If there is a single word that seems to describe the Comprehensive Services Act (CSA) these days it is frustration – particularly when it comes to having to constantly justify why the costs of providing care continue to increase. At the state and local level, the cost issues are too often perceived as a fait accompli, simply the cost of doing business when providing services to a difficult population.

CSA has evolved into a much larger system of care than it was designed to handle originally. By combining the residential and day treatment services offered through special education, foster care and juvenile court services, the state has created an “amorphous entity” without the ability to maintain accountability and control costs.

In 1994 the state and local governments spent $104.6 million to serve 10,214 children and their families under the CSA program. In 2005 the program served 16,272 young people and their families at a cost of $273.2 million.

The frustrations

It has become far too easy for state agencies to transfer their clients and expenses to CSA instead of taking responsibility for their care. For example, since CSA’s inception, the state has all but gotten out of the business of serving children in need of long-term or residential mental health services. During this same time, more children with mental health and substance abuse problems have entered the criminal justice system and received treatment there. The cost of treatment for children in juvenile detention facilities falls primarily on local governments. To make matters even worse, local governments lost a valuable source for treating children in the community when the state cut its support for the Virginia Juvenile Community Crime Control Act by 50 percent.

Another quiet, but significant shift has occurred in many of the school systems throughout the state. The phenomenal growth of special education programs has outstripped the ability of local school districts to meet the needs of children who require highly specialized day treatment and residential services. This is especially true for children who are autistic, who are sex abusers, or who are self-abusers and dangerous to their fellow students. The nature and specialized needs of these treatment programs proved to be financially prohibitive to be offered in each of the state’s school districts.

The birth of CSA

In 1992, the Virginia General Assembly passed the Comprehensive Services Act (CSA), which established one of the nation’s first comprehensive systems of care for at-risk children. This system was put in place to provide treatment services for the growing number of children who exhibit serious emotional and behavioral problems.

The passage of CSA was prompted by numerous problems that plagued the previous system that provided services for at-risk children. Among these problems were a fragmented service delivery system that fostered duplication in the provision of treatment services, and a funding structure that created local incentives to arrange for counseling and related services in the most restrictive and expensive settings.

Through CSA, the General Assembly sought to correct these problems in three ways. First, resources from the multiple funding streams that supported the previous system were combined into one pool of funds. Second, local agencies that are responsible for the provision of services to at-risk children were encouraged to form collaborative arrangements and use the pooled funds to deliver non-duplicative services in the least restrictive settings possible. Finally, to ensure that local CSA programming would not be constrained by state regulations, the General Assembly organized the state structure and leadership for the program with a council of state officials rather than a single agency; gave many of the program oversight responsibilities to local officials; and provided local jurisdictions with the flexibility believed needed to develop and implement service plans for at-risk children. Throughout Virginia, Community Policy and Management Teams (CPMTs) implement the Comprehensive Services Act as specified by the state code.

… From a Joint Legislative Audit and Review Commission review of the Comprehensive Services Act.

There are, however, some alternative approaches that address the needs of this special education population. For a number of years – predating CSA – the State Department of Education has helped to fund a regional response in Tidewater for specialized day treatment services through the Southeastern Cooperative Education Programs. The organization provides a formal structure through which participating school systems can plan and operate programs for children with special needs. Despite the state’s offer to help financially, no other regional entities have been developed. As a result, most school districts turned to CSA to handle these populations.

Over the years, the devolution of state services to localities and the lack of local special education infrastructure have advanced the steady growth of the CSA system. Despite a number of studies and attempts at partial fixes, CSA still lacks cost-effective ways to provide services. The change in administrations every four years makes it difficult to accomplish wholesale changes in the program. Furthermore, responsibility for CSA is shared by agencies in three different secretariats, meaning that there is no defined owner of it. In short, the buck doesn’t stop anywhere.

State policy leaders tend to view the system as a local rather than state system, despite the fact that more than half of the money for providing services comes from the Commonwealth. In FY05, the state contributed $174.2 million for CSA; local governments put in $99 million. In addition, CSA is a “sum sufficient” program, meaning that costs must be covered even if they exceed the state’s appropriation. That approach makes budgeting for CSA at the local level unpredictable.

To address accountability issues, the state has attempted to control some costs through “utilization management” tools. These systems, which manage the use of residential services for children paid for by Medicaid, have had mixed results.

