For previous blogs on Mental Health during the 2024 legislative session, click here and here.

Intro/Desired Outcomes:

The 2024 Legislative Session began with excitement and energy surrounding the continued improvement of the mental health system and continuum in Virginia. The governor proposed significant investments in the mental health of the Commonwealth with a particular focus on young folks in the creation of the Youth Mental Health Strategy. This investment plan focused on the expansion of school-based mental health (SBMH) services, tele-mental health services in schools, and limiting the overuse of social media by young people, especially in schools.

The Behavioral Health Commission (BHC) was charged with bringing forward legislation and budget items that would improve our crisis system for young people by overseeing the reform of the one youth mental health hospital, the Commonwealth Center for Children and Adolescents (CCCA), funding Recovery High Schools for students recovering from substance addiction, and allocating state dollars for youth specific Crisis Receiving Centers and Crisis Stabilization Units.

The BHC additionally brought forward budget items to develop a comprehensive school-based mental health system through the continued funding of the School-Based Mental Health (SBMH) Integration Pilot and concurrently, look at how to sustainably and flexibly fund SBMH services through collaboration with the Department of Behavioral Health and Developmental Services (DBHDS), the Department of Education (DOE), and the Department of Medical Assistance Services (DMAS).

Overall, there was a commitment by the Governor and lawmakers to prioritize youth mental health during the session and rightfully so as we continue to contend with a youth mental health crisis both in Virginia and nationally. Virginia has been 48th in the nation for youth access to mental health services, and young people are continuing to speak out about the lack of services and support in their communities and in their schools. In 2021, the Virginia Youth Survey identified that 38% of surveyed Virginia high school students stated they felt sad or hopeless almost every day for 2 weeks or more, and 21% of respondents seriously considered attempting suicide and self-harmed.

We are particularly struck by national data provided by the AAKOMA Project that highlighted the specific needs of youth and young adults of color. In 2022, they identified that at least half of youth and young adults of color  in their research reported experiencing moderate to severe depression or anxiety. Some specifics: 53.3% of Black youth in the study experience moderate or severe depressive symptoms, 26.9% of Multiracial youth responded that they cut or self-harmed themselves in some way, 58.9% of Latino/e youth in the study experienced mild to severe anxiety, and 83.3% of Latino/e Nonbinary and Transgender youth experienced moderate to severe anxiety.

Disaggregated data, such as the numbers above, highlight that not all needs are the same nor are they going to be addressed by one miracle solution. The reality is that we need to take a multi-faceted, multi-systematic, and community-driven approach to addressing the mental health crisis at hand. Practitioners and professionals know what is going well and what is not going well in practice and young people and their families know what they need, what will support their healing and what will not; it is the duty of folks in power to listen, learn, implement, listen again, change, and relearn.

Much of our time during the 2024 session was spent rebuilding knowledge around youth-centered mental health priorities, solidifying youth mental health legislative champions, and building bridges for impacted folks to be a part of the decision-making process around mental health policy and budget items. Here is where we landed in terms of funding for youth mental health.

Final Outcomes:

School-Based Mental Health:

