Public Comments for 01/26/2021 Health, Welfare and Institutions - Behavioral Health Subcommittee
HB2166 - Involuntary admission; provisions governing involuntary inpatient & mandatory outpatient treatment.
Last Name: Sharkey Organization: VOCAL Locality: Petersburg

Dear Members of the House Appropriations Committee, We are contacting you today in regards to HB2166, Patroned by Delegate Hope. HB2166 amends current processes of involuntary detainment and Mandatory Outpatient Treatment orders. As we voiced during the previous Committee and Subcommittee hearings, VOCAL and our membership of 2,000+ peer/consumers of Virginia's mental health care system, do not support the bill as written. From our perspective, there are two main reasons for our opposition. The first reason relates to HB2166's degradation of personal choice and person-centered care, through the removal of an individual's consent and commitment to the goals within the MOT order. The second reason for our opposition relates to concerns over the preparedness, or lack thereof, of our local communities to support the adherence to MOT orders. Specifically, the inequitable spread of local communities' infrastructure and funding, both of which are critically necessary to support an individual's efforts to comply. We encourage you all to read through the 2019 SAMHSA article "Civil Commitment and the Mental Health Care Continuum" (referenced below) prior to all Committee discussions of HB2166. https://www.samhsa.gov/sites/default/files/civil-commitment-continuum-of-care.pdf Thank you in advance for your time and attention to this important matter.

Last Name: Jennifer Faison Organization: Virginia Association of Community Services Boards Locality: Richmond

The Virginia Association of Community Services Board (VACSB) has no position on this bill; however, the VACSB would anticipate putting forth a budget request in the 2022 session of the General Assembly in order to mitigate for the additional requirements beginning on line 290 in the introduced bill which reads "The community services board responsible for monitoring the person's progress and adherence to the comprehensive mandatory outpatient treatment plan shall report monthly, in writing, to the court regarding the person's and the community services board's compliance with the provisions of the comprehensive mandatory outpatient treatment plan described in clause (viii) of subsection G of § 37.2-817. " Most often, the MOT coordinator in a CSB is going to be a Certified Prescreening Clinician which means that individual, in addition to his/her duties as an MOT coordinator, is conducting emergency evaluations for the purposes of determining whether a request for a TDO is appropriate for an individual experience a psychiatric crisis. If that clinician is spending time organizing submitting paperwork for every individual on his or her MOT caseload, he or she will not be available to do prescreening evaluations. This means that another clinician will need to be paid overtime for coverage or perhaps, depending on the MOT caseload, an additional prescreening clinician will need to be hired. At a minimum, staffing patterns will need to be examined and supplemented in order to comply with these requirements. The VACSB plans to collect data regarding the impact of the legislation, should it pass, in order to support the budget request in 2022.

Last Name: Kanoyton Organization: Gaylene LLC Locality: Hampton

VSC NAACP is in full support of HB 2166

Last Name: Randolph Locality: Chesterfield

Thank you to the committee, my name is Shaddai R. from Richmond, Virginia. I am here to encourage you to.. 1. Increase the allocation of tax revenue towards the reinvestment fund from 30% to 70% because anything less than a majority of the revenues is disingenuous to the priorities of the bill. 2. Allocate 50% of all licenses towards Virginia social equity license holders as no other licenses are required to be owned by Virginia residents. 3. Add another tier of license, micro-business licenses, so that smaller applicants can enter with unique integration privileges. 4. Do not add any new crimes nor criminalize another generation of youth because of a fake war on drugs

Last Name: Jackson Organization: Marijuana Justice Locality: North Chesterfield

I am a constituent of the 7th district but I feel it is necessary to work together to protect the younger members of our society and stop the criminalization of the Hispanic and African American communities. Rules must be stated clearly now so we are better prepared to face a future when marijuana is officially legalized in the Commonwealth of Virginia. Please increase the reinvestment from 30% to 70% for new companies and entrepreneurs. Make sure the new market is equitable and accessible to all not just large corporations.

