Every year around the time that school starts, staff at the only state children’s psychiatric hospital in Virginia know to expect a surge in admissions.
As workers at the Commonwealth Center for Children and Adolescents prepare for the new patients, which come as the stress of school begins to pick up, state officials worry that the system that has already been pushed to its limits will face even more significant challenges.
The number of admissions to the Commonwealth Center, a 48-bed hospital in Staunton, has increased nearly 10% over the past year, from 983 in fiscal year 2018 to 1,075 in fiscal year 2019. Two years ago, it recorded 733 admissions.
The increases happened despite the opening in Richmond of a brand-new facility, the Virginia Treatment Center for Children at VCU, which officials at the state Department of Behavioral Health and Developmental Services said they hoped would ease the pressure on the state-run hospital.
Although VTCC at VCU accepted 1,293 inpatient admissions from its first full month in May of last year through July, Daniel Herr, deputy commissioner for facility services at DBHDS, said the new facility hasn’t made a dent in the Commonwealth Center’s caseload.
Last year, the Commonwealth Center, which is the hospital of last resort after no bed can be found for a child in crisis at any private hospital in the state, could not immediately admit a handful of children in need because the center was already full.
“At some point, a system is unable to keep up with the continual increase,” Herr said. “More kids will be coming to the Commonwealth Center than they are able to admit, treat and discharge.”
Sen. Creigh Deeds, D-Bath, who chairs the Joint Subcommittee to Study Mental Health Services in the 21st Century, said he is impressed with VTCC’s modern, colorful facility, but is disappointed that it has not been accepting “the more complex cases,” particularly since its construction was funded with $56 million in state money.
“I had hoped that it would take some burden off CCCA,” Deeds said.
But VTCC has experienced some setbacks since it officially opened last April with 16 of its 32 beds operational. Because of changing standards set by the Joint Commission, which accredits health care facilities, even though the building was newly constructed, it required significant renovations to ensure the safety of the children staying there, according to Sandy Lewis, the facility’s executive director.
Anything that would hold a shoelace, such as a faucet, door handle or picture frame, had to be removed or replaced with state-of-the-art equipment specifically design to prevent children from using it to harm themselves.
“We had been constantly in a re-renovation stage,” said Nancy Doyle, VTCC’s nursing director for the Department of Psychiatry.
The renovations to the new building delayed the hospital’s ability to operate to its full capacity.
Still, on the average day in May 2019, the first full month that all 32 beds were operation, 29 beds were filled, meaning the hospital was operating at over 90% capacity.
At the state children’s hospital over the last fiscal year, the average occupancy rate per month was 60.1%, with a peak of 77% in May 2019, according to DBHDS.
Of those children admitted, 99% were under a temporary detention order, or TDO, which allows people found to be a threat to themselves or others to be held involuntarily for 72 hours.
All of the state psychiatric hospitals have experienced increasing strain since a law passed in 2014 required them to accept TDO patients if a bed could not be found at a private facility within eight hours.
Since Virginia has only one state children’s hospital, the “bed of last resort” law has impacted children in a unique way, said Margaret Nimmo Holland, executive director of Voices for Virginia’s Children, a child advocacy nonprofit.
“[The Commonwealth Center is] serving children who private hospitals don’t want to serve or are not equipped to serve,” Nimmo Holland said. “State hospitals never have discretion about who they serve. They are trying to absorb all the kids who can’t be served somewhere else. There’s a pretty big mix of ages and needs — that is not the ideal therapeutic environment.”
About 30% of children admitted to the Commonwealth Center are diagnosed with developmental disabilities or autism spectrum disorder, Herr said.
For the Commonwealth Center to see some relief, DBHDS will need to find private hospitals and facilities to partner with that have built up a capacity to serve the children with more serious needs, Herr said.
“At this point, we don’t have a robust partnership for those kids,” he said.
But Julian Walker, vice president of communications for the Virginia Hospital and Healthcare Association, which represents 110 hospitals, said the organization’s members are committed to working with the state to meet the behavioral health needs of the community.
“Our members continue to handle the vast majority of both the voluntary and involuntary admissions in the commonwealth,” Walker said.
In addition, three private hospitals — Children’s Hospital of the King’s Daughters and Kempsville Center for Behavioral Health in Norfolk and North Spring Behavioral Healthcare in Leesburg — are working on adding a combined 104 psychiatric beds for children and adolescents by 2022, according to information from VHHA.
One reason that the Commonwealth Center hasn’t seen any drop in admissions in the past year is that VTCC does not use restraints or seclusion on children, Herr said.
“In order to make a difference for the Commonwealth Center,” he said, “they would have to be willing to use those interventions during a crisis.”
But VTCC doesn’t intentionally pass on the toughest cases to the state hospital, its leaders say.
“They do get tough cases,” Doyle, VTCC’s nursing director, said of the Commonwealth Center. “We get tough cases, too.”
Because VTCC has had some patients who stay for long periods of time, from 65 days to over 80 days, due to the complexity of their situations, the hospital’s average length of inpatient stay has risen from 6.5 days last year to 9.3 days this year, said Dr. Cheryl Al-Mateen, medical director and interim division chair of the Department of Psychiatry.
And they stand by their decision to shirk restraint and seclusion methods that they say only further traumatize a child who is already experiencing a crisis.
“What we do is say, ‘Can we handle this child at this hospital at this time?’” Al-Mateen said.
Al-Mateen said she has practiced psychiatry in facilities that used restraints and she saw how negatively it impacted the patients.
“We are serving a traumatized population,” she said. “We don’t want to lock kids in closets that are dark. ... We don’t want to hold somebody down, somebody with PTSD.”
Doyle said the staff is trained to de-escalate and give children as much space as they need to not hurt anyone.
“We will do everything we can to not engage in that kind of physical altercation,” Doyle said.
Though VTCC functions more like a private hospital in that it has discretion over which patients it accepts, the $56 million in public funding that allowed for the building’s construction gives it a unique relationship to the state.
In addition to its 32 inpatient beds, VTCC has an outpatient clinic that saw 12,753 visits in fiscal year 2019, offers a free resource center that is open to the public, and serves as a research and teaching facility, as well as a training center and gathering place for children’s mental health professionals from across the state.
The building’s design, which took three years to complete and another three years to build, is intended to feel open and welcoming, with high ceilings, natural light, colorful designs and artwork throughout — a contrast to the cinderblock, institutional appearance of the facility where VTCC, which was once part of the state hospital system, was previously housed, according to Doyle.
“What we really want to do is try and decrease the stigma around mental health,” Doyle said. “We wanted to make [the children] feel like it was a healing place and not a prison.”
As demand for psychiatric hospital beds, for both voluntary and involuntary admissions, has continued to increase over the past several years, Nimmo Holland of Voices for Virginia’s Children said it’s clear that there is a lack of community-based alternatives that could help children enough to prevent them from needing hospitalization.
This could include better access to therapy and outpatient services, school-based mental health support and home-based aid that would involve the entire family, Nimmo Holland said.
She believes that Virginia has begun down the right path with the implementation of STEP-VA — a plan that is intended to expand and equalize access to a full spectrum of mental health care across the state — but that there should be more investment that focuses on children.
“It’s really going to take a more statewide, systematic approach to making the services available,” she said.