Deaths in Virginia state psychiatric hospitals have been on the rise over the past several years. The number of deaths in the facilities has nearly doubled since 2014. In 2014, there were 32. In 2018, there were 59.
“The greatest concern that we have: the number of deaths that have happened, and especially the number of deaths that happened so close to admission,” said Colleen Miller, Executive Director of the Disability Law Center of Virginia.
For decades, the Disability Law Center of Virginia has served as a watchdog for the state’s behavioral health system. A recent analysis of the 59 deaths from October 2017 through September 2018 showed nearly 40% occurred within 90 days of admission.
Deaths at Virginia's State Mental Health Facilities
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Data: disAbility Law Center of Virginia's Report on Critical Incidents in Virginia’s State Operated Mental Health Facilities October 1, 2017 - September 30, 2018. Visualization by WCVE Intern Malcolm Key.
Unintended Consequences
There are a lot of unanswered questions about what’s led to the increase in deaths. But two words seemed to come up over and over in interviews with lawmakers, experts and advocates: unintended consequences -- unintended consequences of a 2014 state law.
This legislation has become known as the “bed of last resort” law. It requires state psychiatric hospitals to admit patients after eight hours if no other bed can be found in a private hospital, or other facility.
Virginia Senator Creigh Deeds championed the legislation following a personal tragedy. In 2013, Deeds admitted his 24-year-old son Gus to a local hospital fearing he’d harm himself, but the hospital discharged Gus after they said they couldn’t find an inpatient bed within six hours. Gus took his life soon after that.
The bed of last resort law was designed to prevent tragedies like this, and ensure people get treatment when they need it most. But even Deeds admits the law had unintended consequences. More people -- a lot more people -- being sent to already overcrowded state hospitals.
“The problem that's been created is that mental health hospitals are consistently over 90% capacity and there’s all sorts of evidence out there suggesting anything over 85% [capacity] puts both patients and staff at risk,” Deeds said.
Over the last few years, the number of people being admitted involuntarily to state psychiatric hospitals has more than doubled. Dr. Richard Bonnie with the University of Virginia has studied the trend for years. He says he hasn’t heard of any other states with a law quite like Virginia’s bed of last resort legislation.
“The pressure on the state hospitals has been tremendous,” Bonnie said. “Something needs to be done to alleviate that pressure.”
Goldilocks Syndrome
The search for an in-patient psychiatric hospital bed often starts with community-based crisis clinicians like Lisa D’Alessio, with Henrico’s community mental health center, known as a community services board or CSB.
She works with a small team in a crisis call center, responding to crisis admissions and coordinating crisis evaluations. They’re usually alerted before -- or soon after -- someone is involuntarily admitted to an emergency room because of a psychiatric condition like, say, psychosis. The day I stopped in, Lisa and two others were juggling four calls that had just come in -- all at about the same time.
“There’s an element of feast or famine to our work,” D’Alessio said. “Very rarely is it just a plateau.”
She’s just starting down a long list of 20-30 regional private hospitals she needs to call. If nothing opens up there within eight hours, the nearest state hospital, Central State, has to admit the patients.
“I feel like private hospitals were accepting folks more [before the 2014 bed of last resort law] just because it was not so much an option to get them into the state hospital,” said Sarah Gray, program manager for emergency services with Henrico's Community Services Board.
The number of people they’ve had to send to nearby state hospitals has nearly tripled over the last four years. And Gray says, the ‘no’ responses they get from private hospitals are often not that a bed isn’t available, but that the person has too many medical complications or has exhibited aggressive behavior that their staff members aren’t equipped to handle.
“It’s the Goldilocks Syndrome,” Gray said. “Either they're not acute enough and then they are too acute.”
A spokesperson for Virginia’s private hospital organization says they aren’t able to handle as many involuntary admissions because they’re seeing more people seek voluntary care.
Julian Walker with the Virginia Hospital and Healthcare Association said private hospitals have seen a 12.8% increase in voluntary inpatient admissions from 2015 to 2018. He points out that private hospitals still admit the vast majority of involuntary admissions across the state, although the percent has dropped from almost 92% to 83% from 2014 to 2017.
Facility of Last Resort
Virginia’s psychiatric hospital for geriatric patients -- Piedmont -- has seen one of the most dramatic increases in both admissions, and deaths. In 2017, there were 11 deaths. In 2018, there were 16.
“The culture and the mission of the hospital has essentially changed since 2014,” said Piedmont Director Hilton McDaniel.
Before the “bed of last resort” law, he says they saw 7-8 involuntary admissions every year. In 2018, that number jumped to 125.
Piedmont Director Hilton McDaniel says the hospital is seeing a higher volume of patients with complex medical needs. (Photo: Megan Pauly/VPM)
McDaniel says most patients used to come from private hospitals where they were receiving some medical care. If appropriate, a transfer to Piedmont was negotiated over a week or two. Now, he says, many are coming directly to Piedmont from the community in a matter of hours.
