(From the Behavioral Health Taskforce. (to print out a pdf version click HERE)

DRAFT PROPOSED BEHAVIORAL HEALTH POSITION

February 2018

SUMMARY

Current – Support for a comprehensive state public mental health care system of quality, statewide and community based services that meets the mental health needs of all Virginians, including long-range planning, coordination among agencies and established criteria for allocation of funds; adequate and appropriate housing; comprehensive and consistent service delivery in all local communities; and advocacy programs that ensure patients’ rights at all levels.

New – Support for comprehensive behavioral health care that includes both mental illness and substance use disorder.

  • Access for all people to affordable, quality in- and out-patient behavioral health care, including needed medications and supportive services.
  • Coordination of comprehensive and integrated care among Health and Human Services (specifically Behavioral Health) and other state departments such as Medical Assistance Services (Medicaid), Public Safety( re-entry planning, identification of behavioral health needs in jails/prisons, patient’s rights, substance abuse, and drug/mental health courts), Housing (Transitional and Permanent Supportive Housing), and Education (health education from early childhood through adult). These agencies must provide this care along with a focus on community based services such as Community Service Boards (CSBs).
  • Realignment of the funding equation so that a higher proportion of funds to CSBs rather than state institutions. This will result in more cost-effective care that is more responsive to client’s needs.
  • Adequate funds and other incentives to ensure sufficient trained staff at all levels of service.
  • Continued efforts to decrease the stigmatization of behavioral health problems and care.

THE LEAGUE’S HISTORY

Current – At its 1985 convention, the LWV-VA adopted a two-year study of mental health services in Virginia. As a first step, in March 1986, the League prepared a document describing the public mental health care system in Virginia its history, organization, financing, and clients. A second resource document was distributed in December 1986 dealing with goals for the mental health system, who the system should serve, factors for use in allocating state funds to communities, and a statewide comprehensive management information system.

Additional issues warranting study, identified during the first two years, resulted in a two-year extension by the 1987 convention delegates. In March 1988 a resource document on involuntary civil commitment and patients’ rights was issued. Issues of the 1988 and 1989 Virginia Voter provided resource material on housing for the mentally ill and on organization, management, personnel and hospitalization issues.

New -At its 2017 convention, the LWV-Virginia adopted an update to its existing mental health position, adopted in 1987 and 1989, that would also integrate the current language of the LWVUS Behavioral Health Position adopted at the 2016 LWVUS Convention. “Behavioral health” is today’s nationally recognized terminology. It includes both mental illness and substance use disorder.

THE LEAGUE’S POSITION

Current – Organization and Management

The League of Women Voters of Virginia believes that the goals of the state’s mental health care system should:

  • Provide quality mental health care which utilized the most current knowledge and which respects the dignity and human rights of each individual;
  • Enable the mentally ill to attain their highest level of functioning to lead lives as normal as possible;
  • Meet mental health needs of all Virginians regardless of mental disorder, race, creed, age, sex, or ethnic origin;
  • Endeavor to prevent mental illness and to reduce its incidence and severity. (June 1987)

A public mental health care system should include:

  • Commitment to quality community-based services;
  • A long-range comprehensive plan for meeting clients’ needs;
  • Clear lines of authority and accountability;
  • Coordination among the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) and other agencies providing services to mental health clients;
  • Evaluation of program effectiveness and administrative efficiency; and
  • Sufficient number of qualified and well trained staff. (June 1989)

In allocating state funds among community services boards, it is essential to maintain current programs and fill identified service gaps. It is important to use additional factors in allocating state funds as follows:

  • Total population of area served;
  • Encouragement of local support;
  • Economic resources of the community;
  • Local tax effort; and
  • Number of mental health clinics in the system

Clients

The League of Women Voters believes that it is essential that the state’s mental health system serve:

  • The chronically mentally ill–those suffering from a severe and persistent mental or emotional impairment that seriously impairs their functioning; and
  • People suffering from an acute mental disturbance which produces serious impairment and distress in social relations and vocational functioning.

