Virginia County sues state behavioral health system for failing to admit psychiatric patient

Virginia’s state-run psychiatric hospital system faced trial this week after refusing to admit a juvenile patient who was going through a mental health crisis.

Instead of receiving care, the patient – a child in the care of the Giles County Department of Social Services – spent four days confined to a Richmond emergency room waiting for a state bed to become available. , according to a petition filed by the agency against the Virginia Department of Behavioral Health and Developmental Services, which oversees the eight state-funded mental health hospitals.

The case – one of the first to challenge the state for denying a patient who technically had to be admitted under its own regulations – is the latest blow to the agency, which has been the subject of a scrutiny last summer after temporarily close more than half of its hospitals to new admissions. Under Virginia’s “bed of last resort” law, public hospitals are required to accept patients if a place cannot be found at another facility, including private hospitals with behavioral health units. .

But as publicly funded institutions continue to struggle with staff shortage and widespread overcrowding, experts and frontline providers say the law is not working functionally. Alison Land, the DHDDS commissioner under former Gov. Ralph Northam, described last summer’s order as a desperate response to a dangerous understaffing that was limiting the agency’s ability to provide care.

Even with all eight hospitals reopened to new admissions, capacity is still limited. And with a shortage of private beds, patients in crisis regularly spend days in the emergency room and sometimes have no access to care at all.

Eastern State Hospital in Williamsburg, Va., is one of eight state-run psychiatric hospitals (Photo courtesy of DBHDS)

“I’m just surprised it’s taken this long for there to be a trial,” said Anna Mendez, executive director of the Charlottesville-based nonprofit Partner for Mental Health. “If you are deprived of your civil rights for the purposes of your mental health treatment, you must indeed receive this treatment. And right now we’re seeing people who just aren’t getting that care. »

“Sooner or later it was going to happen”

The petition highlights an increasingly common situation faced by patients in crisis as well as the providers charged with caring for them. According to the lawsuit, the patient – whose exact age has not been revealed – was admitted to Chippenham Hospital in Richmond under a temporary detention order, which allows individuals to be involuntarily detained. they present a danger to themselves or to others.

Richard Chidester, a Giles County attorney, said the February 21 order required the girl to be assessed at Tucker Pavilion, Chippenham’s on-site psychiatric unitand transferred to the Commonwealth Center for Children and Adolescents for treatment.

Located in Staunton, the CCCA is the only public hospital that can accept minors, according to DBHDS spokesperson Lauren Cunningham. But a severe understaffing means it has been operating at around a third of capacity since July. The hospital is currently unable to fill any of its five vacant licensed practical nurse positions and has a 50% vacancy rate among direct care nurses. There are 57 openings for aides who provide hours of direct patient care. As a result, the establishment operates only 18 out of 48 beds.

“We can say that while public and private hospitals are still reeling from staffing shortages and bed closures related to COVID-19, DBHDS has worked with partners across the state to ensure continuity of services. to the extent that they can be provided in both community and hospital settings,” Cunningham said, adding that the agency does not comment on ongoing litigation.

She listed 15 private hospitals with child and adolescent psychiatric units, and Chidester said local assessors also tried to place the patient in a private facility. It is unclear why Chippenham was unable to admit her for inpatient mental health treatment and CCCA was listed as the facility on the girl’s detention order.

Tension between DBHDS and private hospitals is just one component of Virginia’s ongoing bed crisis. The private sector faces growing pressure to support more involuntary admissions from the state, while industry says it is handling a disproportionate share of voluntary cases while facing the same staffing challenges.

Although the state has repeatedly denied requests to add state-funded beds, it has directed money to private hospitals take on more patients. But these facilities are still not legally required to accept involuntary admissions even if they have space available. This has left many patients in a waiting pattern with nowhere to go.

(Getty Images)

In a functioning system, the Giles County patient would have been admitted for treatment within hours of the detention order being issued. But without a private bed — and with the state unable to admit it under its own law on beds of last resort — that hasn’t happened. Instead, the lawsuit alleges the girl spent days in the emergency room, supervised by a police officer, until her TDO expired.

According to the petition, the CCCA notified the county’s Department of Social Services that a bed would likely be available on Feb. 25, four days after his TDO was issued. But after the order expired, the state refused to admit her despite an available spot. After 96 hours in the ER, Chippenham also refused to continue to detain her without DOT and she left without ever receiving mental health treatment.

Virginia College of Emergency Physicians board member Dr. Joran Sequeira said finding treatment for young patients is especially difficult given the limited availability of pediatric mental health beds. But she described the process as grueling for patients of all ages.

“It’s just appalling care for anyone, child or not, to sit in a room for so long,” she said. Emergency rooms can’t provide advice, and Sequeira said doctors aren’t even able to prescribe new psychiatric drugs unless the patient becomes restless or disorderly.

She has seen calm, cooperative patients decline under the stress of confinement and become angry. And aggressive behavior can make many hospitals even less willing to accept psychiatric patients, even if they arrive under stress. Like many experts, she was not surprised that the state’s failure to admit new patients led to a lawsuit.

ER doctors have issued calls for state-level reform with law enforcementwho must regularly spend hours supervising patients in the emergency room before they are admitted to a treatment center.

“You go to some state hospitals and the parking lots are just filled with sheriff cars and police cars waiting to turn patients over,” said John Jones, executive director of the Virginia Sheriffs Association. “It’s a system failure, but I guessed it would happen sooner or later.”

Lawmakers have debated the issue for years, but many frontline experts say there have been few systemic solutions. The sheriffs association successfully lobbied for an invoice, passed by both houses of the General Assembly this year, that would allow law enforcement to transfer custody of patients to third-party state-contracted transportation companies. The legislation would relieve officers from sitting with patients in the hospital, but Jones acknowledged it would do little to address the underlying problem of bed availability.

Governor Glenn Youngkin has pledged to invest in a “mental health crisis plan” on the campaign trail, and the governor “is currently working with lawmakers from both parties to find long-term solutions to ensure that care is accessible and that there are much-needed improvements to state hospital services and services community mental health services,” spokesman Macaulay Porter said. in a report.

The House and Senate budget proposals include about $90 million over the next two years to increase salaries at public hospitals and allocate about $150 million to several priorities, including supportive housing for patients discharged from institutions. Approximately $50.5 million would go to STEP-VAan initiative to expand mental health services through the state’s local community service boards, and both proposals would maintain a 12.5% ​​increase in Medicaid reimbursement rates for private mental health providers.

It’s unclear to what extent the incremental changes will reform the state’s mental health system. Even with growing investments in local services over the past five years, DBHDS estimated it would cost $150 million just to fully fund STEP-VA. And Mendez said Medicaid reimbursement rates are still so low that it’s hard to find providers for much-needed services like intensive outpatient treatment, which has been shown to reduce psychiatric hospitalizations.

“Until we’re ready to make a real investment, we’re going to continue having crisis after crisis after crisis,” she said. “We’ve been undermining our system for so long, it’s frustrating to me that people continue to be surprised by situations like this.”

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