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Virginia psychiatric hospitals remain overcrowded, understaffed

The research arm of Virginia’s Legislature said Monday that the state's psychiatric hospitals are overcrowded and understaffed, leaving patients and staff vulnerable. Among changes to relieve the overcrowding, the commission recommended Virginia shut down its lone psychiatric hospital for children.

Drew Dickinson, an analyst with the Joint Legislative Audit Review Commission,  told lawmakers that the organization is recommending action to give state facilities more leeway to turn away certain patients and encourage private hospitals to take more in.

Their story was reported and written by VPM News

Currently, state hospitals are required to admit patients even if they are unable to appropriately care for them. Dickinson said that’s meant hospitals frequently admit individuals with neurodegenerative disorders or developmental disorders — such as dementia or autism — who would be better served elsewhere. He noted that these people are more likely to be the target of violence in state hospitals than other patients.

In addition,  JLARC found that law enforcement officers were often dropping off patients subject to Temporary Detention Orders at state hospitals before the facilities had an opportunity to evaluate if they could properly care for the patient.

More than 1,400 people were dropped off in such a way from July 2021 through June 2023, concentrated in Western and Southwest Virginia. Sometimes, patients needed nonpsychiatric medical treatment that the hospitals weren't equipped for.

“That puts their life in danger, and we heard many examples of that,” said JLARC Associate Director Tracey Smith.

The state Office of the Attorney General  issued an opinion in January stating that exactly such drop-offs were illegal in the commonwealth, but JLARC found they continued to happen. To counteract them, the commission is recommending the General Assembly pass a bill allowing state hospitals to turn patients away if they haven’t been medically cleared.

“So, what would happen is, because they have to remain in law enforcement custody, law enforcement essentially would have to take them back to the hospital to receive the urgent medical treatment that they need,” Smith said.

While state hospitals have been dealing with overcrowding, private psychiatric hospitals in Virginia have been operating below capacity. JLARC staff said it’s considered best practice for hospitals to operate at about 85% of staffed capacity.

All but one state psychiatric hospital has operated above that 85% threshold in each of the last three years, while only 12 of 43 privately owned psychiatric facilities in Virginia did so in 2022.

Dickinson said the state could consider funding programs to help private facilities take on more patients or using its existing powers to require them to do so. The Virginia Department of Health must issue a Certificate of Public Need to private hospitals before they can open, and Dickinson noted VDH has already used this process in the past to address patients subject to Temporary Detention Orders.

JLARC directed VDH in its report to ensure that facilities that have agreed to take in those patients are actually doing so. The report also said the General Assembly could consider making such agreements a requirement to receive a Certificate of Public Need.

“I think it's helpful to reiterate that none of our recommendations would require private hospitals to accept patients who they do not have the capability or capacity to treat,” Dickinson said. Private facilities in Virginia can turn patients away if they would put the hospital above the 85% threshold.

Another issue contributing to the overcrowding is an increase in the number of people receiving competency restoration services. That's when a facility assists someone who has been charged with a crime to understand both the charges against them and the legal process to come.

Dickinson said the number of people ordered by courts to seek these services has tripled in the last 15 years, following a national trend. He said the services are only offered at state hospitals, but noted they are sometimes handled in an outpatient setting. In Virginia, about three-quarters of competency restoration services are handled inpatient. That’s in spite of inpatient services costing about $110,000while the outpatient equivalent costs just over $1,000.

JLARC’s report suggested Virginia better utilize outpatient services to reduce costs, but made no specific recommendations on how to do so. Instead, the report directed the Department of Behavioral Health and Developmental Services to solicit private facilities to provide inpatient services and help with capacity issues.

It also noted a worker shortage to evaluate people who’ve received services to see if they are ready for trial. JLARC said that’s led to delays in the competency restoration process.

“State hospitals have delayed admitting some defendants for competency restoration because of capacity limitations, which creates risks that the state will be sued for violating defendants’ due process rights,” the report said. “At least 16 states have been sued because of delayed inpatient competency restoration services for defendants.”

State psychiatric hospitals also face staffing shortages of their own, with about 1 in 6 positions vacant as of June 30. While that’s down about 30% since the year prior, Dickinson noted the number would be even greater if the state hadn't hired contractors to fill vacancies. In total, state hospital spending on contractors increased from $4 million in fiscal 2013 to $47 million in FY 2023. (Virginia’s fiscal year runs from July 1 through June 30.)

Dickinson said high turnover — especially among nurses — is contributing to the shortage. Staff who spoke with JLARC reported low pay and unsafe working conditions; about 50% of nurses surveyed said they do not feel safe at work. While inadequate pay was the top issue listed among all workers leaving their jobs at state hospitals, nurses cited poor management most frequently.

Dickinson added that even if hospitals were fully staffed, they don't receive enough funding to provide necessary care. The number of nursing hours funded in fiscal 2023 was about 25% fewer than what nurse leadership determined was necessary for adequate care — even in the least intensive units.

Patient safety was a concern for JLARC at several facilities as well, with Dickinson reporting the issues are most prevalent at the Commonwealth Center for Children and Adolescents in Staunton — the state’s only psychiatric hospital for minors. He said violence between patients and self-harm were more common at the Staunton facility than other state hospitals, as was violence from patients to staff.

Additionally, Dickinson said JLARC found that the facility was more likely to seclude and restrain patients than other state hospitals or similar facilities in other locations. From January 2022 through May 2023, CCCA was 40 times more likely to restrain patients than the national average among children ages 13–17 at inpatient psychiatric facilities and eight times more likely to seclude them.

Nelson Smith, DBHDS’ commissioner, acknowledged the facility’s shortcomings at Monday’s meeting. He said it’s been working to fix those since before nonprofit accreditor The Joint Commission (tJC) reviewed the hospital in May and found 28 deficiencies that made it “an immediate threat to the health and safety of patients.”

“Which means we just had to move faster to fix it for these kids. … We've been working aggressively, we did not take it lightly. We removed the leadership there,” Nelson Smith said. “Through addressing these findings, along with accelerating the strategies that we had already had underway, The Joint Commission has since reduced those deficiencies to two.”

Nelson Smith said use of restraints decreased significantly in 2023, something JLARC also noted in its report.

JLARC added, however, “the 2023 rate of restraint reported by DBHDS (8 hours per 1,000 patient hours) remains almost 20 times higher than the tJC-reported average.” It noted other issues at the Commonwealth Center, including the highest vacancy rate of any state hospital, excluding contractors, and ballooning costs. Dickinson said the facility’s cost-per-bed has nearly tripled since 2013.

As a result, JLARC recommended the state shut down CCCA and find alternative placements for children who would be admitted there. Dickinson noted relatively few states operate their own psychiatric facilities for minors. Instead, most contract with private hospitals for children experiencing severe mental health crises, an approach Dickinson said Virginia could follow.

JLARC’s report also noted Virginia has dedicated funds to crisis stabilization centers that could serve children in need of less intensive care. Dickinson said referring children to facilities closer to their homes would benefit care, something Nelson Smith agreed with.

“Kids in crisis should be able to get help as close to home and their families as possible,” he said. “Youth need to receive care within their communities where they live, learn and play.”

CCCA is a small facility with enough staff to serve about half of its 48 beds, Dickinson said, so relatively few people would need to be relocated in the event of a shutdown.