STAUNTON — As autumn begins, Virginia’s only state mental hospital for children and adolescents is braced for a flood of troubled young people sent here involuntarily from communities across the state because they have nowhere else to turn for help in psychiatric crisis.
The pressure begins to build every year as school begins, but in the fiscal year that ended June 30, the Commonwealth Center for Children and Adolescents admitted 983 children and adolescents, nearly all of them under temporary detention orders seeking a bed in Virginia’s hospital of last resort.
The record-shattering number of admissions — 250 more than in the previous fiscal year — included four consecutive months of 100-plus admissions for a state psychiatric hospital with 48 beds.
Commonwealth Center spent the summer preparing for the worst — bolstering its staff of child psychiatrists and psychologists, nurses and direct-care aides, and training them to handle youth in crisis, more than a quarter of them with intellectual and developmental disabilities, including autism.
“I am anxious about where we’re headed,” said Dr. Jack Barber, the facility’s acting director and former interim state commissioner of behavioral health and developmental services.
So is Dr. Hughes Melton, his successor as state commissioner, who is calling publicly for a fresh look at Virginia’s 4-year-old “bed of last resort” law.
The law requires state mental hospitals to accept patients under temporary detention orders if no bed can be found in a private psychiatric facility within eight hours after they are taken into emergency custody without their consent.
“We’re very concerned that if some of the dynamics occurring in the state don’t change, Commonwealth Center will not be able to meet the needs of our youth in mental health crises,” Melton said in an interview.
State officials have not said how they propose to tweak the law, but the heart of their concerns is the dwindling backup for Commonwealth Center from private psychiatric facilities for admitting youth under temporary detention orders. Those orders, called TDOs, allow 72 hours for involuntary evaluation of people who have been found to be a threat to themselves or others.
Since adoption of the last-resort law in 2014, the number of TDO admissions to the state’s nine mental hospitals has increased by nearly 146 percent — from just under 2,200 to nearly 5,400 in the last fiscal year, even though the total number of orders statewide rose by less than 3 percent.
Private hospitals still accounted for 79 percent of TDO admissions in the last fiscal year, but the percentage had fallen from over 91 percent four years earlier and the total number had declined by almost 11 percent.
Commonwealth Center admitted 325 more youths under TDOs last year than it did in 2013-14, the year before the last-resort law took effect. The health region that includes the Richmond area sent 181 youths to the state hospital under TDOs last year, an increase of 97 percent from the previous year and a whopping 147 percent from four years earlier.
“It’s a massive problem,” said John Lindstrom, CEO of the Richmond Behavioral Health Authority.
The state has a contract with Poplar Springs Hospital, a private facility in Petersburg, to accept children and adolescents under TDOs, but state officials say it’s not nearly enough to meet demand.
“My request for other facilities in the state who could assist in some manner or another is for them to step up to meet the need and share the load,” said Melton, a former official at a private hospital system in Southwest Virginia and northeastern Tennessee.
Private hospitals say they are facing a huge increase in voluntary admissions, more than 29,000 last year, up by 4,000 patients or 16 percent from the previous year.
“At a time when treatment capacity is a concern, it is important to recognize that private hospitals play a critical role in providing substantial care and services to behavioral health patients,” said Julian Walker, vice president of communications at the Virginia Hospital & Healthcare Association.
Virginia’s nine state mental hospitals were operating at almost 94 percent of capacity on Friday. Commonwealth Center was operating at about 65 percent, with 31 beds filled, or 11 more than a month ago before the school year began.
Piedmont Geriatric Hospital in Burkeville had three more patients than beds. Eastern State Hospital in Williamsburg and Western State Hospital in Staunton each was operating at about 98 percent of capacity.
But Commonwealth Center is the only state facility for children and adolescents, including those incarcerated on criminal charges and referred for treatment.
“It’s absolutely critical,” said Margaret Nimmo Holland, executive director of Voices for Virginia’s Children. “Clearly, without CCCA, I can’t even imagine where those kids could go.”
“We can’t take away that safety net,” she said. “It’s the only one we have.”
Admissions spike is ‘all TDOs’
Admissions to Commonwealth Center increased by 55 percent during four months this winter and spring, including the highest number of monthly admissions in its history — 122 in March, 116 in May and 115 in February.
“It’s all TDOs,” said Barber, a psychiatrist who has worked for Virginia’s mental health system for more than 30 years, including 16 as director of Western State before stepping in as interim commissioner in 2015.
The center admitted 101 patients in April. That was one fewer than the previous record, set in October 2014, four months after the last-resort law took effect and 11 months after the family tragedy that inspired it.
On Nov. 19, 2013, Gus Deeds, 24, stabbed his father, state Sen. Creigh Deeds, D-Bath, and then killed himself, just 13 hours after the son was released under an expired emergency custody order when a regional mental health worker failed to find a hospital bed for his treatment.
The General Assembly responded with a package of laws that increased the duration of emergency custody orders from six to eight hours and TDOs from 48 to 72 hours. Most critically, it guaranteed that state hospitals would accept people who qualified for TDOs if no bed could be found in a private facility.
The law ended the phenomenon of “streeting,” in which people in psychiatric crisis did not get appropriate treatment, despite being found to be a danger to themselves or others. But it also shifted the burden of TDO admissions more heavily onto state hospitals.
By the time a child or adolescent comes to Commonwealth Center under a TDO, up to two dozen private facilities have declined the admission, estimated Daniel Herr, assistant commissioner for behavioral health services.
There are many reasons — including aggressive or sexualized behavior, risk to other patients in private settings, age, and the complexity of underlying medical and intellectual disorders, Herr said. Between 25 and 30 percent of the patients admitted to Commonwealth Center have intellectual or developmental disabilities, including autism spectrum disorder.
Walker, a spokesman for the hospital association, said factors affecting a private facility’s capability or capacity to accept TDO admissions include “patient disposition, age and other diagnoses.”
But the last-resort law also reduced the risk of not accepting a TDO admission by ensuring care elsewhere.
“The last-resort law has allowed them more latitude than they used to have,” Barber said.
The consequences of last year’s surge in admissions at Commonwealth Center include a 90 percent increase in overtime cost for the hospital’s undermanned staff and doubling of the rate of injury to employees.
“Really, the priority for us is to make it safer,” Barber said. “The best way to make it safer is a lot more engagement.”
The center used the lull in admissions during the summer to hire and train staff to focus more attention on young patients who thrive on it.
“They love engagement!” said Shantae Fisher, director of nursing.
Backed by targeted state pay raises for direct-care staff, Commonwealth Center has reduced its registered nurse vacancies from 50 percent a year ago to 15 percent last month. It has added a dozen direct-service assistants, hired three therapists and increased the number of psychiatrists to five, including Dr. Jaime Bamford, the center’s medical director.
Bamford is concerned that the mounting pressure on the state hospital reflects larger problems in families and their communities.
“Are we talking about a crisis with kids?” she asked. “Are we looking at something bigger than the Commonwealth Center?”
Part of the challenge is building capacity in communities to serve children and adolescents in their homes rather than hospitals and other institutionalized settings, such as out-of-state residential treatment centers for the most complex cases.
Commonwealth Center sent 10 kids out of state for residential treatment in the first eight months of this calendar year, compared with three in 2017.
Holland, at Voices for Virginia’s Children, wants the state to take a much more detailed look at the kids admitted to the center — where they come from, their special needs, and what their communities have available to serve them to keep them out of institutional care.
“There is a need that is crying out in our state for these kids with complex issues,” she said. “It’s not just public versus private hospitals. It’s what do these kids need?”