A recent decision by the state’s Department of Behavioral Health and Developmental Services to close admission at five of the commonwealth’s eight adult psychiatric hospitals is straining a mental health system already bursting at its seams. The effects of the July 9 decision by Commissioner Alison Land is likely to have ripple effects in communities that were already struggling to accommodate the need for mental health services.
The Capacity and Staffing Crunch
In defending her decision, Land cited a phenomenon felt today in many industries—inadequate staffing levels at the affected hospitals. This is causing potentially unsafe conditions for both staff members and patients at a time when assaults by patients against staff or fellow patients are already high. More than 60 serious injuries of patients and staff have been reported since July 1, and state facilities are averaging 4.5 incidents or injuries a day, Land wrote. The department reports 1,547 direct patient support staff vacancies out of 5,500 positions across the eight facilities, with more than 100 staff resignations just since the month began. Although it remains open to admissions, the only state psychiatric facility for children, the Commonwealth Center for Children & Adolescents in Staunton, can only safely operate 18 of its 48 beds, according to Land.
Her letter to healthcare partners and providers asks for all private beds in hospitals and healthcare facilities to be opened to accept patients under temporary detention orders, when a determination has been made that the individual is a danger to themselves or others. A temporary detention order, signed by a magistrate, requires the individual to receive immediate hospitalization for further evaluation and stabilization, on an involuntary basis, until a commitment hearing can be arranged to determine any future treatment needs. In most cases, such a hearing is required to take place within 72 hours.
Even prior to Land’s decision, state and private facilities were already facing a strain on staffing. The eight state adult mental health facilities, including the three that remain open to admissions, were averaging more than 90% utilization, according to a July 15 presentation to the state’s Joint Committee to Study Mental Health Services in the Commonwealth in the 21st Century, more often referred to as the Deeds Commission. The three facilities that remain open, including the closest state facility to Loudoun, the Northern Virginia Mental Health Institute in Fairfax, are averaging 95% occupancy.
In Loudoun, licensed and staffed beds to accommodate patients receiving mental health services are at a premium. Currently, only Inova Behavioral Health Services at the hospital’s Cornwall campus in downtown Leesburg has mental health beds for adults, at a total of 22. Nearby, North Spring Behavioral Services provides inpatient mental health treatment for teens and adolescents.
“We’re at 100% capacity,” Dr. Linda Lang, president of Inova Health System’s Behavioral Health Services, said in a recent interview.
Lang was referring to the entire hospital system’s licensed and staffed mental health beds, a total of 133 across its facilities in Leesburg, Mount Vernon and Fairfax. The spike in demand from patients experiencing a mental health crisis has been staggering, she said. The hospital system averages 700 to 800 patients voluntarily coming through its emergency room doors, often the first stop for those experiencing a mental health crisis, on a monthly basis. Temporary detention order admissions to the ER were up almost 40% from 2020 to 2021, and Lang said Inova averages about 400 such patients in its ERs every month.
“These are unprecedented numbers coming through our emergency rooms,” she said.
If it is determined by a medical professional that a patient needs more comprehensive inpatient mental health services that a quick trip to the ER cannot adequately address, then the search for an available bed begins. That search is oftentimes taking days, and that means that the patient is taking up a bed in a hospital’s emergency room while they wait.
Law Enforcement Feels the Burden
Those under a temporary detention order who are waiting for an available bed at a mental health facility will have company while they wait, in the form of a local law enforcement officer. And local public safety agencies too are feeling the staffing pinch. In a time when positions in law enforcement have become harder to fill, taking another patrol officer off the streets makes life even harder for local agencies.
Lt. Thomas Thompson is the mental health liaison for the Leesburg Police Department. He said the department has seen its calls for mental health assistance rise in recent years.
“You can imagine when you’re having to watch someone 24 hours for multiple days, that’s a huge burden on our staffing as well. You’re talking about an officer not available for the street. We’re either having to use someone on duty or bring someone in on overtime,” he said.
