In an escalating battle over responsibility for mentally ill people in crisis, Virginia’s private hospitals are pitching a new plan for using $33 million in federal aid to expand options for diverting people in psychiatric emergencies away from the state’s overcrowded and understaffed mental hospitals.
The private hospitals, agitated by what they call “misinformed criticism” about their role in a crisis that prompted Virginia to halt emergency admissions to five state hospitals, said in a letter to General Assembly budget leaders that the federal American Rescue Plan Act offers a “once-in-a-generation opportunity for the commonwealth to invest in strengthening the behavioral health system.”
“If we are to move forward as a commonwealth to address the systemic challenges in the behavioral health care continuum, we must first set aside rhetoric and honestly examine existing barriers to address them effectively,” wrote Sean Connaughton, president and CEO of the Virginia Hospital & Healthcare Association, to leaders of the assembly budget committees.
“Private hospitals are but one part of Virginia’s vast behavioral health care system,” Connaughton said in the letter, made public on Monday, which contends that the number of people admitted to state hospitals had declined by 10% in the past two years.
Sen. Creigh Deeds, D-Bath, chairman of the Virginia Behavioral Health Commission and leader of the state’s efforts to transform its mental health system, said the six-page letter is “nothing new.”
“They just want a lot more money to do the right thing,” Deeds said Monday. “That’s the bottom line.”
The association said its members have proposed new programs for partial hospitalization and crisis stabilization to divert people in psychiatric emergencies away from state facilities without crowding private hospitals with patients they’re not equipped to handle. Its members also recommended state investments in community-based programs to expand outpatient care and services for people coming out of psychiatric hospitals.
“Even though VHHA members have repeatedly proposed solutions that have not been adopted by the state, we again offer our support and services to address these challenges with the hope that the previous pattern of rejection we have encountered does not continue as we move forward,” Connaughton said.
Analysis in dispute
Behavioral Health Commissioner Alison Land challenged the association’s analysis, which she said underestimated state admissions for temporary detention orders by more than 1,300 in the last fiscal year while counting private hospital admissions that had nothing to do with psychiatric treatment.
However, Land said she welcomed what she called the association’s “reconsideration” of the position it took earlier this month “by developing proposals that will help divert the more complex and behavioral challenged population that often are sent to state hospitals, and that help discharge existing state hospital patients to appropriate private step-down units.”
“Proposals of this nature will truly help alleviate the state hospital census crisis,” she said.
Senate Finance Chair Janet Howell, D-Fairfax, said Connaughton’s letter showed “real gall and chutzpah” and accused the association of “misusing statistics” to minimize the jump in temporary detention order admissions to state mental hospitals since 2015.
“I don’t think that the hospital association is taking this crisis seriously enough,” she said, “and I frankly resent the approach they are taking.”
Cases and behaviors
The battle between the state and private hospitals not only revolves around the number of patients that private facilities accept, but also the types of cases and behaviors they must handle.
Connaughton offered this month to open 58 beds, including 40 for adolescents, in one private health system in exchange for $8 million in state funding to hire staff.
Land replied that the state needs to divert patients that private hospitals typically haven’t accepted — those with medically complex conditions; a history of aggression; autism or other intellectual or developmental disability; and elderly people with dementia. She also said the state needs help with services for people to leave public hospitals when clinically ready.
Connaughton, in his letter, answered that the state’s “true desire” is to require acute care private hospitals to handle patients in a setting that is not appropriate for their needs.
“Practically speaking, placing patients in need of long-term care in acute care hospitals is generally not feasible and not clinically appropriate,” he said.
Deeds said he’s glad for any help the private hospitals can give, but questioned why they won’t accept patients with complex medical conditions that state mental hospitals are not equipped to treat.
“They don’t want to take any of the cases we need them to take,” he said.
Land halted admissions at the five hospitals on July 9 because they had too few employees to care for patients safely.
The affected facilities are Central State Hospital near Petersburg, Eastern State Hospital near Williamsburg, Western State Hospital in Staunton, Piedmont Geriatric Hospital in Nottoway County and Catawba Hospital near Roanoke.
The state hospitals that remain open to admission also face a crisis. Three of them were entirely full on Monday, with 44 people waiting in private hospital emergency departments for a bed in a state facility, according to spokesperson Lauren Cunningham.
Cunningham said the five hospitals have reduced the total number of filled beds by 166 since closing to admission on July 9. She said the department is working on plans at each hospital for “bringing beds back online once we achieve a safe patient to staff ratio.”
State law and COVID-19
The crisis had long been building because of an increase in the number of patients admitted involuntarily since passage of a state law in 2014. The law requires state hospitals to accept people who pose a threat to themselves or others if they cannot be placed in a private facility within eight hours of being taken into emergency custody.
The COVID-19 pandemic made the situation worse, with outbreaks that killed 25 patients and two employees in staff facilities and triggered an exodus of trained staff who were unsatisfied with low pay and dangerous working conditions.
In addition to the five hospitals, the Commonwealth Center for Children and Adolescents, the state’s only public mental hospital for minors, is operating just 18 of its 48 beds because it doesn’t have enough employees.
Land is using $25 million in agency reserve money for hiring bonuses and other workforce incentives. She has also requested more than $335 million under the American Rescue Plan Act to deal with the staffing and security crises, including $75 million this year.
The department began bringing on 26 new employees for the five facilities on Monday under a new emergency labor contract. Cunningham called the hiring “a great start for such a short amount of time,” but state facilities still have 1,615 staff vacancies.
“This is the immediate crisis,” Deeds said. “We need to figure out how to get those hospitals open again.”