MIDDLESEX COUNTY, Va. -- In the 13 years since a gunman opened fire on the campus of Virginia Tech in Blacksburg, millions of dollars have been spent to fix the cracks in the state's mental health care system.
Over the past few months, the issue has re-taken center stage with demonstrators from Richmond to Rochester, New York calling for lawmakers and police to change the way officers interact with people suffering from psychiatric problems.
But long before the pandemic and protests, one small-town police department has been trying to figure out a better way to address the issue.
"It's absolutely paramount that we continue to get training," Lt. Casey Mewborn, head of crisis intervention for the Middlesex County Sheriff's Office, said. "For law enforcement, you are only required by the Virginia Department of Criminal Justice Services (DCJS) to get the first eight hours of mental health training in the academy. There are requirements every two years for us to get legal, cultural diversity, and career development, but not anything for mental health."
That, he said, is a problem because the number of calls for people suffering from psychiatric crises has grown. But the number of deputies has not.
"We have as little as one officer on the road for any given shift," said Mewborn. "We're a small agency, but we're an agency that services 12,000 constituents during most of the year, but in the summer we swell to three times that."
And there's another issue that Mewborn said has been handcuffing officers. An issue that emerges after a psychiatric patient has been taken into custody and brought to the emergency room.
If a person is ruled to be a danger to themselves or others, a temporary detention order, commonly referred to as a TDO, is issued.
Once the patient is medically cleared, the officer is responsible for transporting that patient from the ER to a psychiatric hospital.
But that trip can stop before it even starts.
"We're saying, we're ready to go, I got a court-ordered paper that says they have to go seek psychiatric treatment, and this ER is not an acceptable place for them to receive that treatment because there's not a psychiatric doctor here," said Mewborn.
Under state law, if no other psychiatric beds are available, a state-run mental health care facility must accept the patient.
The closest such place to Middlesex is Eastern State Hospital in Williamsburg.
Closest in theory, according to Mewborn.
"They won't let their doctors talk to the ER doctors. They are supposed to take them [the patient]. They have to take them. Their endgame is they're saying that they don't have beds available or they aren't staffed enough, and they're trying to free up that asset, but meanwhile, they're holding law enforcement hostage, they're holding ERs hostage," Mewborn said.
Since the patient cannot be released from custody, the search begins for another psychiatric hospital with an available bed.
That can take hours, essentially leaving the small sheriff's department to operate a man down, and sometimes taking the deputy and the patient very far from home.
"The furthest place I've taken personally would be Roanoke, but we have had officers go out west towards Tennessee," said Mewborn. "My total workday that day was 20 hours."
To put that into perspective, Roanoke is about 250 miles from Middlesex.
And this problem isn't limited to the outskirts of Central Virginia.
'It's frustrating'
"It's frustrating for everybody," said Dr. Joran Sequeira, who sits on the Board of Directors at the Virginia chapter of the American College of Emergency Physicians. "I feel like we could be taking care of our psychiatric patients better by just making it a simpler process."
She said state hospitals are being overwhelmed right now with patients, something that has been made worse by COVID-19.
"The issue is that now we're getting outbreaks at some psychiatric hospitals," said Sequeira. "Now we have fewer beds at each of the psychiatric hospitals because of social distancing."
Sequeira sympathized with law enforcement, but her biggest concern is the health of the patient forced to wait for help.
"They're not getting the psychiatric care they necessarily need, which is group therapy, individual therapy, the right medications because we're not experts at that," she said.
Sequeira said that too much time is often wasted during the bed search process, so an updated and streamlined statewide registry could help.
"It's just such a long, drawn-out process," said Sequeira. "I do know that the state is working on trying to improve the communication about the bed registry."
Mewborn said a regional partnership that allowed off-duty officers and deputies from 10 counties to take over custody of patients from their on-duty colleagues was working, but that has run into funding issues.
The state recently rolled out a new alternative transportation system as well, but it has its limitations.
"They only take over once a bed is found, and the patient is ready to go, like walk out the door," said Mewborn. "They don't come to sit in the ER with them."
Communication Breakdown
The top priority, he said, needs to be fixing what can best be described as a communication breakdown.
"The biggest thing is to figure out why the state hospitals, and it's the state hospitals giving us the most heartache, the ones that their doctors are not calling, and not contacting, and holding up the patient," said Mewborn.
That, he said, will help get law enforcement out of the waiting room, and back on the job.