• New School-Based Mental Health Funding Plan: Language Only. Directs the Department of Education (DOE), the Department of Behavioral Health and Developmental Services (DBHDS), and the Department of Medical Assistance Services (DMAS) to develop a plan for creating a new program to deliver flexible mental health funding to school divisions.
  • Specifies that funding will be used to maintain school-based mental health services and supports, provide technical assistance to bill for Medicaid, and conduct evaluation  capabilities built into programming.
• School-Based Health Centers: $30 million across the biennium will be utilized to provide grants to local school divisions to contract with a Federally Qualified Health Center or other healthcare organizations, to build out school-based health centers in local schools. These centers will provide mental health, dental, and physical health services and serve students, families, community members and school staff.
  • This funding is redirected from the School-Based Mental Health Integration Pilot that was used to provide grants to school divisions to contract with community-based providers and develop school-based mental health programming.
• Recovery High Schools: Recovery High Schools are year-round high schools that are open to any student residing in the defined region who is in the early stages of substance use disorder or dependency. These schools provide academic, emotional, and social support to aid students’ progress toward graduation and recovery.
  • Chesterfield (Item 295 KK and Item 124 MM): $1.4 million across the biennium to support the already established school.
  • Loudoun County: $500,000 in FY25, $250,000 in FY26 to establish a school.
  • Hampton Roads: $500,000 in FY25, $250,000 in FY26 to establish a school.
• Access to Tele-mental Health Services: $14.4 million across the biennium was not included in the final budget. This funding would have been used for mental health and telehealth services in public schools.
• SCHEV – Mental Health Initiative: $6 million across the biennium was not included in the final budget. This funding would have been used for the State Council of Higher Education to coordinate efforts to pursue a common and statewide vendor to provide mental health services including tele-mental health care to students at institutions of higher education.

Crisis Mental Health:

• Fund Mobile Crisis Teams (Item 296 U): $10 million in FY25 allocated to fund the establishment of additional mobile crisis teams in underserved areas of the state.
• RHRN Crisis Services: $64.8 million in FY25 and $42.5 million in FY26 provided to expand and modernize the comprehensive crisis services system (such as developing more crisis receiving centers and crisis stabilization units, pharmacy improvements, and enhancing established sites).
  • Prince William Youth Crisis Receiving Center: $4.5 million across the biennium allocated to support the Prince William Youth CRC.
• Increase Funding for 988 Crisis Line (Item 295 DD): $4.34 million across the biennium ($1.14 million increase across the biennium)
• Inflation Adjustments for STEP-VA (Item 297 KK): $122.9 million in FY25 and $125.7 million in FY26 (a $17.7 million across the biennium increase in funding).
  • $27.8 million in FY25 and $27.8 million in FY26 ($2.2 million increase across the biennium) provided for outpatient mental health and substance use services.
  • $28.7 million in FY25 and $28.7 million in FY26 ($3.6 million increase across the biennium) provided for crisis services for individuals with mental health or substance use disorders.
  • $4.2 million in FY25 and $4.2 million in FY26 ($804,000 increase across the biennium) provided for military and veterans services.
  • $5.8 million in FY25 and $5.8 million in FY26 ($961,000 increase across the biennium) provided for peer support and family services.
  • $3.9 million in FY25 and $3.9 million in FY26 ($300,000 increase across the biennium) provided for psychiatric rehabilitation services.
  • $6.8 million in FY25 and $6.8 million in FY26 ($659,600 increase across the biennium) provided for care coordination services.
  • $4.3 million in FY25 and $4.3 million in FY26 ($363,850 increase across the biennium) provided for STEP-VA-specific case management services.
• Funding for Additional Staff for Crisis Stabilization Units: $5 million across the biennium provided for the CSB’s to hire additional staff for crisis stabilization units whose bed capacity is not fully utilized due to lack of staff.
• Flexible Funding for Children’s Psychiatry and Crisis Response: $27.6 million across the biennium ($2.4 million increase across the biennium) and language change that ensured the flexible use of the funding for children’s psychiatry and crisis response services.
• Bed Restructuring at CCCA: Language Only. Directs DBHDS to identify existing and develop new alternative placements for children and youth who would otherwise be admitted to Commonwealth Center for Children and Adolescents (CCCA). Findings will be reported to the Governor and Chairs of the Appropriations Committees by November of 2024.
  • The Governor introduced Amendment 218 to the Capital Outlay section, C-48 that would allocate $500,000 in FY25 to begin preplanning for a child and young adult psychiatric treatment facility, however this did not make it to the final budget.
• Expand Crisis Intervention Trained (CIT) Workforce: $5.2 million across the biennium provided to DBHDS to contract with the Virginia Crisis Intervention Team Coalition to facilitate the expansion of de-escalation training and skilled knowledge of behavioral health laws and regulations for first responders and law enforcement.

