BY: KATE MASTERS

Eastern State Hospital in James City County (Virginia Department of Behavioral Health and Developmental Services)

For years, mental health treatment for many Virginians has followed a predictable pattern, said Anna Mendez, executive director of the Charlottesville-based nonprofit Partner for Mental Health.

“For community providers like us, a family member will call and say their loved one is in crisis,” Mendez said. “And we can tell that they’re in distress, but they’re not in enough distress to be able to get the care they need.”

The state’s Medicaid system sets strict screening criteria for psychiatric services, and often doesn’t reimburse enough to cover the cost of providing treatment. As a result, many patients don’t receive care until their symptoms reach a crisis point, requiring hospitalization and — frequently — admission into one of the state’s inpatient psychiatric facilities.

A new state model, launched this week, is aimed at interrupting that pattern. Starting Thursday, Medicaid in Virginia will cover three new services that were often unavailable across the state, including intensive outpatient programs and assertive community treatment — a rigorous service that provides daily support and treatment to patients with severe mental illness.

Six additional services will be phased into the program this December, including mobile crisis, which is designed to prevent hospitalization by quickly stabilizing patients and connecting them to treatment. The model, known as Project BRAVO, was spurred by Medicaid expansion, which connected more than 400,000 Virginians to health insurance, said Dr. Alyssa Ward, director of the behavioral health division at the state’s Department of Medical Assistance Services. But it was also driven by a crisis within Virginia’s state-run mental hospitals, which have struggled to stay afloat amid a growing surge of admissions.

“What we have right now is this cascade happening,” Ward said. “People hit the emergency room — that’s just where they go — and they end up being admitted. And we know from data that it’s not the most effective way to deescalate the situation.”

There’s also evidence that Virginia’s lack of community treatment options is exacerbating the census struggles at state-run facilities. At the front end, patients are often hospitalized inappropriately when less intensive services aren’t available in their communities. But once patients are there, it’s often difficult to discharge them.

A 2018 report from researchers at the University of Colorado, who partnered with DMAS and the Virginia Department of Behavioral Health and Developmental Services, found that there are around 200 patients at any given time on the state’s “extraordinary barriers to discharge” list. In practice, that means there’s an entire hospital’s worth of patients who should be released but who often can’t access services that would allow them to live in the community.

“If those 200 people could leave the beds they’re sleeping in, we wouldn’t have this crisis,” Mendez said. It’s a core problem that Project BRAVO is hoping to address. Ward said DMAS spent several years identifying the services that should be included in the first phase of the program and defining the clinical standards that providers would need to follow.

The services will also come with an improved reimbursement rate under Medicaid, now the single largest payment source for many of Virginia’s mental health providers. The hope is that by creating new categories of care — and making it more profitable to provide them — those services will become more accessible across the state.

“If you’re a person with serious mental illness, that’s a chronic condition,” said Mindy Carlin, executive director for the Virginia Association of Community-Based Providers. “So these stepdowns are really important, but they cost money, they cost resources, and they’re going to need time to take effect.”

Community providers, like the agencies Carlin represents, have become a critical part of the state’s behavioral health infrastructure. Most are private businesses that help supplement the state’s 40 community service boards, often known as the “points of entry” to behavioral health services for many low-income Virginians.

CSBs can assess patients and receive state funding for certain core services, a list that’s expanded over the years as part of an initiative called STEP-VA. But since localities also contribute money to the program, funding levels — and the availability of treatment options — can vary widely depending on the region. Financial challenges have also made it more difficult for CSBs to hire staff, straining their capacity in many parts of the state.

“The private sector provides something like 80 percent of the services to Medicaid patients in Virginia,” said Jennifer Fidura, executive director of the Virginia Network of Private Providers. For mental health advocates, Project BRAVO is seen as at least a symbolic step forward in linking mental health treatment across the state. While STEP-VA is focused on improving services at CSBs with additional state funding, better Medicaid benefits will fund more intensive treatment options through private companies.

Building up that network of services is especially crucial given the state’s planned overhaul of its crisis response system, Ward said. Over the next several months, Virginia will be integrating dozens of regional mental health hotlines into one centralized call center. By 2026, the goal is for every CSB to have a mobile crisis team, staffed with trained community professionals, to respond to urgent psychiatric calls.

But there’s also broad acknowledgement, from both advocates and agency experts, that completely reforming Virginia’s mental health system is likely a long way off. One of the biggest concerns for providers is that services included under Project BRAVO aren’t among the most heavily used by patients.

“The services that are included today are focused on the people who are really, really sick and less on prevention and early intervention,” Carlin said. Those include things like assertive community treatment or partial hospitalization, another intensive program designed to provide hours of daily care.

And while the new reimbursement rates are based on a year-long study analyzing the cost of providing those services, they don’t reflect administrative time. Many of the treatments come with new accreditation standards, a way of ensuring quality across the state. DMAS has given providers two years to get that accreditation, but agencies also have to meet regulatory requirements from the state’s six managed care organizations — the insurance companies that are actually responsible for providing benefits under Medicaid.

“The rates, I believe, are so laughably low that we will not see significant increases in those services until they increase,” Mendez said. “But if they are, and if other services come online under Project BRAVO, I do think we’re going to see a shift.”