DBHDS Virginia Department of Behavioral Health and Developmental
DBHDS Virginia Department of Behavioral Health and Developmental Services Differences in Civil Commitment Practice in Virginia James M. Martinez, Jr. Department of Behavioral Health and Developmental Services June 2010
DBHDS Virginia Department of Behavioral Health and Developmental Services Goals of MH Law Reform • “Reducing the need for commitment by improving access to mental health, mental retardation and substance abuse services” • “Reducing unwarranted criminalization of people with mental illness” • “Redesigning the process of involuntary treatment so that it is more fair and effective” [R. Bonnie, Remarks to CMHLR, Oct. 6, 2006] Page 2
DBHDS Virginia Department of Behavioral Health and Developmental Services Goals of Law Reform (cont) • “Enabling consumers of mental health services to have more choice over the services they receive, and” • “Helping young people with mental health problems and their families before these problems spiral out of control. ” [R. Bonnie, Remarks to CMHLR, Oct. 6, 2006] Page 3
DBHDS Virginia Department of Behavioral Health and Developmental Services Promoting “Fairness” Goal 3……. Redesigning the process of involuntary treatment so that it is more fair and effective Page 4
DBHDS Virginia Department of Behavioral Health and Developmental Services Promoting “Fairness” What makes a system “fair”? The system responds the same way to everyone… • A common understanding of law and procedure (across individuals, agencies, communities) • Consistency in practice (application of law) • Uniformity of services and supports • Equitable access to care Page 5
DBHDS Virginia Department of Behavioral Health and Developmental Services Promoting “Fairness” (cont) What has Virginia done in these areas? • CMHLR Task Forces coordinate statutory reform and implementation • Uniform training of CSBs, courts, law enforcement, other partners & stakeholders • Cross-agency collaboration on policy and solving operational problems • Shared technical assistance resources • Targeted funding for new services Page 6
DBHDS Virginia Department of Behavioral Health and Developmental Services Fairness: How are we doing? Despite extraordinary effort to promote consistency, there are significant differences in the civil commitment process throughout Virginia, and in the experiences of service recipients and families with that process. For example… Page 7
DBHDS Virginia Department of Behavioral Health and Developmental Services Hearing Outcomes Statewide Of 15, 196 initial commitment hearings July 2009 - March FY 2010, statewide outcomes were: • dismissal = 19. 0% • involuntary hospitalization = 57. 1% • voluntary admission = 23. 4% • mandatory outpatient tx = <1% Page 8
DBHDS Virginia Department of Behavioral Health and Developmental Services Variations Between Courts • 33 District Courts conducted 100 or more initial hearings • All data that follows is from these District Courts……. Page 9
DBHDS Virginia Department of Behavioral Health and Developmental Services Dismissals Regarding dismissals, state avg. = 19. 0% • 4 District Courts had dismissal rates more than twice the state average, ranging from 39. 8% to 87. 4%, and • 7 District Courts had dismissal rates less than 5%, ranging from 0% to 3. 9%, with two courts having zero dismissals. Page 10
DBHDS Virginia Department of Behavioral Health and Developmental Services Highest Dismissal Rates District Courts with Dismissal rates more than twice state average: • • Galax (361/413) Fredericksburg (233/438) Charlottesville (140/340) Hampton (432/1086) 87. 4% 53. 2% 41. 2 % 39. 8% Page 11
DBHDS Virginia Department of Behavioral Health and Developmental Services Lowest Dismissal Rates DCs with Dismissal rates less than 5%: • • • Danville (21/539) 3. 9% Roanoke (26/816) 3. 2% Salem (16/635) 2. 5% Dinwiddie (3/198) 1. 5% Hopewell (4/320) 1. 3% Bristol (338) and Norfolk (180) had 0% Page 12
DBHDS Virginia Department of Behavioral Health and Developmental Services Involuntary Hospitalization Regarding involuntary hospitalization (state average = 57. 1%): • 8 District Courts had involuntary hospitalization rates higher than 70%, ranging from 73. 5% to 98. 5%, and • 9 District Courts had involuntary hospitalization rates lower than 35%, ranging from 4. 4% to 33. 1% Page 13
DBHDS Virginia Department of Behavioral Health and Developmental Services Highest Involuntary Commitment Rates District Courts with rates > 70% (state avg = 57. 1%) • • • Dinwiddie (195/198) 98. 5% Hopewell (305/320) 95. 3% Chesapeake (406/489) 83. 0% Petersburg (719/870) 82. 6% Richmond (1324/1620) 81. 7% Augusta, Norfolk, Va Beach all above 70% Page 14