Officers may also be called in to respond to a local emergency room if a patient who comes in for unrelated services demonstrates behavior that indicates a potential for harm to self or others. In that case, an Emergency Custody Order is issued, and the law enforcement officer notifies the local Community Services Board to begin the process for reviewing whether a TDO is needed for the individual.
Outside of the time spent in the ER waiting, transporting a patient to a mental health facility can be even more time-consuming. Two law enforcement officers must be on the transport, meaning even fewer officers available for patrol.
“When we have these transports that we have to conduct, at times we’re traveling six-and-a-half hours, just road time, to take someone to a facility that can be as far away as Williamsburg or Petersburg. They have to transport the person, and once they get there they have to turn them over, process them into the facility and then return back. It’s just a huge drain on an agency of our size,” Thompson said.
The Alternative Transportation Program was created by the state and implemented last year to address some of that strain on law enforcement by using a private provider to transport patients under a temporary detention order to a treatment facility. However, its impact in Loudoun has been minimal. According to Thompson, through the spring the program had only been used in the county twice across all public safety agencies in Loudoun, including the Sheriff’s Office and police departments in Leesburg, Purcellville and Middleburg. The criteria for patients eligible for the program can be particularly limiting. If a patient is exhibiting self-injurious or aggressive behavior, if they are an escape risk or if they are medically fragile, they are not eligible for a private transport, putting the onus back on local law enforcement.
“I became an officer to become a police officer. I never thought I was going to be the guy in the white coats in the white vans. It’s just the strangest thing, but it’s the world we find ourselves in,” Thompson said.
Purcellville Police Chief Cynthia McAlister said calls for mental health assistance are straining her small department, already experiencing a staffing crunch that she has not seen in her 39 years in law enforcement.
“This is the worst I’ve ever seen it,” she said.
Of the department’s 21 sworn positions, five are vacant. The Leesburg Police Department reports 13 vacancies among its 90 sworn positions.
McAlister said Sheriff Michael Chapman provides her department with a deputy to assist in mental health transports to lower the staffing impact. Still, a patient transport means that only one on-duty officer remains in town.
“I think the struggle for us in law enforcement is, [mental health] is not a law enforcement issue, but because no one else is out there it becomes a law enforcement issue,” she said.
McAlister called the signing of Marcus Alert legislation by Gov. Ralph Northam at the end of last year “a beautiful philosophy … if we can make that work.” The legislation creates a statewide mental health alert system to ensure behavioral health experts are involved in responding to individuals in crisis by limiting the role of law enforcement. The bill was named for Marcus-David Peters, a high school biology teacher who was killed by a police officer in Richmond while experiencing a behavioral health crisis in 2018.
Many both inside and outside of law enforcement have openly questioned what role law enforcement should play in assisting individuals struggling with a mental health crisis. Chapman has recently instituted a pilot program in the Loudoun County Sheriff’s Office that seeks to provide a softer approach on a call for mental health assistance.
The Community Assistance Response and Empowerment, or C.A.R.E., team assigns one full-time deputy per shift to exclusively respond to and follow-up on mental health, suicide, overdose, and other calls for service involving critical issues. The deputies on the team are current School Resource Officers, available while schools are closed for the summer, who are certified in both basic and advanced Crisis Intervention Training.
They arrive to calls dressed in a green polo shirt and khaki pants. While they are still armed, the softer, more casual approach is intended to make a struggling individual more comfortable. Another key difference is the follow-up the C.A.R.E. team member employs after an initial call for assistance.
“Instead of just taking a call and advising people of the [mental health] resources available to them, we have these deputies 100% committed to going back and following up to those locations and those homes. It’s not just a matter of taking a report and doing a referral, it’s about being actively engaged,” he said.
