RD118 - Office of the Inspector General for Behavioral Health and Development Services Review of Emergency Services: Individuals Meeting Statutory Criteria for Temporary Detention not Admitted to a Psychiatric Facility for Further Evaluation and Treatment


Executive Summary:
This Report summarizes the results of a three-month joint statewide study by the OIG and the DBHDS to follow up on the issue of streeting first profiled in connection with the downsizing of Eastern State Hospital (OIG Report No. 197-10). The complete Report can be found on the OIG website at: http://www.oig.virginia.gov

The Virginia "Bill of Rights" declares that government “ought to be instituted for the common benefit, protection, and security of the people, nation, or community.” (*1) The General Assembly and the Governor have honored this promise with extensive statutory language mandating emergency services to address the needs of citizens experiencing mental health crises. These statutory provisions protect individuals determined to be incapable of caring for themselves who pose a danger to themselves or others.

To qualify for a Temporary Detention Order (TDO) there must be a “substantial likelihood…in the near future” that a person is at risk for “serious harm to himself or others…lack the capacity to protect himself…[and be] in need of hospitalization or treatment.” (§37.2-808, Code of Virginia)

For the most part, this system works as envisioned by the Commonwealth’s statutory framework – thanks in large measure to the efforts of the system’s first responders: the emergency services professionals at the state’s Community Services Boards (CSBs) and Behavioral Health Authorities (BHAs).

During the 90-day study, 72 individuals, who specially-trained mental health professionals had determined met the criteria for temporary detention cited above, received less intensive treatment than the hospitalization that was clinically indicated because no state-operated behavioral health hospital or private psychiatric facility would admit these individuals. (Refer to the Report’s Appendix A for a regional summary.)

To contextualize the 72 failed TDOs, one needs to appreciate that this number is approximately 1½% of the estimated 5,000 TDOs that were successfully executed during the three-months of this study. (Refer to the complete Report’s Figure 5 for a regional comparison of failed vs. executed TDOs.)

Each incident, in which a person is denied the level of services determined by trained mental health professionals to be clinically necessary, represents a failure of the system to address the needs of that individual and places the individual, his family, and the community at risk.

Moreover, a failed TDO can rise to the level of a sentinel event as defined by the Joint Commission if it “carries a significant chance of a serious adverse outcome.”

The data collected during this three-month study also documented that an additional 273 (or approximately 5½ % of the 5,000 executed TDOs) individuals statewide received TDO’s, but after the 6-hour time limit imposed by the Code for converting an ECO into a TDO. The average time required to execute a TDO for this group was 16.6 hours

When the OIG commenced this study, we hypothesized that the underlying cause of streeting had its origin in either system capacity or system access issues. The study confirmed that, depending on the region of the state, in fact, the phenomenon is driven by both capacity and access issues. (*2)

The study revealed that Hampton Roads (PPR V) and Southwest Virginia (PPR III) have the most difficulty finding a willing behavioral healthcare facility to admit individuals meeting the statutory criteria for temporary detention.

While it is difficult to compare failed TDOs in Hampton Roads with those in Southwest Virginia, they have one thing in common: the state-operated facilities in both regions are frequently at capacity, and unable to provide a safety net psychiatric bed for individuals needing temporary detention and further evaluation pursuant to a TDO.

Hampton Roads and Southwest Virginia represent only 30% of the state’s population; yet they accounted for 75% (54/72) of the failed TDOs. Particularly troubling is Southwest Virginia, which is home to only 7% of the state’s eight million residents, but accounted for 45% of failed TDOs.

The recent spike in the average length of stay at Southwestern Virginia Mental Health Institute (SWVMHI) is both perplexing and troubling; effectively reducing the southwest’s state-facility acute treatment capacity by over 40% in the last 18 months.

An infusion of additional funds for discharge assistance planning (DAP) and the creation of additional community treatment capacity likely will be necessary to free-up adult acute facility beds at Eastern State Hospital and SWVMHI to reconstruct a viable public safety net to receive TDOs in Hampton Roads and Southwest Virginia.

Virginia’s emergency services system is a complex array of services delivered by numerous public and private agencies and there is no single solution that will end failed TDOs; but, while there is not one simple driver of the phenomenon, there are important themes that reoccur throughout the state including:

THE STATE-OPERATED FACILITY AND COMMUNITY-BASED SYSTEMS ARE INEXTRICABLY INTERDEPENDENT: The decrease in public and private psychiatric beds during the last decade, while the state’s population has increased by over 10%, has not been accompanied by a commensurate expansion of community based programs and resources.

The practical result of this imbalance is that some state facilities are unable to discharge stabilized residents and return them to their communities. Thus, the facility beds occupied by persons who could be otherwise housed in a community setting are not available to serve as a safety net for individuals in-crisis meeting TDO criteria.

