Who We Are

[Curt White]

Who We Are and Why This Site Exists

Who We Are


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

•National Alliance on Mental Illness (NAMI) Virginia

•Virginia Organization of Consumers Asserting Leadership (VOCAL)

•Mental Health America of Virginia


The Coordinating Committee also consults on a regular basis with the
Virginia Office of the Attorney General and 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.

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, 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.


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