Item 320 CC of the 2020 Appropriations Act provides $3,750,000 in FY20 and $7,500,000 in FY21 in order to pursue alternative inpatient options to care at the Commonwealth’s state mental health hospitals as well as step-down options for patients ready to discharge on the Extraordinary Barriers List.

The census at the Commonwealth’s eight mental health hospitals has been persistently and dangerously high. Though TDO admissions across Virginia have decreased slightly in recent years, Virginia state facilities’ share of TDO admissions are increasing year after year compared to private facilities. This current trend began when the Bed of Last Resort statute was passed in 2014, requiring an individual to be transported to a state hospital at the end of the 8-hour ECO period if no other bed is available. On average, the state hospital census in FY21 is consistently above 85 percent, considered safe operating capacity, and more frequently above 95 percent.

The current process of identifying an available bed for an individual subject to a TDO is done largely via phone calls and based on each hospital’s milieu at the time. There is no central source of information on why there was a refusal from a private hospital. There is, however, documentation within each individual pre-screening form for the reasons. The most common reason listed for refusal is the level of acuity of the patient (specifically historical or current aggression). Other common reasons for refusal include patients who have an exclusionary diagnosis (developmental disabilities or dementia), medical comorbidities, and concerns about housing and placement post discharge. The hospital census pilots in 320 CC of the Appropriations Act as well as other contracts with private hospitals described below seek to either support private or community hospitals in taking these high acuity patients or take on populations that may be more appropriately served in a private hospital (e.g., children under age 12).