Last Name: Nadwodny Locality: Gainesville

Why would you force a vaccine when hyrdroechloraquin and other drugs heal people. CDC says 99.9% of people recover. Why are you using the tool of fear. What is in it for you. It’s being said that covid is just the first part of this bio weapon. The next part will kill those who were diagnosed with it. If you keep this up there won’t be any one to vote. Oh that’s right. Depopulation is part of the plan. You reap what you sow.

Last Name: Creekmore Organization: Various Locality: Henrico

As a Licensed Clinical Psychologist and independent forensic examiner for the court with many years of experience evaluating individuals with intermittent serious mental illness (Schizophrenia, Bipolar Disorder, and Dual Diagnosis Disorder), it is my recommendation that special justices be granted broad judicial discretion to order an MOT order with or without consent under any proposed revision of 37.2-817 under conditions otherwise proposed in the revised Code. "One size does not fit all". Schizophrenia is a disorder that presents in varying ways, to varying degrees, at different stages of the illness and with widely varying prognoses-- usually determined by how early in the disease process effective antipsychotic medication can be prescribed and "adhered to"(John M. Kane, MD, RAISE Research Program). The same point might be made for most SMIs (Major Depression, Bipolar Disorder, etc. ). Psychosis is also commonly a symptom in its acute manifestation that can present initially in many unrelated medical conditions that need to be competently and expertly assessed with rule out. There are many individuals with a history of recurring SMI and presenting to the special justice on a "green warrant" who, after a reasonable initial period of psychiatric stabilization and expert capacity assessment, could benefit from having the legal option to voluntarily consent to a court ordered MOT with periodic review and/or status hearings through the auspices of the CSBs that have the resources to properly implement such "legal clinics". These orograms can be customized according to the needs and resources of the individual and the community. There is something about "answering to a judge" that makes all involved in the proceeding take the whole process more seriously. Many individuals after years of "non-adherence" to treatment and/or failure to obtain appropriate services in the community might recognize that they require and would benefit from voluntary court supervision (particularly those with Dual Diagnoses). Where homelessness or incarceration may be the likely alternative consequence of their actions and choices, this might seem the "lesser of the available evils". Without appropriate judicial prudence, including a "choice" option for the individual whose civil liberty is vitally affected, however, the present incarnation of 37.2-817 may be at risk long-term of going the way of mandatory minimal criminal sentencing and other ill-conceived laws.

Last Name: Sharkey Locality: Petersburg

I can only support involuntary treatment orders when individuals meet the criteria for involuntary detainment (TDO/ECO criteria). In the current version of the bill, "1.b." the Pre-Authorization Step-down MOT option allows for individuals to be mandated to intensive, outpatient treatment, for up to 6 months, at a time when they no longer meet those criteria. I strongly feel that mandated treatments for individuals that do not currently meet criteria for emergency detainment is a threat to their civil rights. Furthermore, the success of mandatory outpatient treatments are contingent on the local communities' infrastructure (or lack thereof) of available public services. I fear that, while the Patron of the bill's community (Arlington) likely has the available services in place, there are countless communities, rural and/or lower socioeconomic, that simply do not currently have the needed services in place. The absence of these services, in my opinion, render the work on the MOT process significantly less impactful.

Last Name: Creekmore Organization: Various Locality: Henrico

As an independent examiner with over 15 years of experience providing independent TDO evaluations for special justices and the courts, I can tell you that safety-- that of the individual with serious mental illness, of family members. and of the community) always comes first in the preparation, execution, and disposition of these civil judicial hearings and cases. In the past, the large majority of the MOT orders have been for "Direct" MOT orders, not "step-down" MOT orders-- whether by advance order of the court or "de novo" MOT hearings and orders after physician approval for discharge. I am concerned that the present House Bill 2166 in its present form will not allow sufficient time under the current statutorily required 72 hour period limit (exclusive of weekends and holidays) in pre-hearing detention to be sufficient for the type of multidisciplinary capacity assessments and judicial deliberations proposed under 37.2-817 et seq. This bill, as proposed in most instances, as it applies at least to "Direct' MOT orders as an alternative to inpatient hospitalization, would allow at most 72 hours for the physician and independent examiner, and others, to accomplish the following: initial risk and capacity assessments, authorized family contacts, authorized medical records releases, initial treatment team reviews and follow-up pre-discharge MOT step-down treatment planning jointly conducted by the hospital and the CSB, and, where applicable, Psychiatric Advance Directive for legal review. Unless the proponents of this bill advocate committing all TDOs for inpatient psychiatric acute hospitalization initially for stabilization, capacity assessment, and extensive case management review, including MOT pre-discharge planning, I would strongly recommend and advocate for a voluntary option for MOT post-discharge planning for those individuals with SMIs who are "at risk" but who are not an imminent danger to self or others. I would also strongly advocate for extending the statutory pre-hearing TDO initial assessment period from 72 to 96 hours. There are many individuals who have been ECO'd or TDO'd by well-meaning family, clinicians, and law enforcement officers "out of an abundance of caution" who are not dangerous but who act or claim to be in order to obtain services that are not immediately available in the community. Often their families are desperate to obtain services. With In in red an extension of the TDO pre-assessment period from 72 to 96 hours, or longer, many of these individuals could be psychiatrically stabilized and diverted to community care safely with or without an MOT order. See Wanchek and Bonnie (2012 Psychiatric Services) for a research study that provide evidence-based findings supporting the cost-effectiveness of such an approach.

