High census levels at the state hospitals serving individuals with mental illness have been a growing concern for General Assembly members and the Administration in recent years. Since 2014, when legislation was enacted requiring state hospitals to serve as the “bed of last resort” for individuals subject to a temporary detention order (TDO), state hospitals have experienced significant growth in the numbers of individuals admitted through civil TDOs. (A TDO is issued by a magistrate when it is determined that a person with mental illness is likely to cause serious harm to him/herself or others or be incapable of protecting him/herself from harm or providing for his or her basic needs, requires treatment, and is unwilling or incapable of seeking treatment voluntarily. A TDO generally lasts for 72 hours, after which time a commitment hearing is held to determine whether the individual should be released, whether the individual will remain in the hospital voluntarily, or whether further treatment or hospitalization should be ordered.)
Total numbers of TDOs have remained relatively flat between FY 2015 and FY 2018, but admissions to state hospitals have increased by approximately 1,000 per year, while the number of TDO admissions to private hospitals has declined. A related issue is the strain on local law enforcement agencies, which are generally tasked with transporting individuals subject to TDOs; difficulty in finding available beds often requires law enforcement to transport individuals far outside their localities, requiring significant local expenditures for travel, overtime, and “backfilling” local shift coverage.
These issues have been the subject of discussions at the Joint Subcommittee Studying Mental Health Services in the Commonwealth in the 21st Century, among other efforts. Senator Emmett Hanger, a member of the Joint Subcommittee, introduced legislation this session to direct the Secretary of Health and Human Resources to convene a stakeholder workgroup to examine the causes of the high census at state hospitals and recommend short- and long-term solutions to the issue, to include considering possible extensions to the initial time period during which an individual experiencing a mental health crisis may be held in law enforcement custody and opportunities to divert such individuals from hospital emergency departments to other locations for evaluation.
The workgroup held its first meeting on April 22 with a series of presentations by workgroup members on stakeholders’ perspectives on the issue. Department of Behavioral Health and Developmental Services Commissioner Hughes Melton outlined his concerns with the state hospitals’ current operating levels and explained that his goals in reducing the census are to improve safety for patients and staff, to decrease institutionalization, and to build capacity within communities, pointing out that the resources needed to keep up with state hospital usage can crowd out investments that might otherwise be made in community-based services.
Representatives of the Virginia Hospital and Healthcare Association pointed out the increase in voluntary admissions to private hospitals as a factor limiting these hospitals’ ability to accept TDO admissions, noted that private hospitals are working to increase bed capacity, and suggested some alternatives to hospitalization, such as crisis stabilization units. Representatives from Community Services Boards explained that searching for available beds consumes significant resources and that the “bed registry” tool developed by the state to assist in the process is of limited usefulness. Law enforcement representatives expressed their concerns about burdens placed on local police and sheriffs’ departments by the current transportation process and their desire to develop a system that is less traumatic for vulnerable individuals, who often must be transported in handcuffs. Advocates for individuals with mental illness and for children emphasized the need to bolster community-based services such as outpatient and crisis services.
Future meetings are expected to include discussion of possible extensions to the initial period during which an individual is detained, prior to the issuance of a TDO; presentations from national experts on how the bed registry might be improved and how mental health transportation is handled in other states; and further conversation about the role of private hospitals. An update is also expected on implementation of a regionally-based alternative transportation program funded by the General Assembly in 2018.
VACo Contact: Katie Boyle