Discussions Continue About State Hospital Overcrowding

July 30, 2019

As reported in an earlier County Connections article, legislation enacted in 2019 requires the Secretary of Health and Human Resources to convene a workgroup to examine the issues surrounding overcrowding in Virginia’s state hospitals, which provide the “bed of last resort” in accordance with statute, and are operating close to capacity. As an indication of the scale of the problem, leadership in the Department of Behavioral Health and Developmental Services (DBHDS) were concerned in the days leading up to the Independence Day holiday weekend that no state hospital beds might be immediately available for individuals in crisis. In such a scenario, it is unclear what would happen to an individual who was held under an Emergency Custody Order (ECO) when it expired if the state hospital could not accept the person, as the “bed of last resort” statute was enacted to prevent such a situation. Fortunately, DBHDS was able to work with several private hospitals to secure beds, among other efforts, and the shortage was avoided, but concerns remain about the sustainability of state hospital usage in the long term. The workgroup established to examine this issue has met several times over the summer to review aspects of the issue and potential options for addressing the problem.

At the June 24 workgroup meeting, Dr. Michael Schafer, Assistant Commissioner for Forensic Services at DBHDS, briefed members on options for law enforcement to assist individuals in crisis and, if possible, to divert them to treatment options outside of the criminal justice system. Crisis Intervention Team training, which equips law enforcement officers with an understanding of behavioral health conditions and techniques to de-escalate confrontations, is widespread in Virginia, with 35 active programs; Dr. Schaefer pointed out that Virginia has the largest number of CIT programs and CIT assessment sites in the nation. CIT assessment sites, which may be located within or near hospital emergency departments or in CSB offices, provide an alternative to arrest in certain situations and allow patrol officers to return to duties by assuming custody of the person in crisis. Some centers also accept voluntary admissions or accept individuals who are brought by family members. There are 37 CIT assessment sites in Virginia, with five under development, and they are spread throughout the Commonwealth, but only seven are able to operate 24/7, and most can only accommodate three or fewer individuals at a time.

The workgroup discussed a set of policy options but came to no consensus. Workgroup members generally expressed support for the concept of expanding the capacity of CIT assessment centers. There was significant opposition to a proposal to extend the ECO time period from the current eight hours to 24 hours, which proponents contend would allow more time for an individual in crisis to enter a hospital voluntarily. Law enforcement representatives were concerned that the expanded time period would translate to more hours where an officer must remain with the individual in crisis; hospital representatives suggested that patients would spend more time in an emergency department environment, which can be noisy and stressful; and CSB representatives pointed out that more time to complete an evaluation is unnecessary, since most of the eight hours are consumed with searching for an available bed.

Narrower policy proposals that would extend the ECO period for individuals who are intoxicated (whether from alcohol or other substances) or have complex medical conditions were not fully discussed in June, but the workgroup’s meeting on July 22 focused on issues surrounding the civil commitment process for individuals in these categories. Dr. Alexis Aplasca, Chief Clinical Officer for DBHDS, discussed the advantages of an acutely intoxicated individual who presents at a hospital emergency department having time to sober up, engage in the CSB worker’s assessment, and possibly be discharged, rather than being placed under a TDO because the ECO expired while he was still in a state where he was unable to care for himself. Dr. Aplasca also explained the challenges posed by an individual in crisis who has complex medical needs, as it may take more than eight hours to stabilize the individual for transportation to a state hospital, coordinate appropriate equipment and medications, and consult with specialists on a treatment plan. Psychiatric hospitals are generally limited in their ability to care for patients with complex medical needs, and often cannot accept such patients, whose care then falls to the state hospitals. Workgroup members discussed medical TDOs, which allow short-term testing, observation, or treatment to be provided to prevent serious harm to individuals who are incapable of making decisions for themselves, as a potential alternative to psychiatric TDOs, although there appears to be some variation across the state in how the statutory criteria are applied, and physicians on the workgroup expressed a desire for more clarity in the statute. Hospital representatives encouraged exploration of sobering centers as another option for individuals who are in crisis and also intoxicated.

The workgroup plans to have further discussion about medical TDOs and sobering centers at a future meeting, in addition to exploring issues surrounding transfers of custody. The next meeting is scheduled for August 26.

VACo Contact: Katie Boyle

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