Arlington mother Michelle Baisden will be paying close attention to what fellow residents say on April 3. That is the day the Health Systems Agency of Northern Virginia (HSANV) will hold a public hearing on the Certificate of Public Need (COPN) application from Virginia Hospital Center, asking to purchase property designed to add 100 medical/ surgical beds. Baisden (who asked that her name be changed to protect her children) says VHC is overlooking an important need in that application. VHC has filed for 100 additional medical/surgical (med/surg) beds but no psychiatric beds, even though VHC’s COPN document estimates a need for 17 additional psychiatric beds in Arlington. VHC has to convince the county that if it purchases the Edison property adjacent to the hospital it will construct additional patient bed space versus a parking garage, and meet the needs of the community, according to Naomi Verdugo, of AMHA.
“Why aren't they asking for psych beds?” asks Baisden. “Because you don’t make as much money on the psych beds as you do on the medical beds?”
Virginia Hospital Center’s Adrian Stanton, vice president and chief marketing officer, says that comment is not fair. He says VHC is making a request for the 100 medical/ surgical beds first because that it the only way the hospital will get any additional space, down the road, for those additional psychiatric beds. There are two different request cycles in the course of a year. “Normally we wouldn’t be going in for med/surg beds,” he said. “Because I don’t even have the land yet. The reason we are doing this is because of an agreement with the county: in order to purchase the Edison site, we have to go through a site planning process and get COPN approval for additional beds. The first bed cycle we could get into was the January cycle for med/surg beds. “
VHC is asking for county approval to purchase the county’s “Edison site” property — adjacent to the hospital — to expand and add beds.
“The other aspect of this COPN is that our greatest need is for med/surg beds. Because Fairfax INOVA got their COPN approved, the state says there are adequate mental health beds in the area. We understand the families don’t like going to other hospitals, and we’d like to work with the AMHA and NAMI to get more beds. But if we don’t get the COPN approved for the med/surg beds, we can’t get the land, and then everyone loses because this upcoming COPN is our best chance at getting more space.”
Stanton continued, “This has nothing to do with how much reimbursement we get for med/surg versus psych beds; if that were true, then we wouldn’t be treating mental health patients at all, and we do continue to offer outpatient services as well as inpatient. The whole reason we are trying to get the land from the county is that we have approved 40 psych beds: we have 17 substance abuse beds and 18 psychiatric beds: that’s five short of the approved number because we have no room to put them.”
The Patient Protection and Affordable Care Act of 2010 requires nonprofit, tax-exempt hospitals to assess the health care needs of their communities every three years and to adopt an implementation strategy to address the needs identified. Each hospital must make its Community Health Needs Assessment (CHNA) and Implementation Strategy available to the public.
AMHA, NAMI, and other groups in the area say those needs are not being met. They want pediatric psychiatric beds and a more favorable location in the hospital for existing beds. Some say the current area is “dark and dingy,” and to get to it, patients and families have to walk past the morgue. Others say the beds are below ground level and have no natural light. Stanton disagreed: “By law, we have to have windows that access the outside in all our rooms,” he said.
AMHA is also asking for single-occupancy rooms for the mentally ill. “I find it odd the VHC website states they are the only hospital in the area with all private patient rooms, says Verdugo, of AMHA, “but all nine psychiatric rooms have two beds.” Stanton agreed the trend nationally is to single-occupancy rooms and any future construction at VHC will only have private rooms.
The Community Health Needs Assessment posted on the VHC website identifies mental illness as the top unmet community health need and the top service gap. “But when the Community Services Board (CSB) met with VHC leadership, VHC said no more beds were needed in our region,” according to Verdugo. CSB data shows 208 of the people on a Temporary Detention Order (TDO) were turned away from VHC in fiscal year 2016. That figure does not include other patients also turned away such as those seeking voluntary admission to the psychiatric unit or court-ordered TDO patients from other Community Services Boards in the region. Arlington CSB data shows the frequency of people with TDOs refused admission to the hospital has grown from 38 percent in FY 2015 to 57 percent in the first half of FY 2017.
Stanton says outcomes are important to measure: beds are not the only way to improve mental health care: the hospital also offers outpatient treatment.
