[April 10 2024] DCPCA Budget Testimony for Department of Behavioral health
To: The Honorable Christina Henderson, Chair, DC Council Committee on Health
Members of the Committee on Health
From: Patricia Quinn, VP of Policy and Partnerships, DC Primary Care Association
Re: Budget Hearing for DC Department of Behavioral Health
Date: April 10, 2024
The DC Primary Care Association (DCPCA) works to build a healthier DC by sustaining community health centers, transforming DC care delivery, and advancing racial and health equity. Our collaborators in this work include community health centers, serving almost 1 in 4 District residents in every ward of the city. Thank you for the opportunity to provide testimony regarding the budget of the District of Columbia Department of Behavioral Health (DBH.)
Behavioral Health Treatment
Last year, we reported an almost 35% decline in the number of mental health patients seen at community health centers between 2019 and 2021 related to workforce challenges. Our 2022 data shows progress, though we are still 13% below 2019 numbers (1). Even more significant is the decline in patients receiving substance use disorder treatment. More than 9,500 health center patients had a diagnosis of substance use disorder, yet fewer than 2,000 received treatment for the condition at a health center. Surprisingly, this ratio of diagnosis to treatment is considerably better than national averages. SAMSHA reports that in 2021, 94% of people with SUD received no treatment (2).
The District’s health system must engage and partner in new ways to reach those struggling with behavioral health challenges who could benefit from life-saving harm reduction services and life-changing clinical supports. According to an interim evaluation of the District’s 1115 waiver to transform behavioral health, measures for initiation of SUD treatment improved, but adherence to and retention in treatment did not. The report recommends expanding access to peer support beyond providers certified by DBH, easing provider burden on service delivery requirements, and continuing to build the policy, payment, and delivery system infrastructure for telemedicine (3). Given these recommendations, DCPCA is concerned about the proposed restriction of audio telehealth services. Audio services provide critical support for residents without access to video-enabled devices, internet, or the privacy necessary to engage in video telehealth.
The proposed FY25 budget for DBH anticipates necessary increases for the District’s share of Medicaid behavioral health costs and for behavioral health services for residents who do not qualify for Medicaid. DCPCA supports these increases and the investment in staffing for the Access Helpline. Our members have struggled with the apparent reduction in Access Helpline service in FY24 in terms of linking patients to the more intensive services offered by DBH grantees.
Of particular concern to DCPCA is the reduction of $4.8 million in School-based Behavioral Health. The Mayor has indicated the savings (and an additional $6.4 million elsewhere in the budget) come from staff vacancies. Rather than eliminating the positions and resources, DCPCA recommends redirecting the savings to continue investment in school-based behavioral wellness through emerging models that broaden the base of behavioral health supports available in school communities. Approaches to care need to build on social capital, individual and community agency, and support connections for a meaningful life.
Opioid Abatement
Opioid-related fatalities in the District have increased every year since 2018, despite focused attention within the health system and DBH’s Live.Long.DC campaign. As a member of the Opioid Abatement Advisory Commission (OAAC), DCPCA is invested in pursuing evidence-based innovation and securing resources for infrastructure using the $14.6 million in opioid settlement funds. Three recommendations emerging from the OAAC deserve specific attention, particularly given that our collective past efforts have yet to stem the tide of opioid overdose deaths (4):
“Bupe in the Field” as described by Dr. Robert Holman, Medical Director at Fire and EMS
• 24/7 buprenorphine induction from EMS medics
• Five consecutive days of EMS visits w/ buprenorphine dosing
• High rate of 30-day adherence to buprenorphine treatment
2. PEP-V type housing for unsheltered residents with SUD
• Private rooms with amenities, three meals plus snacks, and 24/7 security.
• Daily primary care and 24- hour mental health support. Access to medical and community transportation, linkage to care, and support for accessing community services and long-term support.
• Housing-focused case management with permanent housing exit planning. Staffed by people with lived experience, clinicians and peers for clinical, psychosocial support, and skill-building.
3. Contingency management pilot
• Use human-centered design to stand up a contingency management (CM) system founded on and rapid cycle iteration to harness the power of tangible incentives for achieving drug-free tests, session attendance, and milestones.
• Guide a transition to intrinsic self-motivation.
• Embed across outpatient, inpatient, and residential facilities, incorporate peer recovery support, and target populations at higher risk.
• Robust research shows CM's efficacy in increasing adherence, retention and reducing reuse.
Requirements for National Accreditation
DCPCA supports DBH’s efforts to improve quality among District providers by advocating for national accreditations from the Joint Commission, the Council on Accreditation, or the Commission on Accreditation of Rehabilitation Facilities. However, national accreditation should replace existing DBH certification requirements.
Replacing Certification Requirements
FQHCs are asked to maximize efficiency and health outcomes from limited federal funding. Establishing consistent standards across DBH and the accreditation bodies will minimize the administrative burden on FQHC compliance staff, allowing them to focus resources on patient outcomes. DBH should amend language in each Chapter affected by this proposed rulemaking by replacing its current certification requirements with those standards set forth by the national accreditation agencies in order to align both sets of evaluative standards and minimize undue burden on providers.
We are grateful to DBH Director Dr. Barbara Bazron and her dedicated team for their deep commitment to the well-being of District residents. We look forward to further partnership to build and strengthen pathways to recovery for everyone in our city.
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1 District of Columbia Health Center Program Uniform Data System (UDS) Data (hrsa.gov)
2 SAMHSA Announces National Survey on Drug Use and Health (NSDUH) Results Detailing Mental Illness and Substance Use Levels in 2021 | HHS.gov.
3 DRAFT 1115 Interim Eval Report_For public comment (dc.gov)
4 https://dbh.dc.gov/sites/default/files/dc/sites/dmh/page_content/attachments/OAAC%20Meeting%20Presentation_2.14.24.pdf