CENTRAL STATE HOSPITAL — Dr. Hughes Melton took heed of a poster in the admissions ward of the maximum-security forensic unit at the heart of this sprawling state hospital outside Petersburg for Virginians with mental illness.
“A Smooth Sea Never Makes a Skilled Sailor,” the poster cautions.
Melton saw plenty of rough waters to navigate in his first visit to Central State since Gov. Ralph Northam appointed him as state commissioner of behavioral health and developmental services.
The hospital, first established in 1870 as the Central Lunatic Asylum for the Colored Insane at a former Confederate hospital in Richmond’s East End, is the only maximum-security facility in Virginia for people with mental illness committed to the state’s care because of crimes they were accused of committing.
Last year, the state estimated a cost of $169.1 million to construct a single building to replace eight outdated buildings on the campus, not including Hiram W. Davis Medical Center, which sits between Central State and what was the Southside Virginia Training Center for people with intellectual or development disabilities.
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The hospital sits at the epicenter of an escalating shift of people from the greater Richmond region into state custody under temporary detention orders. These are for involuntary evaluation of behavioral conditions that pose a threat to themselves or others, or render them incapable of caring for themselves.
Spike in temporary detentions
The number of TDO admissions at Central State has increased more than 1,000 percent in five years. This year, the hospital has admitted more than 500 people on TDOs, an 84 percent increase over last year with more than a month left in the fiscal year.
“TDO admissions to Central State Hospital are rising exponentially,” said Debbie Burcham, executive director of Chesterfield Mental Health Support Services, which is relying more on the state institution as private hospitals in the region reduce their share of emergency admissions.
With a patchwork of outdated and ill-equipped buildings, including one dating to 1939, the replacement of Central State is a high priority for state mental health officials and lawmakers, who have included $3 million in the proposed state budget to begin a planning process estimated to cost $12 million.
“When we’re at capacity here, it’s a lot more dangerous than a modern facility that’s at capacity,” Melton said during a tour of Building 39, the forensic unit, built in 1950.
Sen. Creigh Deeds, D-Bath, whose family tragedy resulted in a new law to ensure state hospitals will serve as a last resort for people in psychiatric emergencies, will lead a tour of Central State on Tuesday by a commission he leads on restructuring Virginia’s mental health system.
Like most of Virginia’s nine public mental hospitals, Central State is overcrowded. On the day of Melton’s visit, the hospital’s civil units had 104 patients for 100 beds. That doesn’t include the 111 beds in maximum security and 66 beds for low-risk forensic patients that also are linked to the state’s criminal justice system.
A maximum-security ward in the forensic unit includes up to eight private rooms with one bed and three “social rooms” with four to six beds. Hospital officials say the arrangement is difficult for people experiencing symptoms of serious mental illness, including paranoia and psychosis.
“I can’t overstate how a-therapeutic it is for someone who is mentally ill to have to live this way,” Central State Director Rebecca Vauter said.
Civil patients increasingly are too acutely ill and unstable to go from their wards to the hospital’s treatment mall in Building 114, a two-story building constructed in 1962 and designed as a residential unit for adolescents. It has one unreliable elevator to serve a population that is increasingly physically infirm and using wheelchairs.
That leaves two narrow stairwells, locked at top and bottom, that present a harrowing experience for both patients and staff when waiting for a door to open.
“Some of our most serious aggressive episodes occurred in the stairwells,” said Brandi Justice, hospital director of clinical services.
A dismaying ‘eye-opener’
Conditions at Central State surprised Cadiecya Brown, a registered nurse from Jamaica who came to the hospital last year under a two-year contract the state is using to recruit psychiatric nurses to stanch turnover at state institutions.
“Never would I have imagined that in the United States of America I would witness patients sleeping on a mattress on the floor,” Brown said in a staff meeting with Melton after his tour of the hospital on May 17. “All in an effort to ensure safety of the individual himself and other patients due to the unit not being structured in order to care for patients with different needs.”
The hospital’s lack of electronic records and database “was also an eye-opener,” she told the commissioner. Melton had already heard concerns on his tour about the danger to patient safety from reliance on paper records that are not easily shared among members of patient treatment teams who instead carry patient charts each day to and from the treatment mall.
Electronic health record keeping “helps tremendously in ensuring patient safety in keeping a more accurate log of care being given, as well as assisting with safe drug administration,” Brown said.
The pending state budget — adopted on Wednesday and awaiting the governor’s signature — includes $10.2 million over two years to expand electronic health record keeping to all state behavioral health institutions beyond the three hospitals that have it now.
The proposed budget also includes $4.2 million in the second year to implement electronic health records at all 119 local health departments. It also would create a work group to oversee development of a statewide electronic health records system that would link all state agencies, including corrections and juvenile justice, as well as the state health department.