"We've always put a Band-Aid on every problem, we get it fixed," he said. "Well, now we're left with that Band-Aid, and we're fixing it, but at what cost? It's costing our public... our public's safety, and our public's care."
CBS 6 reached out to the Virginia Department of Behavioral Health and Developmental Services for this story.
Lauren Cunningham, the Director of Communications with the Department of Behavioral Health and Developmental Services, provided the following response:
The partnership among Virginia’s state psychiatric hospitals, community services boards (CSBs), private hospitals, and local law enforcement requires collaboration, patience, and open communication. In addition, the COVID-19 pandemic response has challenged our support delivery system and both the state and community providers have taken extraordinary measures to keep staff and individuals safe.
State hospitals across Virginia, including Eastern State Hospital (ESH), are regularly operating at 100% of their bed census.
When all of the state hospitals are full, there may be delays in admissions to state hospitals.
As always, we are not denying admissions except in cases related to COVID-19, but are delaying admissions if state hospital staff need to work to make a bed available.
We understand that this makes it incredibly difficult on local law enforcement, especially smaller departments, who may have to stay with a patient for several hours before a bed becomes available. However, it is absolutely unsafe to leave an individual without police presence while being assessed in the emergency room, or drop an individual off before a bed has been found.
This is specifically mentioned in the Governor’s Executive Order issued on August 17, 2020.
The executive order was issued to help address the significant impact on COVID-19 in Virginia’s state psychiatric hospitals. The critical reality is the state hospitals will remain in this cycle until Virginia implements more comprehensive payment strategies and rules for admissions to private hospitals and strengthens community services that facilitate discharges.
ESH is staffed at or above minimum staffing requirements daily, and staff are working hard to turn out discharges just as quickly as new admissions are brought in to the facility. While going above and beyond to make this possible, it is important to remember that facility staff are also working hard to maintain infection control measures against COVID-19, and this can increase the time that it takes to both turn out discharges and find beds for new admissions.
Staff from ESH met with representatives from the Middlesex Sheriff’s Department and the local CSB in July, at their request, to discuss the issue and work on moving forward in tandem.
ESH leadership has and will continue to make themselves available to discuss these issues with the sheriff’s department and community partners.
It should also be noted that statewide partners, notably Virginia’s 40 community services boards (CSBs), are working intensively alongside state hospital staff to facilitate safe discharges and help those known to be at risk in the community avoid crises. This degree of expenditure of emergency resources is not sustainable.
In addition, DBHDS agrees that law enforcement cannot continue to operate in such a capacity that strains both individuals in crisis and community resources. DBHDS is working through existing discharge processes and engaging in specialized actions to facilitate discharges; however these tremendous efforts have not been enough to reverse the increasing census trends. Below are recent examples of this heavy lift:
- DBHDS developed three, CSB-operated assisted living facilities exclusively dedicated to state discharges.
- DBHDS set up Gateway transitional mental health group homes that have aided in discharges.
- Three new contracts with private providers to divert admissions or increase discharges have been established since December 2019. Ongoing funding is required to sustain these and other similar contracts that will relieve pressure on our state hospitals.
- DBHDS is currently working with urgency with long-term care organizations to safely discharge appropriate geriatric patients.
- Since March, individuals have transitioned through the use of Crisis Stabilization Units for patients ready for discharge. In addition, a contract with Fellowship Health for use of the CSU for state hospital discharges went into effect on July 1.
- A contract with Commonwealth Senior Living is targeting discharges that need assisted living level of care or lower level nursing needs.
- A pilot discharge team, which currently works with Eastern State, began accepting referrals in March with a goal of discharging patients with complex needs with long lengths of stay on the Extraordinary Barriers to Discharge List (EBL).
- DBHDS is working with CSBs on a Discharge Assistance Plan (DAP) workgroup to develop a plan to address an anticipated DAP shortfall in FY 2021.
Finally, it’s important to note that the issue of transporting individuals under a TDO is one we are working on improving across the Commonwealth. Over the last year, DBHDS has begun expanding alternative transportation statewide.
G4S, a nationally recognized contractor for behavioral health security and transportation services, provides alternative transportation for people under a TDO who are assessed to be appropriate for such a service.
Not only does this ease the burden on local law enforcement, it provides a trauma-informed approach to transporting individuals under a TDO. While this service is not yet available statewide, it has just launched in the region that ESH serves.
DBHDS will continue to work in partnership with CSBs, private hospitals, law enforcement, community providers and other critical stakeholders as we implement strategies to manage COVID-19 and manage the current census crisis.
