RD203 - Annual Report on the Implementation of Senate Bill 260 (2014) – June 30, 2018

Executive Summary:

In July 2014, SB 260 was enacted in response to specific concerns with Virginia’s behavioral health emergency response system. SB 260 was intended to ensure that every individual who met clinical criteria for involuntary hospitalization under temporary detention was provided with access to inpatient psychiatric care. In the four years since the enactment of SB 260, the Department of Behavioral Health and Developmental Services (DBHDS) has continued to collaborate with all involved stakeholders, including the community services boards (CSBs), state psychiatric hospitals, private hospitals, and other stakeholders to implement and monitor the requirements set forth in SB 260. An overview of the legislation can be found in Appendix A. Outlined below is a brief overview of the most salient impacts of SB 260 on Virginia’s emergency response system.

• 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 was an initial growth in the average daily number of face-to-face evaluations completed by CSBs emergency services clinicians for involuntary hospitalizations. Since FY 2016, the trend has appeared to stabilize.

* FY 2015: 229 evaluations per day; 83,701 total
* FY 2016: 262 evaluations per day; 96,041 total
* FY 2017: 256 evaluations per day; 93,482 total
* FY 2018 (first two quarters): 250 evaluations per day; 90,192 projected total

• Following a slight increase in the second year, the number of temporary detention orders (TDOs) issued daily has remained relatively consistent over time.

* FY 2015: 68 TDOs issued daily; 24,889 total
* FY 2016: 71 TDOs issued daily; 25,798 total
* FY 2017: 71 TDOs issued daily; 25,852 total
* FY 2018 (first two quarters): 71 TDOs issued daily; 25,632 projected total

• Overall, there has been a continual increase in the daily number of state hospital admissions of
individuals under a TDO, growing by 224 percent between FY 2013 and FY 2017.

* In FY 2013, state hospitals admitted an average of 3.7 individuals per day under at TDO or a total of 1,359 admissions
* In FY 2014, state hospitals admitted an average of 4.3 persons per day under a TDO or a total of 1,579 admissions
* In FY 2015, state hospitals admitted an average of 6.0 persons per day under a TDO or a total of 2,192 admissions
* In FY 2016, state hospitals admitted an average of 9.6 persons per day under a TDO or 3,497 admissions
* In FY 2017, state hospitals admitted an average of 12.1 persons per day under a TDO or a total of 4,391 admissions

The information above illustrates the impact of the implementation of SB 260 across Virginia. After an initial growth in both the number of face-to-face evaluations and TDOs, the trends for both of these categories appears stabilized. However, TDO admissions to state hospitals has continued to increase dramatically, growing from 1,359 TDO admissions prior to the new law’s implementation to a projected total of 4,983 admissions in FY 2018 (or a 375 percent increase).

One factor contributing to this growth in state hospital TDO admissions is the declining rate of private hospital admissions for individuals under a TDO. In FY 2015, private hospitals admitted 22,687 individuals under a TDO (91.2 percent of all TDOs) and in FY 2017, private hospitals admitted 21,861 individuals under a TDO (84.6 percent of all TDOs). Based upon the admission trends for the first six month of FY 2018, private hospitals are projected to admit 20,649 individuals under a TDO (80.6 percent of all TDOs). At the present time, Virginia is using approximately 28.4 more state psychiatric hospital beds each year.

The dramatic increase in the TDO admissions to Virginia’s nine state hospitals has created an unsustainable utilization rate for the state hospitals, with majority of the hospitals routinely operating at 95 percent or more of capacity. National standards and research recognize that operating at 85 percent of capacity is safest for both patients and staff. By consistently operating well above 85 percent, the pressures of the state hospital census are placing both staff and patients alike in potentially unsafe conditions, compromising the quality of care provided, and leading to unprecedented increase in turnover in critical staff. During FY 2017, the turnover rate was the highest it had been in ten years. Correspondingly, the vacancy rates are increasing as hospitals struggle to fill open positions. Figure 2 shows the turnover and vacancy rates for key positions in FY 2017.

The pressures of the state hospital census are further compounded by the lack of appropriate housing and community based services for individuals who are clinically ready for discharge from our state hospitals. Data about individuals who are clinically ready to leave, but for whom appropriate housing, services and supports are not available, is collected through the extraordinary barriers list, or EBL. The EBL is a list generated by DBHDS and identifies individuals in state health hospitals who have been clinically ready for discharge for more than 14 days but are unable to leave because the necessary community housing and support services are not available to ensure a safe discharge. At any point in time during the past year, approximately 13 percent of all individuals in state hospitals were clinically ready to leave but were unable to do so due to a lack of community resources. DBHDS is currently working to address the growing census pressures related to individuals who are clinically ready to leave state hospitals. For example, in partnership with three CSBs, and a contractual relationship with a nonprofit organization, DBHDS invested in the development of four transitional group homes for individuals who are able to transition into more integrated community settings, and three assisted living facilities for those who have more complex care needs and require more supervision.

In an effort to help address state hospital census issues, the 2017 General Assembly required the development of a plan for the financial realignment of Virginia’s public mental health system. DBHDS put forth a budget request to provide the state hospital discharge services and develop the additional housing alternatives to state hospital placement. These elements would help accomplish year one of the financial realignment plan. DBHDS will continue working with the Administration, the General Assembly, CSBs and stakeholders to manage hospital census and build community services needed to discharge individuals more promptly from state hospitals.