Maximum security drives costs
Most important, the budget includes money to begin planning the replacement of Central State. The proposed budget would provide about one-fourth of the estimated cost of detailed planning. The rest would come from special funds reserved by the behavioral health department, which the state would reimburse.
“We’re planning for the planning money,” said Deputy Commissioner Daniel Herr, who estimated the project could take six to eight years to complete.
The model for the new hospital would be Western State Hospital in Staunton, replaced with a modern facility completed in late 2013 after seven years at a cost of $150 million. But replacing Central State would be “significantly more expensive than Western” because of the requirements for maximum security, Herr said.
The likely site for the new hospital would be an empty field directly across Seventh Avenue from Hiram Davis. One thing the complex doesn’t lack is land, with 543 acres. The new hospital would have slightly less space, at 332,026 square feet, but with a much more flexible and efficient design for serving a wide variety of patients and their needs.
Currently, there is little efficiency in the layout of Central State. The hospital, racially segregated as a mental hospital for blacks until 1967, once housed as many as 4,000 patients. Its grounds still include abandoned hospital buildings, slowly being enveloped by vines.
Staff have to travel from treatment wards across the campus to Hiram Davis to pick up medications. Portable air conditioners operate in nursing stations in the forensic unit because of its unreliable heating and cooling system. Treatment space is limited to tiny offices on the second floor of the treatment mall.
The windows and ceiling leak in the forensic unit’s gymnasium, used for holiday dinners, concerts and programs, as well as sports. The gym also demonstrates the challenges of maintaining the safety of mentally ill patients.
A basketball hoop at one end of the gym no longer extends over the court by a stanchion from the wall. It also no longer has a net on its rim — measures taken after a patient leaped up, grabbed the net and climbed up to the backboard in an attempt to hang himself.
“Someone will do something and we’ll realize, ‘This is a safety issue,’ ” said Marcia Parham, director of security at the hospital.
Staffing a challenge
Staffing is an ongoing challenge at Central State, which employs about 800 people with more than 100 additional positions unfilled. On the maximum-security unit, about 60 of 80 security staff positions are filled. Salaries are part of the problem, which the new budget would address with pay hikes for all state employees and targeted raises for nurses and other direct-care hospital staff.
“We still have staff tell us they don’t go to the doctor anymore because they can’t afford the cost of the co-pays,” Melton said.
Melton’s most immediate challenge is to find a way to slow the number of patients coming through Central State’s front door for involuntary evaluation under temporary detention orders, while increasing the number going out the back door when they are clinically ready.
The day of his visit, Central State had 34 patients on the state’s Extraordinary Barriers List, a roster of people who are ready to be discharged but don’t have supportive housing or other services to keep them stable in their home communities.
Under the newly adopted budget, help is on the way with money for discharge planning, permanent supportive housing and a couple of assisted living facilities to help patients transition into communities.
“This budget is potentially transformative for behavioral health,” Deeds said.
The tougher battle might be controlling the front door.
Since fiscal year 2013, a year before the General Assembly adopted legislation to require state hospitals to accept patients for TDOs, the number of people admitted to institutions for civil evaluations has soared by 224 percent. At Central State, TDO admissions rose from just 44 in 2013 to 279 last year, with the biggest single-year jump in 2016, when they rose by 158 percent from 2015.
The result has been a massive increase in admissions to state hospitals, which routinely have exceeded 95 percent of their capacity earlier this year. A mental hospital operating at more than 85 percent of its capacity becomes unsafe, Melton said.
Excluding Central State’s maximum-security wards, Virginia’s nine mental hospitals were operating at almost 92 percent of capacity on May 11, the week before the commissioner’s visit. Central State’s civil and low-risk forensic wards were operating at 88.5 percent, while Eastern State Hospital in Williamsburg and Piedmont Geriatric Hospital in Burkeville were both near 97 percent.
State mental hospitals are taking an increasing number of patients with underlying intellectual and developmental disabilities, including autism, who generally don’t do well in the chaotic environment of an overcrowded psychiatric institution. Those patients now account for 3 to 5 percent of admissions.
Patients are also sicker, as shown by an increase in spending on special hospitalization from $3.1 million in fiscal 2013 to $6.7 million last year. “It’s a proxy for the complexity,” Herr said.
Melton, whose experience includes work as a family doctor, addiction specialist and hospital administrator in Southwest Virginia, said after the tour, “I was struck by the skill and passion Central State Hospital employees bring to their care of our most vulnerable citizens, especially given the overcrowding and failing conditions of their hospital.”
The commissioner added: “I believe our commonwealth will bring them help through increased private hospital participation and funding for a replacement hospital.”