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)
“Broken” is the only word Sheriff Darrell Warren can find to describe Virginia’s mental health system. A 30-year veteran of the Gloucester Sheriff’s Office, he’s part of a growing contingent — law enforcement officials who have turned to state legislators, or the pages of their local newspapers, to share their alarm over a continuing shortage of psychiatric beds.
“The real issue is that we have a person in crisis who’s waiting and waiting and waiting for help,” Warren said. One of his worst cases was a teenager who self-reported to a local hospital with a substance use disorder. But as the boy began withdrawing, his behavior became increasingly aggressive. For more than 90 hours, he was confined to the emergency room — flanked by deputies — as his community services board tried to find him an inpatient treatment bed.
“Do you think this kid, or any of his friends, do you think they’re likely to look for help again if they have to go through what he did, and sit there for 90 hours?” Warren said. “I would suggest no, they’re not. It’s a bad situation, and I don’t know what the answers really are.”
It’s a struggle that’s resounded across agencies as Virginia scrambles to address what officials describe as a “crisis” in psychiatric admissions. At any given time, virtually every one of the state’s 10 mental hospitals are nearing or exceeding patient capacity. Alison Land, commissioner of the state’s Department of Behavioral Health and Developmental Services, described current census levels as “dangerously high” in an April meeting, telling the agency’s board that the number of patients — combined with staffing shortfalls — made working at the facilities “tremendously unsafe.”
“There is simply no way for the state hospitals to continue along this trajectory,” she told lawmakers later that month.
Amid the growing crisis, Virginia has also vocally opposed adding new psychiatric beds. When Central State Hospital is replaced in 2024, it will reopen with 25 fewer beds than it had originally. Lawmakers denied a 2019 request to add 56 new beds at Catawba State Hospital in Roanoke County. Within the last five years, only one facility — Western State — has expanded its capacity, according to DBHDS. But those beds aren’t currently open, and won’t be until the department can find workers to staff them, Land said.
The resistance is often painted as part of a broader initiative to change how Virginia provides — and funds — mental health services. A 2016 report from the Treatment Advocacy Center, a national nonprofit, found Virginia had the third-highest number of inpatient psychiatric beds per capita. Other analysis found that the state spends roughly 75 percent of its funding for mental health care on inpatient beds, according to Anna Mendez, executive director of the Charlottesville-based nonprofit Partner for Mental Health.
Both figures have become oft-cited statistics among members of the Deeds Commission, a long-running committee focused on improving Virginia’s treatment and services. After years of reliance on institutional care, legislators say they’re more focused on using state money to fund community services to keep patients out of the hospital altogether.
“Right now, I think the sense is we don’t want to build more beds if that’s not what we want to do long-term,” said Sen. George Barker, D-Fairfax. “What we want to do is prevent situations where there’s a mental health breakdown.”
In reality, though, Virginia is still devoting millions to boosting bed capacity outside the state hospital system. DBHDS is on the verge of signing a $3.5 million agreement with Carilion Clinic in Roanoke to expand emergency beds for patients going through a mental health crisis. The intention isn’t to provide the same type of long-term care as state facilities, Land said, but the new beds can accommodate patients for at least 24 hours — hopefully long enough to stabilize them.
The department has a similar agreement with Children’s Hospital of the King’s Daughters in Norfolk, which plans to add 60 psychiatric beds for children by the fall 2022. Over the last several years, lawmakers have allocated more than $15 million for similar pilot projects, all designed to “reduce census pressures” within the state’s beleaguered hospital system.
‘When people can’t get the care they need in the community, they end up in crisis’
As admissions continue to spike, experts say those types of investments are nearly impossible to avoid. In 2014, Virginia passed legislation that’s now commonly known as its “bed of last resort” law. The bill was sponsored by Sen. Creigh Deeds, D-Bath (and namesake of the Deeds Commission) after his own son killed himself and seriously injured Deeds during a mental health crisis.
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. As a result, those private hospitals have become more and more reluctant to admit psychiatric patients, especially if they’re experiencing complex or aggressive symptoms.
That’s forced state hospitals to accept more patients — and more often more acute patients — while agencies like DBHDS struggle to incentivize admissions at private facilities. But the bed of last resort law is only one part of the puzzle. At the front end, Mendez said Virginia has also struggled to provide the type of services that would prevent people with mental illness from needing more intensive inpatient treatment.
“We have created a perverse cycle of ‘needing’ — and I’m doing air quotes when I say ‘needing’ — more hospital beds,” she said. “Because when people can’t get the care they need in the community, they end up in crisis.”
Right now, that’s playing out across the state despite millions of dollars in investments into community health services. In 2017, legislators allocated an initial $8.9 million to an ambitious program known as STEP-VA, which aimed to transform the state’s model for delivering treatment.
Under the plan, Virginia’s 40 community service boards are required to provide a uniform set of treatment options. While before, CSBs offered services for mental health, substance use and developmental disabilities “based on local needs and available funding,” according to a state report, STEP-VA aimed to establish a system in which — with more state investment— every Virginian could access the same level of care.
“The goal is to make the mental health service system look more like a ramp than a staircase,” Mendez said. One of the first steps, for example, requires local CSBs to assess patients on the same day they call for help, and then appropriate follow-up treatment within 10 days.
On paper, the system is a major step forward, said Kathy Harkey, executive director of the Virginia affiliate for the National Alliance on Mental Illness.
But the uncomfortable truth is that fully funding psychiatric services requires a huge upfront investment.
According to DBHDS, Virginia has increased its funding for community-based treatment by $185 million since STEP-VA was passed, including $74 million for the fiscal year that ends next June. The initial financial impact statement for the bill, though, estimated the state would need $150 million this fiscal year to fully fund the program. Three of the 10 steps don’t currently have any state money allocated toward their implementation, and while every locality is required to provide a 10 percent match, some — especially parts of Northern Virginia — invest far more, leading to continued disparities in the services available across the state.
“It may be slightly naive to think that a couple of years of relatively low investment through STEP-VA will permanently fix the significant funding issues that have been in place for decades,” said Debbie Bonniwell, the executive director of a CSB that serves the city of Roanoke and four other Southwestern localities. With still-limited dollars, both she and Mendez said the system doesn’t always work the way it’s intended.
Outpatient services, for example, are one treatment option that local CSBs are now required to provide across the state. Often, that means counseling and medication management, Bonniwell said — the kind of early intervention that can prevent psychiatric crises.
While enhanced funding has allowed her CSB to slightly expand its screening criteria, there are still patients with mental health conditions who don’t qualify for treatment. Bonniwell equated it to limiting cancer treatment to patients who have already reached an advanced stage of the disease.
“We still are mostly able to only catch people when their illness has progressed significantly,” she said. “In my opinion, we will never completely solve the problems of the public mental health system until we can get much farther upstream.”
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