It is important to provide needed services to people under major stress and/or at risk of developing mental or emotional disorders. (June 1987)

The state’s mental health care system should provide the specialized services and specially trained staff required to meet the mental health needs of special populations such as children and adolescents, the elderly, people under the purview of the courts, the dual diagnosed (mentally ill/mentally retarded and mentally ill/substance abusers), and immigrants. (June 1987)

NEW – THE LEAGUE’S POSITION

The League of Women Voters of Virginia believes that the goals of the state’s behavioral health care system should provide:

A. ACCESS, DIAGNOSIS, AND INTEGRATION OF CARE

Access for all Virginians with behavioral health issues (including opioid abuse) to early, affordable and timely community-based in-patient and out-patient care and diagnosis including:

  • Case management, counseling, care-coordination services and medication management
  • Behavioral health care for Virginians that is integrated with, and achieves parity with, physical health care
  • Community-based and family-focused behavioral health screening, diagnosis and treatment for children and adolescents in Virginia
  • Community Service Boards (CSBs) that reduce service time for services by adopting “same day access/assessment” statewide, sharing best practices and hiring more licensed behavioral health providers
  • An alternative transportation model to reduce demands on law enforcement for transporting patients to hospitals
  • Expansion of tele-mental health infrastructure, especially for rural counties
  • Vocational services to promote self-sufficiency and a positive self-image

B. DIVERSION FROM THE CRIMINAL JUSTICE SYSTEM

Current

Patients’ Rights

LWV-VA supports the rights of mentally ill persons as defined by the Supreme Court, federal and state court rulings, laws, rules and regulations; internal and external advocacy programs to ensure patients’ rights, and the appointment of persons who are mentally ill to the State Human Rights Committee, to local human rights committees for facilities and for community services boards. (September 1988)

Civil Commitment

The League of Women Voters believes that the state’s civil commitment procedures should provide:

  • Counsel be appointed for the patient as soon as possible to allow time to confer and consider options;
  • An individual detained pending commitment hearings should be offered non-emergency treatment; and
  • Training about the nature and treatment of mental illness and related issues should be provided to justice system personnel involved in civil commitment in Virginia. (September 1988)

NEW – The League acknowledges that there is an intersection between of behavioral health and the criminal justice systems. Accordingly, we urge:

  • Behavioral health screening of jail inmates
  • Specialty behavioral health and drug courts and dockets in all judicial districts in an effort to decriminalize addiction related arrests
  • Therapeutic drop-off centers
  • Expansion of Crisis Intervention Teams (CIT) programs
  • Decriminalizing the reporting of overdoses or drug abuse so friends and family do not fear retribution
  • Civil commitment procedures that provide the client with legal counsel and treatment
  • Training about the nature and treatment of mental illness and related issues for justice system personnel involved in civil commitment in Virginia
  • Excluding those who suffer from serious mental illness at the time of their crime from the death penalty

C. HOUSING

Current – LWV-VA believes that in order to obtain adequate and appropriate housing for the mentally ill, the government of Virginia should:

  • Provide funding; technical assistance to housing providers and public education;
  • Enact statutes to affirm state responsibility;
  • Encourage private/public sector cooperation to obtain housing for the mentally ill. (January 1989)

NEW-HOUSING

The League recognizes the need for affordable and permanent supportive community-based housing and residential services. These services would enable Virginians with a wide-range of behavioral health needs to live as independently as possible in their home communities. Some required initiatives are:

  • Enhanced funds for the Virginia Housing Trust Fund
  • Private/public partnerships to obtain housing for the mentally ill
  • Consider a waiver for Medicaid to pay for counseling for housing options
  • Establish tax credits or financial incentives for landlords and developers who build affordable housing, and local government policies that increase affordable housing stock
  • Provide training in independent living skills
  • Offer case management which will coordinate needs for food, clothing, and medical care for those in housing to include homeless shelters

D. BEHAVIORAL HEALTH WORKFORCE DEVELOPMENT

Current – In order to recruit and retain qualified staff in the mental health care system, the DMHMRSAS should:

  • Increase pay and improve work environment;
  • Form linkages with universities;
  • Provide stipends to students, in return for services, in fields for which there are demonstrated recruitment and retention difficulties; and
  • Provide in service training. (June 1989)

NEW – BEHAVIORAL HEALTH WORKFORCE DEVELOPMENT

The League urges the Commonwealth to adopt the following practices to correct, high turnover, insufficient staffing, and inadequate training:

