3 comments
The Crisis in Crisis Services
Two things were brought in to much better focus with the “release for comment” of the Mobile Crisis Response “Best Practices” Guidance on 20 October (which as of 10/27 has no comments) – first, it appears that efforts to reign in the growing costs of Mobile Crisis continue, but seem destined to be ineffective due to a lack of actual specificity in the rules and the willingness (ability) of anyone to consistently enforce them.
The description below for “provider qualifications” found in Appendix G of the DMAS Manual appears to be the only substantive description of the “provider requirements” for Mobile Crisis:
Mobile Crisis Response providers must be licensed by DBHDS as a provider of Outpatient Service/Crisis Stabilization (07-006) or DD Outpatient Service/Crisis Stabilization – REACH (07-007) and be enrolled as a provider with DMAS (see Chapter II). Mobile Crisis Response providers must follow all general Medicaid provider requirements specified in Chapter II of this manual and complete DBHDS training for this service as required by DBHDS.
Mobile Crisis Response providers must have an active, Memorandum of Understanding (MOU) or contract with the regional crisis hubs. This MOU or contract must be kept up to date with the DMAS Online Provider Enrollment System. This requirement does not apply to CSBs that act as the regional hub or CSBs providing only emergency services pursuant to section §37.2-800 et. seq. and section §16.1-335 et seq. of the Code of Virginia.
And, perhaps more significantly, the service description avoids any concrete example of providing the service for an individual, who at the time of the call, is on the street, in a convenience store or parking lot, and claims no permanent or even temporary address. Instead, the emphasis is placed on “meeting the individual where they are.” As a convenience store parking lot may be the location to de-escalate and assist in preventing acute exacerbation of the symptoms, it is not an ideal location provide the Care Coordination and other intervention in the subsequent hours.
Two specific issues which have been a source of friction seem to be:
There is an attempt to curb the first by recording the response time and providing data to the “dispatch hub” when the response times are consistently below average the provider will be referred to the regional HUB for a “quality service review.”
The Document currently out for comment, which is intended to define and promote quality services, also describes the “best practice” to handoff, when possible to either a CRC (23-hours obs) or a community-based stabilization team. There is no suggestion (as perhaps there should not be) that providers should not provide multiple levels of cars and be able to move individuals as appropriate among those levels.
It appears within the levels of oversight authority:
Perhaps the only way to curtail what appears to be excessive utilization is:
The former may defeat the purpose and the latter will put unnecessary burdens on the staff of the CSB.
The absence of a solution is not only putting a strain on the system as a whole, but is adding to the stress on the “988” Call Centers while they are still in their development and growth cycle. It is critical to the overall success of crisis program that the 988 system be able to accept and process not only high volume, but also a full variety of calls to direct higher acuity calls away from law enforcement to a robust system of crisis care.
The Endependence Center of Northern Virginia (ECNV) operates based on the legacy of Centers for Independent Living all across the state: that all people—especially those with disabilities—deserve to be treated with dignity, exercise control over their care, and be fully included in their community.
We strongly support efforts to improve Virginia’s crisis response system under the proposed guidance. Crisis services must be built on consumer choice, respect, and the right to remain in the community whenever possible. To ECNV, this means that systems must put the needs, safety, and dignity of consumers first. Reforms must also avoid worsening the barriers faced by communities already underserved in our behavioral-health system—especially Black, Brown, Indigenous, disabled, and other marginalized groups.
We appreciate the progress made so far, including statewide training, coordination through 988 and regional hubs, and improved data tracking. To continue strengthening the system, ECNV recommends the following:
1. Prioritize Direct Consumer Choice and On-Site Care
Self-referral must be protected as an essential pathway to crisis services. The crisis system must recognize the right of any consumer to initiate contact directly—whether through a crisis hotline, through a walk-in to a local provider's office (such as a Crisis Intervention Center), or via other direct routes. Any guidance restricting Mobile Crisis Response (MCR) teams from responding to self-referrals, including walk-ins, should be reviewed and revised to explicitly permit such self-referrals. Self-referral recognizes that a middleman and dispatch system is not the right fit for every person or issue. Furthermore, when MCR is deployed, teams must be required to provide the right response to de-escalate the situation at the location where the client feels safest and most comfortable to prevent unnecessary transport, escalation, or institutionalization.
2. Strengthen Accountability, Transparency, and Equity
We support the use of real-time data and recommend public dashboards showing response times, outcomes, regional differences, and data broken down by disability, race, ethnicity, and geography. We also recommend a graduated enforcement process—a clear series of steps DBHDS or DMAS can take when problems arise before using the most severe actions, like ending a provider’s MOU. Examples include technical assistance, corrective action plans, or temporary probation. This helps improve quality without disrupting crisis coverage, especially in underserved regions.
