“We are still negotiating, but as a parent, I’ve come to understand Virginia Hospital Center (VHC) does not serve children. They don’t do anything ‘scheduled’ in pediatrics. Yes, you can be born there, and they do neonatal intensive care if there is an issue ... but nothing else,” Naomi Verdugo, a NAMI [National Alliance On Mental Illness] member, said. “Parents cross their fingers that their kids don’t need to be hospitalized for psychiatric reasons, because there is no place to go for children or those with complex health issues.”

In 2015, VHC proposed the expansion of the hospital on an adjacent parcel of land at 1800 N. Edison St. This initiated a process to evaluate the site and community needs, consider options of purchase agreements and collect public input. A land swap was finalized between the county and VHC. The proposed expansion will now go through the county's site plan review process.

Verdugo urged residents to write to the county board and County Manager Mark Schwartz. The board meeting was pushed back to hear the county manager’s report first. Special education teachers in Arlington public schools and other mental health advocacy groups are speaking about the issue at the Sept. 6 Planning Commission meeting leading up to County Board consideration on Sept. 22. Meetings will take place at the Ellen M. Bozman Government Center at Courthouse Plaza at 7 p.m. and 8:30 a.m. respectively.

The need for more mental health beds in Arlington is just one of the areas of concern in the expansion debate. At the forum/hearing on the VHC’s plans for a new building which took place April 2017, the opening salvo was a statistical summary by Doris Fuller, chief of research and public affairs at the Treatment Advocacy Center, a nationally-recognized, Arlington-based non-profit, known for its research on psychiatric bed shortages nationwide.

Fuller reported U.S. experts estimate the safe minimum number of inpatient psychiatric beds at 50 per 100,000 adult residents. Shortages of hospital beds and other treatment facilities are linked to increases in suicides, victimization and incarceration of individuals with serious mental illness.

Arlington has an adult population of about 180,000, and, according to nationally accepted prevalence rates, is home to approximately 2,000 adults with schizophrenia and 4,000 adults with severe bipolar disorder. Of this number almost half are not in regular treatment, and therefore more likely to need emergency hospitalization. To reach the approved norm for beds, Arlington would need to have 90 adult psychiatric beds. VHC currently offers 18 beds, and there are no other psychiatric beds for adults or children in Arlington, which leaves Arlington below these national norms.

Judy Deane, who is serving a 9-year term on the Arlington Community Services Board (ACSB), has been the lead on negotiating with VHC for more psychiatric services at VHC in view of the proposed expansion on the Edison site. ACSB had four main requests going into negotiations with VHC. When negotiations with VHC on item 3 revealed VHC’s hard line on funding a pediatric unit, the third request morphed into a request for two additional clinicians for the CR2 (Children's Regional Crisis Response, a regional mobile unit service).

Verdugo, Deane, and other advocates of improved community services at VHC cite the balance sheet the non-profit hospital enjoys. Their IRS Form 990 in 2016 shows revenue from parking alone at $2,733,399. Parents complain VHC is still saying, “Just take adolescent psychiatric patients to Dominion Hospital.” HCA VA Dominion Hospital is the only freestanding mental health care facility in Northern Virginia. Parents say VHC does not recognize many adolescents have complex problems like cancer, autoimmune disease, or neurological complications. Dominion Hospital doesn’t treat anything but mental illness.

One of the gauges of need for more psychiatric beds is the Temporary Detention Order (TDO) rate. When Emergency Services clinicians believe that a person in crisis needs to be in a hospital to be safe, but the person does not agree or is unable to agree due to the severity of the crisis, Emergency Services may request a Temporary Detention Order (TDO). The number of TDOs has grown steadily in the last couple of years.

According to Anne Hermann, chair, Arlington County Community Services Board, the number of TDOs in Arlington was 509 for FY 17 and in FY18 it was already 459 in April 2018 (the fiscal year is over in September).

According to CSB in the months of April through December 2017, there were 273 TDOs that could not be placed at VHC. Verdugo is frustrated: “All their (VHC) documents say they serve the region. But they keep on coming up with reasons why they can’t fund the CR2. “

In an interview in 2017, Robin Norman, chief operating officer for VHC, explained the hospital performs a valuable service for the community, and complaints about how much money VHC has in investments and assets are unwarranted. “Looking back to 1979, we were barely making payroll,” she said. “We wanted to professionalize, and we started putting money aside. We wanted to spend it on the right things: when we need to upgrade electronic record systems, it’s not as easy as it should be and it costs a lot: in this case, $77 million.”