  • Sufficient qualified and well trained staff in public and private settings, at all levels, from certified peer specialists to psychiatrists
  • Promotion of full use of internet technology for communications and secure information sharing
  • Enhancement of pay scales for providers in state institutions to compensate for dealing with challenging patients

E. NEWOPIOID ABUSE

The League recognizes that the resolution of the opioid crisis requires cooperation among community stakeholders such as CSBs, law enforcement (see Section B -Diversion from Criminal Justice), and non-profit organizations. We urge educational programs that de-stigmatize addiction. The league supports:

  • Treatment and Recovery
    • Reducing overdose deaths by increasing access for first-responders and laypersons to medications that counteract opioids
    • Expanded use of research-based, medication-assisted treatments (MAT) as part of a recovery program to counteract addiction
    • Reduce the supply of both prescription and illicit opioids
  • Prevention and Education
    • Encouraging non-pharmacological research and improved training for medical professionals in pain management
    • Promoting of proper storage and disposal of prescription drugs
    • Monitoring the prescription and distribution of opioids
    • Establishing effective health education programs in schools and community organizations to educate students, parents and community leaders on the dangers of opioid abuse and recognizing the signs of addiction.
    • Health education from early childhood throughout life that integrates all aspects of social, emotional and physical health and wellness

F. FINANCING

CurrentIn allocating state funds among community services boards, it is essential to maintain current programs and fill identified service gaps. It is important to use additional factors in allocating state funds as follows:

  • Total population of area served;
  • Encouragement of local support;
  • Economic resources of the community;
  • Local tax effort; and
  • Number of mental health clinics in the system.

The DMHMRSAS should study the characteristics and needs of clients in state hospitals, especially those who are either frequently readmitted or have long term hospital stays, and should institute suitable changes to deal with identified problems. (June 1989)

NEW -FINANCING

LWV-VA supports the continuing partnership between federal, state, and local governments in financing behavioral health as follows:

  • Use Medicaid as an important component of funding along with money from the state’s general funds and from local communities
  • Undertake a gradual fiscal realignment of the current behavioral health system so that a higher percentage of funds will be allocated to CSBs (STEP-VA)
  • Provide full funding to enable all 40 CSBs to provide “same day access” and primary care screening
  • Allocate funds for schools (K-12 and college) and public health departments to work with CSBs in coordinating diagnosis and treatment
  • Provide additional resources for first-responders to better respond to an emergency situation that involves opioids
  • Align DMAS and DBHDS so that services will be managed using standardized managed care practices and data reporting tools

APPENDICES

LWV-VA Behavioral Health Position Appendix 1

  1. Definitions of terms

Behavioral Health – An umbrella term that includes mental and emotional health, psychiatric care, marriage and family counseling, and treatment of substance abuse (i.e. addictions). Does NOT address developmental disabilities.

Medical/physical – In this field, may be used interchangeably and to differentiate from behavioral/emotional issues

Peer (in behavioral health field) – A person who has personally experienced a behavioral health issue in themselves or in a parent, spouse, or child AND who is working on recovery with another peer “on a level playing field” of expertise from experience.

Recovery – A long-term process, compared to being “recovered”

Substance Use Disorder (SUD) – in current public discourse, refers primarily to drug abuse and especially opioid addiction; in more clinical settings can refer to abuse involving any substance, including tobacco, food, inhaling bath salts, etc.

Wellness – Refers to a condition of enjoying and supporting whole health

Major providers, programs, and tools

ACE, Adverse Childhood Experiences tool – A brief, tested, easy-to-administer screening tool for youth and adults to indicate likelihood of behavioral illness

DBHDS – (Virginia Commonwealth) Department of Behavioral Health and Developmental Services. In the executive branch, under the cabinet Secretary of Health and Human Services. Formerly “Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS).

DMAS – (Virginia Commonwealth) Department OF Medical Assistance Services. This department manages the Medicaid program.

CSBs — Community Service Boards. The major local provider of services for issues of behavioral health, addictions, and/or developmental disabilities. Funded by federal, state, and local government funds and private health care insurance reimbursements. Governing boards are locally appointed.

NAMI – National Alliance on Mental Illness; national, state, and local branches. Provides non-professional education and support services; individual advocacy; lobbying

Medicaid – Medicaid is a federal and state program that covers medical care for certain people. Each state runs several different Medicaid funded programs for different groups of people. All state programs have some things in common. Each state must cover certain groups of people, including:

  • older people, people with disabilities and people who are blind; and
  • children and pregnant women.

