STAUNTON — When the aides who work at Commonwealth Center for Children & Adolescents pick up lunch at a local convenience store or buy their groceries, they see signs advertising jobs paying $14 to $15 an hour.
But when they return to work, they’re making as little as $12.58 an hour for a job that requires them to work directly with children and teens who may be psychotic, suicidal and violent.
“They work 16-hour days and get hit,” said Nancy Snead, the center’s human resources manager, who has to face those facts while trying to fill 50 vacant jobs for direct-service aides at the only state mental hospital for children and adolescents in Virginia.
The staffing crisis that triggered the sudden temporary shutdown of admissions at five state mental hospitals for adults on July 9 already had crippled the Commonwealth Center, which is still taking patients but has only enough nurses and direct-service aides to safely operate 18 of its 48 beds.
That will pose a serious challenge when summer ends and students return to school, which the center’s staff says always triggers behavior that can lead to bad outcomes for kids with underlying mental health and behavioral problems, autism or a traumatic childhood history.
“I am not sure what is going to happen, because these kids really need somewhere to go,” said Tamara Sadler, a registered nurse manager in two of the Commonwealth Center’s four units. “And a lot of times, the private facilities are not taking them because of how acute they are. We are the bed of last resort.”
“So when they have nowhere to go, I’m not sure how it’s going to play out for the kids that really need our help,” Sadler said Thursday.
Bed of last resort
The overcrowding of Virginia’s public mental hospitals is not new. It was the consequence of a state law adopted in 2014 to ensure that no one posing a threat to themselves or others is released from emergency custody.
That’s what happened to Gus Deeds the previous fall when he attacked his father, Sen. Creigh Deeds, D-Bath, and killed himself just 13 hours after he was sent home because the regional mental health agency failed to find him a bed in a psychiatric facility.
Instead, state hospitals will provide the bed of last resort for people who aren’t placed in a private facility within eight hours of being taken into emergency custody. The number of temporary detention orders issued for people in psychiatric emergencies hasn’t risen much since then, but the state’s share of those cases, particularly the hard ones, has soared by almost 400%.
Commonwealth Center has struggled to keep up as the number of admissions has risen — from 983 in the state fiscal year that ended in mid-2018 to 1,100 the next year and more than 900 in 2020, when COVID-19 changed the game for Virginia mental hospitals and raised the stakes for employees on the front line of a difficult but essential job.
Then COVID-19 swept through the hospital after Labor Day last year, infecting 25 employees and 18 patients, none of whom showed symptoms of the coronavirus disease they were helping to spread. Sadler considers herself one of the lucky ones because she didn’t get sick, but she was working 60 to 70 hours a week because “there was no one to take over.”
Other employees couldn’t come to work — or just refused to return after being sent home.
“They’re working too many days,” said Melissa Ebach, a psychiatric nursing assistant and trainer who said she got sick from the disease. “It’s not worth it to them anymore. They’re not getting paid enough to be worth getting hit.”
Two staffers ‘just walked out’
Ebach can’t train them fast enough and then they leave. Two “just walked out” last weekend, she said.
Dr. Jaime Bamford, director of the Commonwealth Center, said, “That’s 6 percent of our staff who just walked out the door.”
Commonwealth Center employed 32 direct-service aides last week out of the 82 positions it needs to fully staff the hospital — or just 39%. It had 11 registered nurses out of the 20 it needs.
“We have never been able to recover, from a staffing perspective,” Bamford said. “We had a lot of folks who really didn’t want to come back to a facility that had had COVID.”
“It’s been downhill ever since,” she said.
The center was overcrowded the first two months of 2020, before the public health emergency began, and delayed admissions for 120 kids during that span. Admissions always fall in the summer, but last year the center had up to 30 beds filled instead of the usual 15 or 20.
The COVID-19 outbreak shut down admissions temporarily and forced the center to reduce the number of beds it could operate. Normally, Commonwealth has a staffing ratio of one aide for every four patients, but the children and teens it treats often require 1-to-1 staffing because they’re suicidal or coping with a combination of mental illness and autism.
The center was staffing up to 30 beds in February and March, but the patients were too acutely ill and aggressive for a limited number of staff to handle that many kids.
“We couldn’t do it,” Bamford said. “We were hanging on by the skin of our teeth. A lot of mandatory overtime, staff burnout.”
Sen. Emmett Hanger, R-Augusta, is a longtime champion of Virginia’s mental health system, particularly the Commonwealth Center and nearby Western State Hospital, both in his district.
But Hanger knew someone — a relative of a friend — who worked in the center and was “beaten up.”
