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.