In 2014, the General Assembly enacted SB 260 in response to concerns about access to inpatient psychiatric care during behavioral health crises. Among other changes, the legislation established the “Bed of Last Resort" requirement, directing state hospitals to admit individuals under a temporary detention order (TDO) when no private psychiatric bed could be identified during the emergency custody order period. An overview of the legislation is provided in Appendix A.

While the legislation succeeded in expanding access to inpatient psychiatric treatment, it also produced significant unintended consequences for Virginia’s behavioral health system, particularly its state hospitals. Following implementation, civil TDO admissions to state hospitals increased dramatically, rising nearly 400 percent by FY 2019. The resulting demand drove state hospitals to sustained occupancy levels at or above capacity, well beyond the generally accepted maximum safe utilization rate of 85 percent, creating significant challenges for patient care, safety, and staffing.

Although DBHDS has restored nearly all state hospital bed capacity and added new beds to the system, demand continues to exceed available resources. At the same time, state hospitals have experienced substantial growth in forensic admissions, which now account for approximately 63 percent of the inpatient population. As a result, individuals requiring admission under the Bed of Last Resort provision often cannot be admitted immediately, despite statutory requirements.

The Commonwealth now faces a troubling reality: despite substantial investments and reforms, some individuals experiencing psychiatric crises are again unable to access timely inpatient treatment. This challenge reflects multiple factors, including workforce and service gaps in the community behavioral health system, increasing demand for both civil and forensic services, limitations in private hospital capacity for individuals with specialized needs, and broader systemic reliance on state hospitals and the legal system to address behavioral health crises.

This report examines the most significant impacts of the 2014 legislation, efforts undertaken to address unintended consequences, and data related to implementation of the Bed of Last Resort requirement.