In response to concerns about Virginia’s behavioral health crisis response system, the General Assembly enacted SB 260 to ensure that every individual who met the criteria for temporary detention was provided with timely access to inpatient psychiatric care. Since the enactment of SB 260, Department of Behavioral Health and Developmental Services (DBHDS) has continued to partner with the relevant stakeholders, including the community services boards (CSBs), state psychiatric hospitals, private hospitals, magistrates, law enforcement, and others to monitor the requirements set forth in SB 260. An overview of the legislation can be found in Appendix A. The most salient impacts of SB 260 for Virginia’s behavioral health crisis response system are described below.

• Following an initial increase in the second year, the average daily number of face-to-face evaluations completed by CSB emergency services clinicians for involuntary hospitalizations in FY 2016 has decreased steadily.

o FY 2015: 229 evaluations per day; 83,701 total
o FY 2016: 262 evaluations per day; 96,041 total
o FY 2017: 256 evaluations per day; 93,482 total
o FY 2018: 251 evaluations per day; 91,718 total
o FY 2019 (first two quarters): 238 evaluations per day

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

o FY 2015: 68 TDOs issued daily; 24,889 total
o FY 2016: 71 TDOs issued daily; 25,798 total
o FY 2017: 71 TDOs issued daily; 25,852 total
o FY 2018: 70 TDOs issued daily; 25,679 total
o FY 2019 (first two quarters): 70 TDOs issued daily

• Since the enactment of SB 260, there has been a continual increase in the daily number of state hospital admissions of individuals under a TDO, growing by 294 percent between FY 2013 and FY 2018. This trend is continuing in FY 2019.

o In FY 2013, state hospitals admitted an average of 3.7 individuals per day under at TDO or a total of 1,359 admissions
o In FY 2014, state hospitals admitted an average of 4.3 persons per day under a TDO or a total of 1,579 admissions
o In FY 2015, state hospitals admitted an average of 6.0 persons per day under a TDO or a total of 2,192 admissions
o In FY 2016, state hospitals admitted an average of 9.6 persons per day under a TDO or 3,497 admissions
o In FY 2017, state hospitals admitted an average of 10.5 persons per day under a TDO or a total of 3827 admissions
o In FY 2018, state hospitals admitted an average of 14.7 persons per day under a TDO or a total of 5357 admissions
o In FY 2019(first two quarters), state hospitals admitted an average of 15.2 persons per day under a TDO or a total of 2783 admissions

The information above shows, that, while face to face evaluations are trending downward and overall TDO rates are relatively steady across Virginia, TDO admissions to state hospitals have continued to increase dramatically, growing from 1,359 TDO admissions prior to the implementation of SB 260 to a total of 5,357 admissions in FY 2018, for a growth rate of 294%. The primary reason for the continuing growth in TDO admissions to state hospitals is the declining rate of private hospital admissions for individuals under a TDO, dropping from 91.2% in FY 2015 to 80.6% in FY 2018. This overall trend is continuing in the first two quarters of FY 2019. As a result, Virginia is using approximately 28 more state psychiatric hospital beds each year.

Virginia’s state hospitals are operating at a 95% utilization rate or above. Research and national standards show that operating at 85% of capacity is optimal for both patients and staff. Utilization rates significantly above 85% can compromise the quality of care and impact patient and staff safety. Staff turnover and vacancy rates have grown along with the increase in average daily census at the state hospitals. The vacancy rates have increased as the state hospitals struggle to retain current staff and successfully recruit new staff. Figure 2 shows the turnover and vacancy rates for key positions in FY 2018. In FY 2019, DBHDS received $12.2 million to bring the salaries of registered nurses (RNs), license practical nurses (LPNs), and direct service associates (DSAs) within 3% of the market salary. These increases went into effect on January 10, 2019. While it is too early to be certain, DBHDS believes these salary actions, along with the additional $7.8 million for additional RN, LPN, DSA, and psychiatry positions in FY 2020 could significantly impact the turn over and vacancy rates for these positions.

The lack of needed community based housing and support services further compounds state hospital census pressures. In FY 2018, a monthly average of 167 persons, or approximately 12% 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. For the first two quarters in FY 2019, this number has grown to an average of 13% of all individuals in state hospitals.

DBHDS continues to work diligently with the community services boards and private providers to address the growing census pressures related to individuals who are clinically ready to leave state hospitals by investing in needed residential and support services. In FY 2017, DBHDS worked with Tidewater Community Services Board to create an assisted living facility for individuals who required a higher level of residential supervision and support needs. In FY 2018, DBHDS also invested in the development of four additional transitional group homes for individuals who are able to transition into more integrated community settings, and two additional assisted living facilities for those who have more complex care needs. As a result of the development of these services, the number of bed days used by individuals who are clinically ready for discharge has dropped by 44%, declining from 117,181 bed days in FY 2015 to 69,598 bed days in FY 2018. DBHDS will continue investing in specialized community residential infrastructure and support services in FY 2020 and focus on addressing the complex medical and intensive supervisory needs of individuals who are clinically ready for discharge from state hospitals.