Lawmakers studying mental health reforms in Virginia heard Wednesday that most children in need of services do not get them.

Virginia’s behavioral health care system for children is more complex than that for adults but is dogged by the same problems, with overcrowding at the state hospital, an increase in readmissions and a lack of services in the community.

At least one in 10 children in Virginia has had a major depressive episode. Of those, 48,000 children, or 63%, did not receive any services, and of those who did receive treatment only 20% received it consistently, said Nina Marino, director of child and family services for the Department of Behavioral Health and Developmental Services.

Marino told the Joint Subcommittee to Study Mental Health Services of plans to better reach children but said one of the primary hurdles is Virginia’s lack of a behavioral health care workforce. The state ranks 41st in the nation for mental health providers for both children and adults.

Carl Ayres, director of family services for the Department of Social Services, told the lawmakers that turnover in his agency is 40%.

Rhonda Thissen, executive director of National Alliance on Mental Illness Virginia, asked the committee during its meeting in Richmond to appoint a work group to look into developing the workforce.

“We can talk all day about the type of system, but if there isn’t labor to work with management, there is not a system,” she said.

Marino said the state is looking at more ways to integrate behavioral health into primary care and pediatricians’ offices with training, navigators and telehealth.

Also, Virginia’s Medicaid is redesigning its program to pay for mental health care in order to encourage an increase in the number of providers and to elevate the quality of care.

The Joint Subcommittee has been focused on reforms to the structure and financing of the state’s mental health system. It has a work group to look at treatment of inmates with illnesses, but this was the first of its meetings to focus on children.

Marino, Ayres and Dr. Alyssa Ward, behavioral health clinical director for the Department of Medical Assistance Services, were asked to talk about reforms underway at their agencies.

Ward said Medicaid is the largest payer of mental health services in the state.

“One of the big focuses is integrating services into places people are already showing up,” she said.

She said the redesign is incorporating some of what Medicaid learned in launching its ARTS program in response to the opioid epidemic. ARTS sought to broaden access to treatment by training practitioners and paying them more to treat people through evidence-based care.

Ward said they are seeking to expand services for children by paying for treatments that fall outside the education system. Virginia has mostly relied on public schools to provide behavioral services for children 3 and older.

The goal is to shift from paying for hospitalizations to more services in homes and the community.

Virginia owns just one 48-bed psychiatric hospital for children, in Staunton. Admissions have risen in a decade from 615 in 2008 to 1,053 children in 2018. Two other things have changed: A decade ago, 27% of children were readmitted. Last year, 42% were.

Also, all of last year’s patients were brought to the state hospital under detention orders. The same trend has been occurring in the state’s adult hospitals. The committee has questioned whether private hospitals are turning away patients held under detention orders.

Earlier this month, the Virginia Hospital and Healthcare Association said that private hospitals have added more beds, and that they, too, are full and have seen a spike in people voluntarily coming in for services.

The hospitals have asked the state to pay for partial hospitalization and to increase intensive outpatient services. Ward said those items are included in the Medicaid redesign.

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