The proposed best practices strengthen the quality and humanity of care for individuals by emphasizing least?restrictive, community?based responses and reducing unnecessary law?enforcement involvement, especially those who receive involuntary services. Clear statewide pathways and coordinated crisis services help minimize trauma, ensure consistent rights?based treatment, and prevent people from being lost in fragmented systems. Mobile crisis teams, Crisis Receiving Centers, and specialized programs like REACH offer safer, more appropriate alternatives to emergency departments or institutional settings, while strong training and data?driven oversight promote accountability and respectful, person?centered care.  Thank you for your attention to these comments.

Thank you for allowing us the opportunity to send recommendations to the Town Hall pertaining to the Virginia Crisis Continuum. Please see the following recommendations for your review and consideration.

1. The section on Mobile Crisis states, "all employees" are required to complete training. Recommended that this be changed to all employees providing services are required to complete training.

2. The section on service delivery and outcomes states, services may not be provided to more than one individual at a time, even when a team of employees are present. Situations may arise where there is a crisis involving more than one child and there is not a team present. Recommend that it be added that crisis involving more than one child may receive services without a team present. 

3. The section on REACH referrals and response time states, that employees must be physically present for all psychiatric pre-screenings to determine if REACH services can sufficiently mitigate the immediate crisis or prevent hospitalization, ensure that REACH services are fully activated, and provide initial crisis stabilization efforts through the pre-screening process. Recommend expanding language to employees must conduct pre-screenings in person or via telehealth.

4. The section on Mobile Crisis response states, if an ECO or TDO is issued, REACH employees will make all efforts to stay with the individual until an appropriate bed is located or the individual is stabilized in the emergency room setting. However, it may not be feasible for a REACH employee to remain with the individual for the length of time indicated and it limits the assistance we can provide to others during that wait time. Recommend adding that a REACH employee must remain with the individual until the REACH service disposition has been determined.

5. The section on service overview and program description states, that REACH is unable to accept individuals into the CTH who have met the criteria for TDO by an emergency service pre-screener. Recommend changing the wording to REACH is unable to accept individuals under at TDO unless lifted into the CTH.

6. The section on type of admission-step down prevention admission states, that REACH employees will attend TDO hearings, however, if the individual has been admitted to the program, then the TDO has already been lifted. Recommend removing this statement.

7. The section on REACH responsibilities (required prior to admission) states that a signed stabilization service plan is to be signed prior to admission, however, the stabilization plan  is signed after admission. Recommend changing to the stabilization plan is signed after admission.

On page 15 under Crisis Receiving Center, it is noted that the 23-hour unit "must be voluntary at the time of entry; however, they may be referred directly from an emergency custody situation, if appropriate." However, the document notes on pages 15-16, "additionally, guests with an active TDO status should also be deferred"

What does it mean we should defer TDO status? It is our opinion that deferring TDO guest will result in continued Emergency Department boarding and will not defer people from the hospital ED.

This guidance does not address a voluntary guest in the CRC recliner who needs to be converted to involuntary. How are providers expected to handle this situation? 

 According to SAMSHA's Model Definitions for Behavioral Health Emergency, Crisis, and Crisis-Related Services, item 10 High-Intensity Behavioral Health Emergency Centers, a distinguishing feature of 23-hour CRCs is that the "receive individuals on voluntary or involuntary basis (based on jurisdiction guidelines)."

 If the CRC is allowed to accept individuals under an emergency custody order, and the individual is assessed to meet TDO criteria, per DBHDS' guidance, the individual would not be allowed to remain in the CRC but would need to be admitted to the CSU or other inpatient setting. This would prevent the treating provider from working to stabilize the individual within the 23-hour period allowing the TDO to be dismissed prior to the hearing which is allowed by code. This situation is particularly applicable for individuals under the influence of alcohol or another substance who may initially meet TDO criteria based on their presenting behavior/symptoms, however once their intoxication has been treated and stabilized in the 23-hour unit, the individual may no longer meet TDO criteria and can be discharged to outpatient treatment.

