Report: Overcrowding at Eastern State Leads to Early Release of Patients

By Amber Lester Kennedy Wednesday, December 21, 2011

The early release of individuals from mental health facilities, termed “streeting,” was cited as a significant problem in Hampton Roads in the most recent report issued by the Office of the Inspector General last week.

The report, written by Inspector General G. Douglas Bevelacqua, said that “streeting” is a problem throughout the state, but most prevalent in Hampton Roads, where the number of available beds at Eastern State Hospital has been downsized.

A person is documented as “streeted” when that individual meets the criteria for a temporary detention order (TDO), but is released from custody because no facility vacancy can be located. The OIG prefers to call these individuals “unexecuted TDOs.”

In the report, Bevelacqua said, “It is important to note that the failure to execute a TDO does not necessarily mean that people were literally put on the street. Although individual outcomes are difficult to track, the OIG is convinced that emergency service staffs are diligent and pursue a range of alternatives to keep these individuals as safe as possible.”

Possible outcomes for individuals who are “streeted” include seeking admission to a crisis stabilization program capable of accepting a TDO; developing a safety plan with family members that includes strategies for the individual to be seen for services through the Community Services Board; or seeking an agreement for the individual to stay in the emergency room if a crisis occurs after-hours. In the last situation, CSB staff would provide support the next day. Crisis workers also reported that in some instances, charges will need to be filed, if warranted, so a person could be kept in a safe correctional setting, rather than be released.

In July, the OIG collaborated with the Department of Behavioral Health and Developmental Services to study the issue further. The initiative aims to understand the extent and contributing factors associated with unexecuted TDOs. Information will be gathered through a survey, which will document the actual disposition of the individuals in crisis and find out what happens to them.

The study will look at two criteria: how many individuals qualified for a TDO but an accepting facility could not be located and how many individuals whose TDO was executed, but it took well beyond the state code’s recommended time of six hours to find a facility.

The data from the first half of the initiative, from July 15 to Aug. 25, showed that 194 cases met the two criteria. Southwest Virginia and Hampton Roads had the largest amount of unexecuted TDOs, with 21 and 15, respectively. Sixty-three percent of the initial screenings for the 194 cases took place in hospital emergency rooms; the remaining screenings occurred in hospital psychiatric units, CSB offices and local law enforcement facilities.

The review also showed that the recently established safety net bed admissions process at Eastern State has been used, but as a region, Hampton Roads still has the second highest number of unexecuted TDOs in the commonwealth.

At state facilities, the number of people ready to be discharged, but unable to be placed because of limited resources, decreases the number of beds available for admissions.

In addition to collecting data, the Inspector General also spoke with Emergency Services Managers and emergency room physicians to understand their perspectives. ES directors and ER physicians said two of the biggest obstacles to finding beds are a lack of provider census for medical clearance and lack of a clear definition of what constitutes an “appropriate” medical screening or assessment. Some of those problems will be addressed, however. The report says many of the problems were considered in DBHDS’s 2007 “Medical Screening and Assessment Guidance Materials”; system providers just have to apply the guidance in the 2007 document.

In addition, the report says a general lack of communication between attending ER physicians and admitting physicians in both private and state facilities contributes to delays.

The complete joint report on “streeting” is scheduled for released in December 2012.

The OIG made three unannounced visits to Eastern State Hospital in Williamsburg between April 1 and Sept. 30. The hospital has been under extra scrutiny since its Hancock Geriatric Center lost its certification from the Centers for Medicaid and Medicare Services in September 2010 (read more here); it regained its certification in March. At the time, the facility was understaffed, which was cited as the source of many of its problems.

In June, the OIG report found that Eastern State Hospital was full to capacity and the community safety net is insufficient to ensure people who need behavioral health care are getting it. Since 2003, ESH has not accepted short-term, acute admissions; the state charged the CSB to purchase beds in private facilities to treat those cases, but by June, the private beds were also full.

In 2009, the region - a group of nine Community Service Boards - was set to receive $2.6 million in state funding to help pay for more community beds, but the funding was delayed until 2011. Instead, the state gave the region a $1.9 million allocation, most of which is going toward maintaining the private hospital beds. The governor's proposed budget suggests the same allocation for the nine-CSB region.

Read more about streeting and how local law enforcement handles TDOs here.