As a staffing crisis continues, Virginia tries to overhaul its mental health response system

When Alyssa Ward was tasked with overhauling Virginia’s mental health crisis system, she never imagined she’d be training hundreds of therapists live on YouTube from her guest bedroom.

But when COVID-19 hit, that’s exactly what happened. The state’s push to reform its mental health coverage weathered a nearly two-year-long pandemic and weeks of uncertainty after an initial funding freeze. But the final result, after months of collaboration, was the launch of new services aimed at substantially reducing admissions at Virginia’s beleaguered state-run mental hospitals.  

“They really involve the full spectrum of crisis services,” said Ward, director of the behavioral health division for the state’s Department of Medical Assistance Services. “And they’re really going to pack the biggest punch in our continuing battle to resolve the psychiatric bed crisis.”

Starting Wednesday, Virginia’s Medicaid program will cover six new treatment options geared toward adults and children with urgent mental health needs. They include mobile crisis response teams and short-term stabilization units designed to divert patients away from local emergency rooms and psychiatric hospitals.

On the same day, a handful of localities — including the cities of Richmond and Virginia Beach — are launching their own Marcus Alert programs, intended to reduce law enforcement involvement during psychiatric emergencies. But widespread staffing shortages in mental health will limit how far and how fast the reforms will be able to go. 

In theory, the Marcus Alert legislation, named for an unarmed Richmond man who was killed after charging at a police officer during a mental health crisis, is intended to reduce law enforcement involvement during psychiatric emergencies. Localities launching the program have already established protocols to refer mental health calls to local crisis dispatch centers, where operators can triage and refer out to community services. 

In truly urgent situations, such as an active suicide attempt, law enforcement and other first responders might still get involved. But Ward said many calls can likely be resolved over the phone and referred for supportive services later on. And ideally, law enforcement officers would be part of a mobile crisis team with mental health providers, serving a backup role rather than as frontline responders.

“The Marcus Alert is really supposed to meet at the intersection of law enforcement reform and behavioral health reform,” said Alexandria Robinson, a program and training coordinator for the Virginia Department of Behavioral Health and Developmental Services. By 2026, every locality in Virginia is expected to have implemented the program and launched their own mobile crisis teams. The initiative is also aligned with national efforts to establish a centralized mental health emergency number, scheduled to go live in Virginia next summer.

Both the Marcus Alert program and Medicaid expansion are part of a broader effort to dramatically reform Virginia’s behavioral health system. Right now, community services are available through a patchwork of providers with varying levels of access across the state, said Heather Norton, an assistant commissioner for the behavioral health department. Police are often the first responders to psychiatric emergencies, and there’s no guarantee that an officer has been specifically trained in de-escalation or mental health awareness.

“The major reason for transforming our crisis system really comes from our current overreliance on high-acuity, high-cost services,” Norton said. With limited community treatment options, officers often spend hours — and sometimes days — waiting for beds to become available at state-run hospitals. And state facilities are still struggling with overcrowding and staffing constraints that limit the number of admissions they can accept.

Those same staffing shortages, though, are widespread across the spectrum of mental health care, from local community service boards to private hospitals and clinics. And as the state works to expand services, Ward said that’s likely to become the main limiting factor in crisis reform. 

“I think we have done everything in our power across all of these behavioral health agencies to get the ball rolling,” she said. “But we’re going to have to keep pushing those balls up a lot of hills over what I believe will probably be the next decade.” 

By many metrics, Virginia is already at a disadvantage when it comes to behavioral health staffing. According to the most recent report from the national nonprofit Mental Health America, the state ranks 37th in the nation when it comes to access to care — a measure that includes workforce availability and patients who weren’t able to find treatment. State-level data also indicates that far more providers are on the verge of retirement than there are new graduates to replace them. 

But the state’s Medicaid expansion also presents some challenges to providers, potentially slowing the pace of enrollment. When the Department of Medical Assistance Services expanded reimbursement to a broader range of services, it also set higher expectations for them. Ward specifically pointed to treatments known as multisystemic therapy and functional family therapy, which are intended for adolescents with particularly disruptive behaviors.

Some patients are referred to those services through the Department of Juvenile Justice. But when DMAS began consulting with the agency, it realized some programs weren’t hiring licensed clinicians to administer the therapy. Ward said workforce shortages played a role, but having licensed providers on staff is now a requirement as a condition of Medicaid reimbursement.

“There was some rub with the stakeholders when we discovered this and said, ‘Hey, we need to be paying for best practices,’” Ward said. The state is hoping that expanded reimbursement will incentivize more providers to provide more — and better — crisis services. But many of the newly covered treatments Medicaid likely won’t be widely available for months or even years in many parts of the state. And while Marcus Alert programs are launching in some localities, most don’t have the resources to fully execute the initiative.

“This is rolling out during a staffing crisis that has worsened during the pandemic,” Ward warned lawmakers at a recent meeting of the state’s Behavioral Health Commission. “And so, in some ways, I have tempered my expectations personally. Because even though we’re opening up these new services, there’s only so much you can do without the workforce to provide them.”