Verdugo said, “The VHC Implementation Strategy says they maintained and enhanced psychiatric services with the recruitment of a psychiatrist focusing on inpatients. But at this time they do not have that psychiatrist.” Stanton said that doctor had decided to move out of the area: instead of replacing him they decided to use independent practitioners. This is not an unusual way to handle getting specialists, like orthopedic surgeons, he said.
Stanton offered a different view on the turn-away data: there are varying reasons a patient might be turned away: “We might not necessarily be the right facility for them or we might not be able to put the patient in the same room with another patient for safety or gender reasons. The patient might require a unique sub-specialty we don’t have, and it is true we don’t have an adolescent program in our mental health area. We don’t have a lot of pediatric services at VHC. INOVA put in a request to put in another unit,” Stanton said, “I’m not sure where it stands in the COPN cycle — and there is one in Loudoun County — so we are not the only option to handle pediatric psychiatric cases.”
The Dominion Hospital in Falls Church is often the destination for those under 18; however, Dominion is not equipped to treat adolescents with complex mental and physical illnesses. Stanton said he was not very familiar with the Dominion Program; however, he said, “if there is a medical issue, we treat that first, then when the patient is stable, we send them for longer term mental health treatment.”
That is Baisden’s concern: her son could not be treated at Dominion Hospital because he has complex medical issues that go hand in hand with his mental illness, as is often the case with mentally ill patients.
Verdugo said, “It’s more complex than some administrators think: Dominion can’t take court-ordered patients. They have some very restrictive zoning guidelines prohibiting court-involved patients, she said.
”It’s called potential,” said Baisden of her son. “He has all the potential in the world. To walk away from that would be wrong. With the right care he won’t end up in jail or worse … if he gets what he needs, he will be a productive member of society.”
“Up until he was 9, he was perfect. Then he went on steroids, and he exploded with bipolar disease. Shortly after his diagnosis,” said Baisden, “he developed elopement issues, which is where your child disappears and runs into the woods. He also suffers from a muscle disease called juvenile dermatomyositis, an autoimmune disease, for which he receives chemo and shots, and takes about 30 pills every day. One time he took off without his shoes on and ran up Lee Highway. If he’d been hit by a car, then we would have been sent to a hospital. But his everyday issues, and there were many at the time, didn’t entitle him to a hospital bed.”
As a nonprofit VHC is required to provide community benefit, in exchange for their tax exempt status. This includes Charity Care as a percentage of gross revenues; serving Medicaid clients also counts as a community benefit, as does offering low- or negative-margin specialties like psychiatric care. According to data provided to Verdugo by Health Systems Agency of Northern Virginia, VHC ranked next to lowest of the 10 acute care hospitals in Northern Virginia for Charity Care in 2015 and lowest in percentage of Medicaid patients served in 2016. (Data from 2016 on Charity Care exclusive of bad debt, is not available yet.)
The State of Virginia uses occupancy rates as a prime source of data on needs for more beds. For this reason, VHC hospital administrators like Stanton and state officials argue that Northern Virginia is not short of acute care psychiatric beds. Since the psychiatric rooms in VHC are double occupancy, and because patients must be matched by gender, some psychiatric beds go empty to avoid mixing genders. Some psychiatric patients are not stable enough to share a room. As a result, some beds go unfilled even if there is a patient waiting in the ER or court-ordered into treatment. This artificially depresses the bed occupancy rate, a key metric the state uses to determine whether additional psychiatric beds are needed according to Verdugo. While VHC is licensed for 40 Behavioral Health beds, it only uses 35; 18 are dedicated to psychiatric patients and 17 for substance abuse (which does offer private rooms). AMHA and the CSB has asked VHC and state officials to use the number of patients turned away from the hospital as relevant data, like the 208 court-ordered Arlington residents turned away in FY 2016.
In 2012, the Virginia Office of the State Inspector General probed how often clinically necessary TDOs are not issued because no facility is available to accept the patient. Over a 90-day period, the office found that 72 people were turned away despite the fact that they met the criteria to be involuntarily held for treatment. When state Sen. Creighton Deeds was stabbed by his mentally ill son in 2013 — after doctors could not find a psychiatric bed for his son despite a clear need for detention — more Virginians became aware of the issue.
“We are going to commit to reach a resolution on the psych beds issue,” said Stanton. “We really don’t know what the need is; most mental health issues are coming into the hospital first as a physical issue.”
