An overreliance on Virginia’s state-run psychiatric hospitals has resulted in unsafe patient loads, and private hospitals across the state could be doing more to manage the increasing need for inpatient psychiatric services, according to a report released Monday.
The report includes a recommendation that lawmakers shut down the Commonwealth Center for Children and Adolescents in Staunton following a record use of restraints 20 times higher than the national average.
The report by the Joint Legislative Audit and Review Commission, a watchdog group for lawmakers in the General Assembly, found that a 2014 law, nicknamed the bed of last resort law, that requires state hospitals to accept all psychiatric admissions resulted in a lack of control over the hospital’s ability to deny admissions. Since then, public psychiatric hospitals have been operating beyond safe capacities.
Out of the state’s nine facilities, seven filled 95% or more of their staffed beds in 2023. Others operated at 100% capacity. The industry standard suggests that facilities should operate only at 85% capacity to ensure health care workers can respond to changing patient needs.
Privately operated psychiatric hospitals consistently operated below 85% capacity in 2023, according to the JLARC report. Analysts cited in the report said that if private facilities used more of their unused beds, enough patients could be diverted from state hospitals to allow both state and private psychiatric hospitals to operate at a safe level.
The state hospitals have also seen an increase in inappropriate admissions of patients with cognitive disorders such as dementia and developmental disorders such as autism, the report found. These patients, combined with an increase in admissions from the criminal justice system, have resulted in safety concerns, said Drew Dickinson, who led the JLARC study. This limits the hospital’s ability to serve patients coming in from the community.
The proposed recommendations from JLARC include funding increases for private hospitals to accept more patients from the criminal justice system to offset the burden on public facilities.
Leadership in Carilion Clinic’s behavioral health department responded Monday to the call for greater support from the private sector.
“Mental health continues to be a top need highlighted by our communities. Such a complex issue requires robust solutions, and we always appreciate collaborating with partners across the spectrum of psychiatric providers to meet the full range of patient needs,” said Dr. Robert Trestman, chair of Carilion Mental Health.
[Disclosure: Carilion Clinic is one of our donors, but donors have no say in news decisions; see our policy.]
The dependence on state-run facilities has also resulted in long waitlists for individuals under temporary detention orders, or TDOs, which are issued by a magistrate for short-term holds in a psychiatric hospital.
In 2023, about 8,500 individuals with a TDO were placed on a waitlist.
“Some of these individuals were never admitted to an inpatient facility for further evaluation or treatment, some were dropped off at a state hospital before being accepted by the facility, and some were arrested,” the report read.
When a patient is in the custody of a law enforcement officer, that officer is responsible for them until a hospital is able to admit the patient. Due to the bed of last resort law, more officers are dropping people off at state-run facilities, sometimes before a comprehensive medical examination is performed.
Virginia’s attorney general issued an official opinion in January 2023, concluding that drop-offs at psych hospitals are not permissible under state law. Since then, about 450 individuals have been dropped off at psychiatric facilities, according to the JLARC study.
These patients often arrive with needs greater than what the facility can provide, said Dickinson. But because of the bed of last resort law, providers cannot turn patients away.
JLARC has recommended some amendments to the law that would allow state hospital providers to delay admission for patients who need medical services that cannot be provided at the psychiatric hospitals.
Study highlights safety concerns in Staunton
The use of restraints and seclusion occur at higher rates than the national average at most of the state-run facilities, but the frequency with which restraints are used is highest at the Commonwealth Center for Children and Adolescents, the only state psychiatric hospital for children.
Patient restraints at the Staunton hospital occur at a higher rate than any other state hospital, and over 20 times higher than the reported national average, according to the JLARC report.
The report cited multiple metrics that showed the hospital as the worst performer compared with the other state hospitals. For example, the facility has higher readmission rates than national rates, the highest rate of patient-on-patient and patient-on-staff physical safety incidents, the highest rate of patient self-harm, the highest staff turnover and the greatest dependence on expensive contract staff.
Operating costs have also increased at the facility over the last 10 years, totaling $18.2 million in 2023, the report said.
As a result, JLARC has recommended the closure of the facility, which serves about 24 youth at a time.
“Our report is not prescriptive on how the state should move forward, and it is likely that both public and private providers could help support youth who would otherwise be placed at CCCA. Some states lean more heavily on private providers to support youth, whether in psychiatric hospitals or in residential treatment centers, and the report gives examples of those approaches,” Dickinson said in an email after the presentation. “It is likely that some youth could be placed in short-term residential crisis stabilization units, and these units are generally operated by community services boards, which are public entities. The state has increased funding for crisis stabilization units in recent years.”
Nelson Smith, commissioner of the Department of Behavioral Health and Developmental Services, opposed the recommendation at Monday’s presentation, saying that the department is working to make improvements to the facility.
In the last year, the department has tried to address issues at the Staunton hospital with changes in leadership and additional training in de-escalation methods for staff.
All state hospitals cumulatively reported 7,400 incidents of patient-on-patient physical encounters between January 2022 and May 2023. Across all of these incidents, more than 1,400 resulted in patient injuries.
Each hospital included in the JLARC study had at least 20% of staff report that they did not think their respective facilities were safe for patients, citing high numbers of aggressive patients, increasing numbers of patients from the criminal justice system, and the admission of patients with developmental and cognitive disorders.
