RD183 - Annual Report on the Implementation of Senate Bill 260 (2014) – June 30, 2017

Executive Summary:
SB 260 was designed to eliminate specific concerns with Virginia’s behavioral health emergency response system and to guarantee that everyone who met clinical criteria for temporary detention was able to access necessary care. In the three years since SB 260 was implemented, DBHDS has been working with state psychiatric hospitals, community services boards and other stakeholders to ensure that the expectations set forth in SB 260 are met and to address challenges that have arisen as a result of the legislation. A brief summary of the most significant effects of SB 260 on Virginia’s emergency response system is provided below. An overview of the legislation itself can be found in Appendix A.

Since the new law went into effect on July 1, 2014:

• Importantly, no individual subject to an emergency custody order (ECO) who was clinically evaluated and determined to meet clinical criteria for temporary detention has been turned away for lack of a psychiatric bed.

• There has been a sustained increase in the average daily number of face to face evaluations completed by community services boards (CSBs) emergency services clinicians for involuntary hospitalizations over the last two and a half years.

* FY 2015: 229 evaluations per day
* FY 2016: 262 evaluations per day
* First two quarters of FY 2017: 252 evaluations per day

• There has been a consistent increase in the daily number of temporary detention orders (TDOs) issued by magistrates:

* FY 2015: 68 TDOs issued daily
* FY 2016: 71 TDOS issued daily
* First two quarters of FY 2017: 70 TDOs issued daily

• There has been a consistent increase in the daily number of emergency psychiatric hospital admissions:

* In FY 2014, state hospitals admitted an average of 12 persons per day
* In FY 2015, state hospitals admitted an average of 14 persons per day
* In FY 2016, state hospitals admitted an average of 17 persons per day
* In the first two quarters of FY 2017, state hospitals admitted an average of 16 persons per day

As demonstrated above, concurrent with the requirements and implementation of SB 260, the Commonwealth of Virginia continues to experience a significant increase in the demand for emergency services, including all areas related to the involuntary admission process. In the public system, this trend is reflected in both community services and state hospital care. CSBs have conducted more emergency evaluations; while for state hospitals, there has been an overall increase in the number of TDO referrals and hospital admissions. Further, the above data reflect that these statewide trends tilt the system towards more restrictive and resource intensive interventions. These approaches are inconsistent with national best practices and with Olmstead v. L.C.’s (Olmstead)(*1) interpretation of the American’s With Disabilities Act (ADA).(*2) The ADA requires states to provide services to individuals with disabilities in the most integrated community settings.

Virginia’s nine state mental health hospitals are under tremendous strain as they are weathering a 157 percent increase in temporary detention order (TDO) admissions and a 54 percent increase in total admissions since FY 2013. Such increases in admissions have created an unsustainable utilization rate for the state hospitals, placing both staff and patients alike in potentially unsafe conditions, and leading to increases in turnover rates among critical staff.

Compounding the issue is the extraordinary barriers to discharge list, or EBL. Virginia maintains a list of individuals residing in state hospitals for more than 14 days who are clinically ready to be discharged but are unable to leave because the necessary community services are not available to ensure a safe discharge. In March 2017, there were 205 individuals on the statewide EBL. As part of efforts to reduce the EBL, DBHDS initiated a collaboration project with the CSBs with the goal of safely discharging 100 people from the EBL list by July 1, 2017. This project increases community placement capacity by using one-time special revenue funds, repurposed general funds from Central Office and CSBs, and new funds provided for FY 2018. This project is not a long-term solution for the challenging census issues as beds vacated by patients on the EBL are expected to be filled by new admissions. However, the EBL project will allow time to build a definitive and sustainable process to manage the hospitals’ census and build community capacity.

As state hospital census increases continue to cause alarm, it is critical that care is managed from both a clinical and a financial standpoint. Importantly, the vast majority of system experts do not believe adding state beds is the wisest or even the correct solution to this challenge. Adding state beds would be extremely expensive and the hospitals are struggling to staff existing beds. Furthermore, there is no cost for a state hospital bed to CSBs, jails, and Medicaid (for adults), resulting in a financial dynamic that is not aligned to best facilitate community-based care.

To help address this issue, the 2017 General Assembly required that the Office of the Secretary of Health and Human Resources develop an implementation plan for the financial realignment of Virginia’s public mental health system. The plan must contain a variety of requirements, including the following (from General Assembly budget language): “A timeline and funding mechanism to eliminate the extraordinary barriers list in state hospitals and to maximize the use of community resources for individuals discharged or diverted from state facility care; Sources for bridge funding, to ensure continuity of care in transitioning patients to the community, and to address one-time, non-recurring expenses associated with the implementation of these reinvestment projects; State hospital appropriations that can be made available to CSBs to expand community mental health and substance abuse program capacity to serve individuals who are discharged or diverted from admission; And, financial incentive for CSBs to serve individuals in the community rather than state hospitals.” DBHDS will continue working with state agency partners and system stakeholders to collect information and feedback as potential models for such a financial structure are created. The plan is due December 1, 2017.
(*1) Olmstead v. L. C., 527 U.S. 581 (1999).
(*2) Americans With Disabilities Act of 1990, Pub. L. No. 101-336, 104 Stat. 328 (1990).