Dean Montgomery, of the HSANV, said, “It’s true the state health planning people look at occupancy level in determining the need for beds. But at the same time, patients are seldom turned away because there aren’t beds available. Some reasons are clinical. We have advised the families who feel the need is there to come up with some statistics of people who have been turned away solely because there is no bed. Those statistics would suggest additional capacity is needed.”
“But we were the lucky ones,” Baisden said. “Our other son is also on the autism spectrum. We couldn’t go anywhere with the two kids, because one might run off and then what do you do? Our insurance wasn’t accepted at Children’s National Medical Center psychiatric ward. Fairfax INOVA had no pediatric beds. Virginia Hospital Center has zero beds for anyone under 18. Dominion Hospital would not have been able to handle his complex physical illness. But An ECDC waiver allowed us to get Medicaid to pay for an attendant.”
“Luckily my son is stable now. He is 13, 5” 9”, and he attends school part time because he gets tired so easily. The thing about mental illness that people don’t realize, especially in adolescents and children, is that it is a disease like any other, and treatable, like any other,” said Baisden.
The hearings on the VHC certificate will be held on Monday, April 3, at 7:30 p.m., in the Northern Virginia Regional Commission (NVRC) Conference Room, 3040 Williams Drive, Suite 200, Fairfax. The HSANV board of directors will consider the applications, the report of the hearing panel, and any comments received at its April 10 meeting, which will be held at 7:30 p.m. in the NVRC Conference Room, 3040 Williams Drive, Suite 200, Fairfax. To attend the hearings and to submit written comments by April 10 write to Health Systems Agency of Northern Virginia, 3040 Williams Drive, Suite 200, Fairfax, VA 22031 or email email@example.com. The applications are available for public viewing and copying in the HSANV offices.
For further information, see:
The Arlington Mental Health Alliance: www.facebook.com/groups/249057865516670/
NAMI: http://www.nami-northernvirginia.org and the Treatment Advocacy Center, a nationally-recognized, Arlington-based nonprofit, known for its research on psychiatric bed shortages nationwide: www.treatmentadvocacycenter.org.
The Arlington Mental Health Alliance (AMHA) issued comments on Feb. 23, reflecting the need for more acute care psychiatric beds. Noting that state approval is required to add beds at Virginia Hospital Center (VHC), and that hundreds of Arlington residents with serious mental illness are being turned away from VHC each year and sent to other hospitals, often across the state, the AMHA asks VHC to open a minimum of 15 additional adult psychiatric beds in single occupancy rooms within two years and commit to opening additional beds as needed; the alliance asks that VHC open an inpatient psychiatric unit to treat children and adolescents with serious mental illness; that VHC commit to bringing the psychiatric unit into line with best practices with regard to design, natural light, and staffing. They ask that VHC staff its emergency department with a mental health clinician and designate a separate suite of rooms attached to the emergency room, sufficient to serve patients of all ages.
A public forum on psychiatric services at VHC was conducted by the Arlington Community Services Board (CSB) on Nov. 28, 2016 and attended by CSB members and staff, family members, and community mental health advocates. VHC management did not attend, according to Naomi Verdugo of AMHA. About 25 people — primarily family members — either spoke or submitted written comments. In addition, 11 CSB clients with mental illness filled out surveys on their experiences in the psychiatric ward at VHC.
(Adrian Stanton of VHC said key personnel were not available for the forum, but that he subsequently invited a group of interested citizens to voice their concerns in mid-January.)
Family members spoke on condition of anonymity; they said it was hard to share in public the challenging details of getting their loved one to treatment or the lack thereof.
Speakers addressed: bed shortages for adults in crisis (15 speakers); the condition, design and location of the psychiatric ward (nine speakers); the need for beds for children and adolescents (seven speakers); inadequate discharge planning (six speakers); and emergency room problems (six speakers). Bed shortage was the most frequently cited concern for family members.
Statistics from the public forum held on Nov. 28, 2016 by the CSB:
• Ten participants said their family members were not admitted to VHC due to a shortage of beds.
• Four participants said their family members waited for long periods in the emergency room or at home waiting for a bed at VHC.
• Six participants said their family members had to travel long distances to other hospitals to be treated.
• A counselor at a local university reported that they have had to send students as far away as Richmond because of the bed shortage at VHC and other hospitals in the region.