RD31 - Report on the State Hospital Discharge Process – Tuesday, January 11, 2022

Executive Summary:

*This report was replaced in its entirety by the Department of Behavioral Health and Development Services on January 13, 2022.

Virginia state psychiatric hospitals have been running near or over capacity for the past several years, with patient discharge posing a particular challenge to the bed census crisis. Discharges have outpaced admissions at all Virginia state hospitals by a very small margin, with many patients having lengths of stay of 30 days or more. DBHDS, in partnership with the Community Services Boards, requested a workgroup as a result of SB1304 to study the discharge process for individuals in state hospitals.

As a result of bed of last resort legislation (SB260, 2014), state hospitals have taken a necessary shift to a more acute model of care. Focus on readmission rates for patients has increased as this shift occurred. Virginia has a higher than average 30-day readmission rate compared to the national average. Nationally, the average 30-day readmission rate for 2017 through 2019 was 7.4 percent, while Virginia’s was 9.6 percent, though this slightly improved in FY2020.

Discharging patients in a timely manner becomes more important given this information, but there are multiple barriers to doing so for patients that are clinically stable. Patients in state hospitals are regularly rated on their readiness for discharge, with a “1" rating indicating they are clinically ready for discharge. Once an individual receives a rating of “1" for more than 7 days, they are tracked on the extraordinary barriers to discharge list (often referred to as the EBL). The EBL distinction enables state hospitals and CSBs to focus specific attention and resources on discharge planning for this group of individuals.

In FY20, thirty percent of the individuals on the EBL were actively looking for a residential placement: either an Assisted Living Facility (ALF) or Nursing Home (NH). For individuals referred to ALFs, these placements are typically referred to because they provide a 24 hour supervision. Most ALFs do not provide behavioral health support, and primarily provide supervised housing and assistance with medications and other medical health care needs. ALFs often report that they do not have the training and necessary structure to serve individuals discharging from state hospitals. 83 percent of DAP (discharge assistance program) funds are used to support individuals in assisted living facilities.

The census crisis is multifaceted and many approaches and strategies are necessary to address the challenges. If we are to broadly enhance discharge-planning efforts, there are several overarching factors to consider, to include workforce challenges and aligning pay of employees with experience and qualifications.

Other factors that the workgroup identified as assisting in discharge planning relate to diversion of individuals from admission state psychiatric hospitals. There are some unknowns regarding how the new statewide mobile crisis services, coming online in calendar year 2022, will affect diversions and temporary detention orders (TDOs). Some data from other states suggests that mobile crisis services will assist with preventing the need for hospitalization for certain individuals over time. However, there are also concerns that as Marcus Alert co-responding programs are initiated there may actually be an increase in individuals identified needing psychiatric hospitalization.

The workgroup recommends the review and updating of medical clearance criteria (last reviewed in 2018), and guidance for individuals recommended for inpatient hospitalization, in order to avoid psychiatrically hospitalizing those whose primary need is medical care. The workgroup additionally recommends increased efforts in developing community resources for the following specialized populations from this group: individuals with dementia, traumatic brain injury, and personality disorders. The workgroup reviewed current discharge processes for efficiencies and further discussed several areas where improvement or potential changes could be made: overall system, responsibility for discharge planning, training, discharge planning and continuity of care, and discharge placement options.