Until about two years ago, the CSA system lacked any uniform system to gather and report data. There exists today a uniform data collection system that gives a better picture of who is being served by the program and why. While this is a significant step, this reporting system does not measure outcomes to help with monitoring and controlling costs. No system as complicated as CSA can work without a common typology for services, assessment tools and evaluation of outcomes. Some localities have implemented data systems on their own.

The vendor system

CSA spends most of its money to pay private and not-for-profit vendors who provide a variety of day treatment and residential services. Various state agencies license this system of care. The licensing agencies, however, are not funded or sufficiently staffed to monitor these vendors effectively. There is no systematic review of vendors to ensure that the CSA system is getting its money’s worth and the outcomes it desires. What is needed are contracts that spell out for Community Policy and Management Teams (CPMTs) the services that they are purchasing, the per-unit cost of the services, and that include progress reports and measurable outcomes that can be expected.

Vendors largely dictate costs (that keep increasing); some resist efforts to increase accountability and to improve service reporting. Because the CSA system lacks both a single owner and overall cost manager, the system goes unchecked. The most expensive services – residential treatment – lack quality and outcome standards. As a result, lengths of stay are not controlled as tightly as they could be, driving up costs. Vendors who accept Medicaid and its rate schedules often increase rates once children run out of Medicaid assistance, despite the fact that the very same service is being provided. In addition, it is not unusual for CSA children to be sent to more than one residential vendor because the first one could not handle a specific behavioral issue. This poor continuity and quality of service prolongs the lengths of stay for children and makes it virtually impossible for them to return to the community quickly.

Although vendors deal with CSA customers across the state, no effective group purchasing or contracting exists. Despite the fact that state policymakers complain about the spiraling cost of services, the state does not establish or control the rates the vendors charge. This laissez-faire approach is the key reason that vendors keep escalating service costs to localities.

The group home phenomenon

Another unintended consequence of this approach is the location and dispersion of group homes. The homes are concentrated in certain jurisdictions and areas (including Chesterfield County, Henrico County and Winchester) rather than being located uniformly across the state. Ideally, residential services should be located close to a child’s home. This concentration of homes creates hardships both for the host locality and the family of the child who has to drive long distances for visits. Residents of some subdivisions that have concentrations of group homes are upset and bewildered as to why so many of them are located so close together. These children become a burden to the local school district, and sometimes remain as adult dependents in the host locality after aging out of CSA.

The issue became so politically sensitive that the 2005 General Assembly ordered that a study committee look at the causes and effects of the concentration of group homes. Legislation (HB 577) passed the 2006 General Assembly to strengthen licensing and notification requirements to communities.

The devolution of state adolescent mental health services has also created acute problems for sex offenders, self-abusers and autistic children in need of help. There are not enough qualified treatment providers, which results in a lack of quality services. Furthermore, because there are so few vendors, they can set just about whatever prices they desire.

The proliferation of new and single-unit vendors has been caused by the profit making potential of becoming a CSA vendor. Historically, state child residential standards have been lax and largely under-regulated. Vendors can quickly become licensed providers without any real experience in operating residential treatment programs. Many vendors cannot handle behaviorally challenged juveniles and default to local services and public safety officers when children get out of control. Poorly managed homes create problems for their neighbors. This is especially true for senior citizens, many of whom feel powerless to resolve problems.

Autistic children

State iniatives to help autistic young people is especially problematic. The CSA system has become the primary service provider, resulting in high costs for day treatment and residential programs. These children often stay in the CSA system for years, subsisting in a maintenance mode with little change for the investment. The 2006 General Assembly adopted legislation and was considering budget amendments to help address some of the issues surrounding services to autistic children.

What can be done?

There appears to be significant need for improvement in the Virginia CSA system:

Conclusion

These issues cannot be resolved instantly or simply. CSA is a large, expensive and complex system. Its owners are first, the Commonwealth of Virginia, and second, the CPMTs in every community. As such, the state needs to exert more leadership if this program is to serve the best interests of these troubled children, their families and taxpayers.

About the author: Bradford S. Hammer serves as deputy county administrator for human services in Chesterfield.

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Vol. 41, No. 2 -- Feb. 2006

Commentary

Comprehensive Services Act: Time has come for addressing frustrations

By Bradford S. Hammer