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MATT GENTRY The Roanoke Times

Vicki Wells, an outpatient clinician with New River Valley Community Services, conducts a counseling session with a patient in the Montgomery Center in Blacksburg.

BLACKSBURG -- More than two years ago, Bob McDonnell stood with then-Gov. Tim Kaine and survivors and families of those killed on April 16, 2007, to support broad reforms to the underfunded, overburdened community mental health system through which shooter Seung-Hui Cho had slipped.

Next month, the former attorney general and current governor is expected to sign a budget bill that would slash deeply into health and human services, including community mental health.

Those cuts would come on top of two previous rounds of budget reductions for the state's community services boards, the first responders for mental health emergencies.

Two years after legislators promised to better fund treatment and monitoring of the mentally ill, about 60 percent of adults requesting outpatient treatment of the kind ordered by a special justice for Cho in 2005 must be turned away by New River Valley Community Services.

There simply aren't enough clinicians to treat them all, Executive Director Harvey Barker said.

Meanwhile, new mandates for case management and patient monitoring passed by the legislature after the Tech tragedy must be fulfilled.

If proposed cuts to state funding of Medicaid and similar programs that pay for a large share of community mental health are not offset by federal funds, Barker warned, "we're going to crumble."

Down payment revoked

In December 2007, Kaine, flanked by Democratic and Republican lawmakers, called for more funding for community service boards and sweeping system reforms based on the recommendations of a special panel convened to investigate the Tech shootings.

The panel identified myriad problems with how Cho, who had a long history of behavioral and mental health issues, was handled after a December 2005 incident that led to his temporary detention in a behavioral health facility.

An emergency assessment of Cho by a New River Valley Community Services counselor had earlier found that he presented an imminent danger to himself. That finding prompted his involuntary commitment.

But because of staffing issues, no one from the mental health board was available to attend Cho's commitment hearing. A doctor who saw him at the hospital found him suffering from the normal stresses of college life and recommended outpatient treatment.

Despite the court order, Cho never received even that treatment.

Sixteen months later, the troubled student killed 32 people and himself in what has been called the worst school shooting in U.S. history.

In response, the General Assembly passed laws requiring a community services board staffer be present at commitment hearings, among other mandates for better case management and emergency and outpatient services.

Lawmakers appropriated $18 million in new funding for implementation.

At the time, Mary Ann Bergeron of the Virginia Association of Community Services Boards called it a "down payment" on the reforms.

But since 2008, about $25 million in state funding has been cut from the system, Bergeron said.

"Dollar for dollar we have lost more than the dollars that were provided" to meet the new requirements, she said. Despite the constraints, the boards are meeting those requirements.

But to do so, "we have honed down every administrative efficiency that is possible to subtract. There is no more efficiency," Bergeron said.

With the possibility of continued funding cuts looming, she said local mental health boards must face cutting the people who provide the accountability lawmakers demanded.

Demand growing

New River Valley Community Services, based in Blacksburg, is part of the state's community services board system and provides mental health and substance abuse services to children and adults in Montgomery, Floyd, Giles and Pulaski counties, as well as the city of Radford.

The New River Valley's share of reform money appropriated in 2007 amounted to about $300,000, Barker said.

That paid for fewer than five full-time equivalent positions to help meet the new requirements.

But over the past two years, state cuts have taken away about $600,000, wiping out gains from the legislated reforms.

Proposed cuts to state Medicaid reimbursements would further cripple the agency's broad-based public mental health services and its ability to meet the new requirements, Barker said.

Meanwhile, while its $29 million annual budget continues to drop, demand for the board's services has increased.

From July through December, the board served 4,871 residents -- a 9 percent increase over the previous year, according to the board's Web site.

To generate more revenue, the board enters into contracts to provide fee-based counseling to individuals and groups. In fact, fee-based revenues account for about 70 percent of the board's budget, Barker said.

While those fees bring in much-needed revenue to subsidize services for indigent and uninsured patients, the revenue source presents its own challenges.

Because the board can afford to employ fewer than a dozen professional counselors for adult services, the more fee-based services provided, the fewer staff hours are available to indigent patients, he said.

More problematic is the source for those fees. The bulk of them are paid by Medicaid reimbursements, which are also state-funded and in danger of deep cuts.

Bergeron said state mental health officials are hopeful that a proposed extension of federal stimulus funds to boost Medicaid will shore up many community mental health programs across the state, at least until next year.

But Barker worries about the long-term prognosis for community mental health services.

Over his 30 years with New River Valley Community Services, Barker said he's seen state funding drop from about 90 percent of the agency's total budget to about 20 percent.

He worries that the de facto privatization of public mental health care will drive up its costs and leave needy people across the state, including children, without means for treatment.

The state asks public agencies such as the community service boards to operate like businesses, and to identify new and diverse revenue sources, as well as cut costs where necessary, Barker said.

"If a businesslike approach is the will of the state, why doesn't the legislature and the governor look for new revenue streams? Why does it only cut?" Barker said.

"Are they going to wait for another Cho?"