However, the financial eligibility levels for these different groups do not have to be the same

STEP-VA (System Transformation, Excellence and Performance in Virginia)a program to establish necessary capacity in every community to provide integrated behavioral health and health services to persons who lack health insurance and those who are underinsured.

LWV-VA Behavioral Health Position Appendix 2

  1. Access, Diagnosis and Integration of Care

Background

  • Nearly 305,000 Virginia adults have a serious behavioral health problem. (NAMI Virginia 2017)
  • 130,000 to 150,000 children and adolescents in Virginia live with a serious mental illness; 65,000 to 90,000 exhibit extreme impairment.(Voices for Virginia’s Children Website -2017, https://vakids.org/our-work/mental-health )
  • Half of all mental illnesses begin before age 14; one in five children receive the help they need. (Voices for Virginia’s Children Website -2017, https://vakids.org/our-work/mental-health )
  • Virginia dropped from 38th to 40th overall of all states for mental health services. (Mental Health America Website, November 16,2017)
  • State-run mental hospitals will overflow by 2024 if Virginia does not change how it funds and administers public mental health treatment, the state’s behavioral health czar (Dr. Jack Barber) told lawmakers. (Richmond Times Dispatch, September 28,2017)
  • Virginia’s Department of Behavioral Health & Developmental Services (DBHDS) is the lead agency for initiatives, although several state agencies have responsibilities for overseeing, supporting and/or regulating community mental health services. DBHDS operates nine acute care state psychiatric facilities (including one for children) and four training centers in Virginia. ( 2017)
  • DBHDS contracts with 40 CSBs throughout Virginia to provide and administer the community-based services in the local jurisdictions that established them. While the 40 Community Service Boards (CSBs) in Virginia serve as the “point of entry” into public-funded mental health and substance abuse services in Virginia, only 18 CSBs received funding in 2017 for same-day access. (2017)

Diversion from the Criminal Justice System

Background

  • Many Virginians who need mental health services are instead arrested and incarcerated without any behavioral health screening. In Virginia, a State Compensation Board survey conducted in July 2015 indicates that approximately 16.8% of inmates in the 58 reporting local and regional jails had a mental illness; and 50% of those individuals were reported to have a serious mental illness.
  • Judges can create dockets in their courts but only the General Assembly can create a separate mental health court. Currently, Virginia has only one mental health court (Norfolk Circuit Court), but there are other mental health dockets in courts in Richmond, Petersburg, Roanoke, Staunton and elsewhere. The City of Hampton has a drug court and veteran’s court butt does not have a mental health court.
  • In 2008 Old Dominion University conducted a study on the outcomes of the Norfolk Mental Health Court, the only established and recognized full mental health court in the Commonwealth. Reduced recidivism rates for mental health docket defendants were greater than decreases in recidivism for drug court defendants- Drug Courts report recidivism rate of 25%; Mental health dockets report recidivism rates of 10-15%

HOUSING

Background

  • Affordable housing is considered to be housing that costs no more than 30% of a household income.
  • The Department of Behavioral Health and Development Services (DBHDS) submitted a $9.5M budget request in 2017; $4.6M of this was for Permanent Supportive Housing over two years.
  • More than 5,000 clients need permanent supportive housing throughout the Commonwealth. While 170 individuals are ready to be released from Virginia’s nine state hospitals, only 14 are currently accommodated with state funding.
  • Medicaid covers services, but does not include housing.
  • NAMI Virginia is working with a coalition of healthcare and housing groups to support the expansion of housing including the Disability Law Center and the Virginia Housing Alliance.
  • The average daily inpatient hospital cost is approximately $650/daily or $240K annually while it costs approximately $40-50K per client in permanent supportive housing.
  • The term “transinstitutionalization” is used to describe those who end up in settings such as, jails, prisons, etc., rather than in independent living or permanent supportive housing. It is estimated that over 2,700 clients are in this status.
  • The behavioral health implications of the lack of safe affordable housing include an increased risk of all mental illness, especially depression and anxiety for such housed adults. Foreclosure and eviction are directly linked with increased risk for suicide, depression, and overall poor health.
  • Children who live in precarious housing situations or move frequently also are more likely to have behavioral problems, mood disorders, and to be delayed in school by at least a grade level. Adolescents are at greater risk for behavioral issues, academic failure, and early sexual initiation. These families are also at increased risk for child abuse and neglect, which in turn puts children at a higher risk for behavioral health concerns over their lifetime.