This section of DBHDS' guidance document is not in line with the National Best Practice for Crisis Care. It will limit the ability of the CRCs to truly be a "no wrong door" model of care. Additionally, the CRC model of care is designed to rapidly treat and stabilize individuals that are experiencing a behavioral health or substance use crisis. Per the Virginia code, a TDO must be issued within 8 hours of the initiation of the ECO. By not allowing individuals under a TDO to remain in the CRC for up to 23-hours, it will prevent the potential rapid treatment, stabilization and discharge that could potentially be provided, resulting in unnecessary admissions to either a CSU bed or an inpatient unit.

This guidance does not align with DMAS Mental Health Services provider manual:

"23-Hour Crisis Stabilization is considered medically necessary for ALL of the following:

*The medical necessity for individuals admitted under a Temporary Detention Order (TDO) issued pursuant to section §37.2-800 et. seq. and §16.1-335 et seq. of the Code of Virginia is established and DMAS or its contractor cannot limit or deny services specified in a TDO (see the Temporary Detention Order Supplement to the Psychiatric Services Manual for additional details). "

The proposed document states that "guests of the CRC shall receive a clinical assessment by a Licensed Mental Health Professional (LMHP)." However, due to workforce shortages, implementing this requirement would make it nearly impossible to maintain 24-hour clinical coverage and significantly impact programmatic functioning. According to DMAS, "assessments must be conducted by a LMHP, LMHP-S, LMHP-R, LMHP-RP." Therefore, it would be beneficial for this document to align with DMAS guidelines to ensure consistency and practicality. This is especially important considering the current challenges faced in the healthcare industry.

 DMAS recognizes a broader group of qualified clinicians—LMHPs as well as LMHP?S, LMHP?R, and LMHP?RP providers—as appropriate for completing these assessments. Aligning this document with that standard would create a more workable and sustainable expectation, especially given the ongoing workforce pressures across the behavioral health field. Thank you for your consideration.

Thank you for the opportunity to provide comments. Please see below.

On page 15, the document states that the 23-hour unit “must be voluntary at the time of entry; however, they may be referred directly from an emergency custody situation, if appropriate.” However, pages 15–16 also note that “guests with an active TDO status should also be deferred.” These statements appear to conflict with operational practices currently demonstrating positive outcomes.

Prince William County (PWC) has been operating a 23-hour unit located within the same facility as Crisis Stabilization Unit (CSU) beds. Individuals arrive either voluntarily or under an Emergency Custody Order (ECO). While in the 23-hour recliner area, Emergency Services staff evaluate and determine the appropriate disposition. If a Temporary Detention Order (TDO) is recommended, the TDO is issued to the address of the facility, which includes both the 23-hour unit and CSU beds.

If the individual stabilizes in less than 24 hours, they remain in the recliner area and can be discharged prior to the commitment hearing. If stabilization requires more than 24 hours, they are transferred to a CSU bed when available. In this way, the 23-hour unit functions as a therapeutic alternative to emergency department boarding.

This model has produced measurable system improvements in PWC:

• Emergency department wait times have decreased by 66%.
• Police officer man-hours spent on mental health calls decreased by 900 hours in the first month.
• Out-of-area transport for TDOs decreased from 43% to 8%.
• State hospital admissions from PWC have declined significantly.

Importantly, individuals under a TDO can sometimes stabilize within 24 hours and be discharged without requiring an inpatient or CSU bed, preserving scarce system capacity.

Freestanding 23-hour facilities could potentially utilize a similar process if they partner with a CSU or inpatient facility willing to accept transfers when longer stabilization is required. In those cases, an Alternative Facility form could be completed, and the 23-hour staff would provide transportation to the receiving facility.

Greater collaboration with private facilities and state hospitals to accept transfers or referrals from CRCs, without requiring full emergency department medical clearance, would help the crisis system operate more efficiently and preserve higher levels of care for those who truly need them.

I also agree with a previous comment that notes the clear contradiction with SAMSHA, DMAS, and the no wrong door initiative. It also contradicts the right help right now model.