The purpose of this report is to provide a summary and recommendations regarding effective, safe, and therapeutic alternatives to hospitalization at the Commonwealth Center for Children and Adolescents (CCCA). These recommendations are based on information gathered from a variety of stakeholders that are involved in Virginia’s system of behavioral healthcare for children, including Community Services Boards (CSBs), the Department of Social Services (DSS), Children’s Services Act (CSA), private inpatient facilities, private providers, CCCA, families, the Department of Medical Assistance Services (DMAS), DBHDS Central Office, and others.

CCCA has experienced significant changes in the population it serves, as well as the number of individuals served each year, since the Bed of Last Resort law was implemented in 2014 (SB260, 2014). Since 2021, CCCA has seen increasing average lengths of stay for individuals admitted. While there appear to be multiple reasons for this change, the most frequent reason cited was the number of children admitted to CCCA who are in the custody of local Department of Social Services (DSS) agencies, who do not have identified appropriate step-down or foster care placements at the time of clinical readiness for discharge. However, the number of annual admissions to CCCA has decreased dramatically (over 75 percent) in the past five years to a record low of 260 admissions in FY 2024. This averages to less than one admission per day.

• While some of the services recommended in this report already exist in the community, the providers of these services often report an unwillingness or an inability to serve some of the individuals admitted to CCCA, due to the complexities of managing the social and psychiatric needs of these children.

• Many other states contract with private inpatient providers in lieu of operating a state psychiatric hospital for children. While DBHDS has attempted to contract with private inpatient providers to relieve the pressure on CCCA, there has been limited interest from private inpatient providers in this area.

• Additional inpatient bed availability is needed for children and adolescents, specifically in Southwest Virginia. Currently, Carilion Clinic in Roanoke is the children’s inpatient unit that is the furthest southwest in Virginia, which leaves a significant geographic area of the state without any locally available options for children’s inpatient treatment.

• Additional investments and development are needed for community services that provide prevention and step-down levels of care, including community crisis programs, behavioral assessment/applied behavior analysis (ABA)/behavioral consultation services, intensive community-based services such as partial hospitalization programs, intensive in-home services, coordinated specialty care, and high-fidelity wraparound services, among others. It is essential that intensive services are immediately available resources for families, caregivers, and foster care providers to access when crisis behaviors begin.

• Additional comprehensive Assessment and Diagnostic services/programs are needed, particularly for children who exhibit the most complex psychiatric and behavioral symptoms.

• Specialty inpatient programs for children and adolescents with developmental disabilities and challenging behavior and/or co-occurring mental illness are needed in Virginia.

• Out of home placements that provide specialized care are needed to prevent admissions to CCCA. These may include therapeutic group homes (including those for children with intellectual/developmental disabilities), sponsored residential placements with a focus on mental health training/interventions, specialized foster care providers, and psychiatric residential treatment facilities. While for some youth, congregate care may be needed, this should not be the first resort for children and adolescents and every effort should be made to decrease the length of time that youth spend in a congregate care setting and improve the quality of care in those settings.

• It would be beneficial to expand access to evidence-based mental health treatments that decrease long-term morbidity due to mental illness via services such as Coordinated Specialty Care, a program for individuals who have experienced first episode psychosis.

• There is a need to increase systemic coordination by directing resources to expand the availability of resources and support to foster care providers, particularly those that are serving children with intensive behavioral health needs.

• The lack of availability and accessibility of community-based therapeutic services, specifically trauma-based therapies, attachment-based therapies, and child psychiatry, and family support and respite, impact the ability to maintain individuals in the community with their families, rather than seeking psychiatric inpatient admission.

• CCCA staff and culture would benefit from an orientation to the Kin First philosophy. This training would help staff with a primary background in mental health better understand and align with the goals of child welfare workers, ultimately enhancing CCCA’s ability to serve youth across different system, particularly youth in DSS custody hospitalized a CCCA.