This site is operated and overseen by the Coordinating Committee for Promoting Use of Advance Directives by People with Mental Illness. The Coordinating Committee comprises representatives from key private organizations and public agencies as well as other individuals with specialized knowledge regarding the use of advance directives in health care. The participating organizations and agencies include:
• Virginia Department of Behavioral Health and Developmental Services
• Virginia Hospital and Healthcare Association
• Virginia Association of Community Services Boards
• Mental Health America of Virginia
• National Alliance on Mental Illness (NAMI) Virginia
• Virginia Organization of Consumers Asserting Leadership (VOCAL)
The Coordinating Committee also consults on a regular basis with the Virginia Office for Protection and Advocacy.
The activities of the Coordinating Committee are administered by an Executive Committee. Members of the Executive Committee are:
• Richard J. Bonnie, Director of the Institute of Law, Psychiatry and Public Policy, University of Virginia, Charlottesville, VA
• John E. Oliver, Esquire, Attorney, Norfolk, VA
• Jeffrey Swanson, Ph.D., Professor of Psychiatry and Behavioral Sciences, Duke University, Durham, N.C.
• Christine Wilder, M.D., Assistant Professor of Psychiatry and Behavioral Sciences, Duke University, Durham. N.C.
This site is edited by John E. Oliver.
Site construction and technical assistance provided by Mental Health America of Virginia.
Why This Site Exists:
Supporting The Use of Advance Directives by People with Serious
Mental Illness under Virginia’s Health Care Decisions Act:
Implementation of a Major Public Health Reform
In 2009, the Virginia General Assembly enacted major amendments to the Commonwealth’s Health Care Decisions Act (HCDA). The revisions were based on recommendations of the Virginia Supreme Court’s Commission on Mental Health Law Reform, which had solicited extensive input from and involvement of a broad spectrum of stakeholder groups during a two-year period of deliberation and drafting (Bonnie et al., 2009). Because of the statutory revisions enacted in 2009 and 2010, the HCDA now provides a legal mechanism for persons with chronic health conditions, including serious mental illness (SMI), to document, while competent, their treatment instructions and preferences, and to authorize a healthcare agent to make treatment decisions for them during periods of incapacity. These advance directives may also contain individualized, patient-centered plans to prevent crises, as well as to manage and recover from them.
Legal advance directives for mental health treatment represent an innovative and promising approach for promoting treatment engagement and continuity of care for people with serious mental health conditions and could play a significant role in improving long-term health and safety outcomes for this population (Swanson et al., 2006; 2008; Wilder et al., 2007; 2010). A major goal of these directives is to empower psychiatric patients to control their own care and, in so doing, to reduce the need for coercive interventions during mental health crises (Swanson et al., 2000, Scheyett et al., 2007).
With strong support from policymakers and stakeholders alike, Virginia is undertaking an unprecedented effort to effectuate the goals of the HCDA. Beginning in January, 2010, the key stakeholder groups have initiated a multi-pronged consensus-based strategy to promote use of advance directives by mental health consumers and to assist them in completing and executing these legal instruments. This effort was coordinated and overseen during 2010 by the Commission on Mental Health Law Reform, and is now coordinated and overseen by a Coordinating Committee for Promoting Use of Advance Directives by People with Mental Illness. The Coordinating Committee comprises representatives from key private organizations and public agencies and its work is administered by an Executive Committee.
Activities undertaken by the Coordinating Committee include the following:
• The Department of Behavioral Health and Developmental Services is supporting initiatives by public mental health service providers to incorporate advance directive facilitation into routine clinical care. Community mental health services agencies in four localities are serving as “vanguard sites” for these initiatives, which began in the summer and fall of 2010.
• Advocacy organizations, including NAMI, VOCAL, the Mental Health America, and VOPA, are taking steps to facilitate the use of advance directives by members of their organizations and the people they serve.
• Standardized advance directive forms have been developed under the auspices of the Virginia Hospital and Healthcare Association.
• Health law experts are undertaking coordinated activities to clarify the legal aspects of executing and enforcing advance directives.
• Training workshops have been organized to help disseminate more information about the law to advocates and health care providers.
• New administrative data elements are being added to electronic health records to document facilitation and execution of advance directives.
• A web site has been established to provide ready access to resources regarding advance directives for persons with mental illness and to provide information and guidance regarding the legal effect of executing an advance directive under Virginia law.
Successful implementation of Virginia’s Health Care Decisions Act may hold valuable lessons for other states seeking more cost-effective, ethical, and person-centered means to address the serious public health problem posed by untreated mental illness in the community. However, the scope and effect of these facilitation efforts on practice and clinical outcomes is still unknown. Consequently, a research study is being conducted by a team of investigators from the University of Virginia and Duke University to assess the effects of those efforts on a continuing basis.
The first component of the research was completed during the first half of 2010. Taking advantage of initial dissemination and training activities, the goal of this portion of the study was to collect baseline data on knowledge, attitudes and experience regarding the new HCDA statute. Key stakeholders including hospital and community service board (CSB) administrators, clinicians, and other stakeholders (including mental health service users, family members, and advocates of those vested in the care of individuals with diagnosed mental illness) were surveyed to assess their knowledge of and attitudes about the HCDA. A total of 485 respondents across all sampled stakeholder groups completed the online survey. Data analyses are underway.
The second component of the study, initiated in the fall of 2010, examines the process of facilitating and completing advance directives for persons with SMI in two of the “vanguard” CSBs; it will feature focus group sessions with facilitators and interviews with a sample of individuals who execute these documents after facilitation. Initial follow-up interviews will ascertain whether consumers are satisfied with the process of completing advance directives and are finding those documents beneficial to their health care and recovery. Subsequent follow-up interviews will seek to ascertain the effect of executing advance directives on treatment engagement, the occurrence of mental health crises and on the use of coercive interventions. Ultimately, this information will yield recommendations for improving the process of facilitating advance directives, which, in turn, can increase the number of people with SMI who execute advance directives.
The third component of the research will measure the number and content of advance directives executed by the target population in the four vanguard sites and will examine de-identified data from electronic health records in these three sites to compare clients who have executed advance directives and those who have not on a number of clinical and service parameters.
The study’s findings will be used to develop specific recommendations to improve implementation of the HCDA in Virginia and will also be disseminated nationally to inform policymaking in other states.
The research project is being supported by grants from the Robert Wood Johnson Foundation Public Health Law Research Program, the John D. and Catherine T. MacArthur Foundation Research Network on Mandated Community Treatment, the University of Virginia Law School Foundation, and the Virginia Department of Behavioral Health and Developmental Services in cooperation with the SAMHSA Center for Mental Health Services and the David L. Bazelon Center for Mental Health Law.
Richard J. Bonnie
Principal Investigator
University of Virginia School of Law