Saturday, September 23, 2023

Virginia is spending millions to boost security at state-run mental hospitals

Eastern State Hospital in Williamsburg is one of eight state-run psychiatric hospitals that will receive additional security staff over the next two years. (Photo courtesy of DBHDS)

RICHMOND — Over the next two years, Virginia will spend more than $8 million to boost security at its state-run psychiatric hospitals, adding a total of 65 positions across eight facilities. 

The additional funding, approved in the state’s latest two-year spending plan, comes as the Virginia Department of Behavioral Health and Developmental Services continues to grapple with an admissions crisis.

Overcrowding is “the single largest issue currently impacting our state hospitals,” said agency spokesperson Lauren Cunningham, who also said DBHDS requested the funding to enhance safety amid ongoing reports of staff and patient injuries. 

Improving conditions at the facilities, which act as a safety net for some of Virginia’s most critically ill patients, has been a legislative priority for years. But the move to add security positions without significantly boosting pay for much-needed clinical staff has been concerning to some lawmakers and mental health advocates, who say it’s another example of the state prioritizing stopgap measures over long-term solutions.

“Treatment teams, the direct service staff, they’re interacting with people every single minute of every single day,” said Anna Mendez, executive director of Partner for Mental Health, a nonprofit advocacy group that also offers referrals for services to patients in the Charlottesville area.

Adequate staffing “could probably prevent 90 percent of the issues that are now ultimately leading to needing more security,” she added. “So it feels like this is another really strong example of Virginia — instead of being willing to invest a modest amount of resources in preventing a problem — is waiting until there is a crisis and then having to throw a lot more money at it.”

Struggles with staffing

Staffing challenges have been a growing problem at state-run hospitals since 2014, when Virginia passed what’s known as its “bed of last resort” law. The legislation, which requires the facilities to admit patients if a bed can’t be found at another treatment center, was followed by a marked increase in patients admitted to state facilities under temporary detention orders — a type of involuntary civil admission issued by magistrates if patients present a danger to themselves or others.

The rise in TDO admissions, which used to be shared more evenly with private hospitals, has led to serious and sustained capacity problems at Virginia’s psychiatric hospitals. Last summer, more than half of state-run facilities closed to new admissions as overcrowding led to a “dangerous environment where staff and patients are at increasing risk for physical harm,” according to then-DBHDS Commissioner Alison Land. 

Severe understaffing has only exacerbated the issue, according to the department. Shortly before Land shut down new admissions, she told lawmakers that low salaries and burnout were pushing workers out of the field. At the time, pay for most direct care staff started at $11 an hour — the 10th percentile of market rates for the industry. In the two weeks before the hospitals closed, 108 employees resigned from the system

Despite an infusion of federal aid dollars used to boost bonuses and pay, employee shortages are still limiting capacity at state facilities. The Commonwealth Center for Children and Adolescents, for example — Virginia’s only state-run psychiatric hospital for minors — is operating only half of its 48 beds due to ongoing staff vacancies. Systemwide, roughly 45 percent of direct care nursing assistant and licensed practical nurse positions are currently unfilled, along with nearly 30 percent of registered nurse positions. 

The Commonwealth Center for Children and Adolescents is the only state psychiatric hospital that accepts children. Currently, only half of its beds are open to admissions. (Image courtesy of the University of Virginia Medical School)

The combination of low staffing and overcrowding has led to an ongoing stream of disturbances involving patients and employees. Over the last fiscal year, which ends this month, more than 70 percent of workers’ compensation claims were linked to injuries from patients, according to DBHDS data. In the last four months, there have also been 52 critical incidents involving patients — a category that includes deaths and serious injuries.

Cunningham said DBHDS saw the additional $8 million in security funding as “part of larger efforts to address the census crisis.”

“The increase will allow hospitals to staff the necessary amount of officers for each shift based on facility needs, ensuring at least two officers are always in the hospital building for safety/security and to respond to emergencies or incidents on patient units,” she said

‘A path that may be difficult to come back from’

The plan to add security officers at every state-run facility sparked little debate from lawmakers, who approved a new two-year spending plan earlier this month.

