Eastern State Hospital in James City County is one of Virginia’s eight publicly run mental hospitals, which have struggled with understaffing and an influx of psychiatric admissions. Expanded mental health services under Medicaid were intended to reduce admissions at state-run facilities. (Virginia Department of Behavioral Health and Developmental Services)
Staffing shortages have left Virginia’s mental hospitals overwhelmed as the facilities continue to struggle with a surging patient population. It’s a problem that’s only grown worse since the start of the COVID-19 pandemic.
Alison Land, commissioner of the Department of Behavioral Health and Developmental Services, told state lawmakers Tuesday that low pay, burnout and growing workloads are pushing employees out of the field. In many cases, the shortages leave available staff scrambling to respond to a high-need patient population. Assaults and injuries within facilities are common, Land said — a difficult cycle that leads to more turnover.
“This is a very complex, acute, somewhat assaultive and aggressive patient mix that’s coming in,” Land told the agency’s board in a similar presentation last week. “And it’s low pay that we’re able to offer them. So you see how a serious situation begins to emerge.”
Even before the pandemic, DBHDS had more than a thousand vacancies at state-run mental hospitals — roughly one-fifth of the roughly 5,500 staff the facilities normally require. In fiscal 2020, some facilities saw more than 30 percent of their direct care positions remain unfilled. At Eastern State in James City County, for example — the first hospital in the country built specifically for patients with mental illness — there was a 37 percent vacancy rate among nursing staff and a 52 percent vacancy rate among physicians, including psychiatrists and internal medicine specialists.
Those empty positions have only grown, and Land said facilities across the state are operating at roughly 65 to 70 percent of staffing. At the same time, most have either met or exceeded their available bed space.
Even in ideal circumstances, DBHDS hospitals are staffed — and budgeted — with the assumption that roughly 90 percent of their beds will be full at any one time, said Angela Harvell, the agency’s deputy assistant commissioner for facility services. But at its highest point in fiscal 2021, the statewide census was at 112 percent of its total capacity.
“So, we obviously have morale issues with the current workforce,” she said. “They work a significant amount of overtime. And we’ve had to tap into other positions at the facility — administrative staff, professional clinical staff — just to maintain our hospital coverage.”
Staffing and census problems at state-run facilities are nothing new. Sen. George Barker, D-Fairfax, said many of the challenges date back to 2014, when Virginia passed legislation that’s now more commonly known as its “bed of last resort” law.
Under state code, Virginia’s psychiatric hospitals are required to admit patients after an eight-hour period if a bed can’t be found at another facility (including private hospitals with behavioral health units). But over the last five years, Land said state hospitals have become more like the bed of first resort for many patients.
Since 2017, there’s been a statewide decline in temporary detention orders, which mandate mental health evaluations and treatment. But the share of TDO admissions at state hospitals has increased — what many say is the result of fewer private facilities willing to accept patients with behavioral health concerns.
“In a lot of instances, private providers and private hospitals are saying ‘We can’t take this person’ because they don’t have enough staff or whatever issue is there,” Barker said. “But it’s not as if their beds are all full.”
Land said that pattern of growth was unsustainable for state-run facilities, which were originally designed to serve chronic, longer-term patients. In some cases, staff have been forced to find space for patients on cots in hallways or common rooms, making patients vulnerable to victimization and compromising their treatment.
One of the biggest concerns is that state hospitals won’t be able to keep up with the growth. At full staffing, the facilities count around 5,500 employees. With roughly one-fifth of positions unfilled, current staff are cumulatively taking on hundreds of hours of overtime — or receiving supplemental help from contract workers, whose pay is often two to three times more expensive.
That makes burnout a significant concern amid record census counts. Stacy Pendleton, chief human resources officer for DBHDS, said most direct care staff start at $11 an hour. The agency is competing not only with other health care providers, but employers like Target and Walmart, which offer higher starting salaries for many of their employees.
“Our recruitment efforts really mirror what private hospitals are doing,” Land said. “But when we see yard signs saying come work at the Sheetz or the Wawa and they’re going to pay over $15 an hour — I think it’s attractive to our staff. And then they don’t have the added stress of working face-to-face with COVID-positive patients and psychiatric patients.”
In the short-term, Land said the agency is considering adding security staff to “decrease the daily risk” for employees. Barker said lawmakers are also examining more lasting solutions, including increasing Medicaid reimbursement rates. Private hospitals often aren’t fully compensated for the cost of behavioral health treatment, he said, making many of them less willing to accept those patients.
But the shortage of staff — and beds — is also having a trickle-down effect on other parts of the state’s mental health safety net. In late March, officers from seven law enforcement agencies held a press conference to criticize lengthy admission delays at state-run facilities. The same delays impact local emergency departments, where beds are frequently taken up by psychiatric patients.
“What’s happening is these people are just sitting there,” said Dr. Joran Sequeira, an emergency room physician in Richmond. “And I just feel bad for these patients. Because they’re the ones who are sometimes going days without the proper treatment.”
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