In response to concerns about Virginia’s behavioral health crisis response system, the General Assembly enacted SB 260 in 2014 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. The COVID-19 pandemic, experienced most acutely in the last two quarters of FY20 and the first two quarters of FY21, has affected the number of evaluations for temporary detention orders (TDOs), TDOs issued, and daily TDO admissions to state hospitals.  State hospitals experienced a decrease in admissions during the first four months of the pandemic, however, they have since experienced increased census and critical staffing shortages from that point forward into FY21.

• 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: 239 evaluations per day; 87,490 total
o FY 2020: 208 evaluations per day; 75,805 total
o FY 2021: (first two quarters) 216 evaluations per day

• After a slight increase in the second year, the number of temporary detention orders (TDOs) issued daily has remained relatively 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: 69 TDOs issued daily; 25,205 total
o FY 2020: 64 TDOs issued daily; 23,512 total
o FY 2021 (first two quarters): 72 TDOs issued daily

• Since the enactment of SB 260, there was a continual increase in the daily number of state hospital admissions of individuals under a TDO between FY 2015 and FY 2019, growing by 389 percent between FY 2013 and FY 2019. The final two quarters of FY 2020 indicate a slight decrease in the daily number of state hospital admissions of individuals under a TDO.

o In FY 2013, state hospitals admitted an average of 3.7 individuals per day under a 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, state hospitals admitted an average of 18.2 persons per day under a TDO or a total of 6649 admissions
o In FY 2020, state hospitals admitted an average of 14.8 persons per day under a TDO or a total of 5412 admissions.
o In FY 2021 (first two quarters), state hospitals admitted an average of 17.2 per day under a TDO

The information above shows that while the number of face-to-face evaluations and TDOs are relatively steady across Virginia, TDO admissions to state hospital have overall increased dramatically, growing from 1,359 TDO admissions prior to the implementation of SB 260 to a total of 6,649 admissions in FY 2019, for a growth rate of 389%. TDO rates to state hospitals decreased slightly in FY 2020, which correlated with a decrease in overall evaluations. This is likely related to the impact of the COVID-19 pandemic in the third and fourth quarter of FY 2020. Thus far in FY 2021, evaluation rates and TDO rates have increased to pre-pandemic levels. One of the reasons for the continued high rates of 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 77% in FY 2020. This overall trend continued in the first two quarters of FY 2021.

Virginia’s state hospitals are operating at a 98% 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 (see page 5 of the report) shows the turnover and vacancy rates for key positions in FY 2021 (through May 2021). 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. Since that time turnover and vacancy rates have continued to increase for DSA and LPN positions. The vacancy rates for RN positions have improved slightly, however RN turnover has increased. The Medical Internist turnover rate has decreased slightly from the previous reporting period while the vacancy rate has increased; and the psychiatrist turnover and vacancy rates have slightly decreased since the last reporting period. State facility staffing has reached critical levels due to compensation well below market rates, safety and risk to self, high patient acuity, and the increased number of direct care vacancies. Current direct care staffing levels are not sufficient to maintain safe operations and quality care within our behavioral health hospitals.

The lack of 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. In FY 2019, the number grew to an average of 13% of all individuals in state hospitals, and in FY 2020 the percentage increased even more to 17%. In the first two quarters of FY 2020, an average of 16% of all individuals in state hospitals were considered clinically ready for discharge but unable to leave due to a lack of appropriate community resources. There are currently 188 persons who are clinically ready for discharge from state behavioral health hospitals for at least 14 days.

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 residential and support services. Beginning in FY 2017, DBHDS began working with three CSBs to create assisted living facilities (ALF) for individuals who require an ALF level of care after discharged from state hospitals. 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, in addition to the two group homes that already existed. DBHDS also partnered with the Department of Aging and Rehabilitation Services (DARS) in 2017 in order to provide public guardianship slots for individuals in state hospitals who require this prior to discharge, as well as contracting for additional private guardianship slots in FY 2019 and FY 2020. In FY 2020, DBHDS began additional initiatives to assist in expediting discharge of individuals from state hospitals who are clinically ready to discharge, including increased partnering with CSB crisis stabilization units (CSUs) for state hospital stepdown and discharges, as well as partnering with a private assisted living provider and a long-term care organization to facilitate state hospital discharges for individuals who require these levels of care. In FY 2021, DBHDS initiated several partnerships to create specialized residential services for individuals discharging from state hospitals.
These include:

• the addition of two transitional group homes for adolescents discharging from CCCA;
• partnerships with eight CSBs for additional transitional supervised housing resources for adults discharging from state hospitals;
• partnerships with Mount Rogers CSB and Western Tidewater CSB to develop and provide specialized behavioral health services for older adults, including those with dementia;
• and partnerships with two private hospital systems to provide specialized diversion and stepdown services to individuals who would otherwise be served by a state hospital.

In FY 2022, DBHDS will continue to expand services for children and adolescents discharging from CCCA, as well as specialized services for older adults.