Staff to the Joint Legislative Audit and Review Commission (JLARC) presented findings and recommendations to JLARC members on December 11, and provided a follow-up briefing to members of the Behavioral Health Commission two days later. Behavioral Health Commission members reviewed the study’s recommendations dealing with legislative or budget actions by the General Assembly and agreed to advance several of these proposals during the 2024 legislative session.
The study outlines serious concerns about the state’s psychiatric hospitals, which have been operating with caseloads above safe levels and experiencing high turnover and staff vacancies, with staffing challenges attributable to uncompetitive compensation and safety concerns. JLARC staff reported that in recent years, state hospitals have been operating at more than 85 percent of their staffed bed capacity, a situation that is generally considered unsafe. State hospitals are considered the “bed of last resort” under Virginia law, as they must accept patients under a temporary detention order (TDO) if no other facility will accept them. The report notes that this designation bars state hospitals from refusing to accept patients under TDOs, even if a patient does not need psychiatric treatment, such as patients with neurocognitive or neurodevelopmental disorders, who are not likely to benefit from the treatment offered at state hospitals, but who often stay for relatively long periods of time. Similarly, JLARC staff also expressed alarm about the ongoing practice of law enforcement dropping off patients at state hospitals, some of whom have serious medical conditions that state hospitals are not equipped to treat, requiring them to be transported to other facilities.
Forensic patients are another population that is stressing state hospital capacity; JLARC staff note in the report that in FY 2023, forensic patients (criminal defendants ordered by a court to receive inpatient psychiatric evaluations and treatment) used the majority of all available state psychiatric bed days (forensic patients remain in the hospital an average of three times longer than civil patients).
JLARC staff raised particular concern about the state’s facility of last resort for youth in need of inpatient psychiatric care, the Commonwealth Center for Children and Adolescents (CCCA), writing, “persistent operations and performance problems at CCCA justify reconsidering whether CCCA should continue to operate.” The report recommends that the state develop a plan to close CCCA and develop alternative placements for children and youth who would otherwise be served there.
The report encourages private hospitals to shoulder more of the responsibility of accepting patients in need of inpatient psychiatric treatment, noting that private psychiatric hospitals have unused staffed capacity that would enable both private hospitals and the state hospitals to operate at safe census levels.
Key recommendations from the report include:
- Amending Virginia Code to specify that behaviors and symptoms that are manifestations of a neurocognitive or neurodevelopmental disorder are excluded from the definition of mental illness for the purpose of TDOs and civil commitments. A related recommendation would direct the Secretary of Health and Human Resources to evaluate the current availability of placements for individuals with such disorders and develop alternative strategies to support these populations. The Behavioral Health Commission members discussed these recommendations at length, expressing concern about the unintended consequences of directing these admissions away from state hospitals without creating alternative placements. Members ultimately adopted a revised recommendation that would require development of a funding plan for the alternative placements and incorporate a reenactment clause making implementation contingent on the Secretary’s report and funding plan.
- Amending Virginia Code to allow state hospitals to delay admission of an individual under a TDO until the hospital determines that the individual does not have urgent medical needs that the state hospital cannot treat. The Behavioral Health Commission adopted this recommendation.
- Amending Virginia Code to allow state hospitals to decline admission of an individual under a TDO if the admission would result in the hospital operating in excess of 85 percent of its staffed capacity. The Behavioral Health Commission discussed but did not endorse this recommendation.
- Providing funding to enable private hospitals to increase the percentage of involuntary admissions they accept (funding could be used for additional security positions, staff training, or safety improvements). The Behavioral Health Commission approved this recommendation with an amendment to require these hospitals to commit to increasing involuntary admissions. A related recommendation, also approved by the Commission, would allow private hospitals to receive discharge assistance funding (which is currently only provided to assist with discharges from state hospitals).
- A set of recommendations to address staffing concerns, including increasing salaries for staff at state hospitals and requiring annual reporting on average turnover and vacancy rates; directing the Department of Human Resource Management to allow state hospitals to define 36 hours per week as full time for state hospital nursing staff (to align with industry standards); funding scheduling software for state hospital nursing shifts; funding additional nursing positions to a level that would ensure adequate and safe patient care; and contracting for assessments of the adequacy of each hospital’s staffing levels. The Commission adopted these recommendations.
A full list of the report recommendations is available at this link, and the report is available at this link.
VACo Contact: Katie Boyle