Background and History
Agency Background Statement
State Hospitals and Medical Center
The Department of Behavioral Health and Developmental Services (DBHDS) operates nine state mental health facilities (state hospitals) and a medical center. Eight state hospitals serve adults:
Catawba Hospital (CH) near Salem,
Central State Hospital (CSH) near Petersburg,
Eastern State Hospital (ESH) in Williamsburg,
Piedmont Geriatric Hospital (PGH) in Burkeville,
Northern Virginia Mental Health Institute (NVMHI) in Falls Church,
Southern Virginia Mental Health Institute (SVMHI) in Danville,
Southwestern Virginia Mental Health Institute (SWVMHI) in Marion, and
Western State Hospital (WSH) in Staunton.
The Commonwealth Center for Children and Adolescents (CCCA) in Staunton is the only state hospital for children and adolescents with serious emotional disturbance.
The Hiram Davis Medical Center (HDMC) in Petersburg provides medical and skilled nursing services to individuals receiving state facility services who have serious physical and medical care needs.
Major Products and Services
State hospitals provide highly structured intensive inpatient services, including a range of psychiatric, psychological, psychosocial rehabilitation, nursing, support, and ancillary services. Specialized programs are provided to older adults, children and adolescents, and individuals with a forensic status.
Hospital forensic services include inpatient pretrial evaluation, competency restoration, and a variety of clinical and inpatient interventions. At CSH, a maximum security forensic unit has perimeter and internal security and security staffing equivalent to a medium security correctional center and an intermediate security unit has a medium correctional center level of perimeter security. Three hospitals have medium security units or programs, ESH, SVMHI, and WSH, with specialized staff and a minimum of two levels of locked security to prevent escape. Adults with a forensic status also receive services on state hospital civil units.
Geriatric centers at ESH, SWVMHI, CH, and PGH provide a variety of specialized clinical and inpatient interventions in areas of behavioral management, cognition, interpersonal skills, self-care, and leisure time development that are specifically designed to address the unique and complex recovery, treatment, and support needs of older adults (65 years and older).
State hospital inpatient medical services include a broad range of medical, dental, laboratory, and nursing services, but most predominantly include skilled nursing, infirmary services, and acute medical or surgical care. Services are provided in medical/surgical units and HDMC or by referral to local acute care hospitals through the DBHDS special hospitalization program.
Customers Customer Summary
In FY 2014, 4,506 unduplicated individuals received 5,508 episodes of care in state hospitals. Between FY 2004 and FY 2014, the state hospital average daily census (excluding HDMC) declined by 373 or 23% and admissions and separations (discharges) each declined by more than 25%. Over the past ten years, state hospital beds occupied by adult forensic patients increased from 28.9% to 40.1%.
The state hospital customer base will likely increase in response to legislation enacted by the 2014 session of the General Assembly to require state hospitals to accept civil temporary detention order (TDO) admissions if other alternatives have not been identified within the eight hour emergency custody order period.
State hospitals and HDMC are experiencing an increase in individuals who have significant or complex needs or serious conditions requiring specialized services and supports. Many have co-occurring combinations of mental health and substance use disorders, significant behavioral challenges, or acute or chronic medical conditions. Children and adolescents receiving care are among the most challenged and traumatized children in Virginia.
Finance and Performance Management
Finance Financial Summary
Funds depicted in the table below are general fund dollars and non-general funds derived from the collection of fees from Medicaid, Medicare, private insurance, private payments, and Federal entitlement programs related to patient care.
|Fund Code||Fund Name||FY 2015||FY 2016|
|1000||Federal Trust||$200,000||$200,000|Revenue Summary
Revenue collections include fees from Medicaid, Medicare, private insurance, private payments and Federal entitlement programs related to patient care.
Performance Performance Highlights
An important measure of state hospital performance is readmissions of individuals within 30 days of discharge because this measures the effectiveness of hospitals in addressing the treatment needs of admitted individuals completely, working with the individuals’ case management CSBs on discharge planning, ensuring applications for any necessary benefits (e.g., Medicaid or SSDI) have been applied for, preparing the individuals for discharge, and maintaining effective working relationships with the CSBs they serve to avoid unnecessary readmissions soon after discharge. A measure of productivity for state mental health facilities is hospital clinical costs per patient day. Clinical costs include medical and nursing staff, psychologists, social workers, therapists, and other staff and activities that are directly associated with the provision of care to individuals receiving hospital services This measure tracks the overall productivity of its clinical service staff and its ability to identify and address staff capacity issues across hospitals.