BEHAVIORAL HEALTH WORKFORCE DEVELOPMENT

Background

  • Direct care staff turnover in state hospitals is at its highest rate in 10 year according to a DBHDS Update to the Joint Subcommittee on Mental Health in the 21st Century, September 28,2017
  • Community Service Boards are losing case managers to jobs with higher salaries and better incentives.
  • 74% of the workforce professionals in Virginia state hospitals are white women over 40 years of age.
  • Virginia’s very low pay scale is a major contributor to high patient/professional caregiver ratios.
  • While Virginia ranks very high nationally as a wealthy state, its pay scale is near the bottom for healthcare staff such as nurses. This makes it very difficult to recruit replacement staff. According to the September 2017 DBHDS Update to Joint Subcommittee on Mental Health in the 21st Century, increased salaries are needed to make Virginia more competitive and better able to recruit and retain qualified staff.

OPIOID ABUSE

Background

  • The opioid epidemic is now a full-blown national crisis the issue is incorporated in the updated behavioral health study.
  • Since 2000, the opioid and heroin epidemic has claimed more than 200,000 lives — more than three times the number of Americans killed in the Vietnam War.
  • The Centers for Disease Control and Prevention (CDC) reports that in 2016, opioids killed more than 42,000 men, women and children across the U.S. — more than any year on record. Forty percent of those deaths involved a prescription opioid.
  • For the second year in a row, life expectancy in the U.S. dropped, largely as a result of the opioid epidemic.
  • Virginia is not exempt from this crisis. The opioid epidemic has resulted in 1,138 overdose fatalities in the commonwealth in 2016, a 40.3 percent increase over 2015. The total number of deaths has nearly doubled since 2007.
  • It is important to emphasize this issue is multifaceted and wide-ranging, affecting not only the individual users but families and communities. It is a solvable problem if we work toward better treatment for those addicted, support for families affected, education efforts to prevent opioid abuse, and improved resources and training for law enforcement to both address the problem and stem the importation of illicit drugs into our communities.
  • Federal, state and local governments, as well as private and public community organizations, are marshalling resources to address this behavioral healthcare crisis.
  • The Council of Economic Advisors estimates the opioid crisis cost the economy more than $500 billion dollars in 2016.

FINANCING

Background

  • Virginia’s behavioral health system has been chronically underfunded; it spends $50 per capita versus $89 per capita national average.
  • 54% of state funding is directed to inpatient hospitals while 46% goes to CSBs. The national state average is 23%.for inpatient hospitals.
  • The annual cost associated with increased demand and the maintenance costs of ever larger state hospitals are unsustainable.
  • Providing consistent access to the full array of comprehensive, high-quality behavioral health services to individuals of all ages regardless of their geographic location or their ability to pay, would cost around $184 million annually.

LWV-VA Behavioral Health Position Appendix 3

  1. Sources of Information – 2017 and 2018

Interviews/Presentations

Bane, Greg, Attorney, Personal Injury, Criminal Defense, Family Law, Hampton Drug and Veteran Courts, Telephone, October 16, 2017

Brown, Rev. Jan, Founding/Executive Director and McDonald, Rev. Lauren, Director of Spiritual and Community Programming, SpiritWorks Foundation Center for the Soul – A Community Recovery Organization – Williamsburg, Virginia, November 17, 2017.  

Brown, Richard “Ric”, Virginia Secretary of Finance (2008 – 2018) – Medicaid and other state funding sources and waivers, LWV-VA Pre-Session, Richmond, Virginia, December 6, 2017

Coe, David, Executive Director, Colonial Behavioral HealthWilliamsburg – Community Services Board objectives and priorities , CBH Administrative Offices, McLaws Circle, Williamsburg, VA, October 6, 2017

Dunn, Chief Sean, Williamsburg Police Department, Williamsburg, Virginia, January 8, 2018

Kutsch, Andy, Executive Director American Addiction Treatment Center – Newport News – Opioid Crisis Presentation, Williamsburg Regional Library, January 18, 2018