DBHDS Virginia Department of Behavioral Health and Developmental Services Lowest Involuntary Commitment Rates District Courts with Rates < 35% (state avg = 55. 2%) • Galax (18/413) 4. 4% • Winchester (15/238) 6. 3% • Montgomery (110/487) 22. 6% • Russell (43/171) 25. 1% • Prince Wm, Mecklenberg, Fairfax County, Fredericksburg, Bristol, all below 35% Page 15
DBHDS Virginia Department of Behavioral Health and Developmental Services Mandatory Outpatient Treatment Regarding Mandatory Outpatient Treatment: • Only 56 MOT orders were issued statewide July 2009 - March 2010 • Only 11 District Courts had MOT orders • 33 of 56 total MOT orders were from one jurisdiction - Prince William Page 16
DBHDS Virginia Department of Behavioral Health and Developmental Services • • • Courts with MOT Orders Prince William (33/452) 7. 3% Augusta (3/153) 2. 0% Alexandria (2/154) 1. 3% Lynchburg (3/564) 0. 5% Smyth (5/950) 0. 5% Fairfax County (2 orders), Roanoke (3), Rockingham (1), Salem (2), Danville (1), and Montgomery (1) all < 0. 5% Page 17
DBHDS Virginia Department of Behavioral Health and Developmental Services Voluntary Hospitalization Excluding dismissals and MOTs, there were 12, 232 hospitalizations • About 70% of these were involuntary and 30% voluntary (i. e. , person accepts court offer of voluntary admission) • In District Courts with 100+ hearings, an average of 29. 0% of hospitalizations were voluntary Page 18
DBHDS Virginia Department of Behavioral Health and Developmental Services Highest Voluntary Rates 11 District Courts with 100+ hearings had 50% or more voluntary hospitalizations, ranging from 50. 7% to 91. 9% • • • Winchester (of 186 total hosp) 91. 9% Montgomery (of 381 total hosp) 71. 1% Russell (of 146 total hosp) 70. 5% Bristol (of 338 total hosp) 66. 9% Mecklenberg, Galax, Prince William, Fairfax County, Danville, Loudoun, Rockingham all above 50% Page 19
DBHDS Virginia Department of Behavioral Health and Developmental Services Lowest Voluntary Adm Rates 6 District Courts with 100+ hearings had less than 10% voluntary admissions, ranging from 0. 0% to 9. 9% • Smyth (of 724 total hosp) 9. 9% • Charlottesville (of 200 total hosp) 9. 5% • Chesapeake (of 438 total hosp) 7. 3% • Lynchburg (of 358 total hosp) 7. 3% • Hopewell (of 316 total hosp) 3. 5% • Dinwiddie (of 195 total hosp) 0. 0% Page 20
DBHDS Virginia Department of Behavioral Health and Developmental Services Some Thoughts on Variance • Variance in dismissal rates may indicate criteria are interpreted differently (e. g. , by CSBs, examiners, court officials) • Variance in voluntary admission rates may indicate different views about threshold for voluntary admission (e. g. , Winchester). • MOT usage in Prince William, and dismissal rate in Fredericksburg, is related to using full 48 -hour TDO period, and second CSB eval prior to hearing. Page 21
DBHDS Virginia Department of Behavioral Health and Developmental Services Other Sources of Variance? • Different perspectives among CSB staff and IEs • Variations in hearing process (evidentiary and procedural rules, attorney role, etc. ) • Hospital admission criteria • Payment options (e. g. , LIPOS), etc. Note - Differences may be more or less explainable or acceptable (e. g. , availability of alternatives to hospital vs widespread differences in statutory interpretation) • What are your thoughts on this? Page 22
DBHDS Virginia Department of Behavioral Health and Developmental Services Strategies to Reduce Variance • Training, technical assistance, oversight • A minimum core array of services? • Uniform eligibility and admission criteria, and consistent utilization management processes? • Consistent payment to providers to support desired outcomes? • What else? Page 23
DBHDS Virginia Department of Behavioral Health and Developmental Services In Closing…… • Consistency is toughest goal to achieve • Data just beginning to illuminate variations and possible problems • All communities & all cases are different • State, regional and local interests are different • Commission on MH Law Reform is setting up workgroup to address these issues. Page 24
DBHDS Virginia Department of Behavioral Health and Developmental Services In Closing…… What are your ideas for making the civil commitment process more consistent and fair? Page 25
DBHDS Virginia Department of Behavioral Health and Developmental Services Thank you! James M. Martinez, Jr. 804 -371 -0767 (office) 804 -786 -4837 and 804 -786 -5927 (main) jim. martinez@dbhds. virginia. gov Page 26
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