Key Risk Factors
Several factors will have a significant effect on state mental health facilities over the next four years.
- State hospitals as facilities of “last resort:” The 2014 General Assembly amended the Code of Virginia to require state hospitals to accept civil temporary detention order (TDO) admissions if other alternatives have not been identified within the eight hour emergency custody order period. CSBs must notify the primary state hospital serving the CSB’s area when an emergency custody evaluation is needed. State hospitals are required to admit any individual for temporary detention who is not admitted to an alternative treatment facility prior to the expiration of the emergency custody period. Based on data to date, this legislation has already resulted in a significant increase in TDO admissions to state hospitals. Admissions to state mental health facilities increased 20% in the second half of 2014 versus the first half. Data indicate that the need for medical treatment is the most frequent reason for delayed access to a community psychiatric bed.
- Lack of community alternatives: Delayed discharges from state mental health facilities increase pressure on local hospital emergency rooms, law enforcement, and individuals who would benefit from state hospital services. In FY 2014, 327 individuals who were determined by their treatment teams to be clinically ready for discharge experienced barriers to discharge that extended their hospitalization over 30 days because community supports and housing arrangements meeting their specific needs are not available. Approximately one-third of those individuals were civil patients with special needs, one-third were geriatric patients who need nursing home placements, and one-third were forensic patients who are committed as not guilty by reason of insanity and whose services need court approval.
- Forensic pressures on state hospital bed capacity: With adult civil beds increasingly occupied by adults with a forensic status, fewer state hospital beds are available for civil patients. Even with a statutory preference for outpatient competency evaluations and competence restoration whenever possible, many persons who could be served on an outpatient basis are instead referred to state hospitals. Continued investment in community-focused forensic services such as outpatient and jail-based evaluations, restoration of competency, and treatment for persons found not guilty by reason of insanity (NGRI) and ongoing diligence and aggressive utilization management of hospital jail inmate admission waitlists are required to offset the increasing demand for state hospital beds by adults with a forensic status.
- Geriatric pressures on state hospital bed capacity: Virginia serves many older adults with psychiatric needs in its state hospital geriatric centers (representing 12% of total hospital bed days for FY 2014) rather than in the community. This rate is among the highest in the nation, in large part because the Commonwealth lacks adequate community alternatives that provide specialized programs and providers trained to address the specific needs of older individuals with mental health or substance use disorders. Specialized crisis response services for older individuals with behavioral health disorders are not widely or routinely available across Virginia. Even as demand is expected to increase as this population group increases. DBHDS is working closely with health and long-term care partners to strengthen the availability of community services and supports for these individuals, including emergency and crisis response services.
- Facility capital requirements: With the completion of the new WSH, the average age of state hospital buildings is nearly 50 years old. Many of these older buildings have significant physical plant problems requiring major renovation. CSH is the remaining hospital that needs to be replaced. A recent survey found that the deferred maintenance needs at state mental health facilities exceeded $ 294,573,930 million.
- Inadequate technical support capacity: As the mental health treatment centers expand use of electronic health records, implement health care reforms, improve performance through technology improvements, and replace aging, expensive technologies with more cost effective solutions, reliance on technical support will increase. An increasing number of mission critical clinical and financial processes rely on technology provided by a limited number of facility and central office information technology staff.
Agency Statistics Statistics Summary
The following statistics provide a snapshot of state hospital operations during FY 2014:
General Information About Ongoing Status of Agency
State hospitals have made significant progress in changing their cultures to support recovery, self-determination, and empowerment. Recovery-oriented and person-centered principles are now increasing the recovery experience for individuals receiving services through peer-to-peer supports, treatment planning partnerships, and educational and career development and job training opportunities.
State hospitals continue to focus on improving bed utilization through aggressive monitoring of service plans and discharge efforts that reduce hospital lengths of stay and enable individuals to be integrated more quickly into the community. In addition, Discharge Assistance Program (DAP) funds are supporting creation of of individualized services and supports for individuals residing in state hospitals who are clinically ready for discharge but have significant barriers to their discharge. Local Inpatient Purchase of Service (LIPOS) funds are being used by CSBs to ensure treatment is provided in the community rather than in more restrictive settings. Both programs received additional funds from the 2014 General Assembly.
To offset the increasing demand for state hospital beds by individuals with a forensic status, ongoing efforts continue to improve forensic patient management, review, and oversight processes and to safely and appropriately divert forensic admissions when possible. Although the Code of Virginia expresses a preference for outpatient competency evaluations and restoration whenever possible, many persons who could be served on an outpatient basis are instead referred to state hospitals. DBHDS is working to develop community-focused forensic services, including jail evaluations and treatment and outpatient competency restoration services in either the community or jail, to safely and appropriately divert forensic admissions to community alternatives.
