Mental Health Crisis Emergency Response: Improving Care for People in Crisis in Virginia

Report to SJ 47 Joint Subcommittee and the Statewide Stakeholder Task Force Summarizing Deliberations of Regional Stakeholders Meetings

October, 2018

PRODUCED BY THE
Institute of Law, Psychiatry, and Public Policy at the University of Virginia

In response to the current crisis, the Joint Subcommittee to Study Mental Health Services in the 21st Century established a statewide Task Force to conduct a comprehensive study of the factors contributing to the crisis and to identify possible solutions. In collaboration with the SJ 47 Expert Panel on Emergency Services and Crisis Response, the Task Force convened stakeholder meetings over the course of several months in 2018 in each of the five Primary DBHDS Regions in Virginia. This preliminary report summarizes the observations, viewpoints, and recommendations that emerged out of that process. In addition, specific proposals for changes to or additional services for the crisis response system have been developing, with some of them emerging out of the regional meeting process and others having already started independently. Those service proposals, which are in various stages of conceptual development, are briefly described at the end of the report along with recommendations for how their development may be supported by financial or statutory actions of the General Assembly.

Characteristics of Adult Residential Crisis Stabilization Units in Virginia

S.A. Larocco
October, 2018

PRODUCED BY THE
Institute of Law, Psychiatry, and Public Policy at the University of Virginia

In recent years there have been dramatic increases in admissions to both public and private hospitals. Residential crisis stabilization units (CSUs) have been suggested as a possible solution to this problem, allowing an alternative environment where people in crisis can go instead of the hospital. This report explores the characteristics of Virginia’s adult CSUs, including the populations they work with and the features and resources that allow them to do their work. CSUs work with patients with depression, anxiety, bipolar disorder, post-traumatic stress disorder or substance use disorder, but they are not equipped to care for patients with medical complexities.

Children’s Residential Crisis Stabilization Units

S.A. Larocco
August, 2018

PRODUCED BY THE
Institute of Law, Psychiatry, and Public Policy at the University of Virginia

As psychiatric hospitalizations increase in Virginia and the census at the Commonwealth Center for Children and Adolescents is at an all-time high, advocates and policymakers look for alternatives to hospitalization to ameliorate the problem. One such alternative is the crisis stabilization unit, a therapeutic environment for people in a sub-acute state of crisis. Current approaches used in these programs are geared toward patients with depression, anxiety, post-traumatic stress disorder, substance use disorders and executive functioning deficits.

Increased Utilization of State Hospitals from Fiscal Year 2017 to 2018

S.A. Larocco, R.J. Bonnie
April, 2018

PRODUCED BY THE
Institute of Law, Psychiatry, and Public Policy at the University of Virginia

Over the past three years, temporary detention order (TDO) admissions to state psychiatric hospitals have been on the rise in Virginia. The current report focuses on increases in TDO admissions to state hospitals from the first half of fiscal year 2017 to the first half of fiscal year 2018. Fiscal year 2018 saw the greatest increase in TDOs to state hospitals in recent history, largely the result of reduced TDO admissions to private hospitals.

Trends in Utilization of Adult Psychiatric Beds in Virginia

R.J. Bonnie, S.A. Larocco
February 2018

PRODUCED BY THE
Institute of Law, Psychiatry, and Public Policy at the University of Virginia.

Over the past five years, admissions to state psychiatric hospitals have increased by 55%. This report looks at the changing nature of those admissions, as admissions under temporary detention orders are taking up an increasing share of hospital capacity. The greatest increase in state hospital admissions occurred in the 2016 fiscal year, and this increase was driven by temporary detention orders. Forensic admissions have been increasing steadily, but more slowly, and other civil admissions have been in sharp decline.

Characteristics of Communities Associated with Increased Utilization of State Hospitals

S.A. Larocco, R.J. Bonnie
December 2017

PRODUCED BY THE
Institute of Law, Psychiatry, and Public Policy at the University of Virginia.

