Use of Advance Directives by People with Serious Mental Illness under Virginia's Health Care Decisions Act: Implementation of a Major Public Health Reform Project Overview: December 31, 2010

Article excerpt

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 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, http://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+54.12981. 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, including the Office of the Attorney General, 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: www.advancedirectivesva.com.

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. …