Virginia’s new behavioral health director orders strategic plan for struggling state agency

For the first time in nearly a decade, Virginia’s beleaguered behavioral health agency is developing a strategic plan to pull the state’s system out of an ongoing crisis in psychiatric care.

Nelson Smith, appointed by Gov. Glenn Youngkin to lead the state’s Department of Behavioral Health and Developmental Services, announced the plan at a Wednesday board meeting for the agency, describing it as a “North Star objective” to guide much-needed improvements.

“An agency without a strategic plan, it’s like we’re navigating in a stormy sea with no direction,” Smith said. “And if we don’t have that direction, how can we expect the community to know which way we’re going?”

Agency spokesperson Lauren Cunningham said it’s the first new strategic plan in eight years for the agency, which oversees Virginia’s eight publicly funded mental health hospitals. The facilities have been struggling with growing patient volumes for years, but the ongoing COVID-19 pandemic led to a series of new emergencies.

In July, former DBHDS Commissioner Alison Land closed more than half of the state’s hospitals to new admissions, citing severe understaffing and overcrowding that had created a “dangerous environment” for both patients and workers. Many hospitals are still operating below their bed capacity as the agency struggles to hire and retain employees.

As a result, experts and advocates say the state is functionally unable to comply with its own “bed of last resort” law, a 2014 statute that requires state hospitals to accept involuntary admissions if a psychiatric bed can’t be located at another facility. Unable to find treatment, patients are increasingly forced to stay in local emergency rooms for hours and sometimes days at a time under law enforcement custody.

Earlier this month, the department was sued by a local social services agency after a juvenile patient going through a mental health crisis was boarded in an emergency room for four straight days. According to the petition, the patient — a foster child under the county’s care — was denied psychiatric care and released after her temporary detention order expired, even though a bed had become available at the state’s mental health hospital for children. 

There’s wide acknowledgement that the state’s bed of last resort law — driven by concerns for patient safety — contributed to long-running challenges within the state’s psychiatric system. In the eight years since the legislation passed, private hospitals have taken on a smaller share of involuntary admissions, leaving state-run facilities to treat a growing number of patients with more complex psychiatric challenges.

Despite the significant changes it imposed, DBHDS hasn’t developed a new strategic plan since the law was passed. Smith — an Army veteran with a background in hospital administration — said the agency has also been siloed from other providers, including the private sector and local community service boards.

“All of these organizations that kind of live in the stovepipes, we want to integrate,” he said. “It can’t just be that DBHDS has its own plan and [the Virginia Hospital and Healthcare Association] has theirs. Those things have to be shared.”

Previous commissioners have faced their own challenges in managing the state’s sprawling behavioral health system, including Land, who also had a background in the private hospital sector. In addition to overseeing the state’s psychiatric facilities and coordinating with private partners, the agency is also responsible for licensing residential substance-use disorder providers and managing services for thousands of Virginians with developmental disabilities.

Some lawmakers say the heavy load has contributed to the department’s ongoing challenges. DBHDS has also struggled to exit a 2012 settlement agreement with the U.S. Department of Justice that required Virginia to close most of its training centers — large congregate living facilities for individuals with disabilities — and provide care in the community. But experts say a continued shortage of those services has prevented the state from fully resolving the agreement.

The ongoing challenges underscore one of the biggest problems facing the agency: workforce availability. Smith said strengthening Virginia’s pipeline of behavioral health staff would be one of his biggest priorities and a central platform of the new strategic plan.

“At the end of the day, what I know is that the people aren’t there,” he said. Data from the Virginia Health Care Foundation showed that the state’s already overburdened mental health workforce is expected to shrink over the next few years — a shortfall that’s already impacting Virginia’s efforts to reform its mental health crisis system. 

State-run hospitals still have a roughly 35 percent vacancy rate despite pay raises and bonuses offered to staff through federal pandemic rescue funding. And Smith said local agencies are worried the state doesn’t have enough community providers to support new waiver slots for individuals with developmental disabilities.

The state’s next biennial budget, which is still being debated by lawmakers, includes some funding for workforce retainment and development, including a Senate proposal that would raise wages for employees at state-run hospitals to the 75th percentile of national averages. But agency leaders aren’t sure the funding will be enough to solve the staffing crisis.

“Even with the 75th percentile, we’re going to be behind where we need to be,” said Stacy Pendleton, chief human resources officer for DBHDS. “People are taking work with less risk and the pay is the same or higher.”