It’s a program that has already been well utilized since its July 1 start. This month alone, the Sheriff’s Office has had 229 calls for mental health assistance and 103 follow-ups by a C.A.R.E. team member. On the whole, Chapman said the agency’s calls for mental health assistance have not gone up dramatically, but the time required to handle to each call has. For the recently completed Fiscal Year 2021, that amounted to 5,157 hours, up from just over 4,000 hours the previous fiscal year.
Chapman said he will re-evaluate the new program after the school year begins and the SROs return to fully reopened public schools.
“The question is whether we’ll be able to get the resources in the future to continue it,” he said.
Advocacy & Community Investment
Katrina Cole, president of Friends of Loudoun Mental Health, doesn’t mince words when it comes to the current state of affairs.
“We’re in the biggest mental health crisis in this country that we’ve ever been in,” she said.
For many, the COVID-19 pandemic and resulting social isolation exacerbated an existing mental health crisis. While the stigma attached to receiving mental health services has waned over the years, the need for those services has not. In fact, she and others said, the acknowledgment by individuals that they need inpatient or outpatient help, while a positive change, has strained an already strained system.
The goal for many is to keep patients from needing inpatient services, by taking a proactive approach to mental health treatment. But many in need of treatment at state psychiatric facilities already are struggling financially and may not have the insurance or the resources to afford inpatient care at a private facility, or even outpatient services, she said.
The need for help from the state is great, and Cole and others in the nonprofit world who help people in crisis are urging the public to write to their state representatives to provide funding for incentives, bonuses and pay raises to retain or attract employees for mental health facilities.
“This problem did not just happen, and it didn’t just happen because of COVID. It exacerbated the situation,” she said. “Why hasn’t the state been on top of the funding? We’ve got to find a way to staff up these hospitals, because a state hospital is part of the safety net that we need to provide for people with mental illness.”
Sen. R. Creigh Deeds’ (D-25) advocacy stemmed in part from his own personal tragedy. Deeds’ son, Gus, who was struggling with severe mental health challenges, attacked his father at their family farm in November 2013. Gus killed himself shortly after the attack and news reports would soon bring to light that healthcare workers had been unable to find an available psychiatric bed for Gus, who had been brought to an emergency room under a temporary detention order requested by his father.
Since then, Deeds has led the charge for reforms to the mental health system in the state and said Virginia has made many strides. He said many blame the current situation at state-run psychiatric facilities on the bed-of-last-resort legislation, signed into law a year after Deeds’ attack. The law requires state mental hospitals to accept patients under temporary detention orders if no bed can be found in a private psychiatric facility within eight hours after a patient taken into involuntary emergency custody.
He points out that the number of temporary detention orders across the state has gone down over the past decade. But not enough has been done to solve the lingering workforce issue, he said.
“We need to make sure we have a pipeline of [behavioral health] workers being trained and ready to go. We haven’t really done enough work there, but we’ve done some. We have to make the jobs attractive enough. We have to pay people decently, with good incentive bases,” he said.
Deeds said the upcoming General Assembly session to deal with American Rescue Plan Act funding won’t be the time to find a long-term solution but suspected there would be support for putting funding into one-time bonuses while legislators work towards a better pay plan.
There’s a big picture issue that also can’t be ignored, Deeds said.
“We’ve chronically underfunded community services and that’s a state problem, also a local government problem,” he said. “If you keep people out of crisis they’re not going to go to the hospital. Make sure they receive services in their community and treat them more efficiently and effectively.”
“State beds need to be reserved for long-term care,” he said. “The vast majority of people who have mental health and substance abuse issues can be served in the community. We have to change the way we think about the institutions and focus on community services and invest there.”
Localities are required to dedicate 10% of their state appropriation to community services, but there is no real penalty for not doing so, Deeds said. While Fairfax County and the City of Falls Church outperform that metric, and Loudoun does better than most, many localities, including Deeds’ own constituencies, do not dedicate adequate funding to community services, he said. That, too, can have its own negative consequences.