He said he intervened to address what had become a dangerous situation for employees and patients. “Part of correcting it was not trying to fill more beds than you can comfortably deal with,” he said.
In the fiscal year that ended June 30, the Commonwealth Center recorded 157 serious injuries to staff — 153 of them “due to patient aggression,” said Snead, the HR director. These were injuries that required medical treatment — concussions, bites, lacerations.
The severity of the behavioral issues the center treats also has intensified during the COVID-19 pandemic, Bamford said. “They are coming in more aggressive.”
Many of the children come to the center from foster care and traumatic childhoods. Some come through the juvenile justice system, or increasingly avoid the system as it tries to divert kids who get in trouble away from detention.
“Almost all of them are traumatized in some way or another,” said Dr. Jack Barber, a psychiatrist who served as acting director of the center for a year after he was replaced as the state’s interim commissioner for behavioral health and development services in 2018. “It’s a tough environment to work.”
It’s also a tough place for children and teens with autism spectrum disorder, who don’t respond well to chaotic, unpredictable environments. They account for up to 30% of admissions at the Commonwealth Center and often require 1-to-1 staffing.
“It takes away staffing we really don’t have,” Bamford said.
Virginia is negotiating with Children’s Hospital of the King’s Daughters to divert children under 12 years old — about 25% of the Commonwealth Center’s patient population — and those with autism to a new 60-bed, $224 million facility it is constructing in Norfolk for mental health services it previously has not been able to provide.
“That’s why this is such an ‘oh my goodness’ kind of event,” said Jim Dahling, president and CEO of CHKD Health System.
The nonprofit organization also is redesigning its emergency department to better handle children with behavioral health problems and creating a unit for children with both medical and psychiatric conditions, which Virginia mental health spokeswoman Lauren Cunningham calls a potential “game changer” for serving children “who are not traditionally accepted for management in private facilities.”
But the new facility will not be completed for 13 months and will offer just four beds for children with autism and behavioral health issues, whom Dahling called “the toughest of the tough to treat and maintain.”
“Those four beds will be filled most of the time,” he said.
Bamford, at the Commonwealth Center, said, “We’ll eat that up in a minute.”
‘I am somebody’
Still, she said, “I will take anything that you give me for these kids because they deserve better.”
That sentiment also is why Sadler and other Commonwealth Center direct-care staff keep coming to work.
“A lot of them feel like they’re garbage,” she said of the children in her charge. “No one really cares about them.”
When employees are able to work closely and engage with them, Sadler said they respond. “They see the nurses and staff care about them and it tells them, ‘I am somebody.’ ”
But it is not easy to help children battling depression and thoughts of suicide or who may injure themselves, while also dealing with others whose disruptive behavior requires constant attention, she said. “Those patients take so much away from the kids who really need the care we can give them.”
‘This is a hard job’
Imagine then, the difficulty of preparing an 18- or 19-year-old high school graduate to work in that environment, increasingly the only people who want to work at Commonwealth Center because of the pay and danger, Sadler said. The center normally receives about 120 job applications a year, but it had just 83 in the past fiscal year — a 30% drop.
“They’re not mature enough to deal with the kinds of problems these kids have,” she said.
Ebach, a former preschool teacher with a college degree in family community services, said, “This facility is not a place to go to just get a job. This is a hard job.”
Even if the center is able to hire staff and keep those it has, Snead said, “we are in the vicinity of a year out to be fully staffed again.”
They all agree the solution has to begin with money for higher salaries, signing and retention bonuses, and safety improvements to help the Commonwealth Center compete for talent with Children’s Hospital of the King’s Daughters and many other private hospitals across Virginia and outside the state.
“It is understaffed and underpaid, and I think we’re going to be able to correct that quickly,” said Hanger, who supports a request by the Department of Behavioral Health and Developmental Services for $75 million this year and a total of $311.5 million over four years in federal aid under the American Rescue Plan Act.
Previous attempts to address pay at the hospitals have not worked. Not the 5% raise for all state employees that showed up in paychecks at the beginning of this month. Not targeted raises for direct-care workers in the budget in 2018, when Virginia expanded its Medicaid program.
This year, the General Assembly included more than $765,000 in the budget to hire clinical staff at Commonwealth Center, but the hospital and its supporters say it’s going to take much more to get qualified staff to come and stay.
Barber, who worked in Virginia’s behavioral health institutions for more than 30 years, thinks the state needs to make “a full-bore effort for hiring, retaining, making it safer and getting people out of the state hospitals.”
“It’s like doing a year’s work in three months.”