“A lot of these patients have come in without any regimen of care. I mean, there's just no medication,” McDaniel said. “Some come almost straight from the street to the emergency room to us.”
The state psychiatric hospitals are also admitting patients who are a lot older -- and a lot sicker. According to Virginia’s medical examiner, 50 out of 60 deaths reported statewide in 2017 were of people over the age of 55. The state determined the majority were natural deaths.
A 2017 report on geropsychiatry in Virginia found that as many as one in ten admissions to state hospitals required the hospital to immediately refer individuals to the acute care facilities due to medical needs.
Eastern State Hospital in Williamsburg is also busier than ever these days. It’s the oldest state-run psychiatric hospital in the nation. A new 2010 facility decreased the number of available beds from 364 to 302.
“Just about every weekend we’re close to 100% occupied,” said Eastern State Hospital Director Frank Gallagher. “It was kind of a sleepy hospital in 2010 with maybe 90 some admissions. As of 2018, we had about almost 1,200 admissions.”
Patient deaths at this hospital have also been on the rise. In 2017, there were 11. In 2018, there were 14.
“At times it's been more issues like pneumonia,” Gallagher said. “There have been folks that have been undertreated and we've had folks that due to complications with diabetes have led to further complications.”
Health issues like pneumonia are often called “medical triggers.” That means if caught early enough, they don’t have to cause death. There are seven common medigal triggers, among them: dehydration, constipation and urinary tract infections.
Virginia’s Department of Behavioral Health says they don’t keep track of how many people with mental illness died from medical triggers, those preventable health issues like seizures or pneumonia.
Colleen Miller with the Disability Law Center says they should track that. “That should be probably a top priority for them,” Miller said.
Eastern State Hospital was founded in 1773. It’s the oldest state-run psychiatric hospital in the U.S. (Photo: Megan Pauly/VPM)
The Funnel Effect
Virginia’s Department of Behavioral Health and Developmental Services says they’re doing their due diligence to ensure each death is properly investigated. They’ve recently created a new mortality review committee and hired a new chief clinical officer.
They wouldn’t provide copies of corrective action plans for deaths because they are considered privileged information. They did say that the Joint Commission, an external group that reviews all unexpected deaths, hasn’t issued any findings relating to the hospitals’ review of deaths and subsequent actions plans in the past five years.
But, advocates are still really worried. They want to know more, like why it took a report from the Disability Law Center of Virginia to reveal the trend of increasing deaths.
“The public has a right to know, we’re paying for these facilities,” said Bruce Cruser, Executive Director for Mental Health America of Virginia.
In the meantime, Cruser and other stakeholders are part of a workgroup that lawmakers have tasked with figuring out how to alleviate some of the pressure the hospitals have been experiencing.
According to a 2017 report, that pressure has created a “funnel effect." The funnel is wide at the top for admissions to the state hospitals, but very narrow and restricted at the bottom for returning to the community. The report states that most of Virginia's geropsychiatric facilities indicated that they could discharge 50-75% of their patients if there was adequate support in the community. It goes on to say that "in fact, the level of care that they receive in the hospital is often like these community settings but at a much higher cost to the state."
Many states across the country are closing state psych hospitals and instead providing care to people in the community. Virginia has been slow to follow suit. The state still spends more on state hospital care -- twice the national average.
“It's certainly much cheaper to have someone be treated in the community,” said Rhonda Thissen with the National Alliance on Mental Illness of Virginia.
But that’s starting to change. The state recently authorized funding for a new state hospital in central Virginia. The plan calls for a reduction in the number of beds there, with the idea that by the time the new hospital comes online in five years there’ll be more services available in the community.
Thissen hopes the conversation will go beyond just hospitals and community services to include other models like psychiatric emergency rooms and mobile crisis teams.
“In the crisis continuum, there are other alternatives to hospitalization and they're less expensive than hospitalization,” Thissen said. “And we're not really sufficiently evaluating and implementing those alternatives in Virginia.”
WCVE recently learned there have been leadership changes at Eastern State Hospital that occurred after these interviews took place, but before this story was originally published. According to the Virginia Department of Behavioral Health and Developmental Services (DBHDS), Director Frank Gallagher began leave May 30. Eastern State Hospital's Renee Coles resigned on June 7, and leave for Chief Nurse Executive Shirley Quarles began June 7.
DBHDS has not confirmed any details or circumstances surrounding or leading up to these changes. Dr. Donna Moore is serving as Eastern State's Interim Director. According to DBHDS, she is "one of DBHDS' most senior licensed clinical psychologists and prior to this assignment she was assisting state hospitals statewide with improving clinical processes with a specific focus on enhanced treatment planning and community discharge."
Updated June 26 at 7:26 p.m.
This report was made possible thanks to grant support from the Scattergood Foundation.
*A previous version of this story incorrectly spelled Bruce Cruser's last name as Cruzer. We apologize for the error.