Initially, budget negotiators allocated $3.6 million for 29 new positions at Eastern State Hospital in Williamsburg and the Northern Virginia Mental Health Institute, which were selected based on staffing levels and the high needs of their patient population, according to Cunningham. This June, an amendment from Gov. Glenn Youngkin added $4.7 million for 36 additional officers across all eight facilities. The proposal passed both legislative chambers nearly unanimously.

In an interview last week, Sen. Creigh Deeds, D-Bath, described the positions as vital to Virginia’s efforts to enlist more clinical staff, especially given the intense workload in psychiatric hospitals. 

“If we can provide more security, I think we can do a better job of recruiting people,” said Deeds, who sponsored the state’s bed of last resort law. “When there are patients and staff being assaulted every day, you have to provide some safety.”

Sen. Creigh Deeds, D-Bath. (Photo by Ned Oliver/Virginia Mercury)

Some mental health experts, though, are dubious that the officers will be a panacea for safety concerns. Mendez pointed out that even as legislators approved millions for security personnel, they only boosted pay for clinical staff to the 50th percentile of current market rates. While the increase is still a sizable bump compared to previous salary levels, it’s well below the 75th percentile increase proposed in a prior Senate budget plan.

In earlier conversations with lawmakers, Land worried that raising pay even to the 75th percentile wouldn’t be enough to compete with private providers and outside industries. And with the starting salary for some officers listed higher than the pay band for some clinical staff, including certified nurse assistants, Mendez said the state was deprioritizing health care workers.

“At least part of the reason there are increasing safety concerns is because they’re still understaffed by treatment team providers,” she said. “Well, perhaps if we paid our licensed practical nurses what we’re offering our security officers, we could fix that.”

In a Friday statement, Cunningham said that some security staff “may be responsible” for developing a rapport with patients and supporting direct care staff along with checking for contraband, patrolling facilities and escorting patients to and from appointments. But a work profile provided by the agency does not list clinical support or de-escalation training as part of the job, which does require the ability to “physically control, confine, restrain, and arrest in difficult situations.”

Sen. Monty Mason, D-Williamsburg, worried that a growing reliance on security workers could lead to Virginia’s state hospitals becoming increasingly jail-like with little planning or discussion.

Over the years, he said, facilities have witnessed changes in their admission trends, including the growing number of patients admitted through temporary detention orders. Eastern State, in his home district, has also seen a spike in so-called “forensic” patients, who are referred to the hospital from the criminal justice system.

Eastern State Hospital in James City County is one of Virginia’s eight publicly run mental hospitals, which have struggled with understaffing and an influx of psychiatric admissions. (Virginia Department of Behavioral Health and Developmental Services)

There’s no evidence, though, that forensic patients are any more likely to be disruptive than patients from the general population. And while facilities have anecdotally shared that patients with TDOs often seem to have higher needs, DBHDS doesn’t track whether critical incidents are linked to civil admissions or patients referred through the courts.

Given the limitations of available data, Mason said it isn’t clear whether adding security personnel actually boosts safety.

In 2021, Eastern State created a crisis prevention response team that paired officers with clinical staff to defuse psychiatric crises. Unlike some of the agency’s general security listings, officers on the team were expected to have experience in mental health and training in de-escalation techniques.

Ongoing staffing shortages, though, meant the program has never been fully executed. 

“Some of the clinicians didn’t like the direction in the first place because you’re trying to restore people,” Mason said. “And having a law enforcement authority there is likely something that’s been traumatic for the patient in the past.” 

He also pointed out that there was no formal state assessment of Eastern State’s program, which was specifically designed to be therapeutic. Without evidence backing the role of security officers in state-run mental hospitals, he questioned the decision to dramatically increase funding in the budget.

“Our program started out as a pilot, and now here we’re putting money in the budget for expanding the security force across the board,” Mason said. “I understand the need, but I just wanted to make everyone aware that we are headed down a path that may be difficult to come back from.”

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