“Arlington as a community is aging and growing,” Norman said. “The land swap will allow us to put outpatient services there and it will cost $250-300 million. There is no space on this campus to put additional beds, so the only way we will get the space we need for psychiatric beds is to move outpatient services.”

“Our women and children facility at 1701 N. George Mason Drive will need to be replaced eventually, despite maintenance on the building, it won’t be viable long term.”

“We are a private-non profit hospital,” said Norman. “There is no official oversight because we are an independent hospital. There are only nine such hospitals left in Virginia. Having a small, independent hospital is good for Arlington. We have the second largest number of babies born in the state of Virginia and our presence makes it possible for seniors to remain independent — we speak about that in the community.”

Speaking to the issue of the psychiatric beds at VHC being located “below ground,” both Norman and Adrian Stanton, the vice president for marketing at VHC, insisted that is not the case. While a tour of the unit itself was not possible because of privacy laws, Stanton provided a tour of the exterior and pointed out the land is in a bowl, so you do drop down in that area of the building, but there are windows in each room. They are, for safety reasons, windows divided into thirds, with opaque safety coverings on the windows, which also keep the rooms private. The unit has 18 beds in nine rooms. Shared rooms are not always an option for mentally ill patients and Stanton acknowledged not all 18 beds would be available if a patient required single occupancy.

“What’s the best answer to the issue of psychiatric beds?” Stanton and Norman asked. “Hospital beds might not be it.”

There may be a way to make all parties happier. Hermann noted one of the “asks” of the CSB had evolved since VHC made it clear they would not set up a pediatric unit: that ask is now to fund improved treatment options for children and adolescents with serious mental illness.

In this category, Hermann described the CR2. In FY17, there were 525 referrals (region-wide) and 125 of these (23 percent) needed to be deferred, she said. “There are two mobile units in the region, and we are advocating for two additional clinicians.”

The CR2 units have played a role in filling the mental health service void particularly for adolescents left by VHC and, in the case of patients with physical as well as mental problems, by Dominion Hospital. Parents like the CR2, but say they have called the CR2 and too often the response is: “We don’t have anyone right now, too busy.” In the absence of a CR2 clinician, families or schools often call the police, with a far greater likelihood of the child being hospitalized or landing in juvenile detention.

The CR2 units cover Loudoun, Fairfax, Prince William, and Arlington counties, and the cities of Alexandria and Falls Church. Verdugo specified that since VHC has no real pediatric expertise, and since the Arlington Pediatric Center (funded by VHC) serves only indigent clients and refers those with psychiatric issues to the county’s Department of Human Services for treatment, the contribution VHC could make to serving children under age 18 could be relatively easy. “We would like VHC to fund two additional clinicians to focus on Arlington County and adjacent areas of Alexandria. But VHC is keeps on coming up with reasons why they can’t do this, even though the cost of such a team is only about $200,000 per year. VHC has said, according to Verdugo, they hesitate to fund a program that might expire after five years, or, to fund a program that pools money from Arlington into a general “Region II” fund. “We and they know this is their last chance to expand, and there are no plans to add psych beds beyond the adult ones. So this should be a priority in the negotiations with VHC. Arlington’s Department of Human Services, the fiscal agent for the CR2, as well as the county manager, have indicated they can accept funds from VHC for this purpose. They can set up a "trust and agency account" solely for funds to the CR2 program,” Verdugo said. VHC’s own IRS filing from 2016 states “all surplus funds generated by hospital operations are reinvested in the community through the development of new and existing programs and services as well as the purchase and investment in current and future property, plant and equipment.”

The VHC community health needs assessment, a survey of 28 community leaders from Arlington County, identified mental illness as the top service gap in both 2014 and 2017. In 2017 one respondent wrote from the law enforcement perspective, that substance abuse and mental health are the most pressing concerns.” The CR2 addresses both.

Deane emphasized: “It’s really important for the community to understand how important this is. What is happening now is that people are coming in to get help for mental health and not getting it. It’s dangerous to the community. CSB and VHC need to work together. We need a place for them to go. There is nowhere to send them.”