Last Name: Sharkey Locality: Petersburg

I am a social worker by training and a person in recovery from mental health challenges. I believe in the autonomy and choice of individuals to direct and control their recovery process. I recognize that without the investment from the individual, all behavioral health interventions will be destined to fall short. With that said, I disagree with HB2216's removal of the individuals consent/agreement requirement, within the MOT process. The consent of the individual should not be overruled, except in instances where a magistrate has ruled the individual lacks decisional capability. I also stand in opposition to the bill's significant extension of the time period for the mandated, intensive, outpatient, treatment order. The current lifespan of an MOT order lasts 90 days. HB2216 proposes to double that time period to 180 days. Individuals should be treated in the least restrictive settings--this intention of the recent reinvigoration for promoting the use of Mandatory Outpatient Treatments, is one I support. However, the community services and the individual's social supports MUST be in place in order for an MOT to be successful. I cannot speak for all of Virginia, but I can say that I highly doubt that Petersburg, VA has the current infrastructure of community services needed to support individuals working to adhere to MOT orders. Please listen to me and my fellow consumers on the ground and vote "nay" on HB2216. This is a complicated, technical piece of Virginia's Behavioral Healthcare system and a quick fix will not work.

HB2230 - Supported decision-making agreements; DBHDS to develop and implement a program, etc.
Last Name: Randolph Locality: Chesterfield

Thank you to the committee, my name is Shaddai R. from Richmond, Virginia. I am here to encourage you to.. 1. Increase the allocation of tax revenue towards the reinvestment fund from 30% to 70% because anything less than a majority of the revenues is disingenuous to the priorities of the bill. 2. Allocate 50% of all licenses towards Virginia social equity license holders as no other licenses are required to be owned by Virginia residents. 3. Add another tier of license, micro-business licenses, so that smaller applicants can enter with unique integration privileges. 4. Do not add any new crimes nor criminalize another generation of youth because of a fake war on drugs

Last Name: Jackson Organization: Marijuana Justice Locality: North Chesterfield

I am a constituent of the 7th district but I feel it is necessary to work together to protect the younger members of our society and stop the criminalization of the Hispanic and African American communities. Rules must be stated clearly now so we are better prepared to face a future when marijuana is officially legalized in the Commonwealth of Virginia. Please increase the reinvestment from 30% to 70% for new companies and entrepreneurs. Make sure the new market is equitable and accessible to all not just large corporations.

