 49