This outcome is contrary to the standards articulated by the Olmstead decision and, moreover, it is making it more difficult to serve the most challenging individuals meeting criteria for temporary detention.

State-operated facilities and CSBs must jointly sharpen their focus on the systemic flow of individuals from the facilities to the communities. Virginia lacks the surplus facility capacity to afford the dubious “luxury” of permitting individuals who are discharge ready to remain in state facilities.

During this study, people in dire need of inpatient psychiatric treatment in state hospitals were denied admission to state hospitals because individuals, who could have been served in the community, occupied the state-facility beds needed to serve some of the state’s most challenging TDOs.

THE PROTOCOLS FOR MEDICAL SCREENING AND ASSESSMENT MUST BE STANDARDIZED: The Inspector General met with hospital medical directors and CSB emergency services directors around the state and these healthcare professionals were unanimous in their opinion that the current approach to medical screening and assessment creates unnecessary additional costs and actually contributes to unacceptable outcomes – including failed TDOs and TDOs executed beyond the six-hours contemplated by statute.

This Report recommends updating and prompt implementation of the appended "Medical Screening and Assessment Guidance Materials" (2007) developed by the DBHDS in collaboration with the CSB system, the Hospital and Healthcare Association, and the College of Emergency Physicians (Appendix C).

THE SYSTEM SOMETIMES DISCRIMINATES AGAINST THE CITIZENS MOST IN NEED OF TREATMENT: In a chronically underfunded system subject to iterative budget reductions, the system sometimes defaults to serve selectively the least challenging individuals – the so called “soft-TDOs.” Private psychiatric hospitals, state behavioral health hospitals, and the crisis stabilization units all have limitations and restrictions on whom they will serve and under what conditions. These restrictions may screen for age, gender, psychiatric profile, history of assaultive behaviors, suicidal ideation, substance use, security concerns, medical complications, hours of operation, self-care ability, and psychiatric support staff availability.

The 72 failed TDOs, who were denied admission to a state-operated hospital or a private psychiatric facility, may be Virginia’s “canary in the coal mine” warning us that the system has yet to create sufficient community capacity to serve our neighbors and family members who, decades ago, would have been treated in state-operated behavioral health facilities.

When viewed collectively, these restrictions can serve to deny services to individuals who most need treatment in a secure psychiatric facility – especially in Hampton Roads and Southwest Virginia where the state facilities are regularly unable to accept TDO admissions because they are at, or beyond, full operating capacity.

ACCOUNTABILITY FOR EMERGENCY SERVICES IS FRAGMENTED: CSB pre-screeners, who are tasked with assessing individuals in crisis, do not have the authority to direct that a facility admit a person meeting TDO criteria. This Report recommends real-time monitoring of TDO outcomes and the designation of a regional senior manager with region-wide responsibility to locate a state-operated or private facility to admit a person meeting criteria for temporary detention.

Additional OIG findings and recommendations appear in the Report. These recommendations include:

• The creation of system quality indicators to monitor unexecuted TDOs and TDOs executed beyond six hours;

• The prompt review, adoption, and implementation of the "2007 Medical
Screening and Assessment Guidance Materials;"

• The designation of a senior-level person within each region (and at the DBHDS) with the responsibility and empowered to assure that every citizen in the region meeting TDO criteria is treated at the clinically appropriate level;

• That consideration be given to creating “intensive psychiatric beds” with private psychiatric hospitals in Hampton Roads and Southwest Virginia until a reliable state-operated safety net is recreated for these regions;

• Repeating this study in FY 2013 in Hampton Roads and Southwest Virginia; and,

• That the DBHDS evaluate the unique issues in Southwest Virginia and Hampton Roads and the additional programs and resources needed to create the community capacity required to end the phenomenon of failed TDOs, and restore the Commonwealth’s safety net for citizens determined to need temporary detention.

In conclusion, this Report cannot overstate the importance of the Commonwealth’s emergency services professionals who, despite formidable obstacles, somehow manage to cobble together creative alternatives to assure the safety of Virginians who are incapable of caring for themselves.

Without the clinical skill and dedication of CSB/BHA emergency staff, our most vulnerable neighbors – and our communities – would have doubtless experienced many tragic outcomes.
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(*1) Constitution of Virginia, Article 1, Section 3.
(*2) Wherever possible, the OIG has substituted “failed TDO” for “streeted” because of reasonable objections to the negative connotations attached to the term “streeted.” The term “streeted” was used in Hampton Roads to categorize individuals that met criteria for temporary detention who received a less intensive intervention – or no intervention and were released.