Thissen, Rhonda, Executive Director, National Alliance on Mental Illness (NAMI) Virginia – NAMI’s priorities for Virginia , Williamsburg Regional Library, Williamsburg, Virginia, January 11, 2018

Studies and Periodicals
Bloomberg, Michael R., “A Seven-Step Plan for Ending the Opioid Crisishttps://www.bloomberg.com/view/articles/2018-01-10/a-seven-step-plan-for-ending-the-opioid-crisis

Commonwealth of Virginia, Secretary of Administration, Compensation Board, “Mental Illness in Jails Report “, 2017

Higham, Scott and Bernstein Lenny, Washington Post, “The Drug Industry’s Triumph Over the DEA,” October 15, 2017

Iskra, Sheila and Pablo, Kathleen, “Opioid Epidemic: The United States, Virginia & Fairfax County”, March 2017

James City County Workforce Housing Task Force, “2016 Housing Conditions Study”

LWV-Colorado, “Behavioral Health Position/Study”, August 2015

LWV-US, “Position on Behavioral Health”, Adopted by LWV-US Convention, June 2016

National Geographic “The Science of Addiction,” September 2017

New York Times Editorial Board, “America’s 8-Step Program for Opioid Addiction,” September 30, 2017

Sharfstein MD, Joshua M., “A New Year’s Wish on Opioids,” JAMA Forum, Journal of American Medical Association, January 3, 2018

Szalavitz, Maia, New York Times, “The Wrong Way to Treat Opioid Addiction,” January 17, 2018. https://www.nytimes.com/2018/01/17/opinion/treating-opioid-addiction.html

Virginia Association of Local Human Service s Officials (VALHSO) Conference, Where We Are on Mental Health Issues, October 16, 2017

Virginia General Assembly, Joint Subcommittee Studying Mental Health Services in the Commonwealth in the 21st Century, “DBHDS Update on Behavioral Health System Reform Efforts,” Dr. Jack Barber, Interim Commissioner VDBHDS, September 27, 2017

Virginia General Assembly, Joint Subcommittee Studying Mental Health Services in the Commonwealth in the 21st Century, “Update on Financial Realignment of Virginia’s Public Behavioral Health System,” Dr. Jack Barber, Interim Commissioner VDBHDS, November 25, 2017

Virginia General Assembly, Joint Subcommittee Studying Mental Health Services in the Commonwealth in the 21st Century, “Progress Report to the Joint Subcommittee and Recommendations for the Legislative Consideration in 2018”. Envisioning Mental Health Services in the 21st Century: Goals and Challenges,” Richard J. Bonnie, Chair, November 27, 2017

Virginia Lawyer “Advancing Mental Health Courts,” December 2016

Worker, Andrea, Alexandria Gazette, “Facing — and Fighting — the Opioid Crisis” , October 29, 2017

Web Sites
Centers for Disease Control and Prevention, Opioid Overdose https://www.cdc.gov/drugoverdose/index.html

Governor’s Task Force on Prescription Drug and Heroin Abuse https://www.dhp.virginia.gov/taskforce/

Hardest Hit” –Video from the Office of the Attorney General of Virginia”, http:hardesthitva.com

Healthcare for all Virginians (HAV) http://havcoalition.org/

Mental Health America of Virginia https://mhav.org/ – Mental Health Advocacy

Positive Behavioral Intervention Support (PBIS) programs in schools https://www.pbis.org/

Substance Abuse & Addiction Recovery Alliance (SAARA) https://www.saara.org/

Substance Abuse and Mental Health Services Administration (SAMHSA) https://www.samhsa.gov/

Treatment Advocacy Center http://www.treatmentadvocacycenter.org/ http://www.treatmentadvocacycenter.org/browse-by-state/virginia

Virginia Department of Behavioral Health and Developmental Services; System Transformation, Excellence and performance in Virginia (STEP-VA) approach http://www.dbhds.virginia.gov/developmental-services/step-va

Virginia Housing Alliance http://vahousingalliance.org/

Virginia Housing Development Authority https://www.vhda.com/Pages/Home.aspx

Virginia’s Joint Subcommittee to Study Mental Health Services in the Commonwealth in the 21st Century http://dls.virginia.gov/interim_studies_MHS.html

Virginia Network of Private Providers https://vnppinc.org/

VOICES for Virginia’s Children https://vakids.org/

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