3. Expand Workforce Training Across the Crisis Continuum
Training must go beyond current requirements. Crisis workers need practical skills in disability-competent response, accessible communication, trauma-informed care, and understanding of sensory, psychiatric, cognitive, and developmental disabilities—including autism. Ongoing refresher trainings and support are critical, especially for under-resourced areas.
4. Strengthen Community Infrastructure and Reduce Responder Strain
The Commonwealth should continue investing in Community Services Boards and regional hubs to ensure consistent and equitable coverage. Support is also needed to reduce burnout and pressure on emergency responders involved in crisis work.
5. Expand Peer Support and Lived-Experience Roles
Peer support models are highly effective. We recommend increased funding for Certified Peer Mentors and more opportunities for people with lived experience to work in Mobile Crisis, stabilization, and follow-up services.
6. Improve Continuity of Care and Community Integration
Warm handoffs—from MCR to Community Stabilization, outpatient care, peer support, or Centers for Independent Living—are essential. We recommend follow-up within 24–48 hours after a crisis event and safety planning that respects the person’s communication needs, preferences, and long-term goals.
7. Ensure Accessibility Across All Platforms and Services
All crisis services must be accessible to people with disabilities. Accessibility standards should apply to VCC, dispatch systems, documentation, communication tools, and follow-up services. Regular accessibility audits and documentation of accommodations used during crisis response will help ensure meaningful, equitable care for disabled people across the state.
In conclusion, ECNV supports Virginia’s ongoing work to create a strong, community-based crisis response system. By strengthening accountability, accessibility, and person-centered care, the Commonwealth can fulfill the goals of the Marcus-David Peters Act and ensure that all Virginians—especially those most marginalized—receive the support they need, when they need it, in the most community-based setting.
Thank you for the opportunity to provide comments on the proposed MCR Best Practices. The Arc of Virginia promotes and protects the human rights of people with developmental disabilities and actively supports their full inclusion and participation in the community throughout their lifetimes. To help ensure these best practices promote the dignity, safety, and inclusion of people with developmental disabilities, we offer the following recommendations:
Add the bolded text in quotes: MCR aims to reduce the utilization of hospitals “or other forms of institutionalization” when there are other options available, however an individual presenting signs of significant risk may require hospitalization.
Add the bolded text in quotes: While MCR can be provided for up to 72 hours, it is best practice, when possible, to handoff as soon as practical to a community-based stabilization team or other service best designed to meet the individual's needs. “Practical can be defined as when the MCR has identified appropriate community-based supports that meet the individual’s needs.” This is especially true for youth and individuals with developmental disabilities.
Clarify Concerns About “Fast Response Times” and Avoid Penalizing Providers Who Respond Quickly: We understand the Department’s concern about some providers “self-referring”—calling mobile crisis for a person who is already in their care and then accepting the dispatch themselves. This can make it look like a mobile crisis response occurred when it did not. However, the guidance says response times “should not consistently occur in less than one minute.” This wording is confusing and may unintentionally punish providers who are simply being efficient. We recommend updating this section to:
Clearly explain that the concern is about inappropriate self-referrals, not fast response times
Give examples of when self-referral is not allowed and when quick dispatch acceptance is appropriate
Make sure providers do not feel discouraged from responding quickly to real crisis calls
Base quality reviews on whether the process was used correctly, not on a time threshold alone
Clearer language will prevent misuse while still protecting providers who respond promptly and appropriately.
MCR providers will have an active, DBHDS-approved memorandum of understanding (MOU) or contractual agreement with the regional crisis hubs and update it as necessary. Providers must meet the criteria set forth by regional MOU requirements, however not every provider will receive one.
Clarify the process and criteria for determining whether a provider receives an MOU or a contractual agreement, and ensure that all providers have a timely path to obtain the required documentation. Specify that providers must meet the criteria outlined in whichever document they receive.
Providers must have an active MOU before obtaining a DMAS enrollment.
This qualification reads as incomplete given the previous qualification. If not every provider will receive an MOU, this should include contractual agreements with the regional crisis hubs.
Services may not be provided to more than one individual at a time, even in situations where a team of employees are present.
Define “at a time” clearly. For instances when two individuals are in crisis at the same time in the same location, detail how a MCR team may respond. For example, would it be acceptable to respond to a call involving two individuals if the individuals a separated?
We have also read the comments from Endependence Center of Northern Virginia, and support their recommendations.
Thank you again for the opportunity to provide comments on the proposed MCR Best Practices, and please let us know if you have any questions about the recommendations above!