RD159 - Report on the Implementation of Senate Bill 260 - June 30, 2015


Executive Summary:
SB 260 (Chap. 691, 2014) amended several existing sections of the Code of Virginia and added new sections related to emergency custody and temporary detention of adults and minors. The fourth enactment clause of this legislation reads as follows:

"4. That the Department of Behavioral Health and Developmental Services shall submit an annual report on or before June 30 of each year on the implementation of this act to the Governor and the Chairmen of the House Appropriations and Senate Finance Committees. The report shall include the number of notifications of individuals in need of facility services by the community services boards, the number of alternative facilities contacted by community services boards and state facilities, the number of temporary detentions provided by state facilities and alternative facilities, the length of stay in state facilities and alternative facilities, and the cost of the detentions in state facilities and alternative facilities."

This report was prepared pursuant to the above language.

Senate Bill 260 arose from concerns about Virginia’s behavioral health crisis response system. In particular, there were instances across the Commonwealth where individuals who needed temporary detention were not hospitalized because of the lack of a willing facility that would admit them. SB 260 was designed to eliminate these occurrences, guaranteeing that everyone who needed temporary detention was able to access this care.

A brief overview of the most salient effects of SB 260 on Virginia’s emergency response system is provided below.

• Since the new law went into effect on July 1, 2014, no individual who needed such care has been turned away for lack of a bed.

• There are more than 1,000 emergency contacts with CSB emergency services each day.

• CSB emergency services clinicians complete an average of 200 face-to-face evaluations for involuntary hospitalizations each day.

• Magistrates issue an average of 70 TDOs each day for involuntary hospitalization.

• Loss of custody and medical instability requiring stabilization in the emergency department, or admission to a medical unit, are the two most common reasons for a delay in executing a temporary detention order (TDO).

• Since July 1, 2014, admissions to state hospitals have on average increased by 22 percent over the preceding year with wide variations and fluctuations in the percentage of increase by age, region, and season.

The Department of Behavioral Health and Developmental Services (DBHDS), community services boards (CSBs) and private inpatient hospitals implemented several initiatives prior to July 1, 2014 to respond to the needs of individuals needing access to inpatient temporary detention and to prepare for full implementation of SB 260. These actions included:

• Initiated full operation of the Virginia Psychiatric Bed Registry on March 3, 2014;

• Implemented a statewide Medical Screening and Medical Assessment protocol on April 1, 2014;

• Conducted extensive training on the new law for providers, law enforcement officers, and others throughout May and June, 2014;

• Revised and disseminated regional acute care access protocols to ensure consistent crisis response and access to inpatient care in June 2014; and

• Conducted a “Soft Launch” of SB 260 procedures on June 16, 2014, in advance of the July 1 effective date of the new laws, to ensure effective implementation statewide on July 1.

In addition, DBHDS designed and implemented new statewide reporting requirements to identify and monitor trends in:

• Emergency contacts to CSBs;
• Emergency evaluations conducted by CSBs;
• Temporary detention orders (TDOs) issued and executed; and
• Timeliness of access to care, and other variables associated with the new TDO procedures.

DBHDS also implemented a new reporting system for high risk events that involve individuals who are evaluated and need temporary detention, but who, regardless of the reason, do not receive that intervention. Each of these events is reported by the involved CSB on a case-by-case basis as the events occur, through submission of an incident report. Each report results in an immediate review by a DBHDS Quality Oversight Team (*1) to assess the incident and the follow up actions of the CSB for comprehensiveness and appropriateness. Each incident is monitored actively by DBHDS and the CSB until the situation is resolved and all post-incident follow up is completed.

Concurrent with the development and implementation of SB 260 and its requirements, the Commonwealth of Virginia experienced a significant increase in the demand for emergency services, including all areas related to the involuntary admission process. Beginning in January 2014, referrals for involuntary admission under TDOs, including TDO admissions to state hospitals, markedly increased. From January through June 2014 the number of admissions increased to 923 from 638 the year before. The increase has continued through FY 2015 with 1,482 admissions fiscal year to date (FYTD) (March 2015), versus 1,071 for FY 2014 and 1,045 for FY 2013 for the same period of time.

Operationally, this trend is also reflected in increases in emergency contacts to CSBs and emergency evaluations conducted by CSB staff. For state hospitals, this increase is reflected in increased TDO referrals and admissions overall. These statewide trends toward more restrictive and resource intensive interventions are at odds with national best practices and with Olmstead v. L.C.’s (*2) (Olmstead) interpretation of the American’s With Disabilities Act (*3) (ADA). The ADA requires states to provide services to individuals with disabilities in integrated community settings.

Lastly, SB 260 contributed to multifaceted changes in Virginia’s behavioral health emergency and crisis services. In addition to ensuring a safety net of inpatient care for all who need this service, DBHDS also remains committed to increasing prevention, early intervention and ongoing supportive services. A comprehensive array of community-based services across the life span is essential in order to avert crises, enable individuals with behavioral health needs to be served in their home community, and, whenever possible, avoid intensive hospital-based care and inappropriate contact with the criminal justice system.
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(*1) The Quality Oversight Team includes the DBHDS Medical Director, Assistant Commissioner for Behavioral Health, Director of Mental Health, and MH Crisis Specialist.
(*2) Olmstead v. L. C., 527 U.S. 581 (1999).
(*3) Americans With Disabilities Act of 1990, Pub. L. No. 101-336, 104 Stat. 328 (1990).