Over the past three years, temporary detention order (TDO) admissions to state psychiatric hospitals have been on the rise in Virginia. This removes patients from their communities and creates unsafe conditions as state hospital utilization rises well above 90%. A previous report has identified some of the important events associated with the increase in the number of TDOs across the Commonwealth since 20141. The current report focuses on increases in TDO admissions to state hospitals. Much of the increase in TDOs to state hospitals is driven by increases in TDOs in general, especially in the Northern Virginia Mental Health Institute (MHI), Western State and Catawba catchment areas. There was, nonetheless, a substantial part of the increase attributable to changes in private hospital acceptance of patients under a TDO, especially in the Central State and Southwestern MHI catchment Areas.

Rise in Temporary Detention Orders in Virginia, 2013-2017: Possible Contributing Factors

University of Virginia Institute of Law, Psychiatry and Public Policy
S A Larocco, R J Bonnie, H Zelle
January, 2017

From 2013 through 2017, there has been a substantial increase in temporary detention orders (TDO) in Virginia. State hospitals are absorbing an increasing number of these patients. This report explores various theories put forth to explain the increase in temporary detention orders in general. Factors that appear to have contributed to the increase in temporary detention orders in general include attention to the death of Austin Deeds, the implementation of the Governor’s Access Plan, and the opening of increasing numbers of crisis intervention team assessment centers, although other factors may have had subtle effects as well.

Telemental Health in Emergency Settings

AA Allen and KM Faris
June 2017

PRODUCED BY THE
Institute of Law, Psychiatry, and Public Policy at the University of Virginia.
PREPARED FOR
The Joint Subcommittee to Study Mental Health Services in the Commonwealth in the 21st Century
WITH SUPPORT FROM THE
Department of Behavioral Health and Developmental Services

“Smart Practices” for Community Services Boards Learned from the Field

The following report was created to support “SJ-47” – the Joint Subcommittee to Study Mental Health Services in the Commonwealth in the 21st Century, specifically, the work of the Emergency Services Expert Advisory Panel. Telemental health has been frequently discussed by the panel as a way to enhance emergency services. In order to inform the panel and Community Services Boards (CSBs) statewide on how telemental health can be used specifically to enhance emergency services, researchers from the Institute of Law, Psychiatry, and Public Policy (ILPPP) have been looking closely at existing emergency telemental health practices and their current and potential use in emergency departments and other emergency settings. Researchers interviewed five CSBs who were identified as using emergency telemental health services through ILPPP surveys of CSBs in 2016. Two hospitals that have partnered with Fairfax-Falls Church CSB were also identified during the interview process and contacted for interviews on their experiences and perspectives on their internal use of telemental health and their telemental health partnerships with Fairfax-Falls Church CSB.

This report, using the experiences and examples provided by these existing programs, provides “smart practice” recommendations for CSBs when implementing and structuring an emergency telemental health program. The recommendations were formed after speaking with the five CSBs that either currently have an operating emergency telemental health program or are in the process of implementing a program. The recommendations themselves come from researchers’ synthesis of information gained from the interviews and from recommendations offered by CSBs and CSB partners.

We would like to thank the CSBs, hospitals, and VACSB who contributed their time and expertise to this report. Your contributions are greatly appreciated.

Virginia Civil Commitment Procedure and Practice

Policy Analysis and Recommendations to Increase Voluntary Admission

What policy changes can the Virginia Commission on Mental Health Law Reform recommend and implement to reduce the number of involuntary commitments in favor of voluntary admission? The Commonwealth of Virginia Commission on Mental Health Law Reform (the Commission), is tasked with improving mental health laws, procedure, and policy to better serve people with mental illness. One of the Commission’s goals is to increase the fairness and effectiveness of the civil commitment process. All of the analysis presented in this report is the result of extensive inquiry. With the aid of quantitative data, I was able to identify and target areas of the state with large variation in involuntary commitment rates among either Community Service Boards (CSBs) or special justices. I interviewed CSB emergency services managers and special justices about their operating procedures and attitudes concerning civil commitment. I also spoke with mental health experts and hospital officials including doctors, intake coordinators, personnel managers, nurses, and social workers. While current civil commitment procedure in Virginia allows individuals suffering from mental health crises to admit themselves voluntarily, many people do not. There are several reasons beyond a lack of capacity that might influence a person’s decision not to agree to care voluntarily. Based on my research and analysis, I recommend five specific policies that the Commission could adopt or recommend to encourage the election of voluntary admission by people with mental illnesses in lieu of involuntary commitment.