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). "