Last Name: Easter Organization: Elk Hill Locality: Fluvanna

As the Chief Operating Officer of Elk Hill, a non-profit that has provided TDT services since 2012, I would like to share some of our experiences with the MCOs and TDT. The MCO interpretations of DMAS TDT regulations create barriers to service with little clinical rationale. Mental health/behavioral interventions provided by the school are no longer considered previous mental health interventions, even when provided by LCSWs or LPCs. Some MCOs require that a child be at risk of out of home placement to qualify for TDT, even if the other two of three criteria for service have been met. Virginia’s focus on keeping children in their home make this an almost impossible criteria to meet. MCOs deny TDT services, recommending lower level services even when those services are unavailable in the child’s community. TDT was designed as an intervention for the most significant behavioral and mental health impairments yet MCOs are now denying children services because they’ve been in service too long. These are children with chronic mental health conditions which are not cured by TDT or other therapeutic intervention. Their conditions are managed through these services, just as diabetes may be managed through insulin. The idea that a health professional would deny a diabetic insulin because “they’ve been taking it too long” is absurd yet that is exactly what the MCOs are doing for children with severe mental health conditions. TDT is often the service that maintains these children in public schools rather than referring them to private day placements. More than 80% of Elk Hill’s initial service request authorizations (SRAs) are initially pended for more clinical information yet in almost every case, the information requested by reviewers was already included. Our clinicians have been told by MCO medical directors that their reviewers don’t have time to read the entire SRA . Our clinicians must then submit the requested information in writing again and the MCO has another three days to respond. MCO reviewers have recently started “bargaining” with units. We may have requested 140 units over a three- month period and the reviewer will offer 100 units, stating that if we don’t accept the 100 units, the request will be denied altogether and the family will have to go through the appeal process. DMAS oversight of the MCOs thus far has been largely ineffective. Between November 2019 and January 2020, my clinicians submitted 12 complaints regarding the MCOs to the established DMAS complaint e-mail with no response from DMAS, beyond an automatic reply receipt. In October 2020, I contacted DMAS acting behavioral health senior program advisor. She requested more data and more complaint forms. We submitted four of those complaint forms on October 13, 2020. To date, we have had one e-mail from an MCO representative who has since not responded to my clinician. Elk Hill spent over $150,000 in private donor funds in FY2019 to subsidize TDT services in the public schools. Our mission is helping children and we did not abandon those children as many of our for-profit counterparts did when the MCOs made the model economically unsustainable. Although we are a non-profit, we cannot sustain loss indefinitely. The reduction of TDT services is not in keeping with Virginia's earlier commitment to provide community based services to children. Respectfully submitted, Laura Easter, PhD, LPC Chief Operating Officer, Elk Hill

Last Name: Nadwodny Locality: Gainesville

Why would you force a vaccine when hyrdroechloraquin and other drugs heal people. CDC says 99.9% of people recover. Why are you using the tool of fear. What is in it for you. It’s being said that covid is just the first part of this bio weapon. The next part will kill those who were diagnosed with it. If you keep this up there won’t be any one to vote. Oh that’s right. Depopulation is part of the plan. You reap what you sow.

Last Name: Creekmore Organization: Various Locality: Henrico

Supported Decision Making (SDM) legal agreements should not be limited to ID/DD (Intellectually Disabled/Developmentally Delayed) individuals and their supporters alone. Serious consideration should be given by DBHDS in this bill to legal SDM agreements, negotiated between the Community Service Board (CSB), designated family advocates, and treatment providers, as "designated supporters", and individuals with SMIs (Serious Mental Illnesses, such as Schizophrenia Spectrum, Bipolar Spectrum). This could conceivably be as part of routine outpatient treatment planning and care or as part of the terms of a court-ordered "Mandatory Outpatient Treatment" (MOT) order. Such agreements would typically take the form of Psychiatric Advance Directives (PADs) negotiated by individuals with SMI judged mentally competent, as recommended by a qualified forensic physician or psychiatrist, to have sufficient mental capacity to understand and give informed consent, with support, to a PAD (binding mental health contract with or without Ulysses Clause). See Paul F. Stavis "The Nexum: A Modest Proposal for Self-Guardianship by Contract: A System of Advance Directives and Surrogate Committees-at-Large for the Intermittently Mentally Ill" Journal of Contemporary Health and Law Vol 15-1 for an example. (Proposed to the New York Legislature as a bill in 1999). Such SDM agreements in the form of a freely negotiated PAD could serve as one alternative to full or plenary guardianship orders for persons with SMIs or in transition through "limited guardianship" (in the form of a modified court order under 64.2-2009) in negotiating an SDM PAD agreement with the long-term goal of full restoration of the affected individual's full legal emancipation and civil rights. In a legally contested case, such a court order could be negotiated through legal mediation and entered by the court as a "consent agreement" by the parties.

End of Comments