In response to concerns about Virginia’s behavioral health crisis response system, the General Assembly made significant changes in 2014 to the Commonwealth’s civil commitment laws in an effort to ensure that every individual who met the criteria for temporary detention received timely access to inpatient psychiatric care. The new laws made sweeping changes in Virginia’s emergency custody order (ECO) and temporary detention order (TDO) statutes, including extending the ECO timeframe to eight hours, creating the “Bed of Last Resort" precedent to require state hospitals to admit individuals under a TDO for whom no private bed could be located during the ECO period, and updating other communication and notification requirements. Since the enactment of this legislation (contained in SB 260 (2014)), the Department of Behavioral Health and Developmental Services (DBHDS) has continuously worked 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 the new laws. An overview of the legislation can be found in Appendix A.

The 2014 law changes, particularly Bed of Last Resort, have had dramatic unintended effects on the behavioral health system in Virginia, most notably the state hospital system. As noted in this report, civil temporary detention order (TDO) admissions to state hospitals rose dramatically after the legislation was implemented in FY 2014. By FY 2019, civil TDO admissions to state hospitals had risen by almost 400 percent. This increased demand for services, high hospital census, and constant utilization of state hospital beds at 100 percent or above (85 percent is considered the optimum maximum safe utilization) has had significant impacts on the state hospital system’s ability to maintain a safe therapeutic environment and adequate staffing levels. In an attempt to maintain minimal safety in its state hospitals, in July of 2021, DBHDS temporarily reduced bed capacity to improve staff to patient ratios. Since that time, DBHDS has made significant progress in recruiting and retaining staff to safely operate state hospitals, and all adult and geriatric state hospital beds have been restored. Only the Commonwealth Center for Children and Adolescents (CCCA) remains at limited capacity due to staffing levels, currently operating at 50 percent of its 48-bed capacity.

DBHDS has maintained a waitlist of individuals awaiting admission under TDOs since July of 2021. Despite most state hospital bed capacity being restored, and the addition of 56 adult beds to the system at Western State Hospital in 2024, individuals under civil TDOs who require a state hospital bed under the Bed of Last Resort are still often not able to be admitted immediately. This is due, in part, to the significant rise in individuals under forensic court orders that state hospitals are required to admit. Currently almost 60 percent of patients in state hospitals are hospitalized under a forensic court order.

While the intent of the law changes was to ensure that any Virginian in an acute psychiatric crisis had timely access to the treatment required, Virginia has once again found itself in a situation in which some individuals in psychiatric crisis, that have been assessed to require inpatient care, are being released without treatment. This may be attributable to a variety of factors: Virginia’s still in development community based system of behavioral healthcare; over reliance on the state hospital system; the dramatic increase in admissions to state hospitals that was proven unsustainable; state hospitals being required by the Code of Virginia to serve as the last resort for both forensic and civil patients; private hospitals denying admission for some individuals under TDOs who have specialized needs (medical needs, intellectual/developmental disabilities, older adults and individuals with challenging behaviors, etc.), over-reliance on law enforcement and the involvement of the legal system in behavioral healthcare, and a culture of risk aversion.

This report contains information regarding the most significant impacts the law changes in 2014, efforts and initiatives to address unintended impacts, and a variety of data points related to the Bed of Last Resort legislation.