DBHDS has implemented annual consultative audits (ACAs) to improve state hospital service delivery. ACAs use a peer-review process involving colleagues from other state hospitals, individuals receiving services, and central office staff to review and provide feedback on facility operations and compliance with oversight and accreditation requirements and offer consultative suggestions to improve service delivery. ACA results are being used to facilitate adoption of best practices and operational efficiencies; standardize procedures, as appropriate; and reduce duplication. Operational efficiencies also should result from the implementation of the electronic health record system (EHRS) clinical treatment/medical record, pharmacy, ancillary, and accounts payable modules.
With increasingly complex caseloads, state hospitals must maintain sufficient numbers of staff trained in best practice guidelines and evidence-based approaches in the treatment and care of individuals receiving state hospital services. Hospitals are working to improve staff cultural and linguistic competence so they can better address the recovery and communication needs of individuals and families in a culturally relevant manner.
Mental health treatment centers maintain small teams of information technology (IT) staff to support locally developed application systems and their local information technology infrastructure environments. The DBHDS central office Information Services and Technology (IS&T) office provides coordination, guidance, oversight, and support to ensure that these local systems comport to Commonwealth of Virginia (COV) security requirements and to enable required data integration with central office provided systems.
Implementation of a single electronic health record system (EHRS) to serve all mental health treatment centers will materially affect the demands for local information technology support at the hospitals. Infrastructure modernization, normalization of independently developed local applications, and rapid response end-user device (desktop) support requirements will all increase dramatically as health care delivery processes become wholly dependent on EHRS access.
State hospitals operate 24 hours a day, seven days a week and depend on a cadre of skilled and dedicated employees in a wide variety of classifications. Most provide direct care or support facility infrastructure. Among the human resource challenges hospitals face are workforce aging; competition for psychiatrists, occupational and physical therapists, nurses, pharmacists, and direct care staff; and turnover due to the difficult nature of the work.
The hospital workforce average age is 47.2 years old and average work tenure is 11.5 years. The direct care separation rate is 23.9% and the turnover rate for security positions is 19.6%. During the next 5 years, 21.3% will be eligible to retire with unreduced benefits.
The new EHRS and increasing service demands will require skilled staff with cultural and linguistic competence to serve an increasingly diverse population. Technical or clinical expertise, communication and analytic skills, ability to create and apply sophisticated new technologies, and reasoning and problem-solving capabilities will be needed. A variety of classes in performance management, computer skills, linguistics, and use of interpreters are provided to enhance workforce competence.
DBHDS is responsible for the operation of 10 state-owned mental health facilities. The state hospitals, along with HDMC, have approximately 3,000,000 square feet of building with an average age of nearly 50 years. Lack of adequate maintenance reserve funding continues to present problems with reference to these older structures.
These facilities consist of over 200 individual buildings served by a variety of mechanical heating and cooling systems ranging from central plant distribution systems to individual package heating and cooling units and in some instances makeshift systems. Replacement of these systems based on age and physical condition has typically been deferred due to an uncertainty of the long-range need for continued use of the buildings. Many buildings are anticipated to remain in use for a defined duration have reached the point of requiring an investment to maintain reliable systems for the remaining duration of their use. Buildings that may reach surplus status require conditioned environments to prevent deterioration, therefore enhancing possible future utilization. Although substantial critical system improvements have been achieved in recent years, a substantial backlog of potential system failures and system inefficiencies remain.
More than 400 acres of the current ESH campus have been declared surplus and will be advertised for sale by the Department of General Services. WSH construction is completed and the building is fully occupied. The old WSH campus has been sold.
The DBHDS six-year Capital Outlay Plan includes the following:
Replacement of CSH,
Expansion of WSH,
Renovation of PGH,
Improvements at ESH to create a safe adult mental health environment,
Major system renovations for greater security, and
Major renovation projects for roofs, infrastructure, abatement of hazardous materials, and HVAC/boilers repairs and replacement.
DBHDS is assessing ways to make facilities more efficient. This includes an examination of food service and laundry operations.
Note: This is one of five DBHDS Executive Progress Reports. See Department of Behavioral Health and Developmental Services (720); Grants to Localities (790); Intellectual Disabilities Training Centers (793); and Virginia Center for Behavioral Rehabilitation (794).