• Crisis Co-Responder Programs (Item 297): $3.43 million in FY25, $3.3 million in FY26 provided to support the ongoing costs of seven crisis co-responder programs established during the 2024 Fiscal Year.
  • Crisis Co-Responder Programs are aligned with the Marcus Alert law that requires 911 and 988 crisis call centers, law enforcement and local behavioral health agencies to work together to improve responses to individuals experiencing a mental health crisis.
• Alt. Transportation/Alt. Custody for TDO/involuntary commitment: $29 million across the biennium.
• Salary Alignment at State Facilities: $20.8 million across the biennium.
• Fund Comprehensive Psychiatric Emergency Programs (CPEP): $10 million in FY25 was not included in the final budget. This funding would have been used to develop and support comprehensive psychiatric emergency programs or similar models of psychiatric care in emergency departments. These programs provide specifically mental and behavioral health emergency/crisis services in the emergency departments of hospitals and would be in partnership with the region’s Community Services Board or Behavioral Health Authority.

Workforce:

• 20 Additional Psychiatric Residencies (Item 288 UU): $2 million GF, $2 million NGF across the biennium used for supplemental payments to fund 20 graduate psychiatric residents who begin their residencies in July of 2024.
• Mental Health Treatment Centers, Clinical Training Sites (Item 301 F): $741,889 in FY25, $711,989 in FY26 provided to establish and support formal partnerships between academic institutions and three state-operated facilities to serve as clinical training sites for licensed mental health professionals, medical residents, nurses, nurse practitioners, and physician assistants.
• Boost 200 Expansion (Item 295 AA): $1.15 million across the biennium provided for DBHDS to contract with the Virginia Health Care Foundation to pay for costs of supervisory hours needed for students working toward their social work or counseling licensure.
• VMAP (Item 296 G): $29.6 million across the biennium ($7.96 million increase across the biennium) provided to DBHDS to contract with Virginia Mental Health Access Program to develop integrated mental health services for children.
• Behavioral Health Loan Repayment Program (Item 271 C): $14.7 million across the biennium ($10 million increase across the biennium) provided for the Behavioral Health Loan Repayment Program.
  • Eligible practitioners: psychiatrists, licensed clinical psychologists, licensed clinical social workers, licensed professional counselors, child and adolescent psychiatrists, child and adolescent psychiatry Fellows, psychiatric physician assistants, psychiatric pharmacists, psychiatric registered nurses, and psychiatric nurse practitioners.

• Initiatives to Expand Mental Health Workforce: $595,876 in FY25, $645,876 in FY26 were not included in the final budget. This funding would have been used to expand the mental health workforce by conducting an evaluation of the licensing process, funding a workforce training director and providing scholarships to behavioral health technicians.

The Way Forward:

The mental health budget outcomes of the 2024 General Assembly Session include some great investments in crisis services and support for mental health professional licensees and residents as well as great losses of significant funding for school-based mental health initiatives that would prioritize prevention services over reactive crisis services. While we need both crisis and prevention services concurrently, it is important that we continue to uplift preventative measures to addressing the youth mental health crisis through advocating for and prioritizing services such as school-based mental health, restorative practices, and early intervention.

According to youth.gov, mental health prevention is defined as “intervening to minimize mental health problems by addressing determinants of mental health issues before a specific mental health problem has been identified in the individual, group, or population of focus with the ultimate goal of reducing the number of future mental health problems in the population.”

We must take a holistic approach to prevention by still supporting efforts to improve access for young people to receive treatment when symptoms arise and crises occur. Concurrently, we must prioritize getting ahead of the symptoms and crises by supporting young people and their families earlier in life through things like social-emotional skills, coping strategies, and destigmatizing mental health. Furthermore, we must always be working to dismantle the root causes of mental health challenges and mental illness by addressing the social determinants of mental health such as economic insecurity, housing insecurity, and community violence.

More specifically, the mental health workforce shortage continues to be a concern and we are listening.

