By Prue Salasky, firstname.lastname@example.org
7:36 PM EST, January 15, 2014
Mental health workers had six hours to find a suitable psychiatric bed for Gus Deeds, the mentally ill son of state Sen. Creigh Deeds, being held under an emergency custody order for evaluation. When the ECO time elapsed before Rockbridge County Community Services Board evaluators could locate an appropriate bed, law enforcement released him.
The November incident set off a personal tragedy for the Deeds' family. Less than 24 hours after his release, the 24-year-old Deeds stabbed his father, before taking his own life.
The violent episode highlighted the flaws in Virginia's ECO/TDO (temporary detention order) system, used for evaluating and stabilizing those in psychiatric crisis, and once again raised the issue of access to appropriate psychiatric beds since the downsizing of state hospitals.
More than a year ago, a 2012 report by the Office of the Inspector General for Behavioral Health, found that in a three-month period 72 people deemed an "imminent threat" to themselves or others were released in similar circumstances to the younger Deeds. Its author, G. Douglas "Doug" Bevelacqua dubbed the failed TDOs as "streeting." Another 273 individuals, or 5.5 percent of ECOs, took an average of 16.6 hours to be placed, well beyond the statutory six-hour limit, the report revealed. This year, a University of Virginia study of emergency CSB evaluations conducted in April found that statewide 3.4 percent of TDOs exceeded the time limit, a "marginally worse" outcome, according to Bevelacqua.
The key problem, according to the 2012 report, was the scarcity of psychiatric beds. It cited, in particular, the effects of the downsizing of Eastern State Hospital in James City County on the disproportionate number of failed TDOs in the Eastern Region.
Now, outgoing Gov. Bob McDonnell and Sen. Deeds, among others, have urged the extension of time for an ECO — from anywhere from eight hours to 24 — in order to find a suitable hospital bed to implement a TDO. A TDO allows someone in crisis to be held for stabilization for 48 hours before a civil commitment hearing. In his budget, McDonnell proposed that TDOs be extended to 72 hours and suggested funding of $1.3 million in the first year and $1.6 million in the second, part of a recommended infusion of $38 million for mental health care over the next two years.
Following the governor's lead, Del. Joseph Yost, R-Giles, has filed bills in the legislature to extend the permitted time for ECOs and TDOs, and Del. Rob Bell, R-Albemarle, has filed complementary bills outlining a more efficient process surrounding them. Other suggestions for mental health crisis care reform, including a bill from Deeds, include establishing a computerized registry of available psychiatric beds in real time.
Crisis care on the Peninsula
On the Peninsula, the demand for beds is constant. In Newport News, Sheriff Gabriel "Gabe" Morgan, a member of the governor's task force on mental health reform, reported that his office alone handled 547 TDOs last year, well more than one a day.
Similarly, in one month from Oct. 12 to Nov. 9, mental health professionals with the Hampton-Newport News Community Services Board evaluated 336 people in crisis, according to HNNCSB records; of those, it detained 102, and sent 32 to a Crisis Stabilization Unit, a voluntary program.
Of the 102 detained, 50 TDOs, issued by a magistrate, were requested.
The process involved HNNCSB evaluators calling a roster of 20 hospitals, from Fredericksburg to Virginia Beach, and Galax to Lynchburg, to find a suitable emergency bed. "If the ECO time was longer, we'd be able to find beds easier," said Derek Curran, clinical services administrator, HNNCSB. (See sidebar.)
UVA's month-long study found that statewide one in four initial ECOs expired, and in almost 250 cases it took calls to more than three hospitals to execute a TDO. Of those accommodated, 15 percent were sent to a hospital in a different region. The Eastern Region needed the most time to locate beds, with 18 patients taking more than six hours to accommodate.
Not all hospitals appropriate
Evaluators call the most suitable hospital first, according to Gina O'Halloran, HNNCSB emergency services manager, noting that making simultaneous calls to different hospitals isn't practical as if they're not used, then they don't cooperate in the future.
Locally, individuals with a co-occurring medical problem, and those on "straight Medicaid," are limited to just three med-surgical facilities: Sentara Obici in Suffolk, Sentara Norfolk General, and Bon Secours Maryview in Portsmouth. "Free-standing" facilities, including Riverside Behavioral Health in Hampton and The Pavilion in Williamsburg, do not take adult Medicaid patients. Some other facilities are age-restricted, or there might only be a shared room available, in which case gender is an issue. All those are factors that limit availability, noted O'Halloran.
"Some hospitals will accept patients until the commitment hearing (at the expiration of the TDO) as long as they're moved to provider hospitals after. It's like a big circle because they know they'll get stuck until a transfer to a state hospital where there are waiting lists," she said. Twenty nine, almost 10 percent, of Eastern State's beds are occupied by those clinically ready for discharge, according to "Broken Promises," a December report by the disAbility Law Center of Virginia. Private facilities typically discharge patients when their insurance runs out, O'Halloran added.
People may be hospitalized and detained multiple times, said Curran. "It's not unusual for us to see people very shortly after discharge."
Wanda Yvonne Parks went through the system with her son Jason Daniel Tully, 25, who was diagnosed with schizoaffective disorder. She estimates he had about 30 hospitalizations in all; he also served time in local jails. This year, after less than a week at Maryview Hospital, Tully was released though Parks asserts that she told the hospital he wasn't ready. One hour after his release he had a psychotic episode. Three days later, Tully collapsed in Hampton police custody and died in hospital on April 25. "He'd be in these short-term facilities. I begged and begged and pleaded for Eastern State. A week or two stay is not sufficient," said Parks. "My son's life ended very sadly."
There are three safety net beds at ESH for the region for people detained directly from the community, according to Curran. "To use them, we have to get someone else out who is discharge-ready. Then we have to have a plan for the admitted person to leave after five days. It's a lot of juggling," he said.
Prompted by the Deeds' case, the state has recommended not only an extension of time for the ECO, but also removing the requirement to name the facility of temporary detention on the order (TDO).
It further recommended completing the implementation of the state's electronic psychiatric bed registry, showing available beds in real time. However, community service board workers point out the shortcomings. "There might be people in the waiting rooms or people might walk in. There's a difference between a hospital having beds and those beds being available. There are a lot of things that play into that," Halloran and Curran emphasized.
HNNCSB Executive Director Chuck Hall doesn't believe the registry's a solution either. The key question, he said, is whether a hospital is equipped to treat the person. However, Sheriff Morgan supports the registry, believing it could help with initial screening, thereby shortening the process. He is opposed to a further extension of the ECO time as an unfunded mandate on law enforcement. "We should be working to meet the time. It's about capacity," said Morgan.
The state behavioral agency, DBDHS, wants to clarify when it is appropriate for a state hospital — Eastern State in the Eastern Region — to be utilized for a TDO and the process involved for access to it.
Hall believes that responsibility lies with the state and not the local authority. "The key is to have a no-fail default response — it should be a state responsibility that state facilities have to be available. We have not solved the problem," he said.
Salasky can be reached by phone at 757-247-4784.
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