“When we don’t invest money keeping people out of crisis, we end up incarcerating at a huge expense to our taxpayers. I don’t need to remind you how many incidents involving law enforcement ultimately involve people that struggle with mental health and substance abuse,” he said.
Margaret Graham, director of Loudoun’s Department of Mental Health, Substance Abuse and Developmental Services, points to the resources currently available to county residents, like the CrisisLink hotline and the Crisis Intervention Team Assessment Center, which provides mental health evaluation, crisis intervention and stabilization services, as well as links to various resources for anyone experiencing a mental health or substance use related emergency. It’s available to all residents, regardless of insurance, and can be accessed seven days a week from 7 a.m. to 11 p.m. In the instances where an individual is brought in for assessment by a law enforcement officer, they are received by a deputy so that officer can return to patrol duties.
In another effort to keep individuals out of the hospitals, if conditions allow, a crisis call center operation is being developed in the current fiscal year to be a liaison to and from emergency dispatchers, to act as a triage and ensure individuals are getting the right services, she said. CrisisLink will eventually fold into that operation.
“In addition to that, in Northern Virginia we’re in the process of developing a residential crisis stabilization unit which is going to be located in western Fairfax but will serve all five Community Services Boards [including Loudoun] in the region. It will bring people in who need a 23-hour bed or period of crisis stabilization. It will divert folks from the hospital so it will have a greater scope than what we operate in CITAC,” she said.
Help In Sight?
As with many things, more funding may need to be part of a long-term solution to address the mental health staffing shortage and resulting fallout.
Julian Walker, vice president of communications for the Virginia Hospital and Healthcare Association, said they have sent a letter to the state offering to open up 58 beds for psychiatric patients across its member hospitals—40 for adults, and 18 for juvenile patients. They are requesting $8.5 million to address the staffing needs for those licensed beds. Land, on behalf of the Virginia Department of Behavioral Health and Developmental Services, is requesting hundreds of millions of dollars from the state to address its severe staffing shortage at mental health facilities.
Walker said the hospital and healthcare association has worked with the state government on numerous occasions to address challenges with the mental health system, and this proposal is just another effort to continue doing that.
“We have a shared interest with the state in solving these issues,” he said. “For many years, we’ve proposed a number of policy solutions, some of which the state has been receptive to, others less receptive. Ultimately, we all share the same interest.”
Cynthia Benbow, executive director of behavioral services for StoneSprings Hospital Center, hopes that the new adult behavioral health unit at HCA’s Aldie hospital provides some relief locally to the statewide bed shortage. The opening of the unit, slated for October, will bring 17 adult psychiatric beds to the county.
“We’re excited about bringing on the unit, being an extension to the community,” she said. “We want to be a part of the solution to meeting the needs of the solution. This is not a stop, it’s a start. We need more.”
Even with the new unit, that brings the total number of licensed adult mental health beds in Loudoun hospitals to just under 40—in a county whose population exceeds 400,000. She said the hospital will work closely with Dominion Hospital, its sister hospital in Falls Church that provides mental health treatment, to meet the needs of the local community.
“As we come online and find ourselves full at times we’ll partner with Dominion to maybe take some overflow that we’re not able to meet. The whole goal is to be here to be available to be an arm to the community and be able to admit [patients] in a timely fashion and meet their needs when a crisis is occurring.”
With no apparent signs of battle fatigue, Deeds remains resolute in continuing to address the mental health crisis in the commonwealth. He said the state cannot sit on its laurels until another high-profile incident, like the 2007 massacre at Virginia Tech or his own personal tragedy, makes headlines. Quick-fix funding solutions that become less important as time wears on, or if and when the sentiment toward mental health changes, will not work.
“We’ve done all we can, just not enough. We have to redouble our effort and we will,” he said.
Like Deeds, Benbow said the community, state and country cannot take its collective foot off the gas when it comes to addressing mental health needs.
“We just have to keep talking about it,” Benbow emphasized. “We need to keep being on the forefront. We can’t stop talking like it’s not an emergency because it is.”