We continue to hear concern, nationally and in the state, that the mental health professional workforce shortage is at the forefront of our inability to meet the youth mental health crisis and address prevention across systems. This is a serious challenge and one that we can prioritize; chipping away at some of the weaker pieces of our mental health system to build it back stronger for young people across the continuum.

Our mental health workforce is waning as caseloads are high, administrative work is burdensome and time-consuming, and practitioners are not being paid for the significant and impactful work they provide to their clients. Up until this point, Virginia’s efforts have focused on workforce recruitment partnerships with key organizations like the Virginia Health Care Foundation (VHCF) that developed the Boost 200 program and the Virginia Mental Health Access Program (VMAP) that worked with healthcare professionals to integrate mental health services for children. Additional markers of progress include state investments in residencies, establishing clinical training sites, and incentivizing higher education in mental health through loan repayments and programming. These initiatives address recruitment challenges by breaking down barriers to becoming a licensed mental health professional across various areas of specialty including social work, psychiatry, psychology and nursing.

The questions that remain are 1. why are there high turnover rates in the field and 2. what systemwide improvements need to be made to support the existing workforce.

In 2023, the Virginia Health Workforce Development Authority (VHWDA) released a report that assessed the current state of primary care, nursing and behavioral health workforce in Virginia. They looked holistically at both recruitment and retention and highlighted infrastructural issues associated with working in the mental health field, such as low pay, stressful work environment and administrative burdens taking providers away from their direct services. Closing data collection gaps around vacancies and turnover as well as pipeline data assessing school to licensing to practicing and beyond were recommended by the authority and we are glad that the BHC and the Joint Commission on Healthcare (JCHC) are both going to be conducting studies around the health workforce and will be releasing recommendations in September and December. We are eager to see what they will find and policy solutions they will consider  bringing to the 2025 General Assembly Session.

By assessing the workplace environment for our mental health professionals, offering solutions to the infrastructural challenges of retention, addressing the Medicaid reimbursement inequities, thinking creatively about how we can build culturally rooted and healing-centered practices into our systems, and continuing to fund recruitment initiatives, Virginia will be taking the right steps to meeting the multi-tiered, multi-faceted mental health needs of our young people. That is prevention.

Voices’ will continue to uplift the priorities of those most impacted by these recommendations and policy decisions and provide opportunities to support folks who are interested in advocating and sharing their stories with legislators to enact change. Please connect with Cat Atkinson, cat@vakids.com for more information related to youth mental health or mental health workforce and connect with Sophia Booker, sophia@vakids.org for advocacy opportunities and training.

Glossary:

• Conference Budget: Appropriations of state revenue agreed to by the budget conferees from the House and Senate and passed by the General Assembly. The conference budget is sent to the governor for approval.

• Governor’s Budget Actions
  • Veto: Action by which the Governor refuses to sign legislation, including the budget, passed by the General Assembly. A 2/3 vote of each body is required to override a veto.
  • Amendment: A proposed change that inserts and/or strikes language from the legislation or budget.
  • Sign: Action by which the Governor signs the legislation, including the budget, and it becomes law. Effective dates are July 1, unless otherwise specified through an emergency clause.
• Final Budget: Appropriations of state revenue agreed to by the General Assembly and Governor.
• General Fund (GF): The predominant fund for financing state government programs. The primary sources of revenue for the General Fund are the personal income tax, sales tax, and corporation taxes.
• Non-General Fund (NGF): All sources of revenue other than the General Fund. For example: federal appropriations, grants, and contracts.
• Biennium (FY25-FY26): A two-year period used by the state for financial and budget purposes. It includes two fiscal years, running from July 1 in an even-numbered year to June 30 of the next even-numbered year.
• Fiscal Year (FY): A fiscal year is a 12-month accounting period. The fiscal year for Virginia state government begins July 1 and ends June 30. For example, FY25 is from July 1, 2024-June 30, 2025 and FY26 is from July 1, 2025 – June 30, 2026.

---