The draft TDO Supplement should be revised to reflect Virginia’s evolving high-quality community crisis system, particularly the operational role of CRISIS NOW facilities aligned with SAMHSA’s highest fidelity National Guidelines for Crisis Care. Current restrictions appear to rely on outdated assumptions about where individuals under ECOs or TDOs can safely receive assessment and treatment, and may undermine efforts to reduce law enforcement burden, emergency room boarding, and pressure on state psychiatric hospitals.

The key recommendation is to base TDO-related limits on each facility’s demonstrated security and clinical capabilities, rather than applying blanket restrictions. Where a 23-hour program is not intended to hold an individual for the full TDO period, CSBs should plan transfer to an attached CSU bed when available or seek an alternate placement if needed. Medicaid and TDO rules should preserve enough flexibility for Crisis Now facilities to meet the community needs they were designed to address.

Connections Health Solutions appreciates the opportunity to submit these comments.  Since November, 2025 Connections has been operating the Prince William County Crisis Receiving Center Complex filling critical gaps in behavioral health crisis care.   The immediate impact we are seeing is reduced avoidable hospitalizations, alleviated strain on emergency departments, and improved efficiency across the healthcare, public safety, and criminal justice systems.  We operate centers in five states nationwide, and we will be opening a second full-continuum center in partnership with Loudon County later this year. We bring proven experience and outcomes to Virginia’s evolving crisis system.  The high level of demand we’re serving in Prince William County reflects both the gaps in the system—and the effectiveness of the model.

Rather than defaulting to hospital emergency departments, inpatient psychiatric units or jail, this center provides a safe, clinical alternative—aligned with SAMHSA’s highest fidelity National Guidelines for Crisis Care—to stabilize people quickly and connect them to ongoing community-based services.

Connections centers are an emergency response resource - open 24 hours a day, seven days a week accepting every individual who comes through the door—including people brought in by law enforcement and first responders—and it serves individuals experiencing the highest acuity mental health and substance use crises, including those who require Emergency Custody Orders and Temporary Detention Orders.

Basic Concern with DRAFT Revision of TDO Supplement

The original premise describing the appropriate location to provide services for an individual under and ECO or a TDO is both out of date and flawed.  In order to take into account the rapidly changing landscape of the services available for individuals in crisis and reflect the ongoing capacity issues with the State Psychiatric Hospitals several changes are warranted in the draft:

• The implementation of the CRISIS NOW Model in Virginia allows for a allows, in the locations where the model is functional, for any individual in crisis to be admitted at any time regardless of the legal status – voluntary, under and ECO or under a TDO. 
• The close working relationship with the local CSB-ES team permits immediate engagement and assessment for any individual regardless of their type of entry (walk-in or law enforcement drop=off)
• One of the significant benefits is a marked reduction in lime any member of law enforcement must be taken from their regular duties and similarly a significant reduction in the time (hour or days) that an individual spends in an Emergency Room with little or no treatment.
• However, with no restrictions on entry, facilities must utilize all of their capacity to provide safe and effective assessment and treatment. 

If the restriction on placing someone who is on a TDO (TDO issued to the facility in question) is based upon the need for “security” and clinical capability – then the facility should be judged on that basis and the TDO “stipulation” attached to their licenses should reflect that.

If, however, the restriction is based on the fact that the 23-hour program is not intended to “house” someone for the 72 hour duration of a TDO then the CSB should note that placement will be made in the attached CSU as soon as a bed becomes available.  If it is unlikely that a bed will be available in the specified amount of time, the CSB may choose to seek a different location.

While it within the purview of Medicaid to set limits on payment this seems to be contrary to the State’s intent to improve the functionality of the Community Crisis System.  As we read these restrictions:

• If someone enters a Crisis Now facility on an ECO and is transferred to the custody of the facility for immediate intervention and further assessment (in the 23-hour Obs Unit) and is a Medicaid recipient, payment must end if the CSB determines that a TDO is warranted and a TDO for detention to that same facility is issued. 
• The restrictions also seem to include that if the individual enters the facility on a TDO it may only occur if there is a bed available in the CSU.  This severely limits the functionality of the facility to meet the community needs it was designed to meet.

The original premise describing the appropriate location to provide services for an individual under and ECO or a TDO is both out of date and flawed.  In order to take into account the rapidly changing landscape of the services available for individuals in crisis and reflect the ongoing capacity issues with the State Psychiatric Hospitals several changes are warranted in the draft:

• The implementation of the CRISIS NOW Model in Virginia allows for a allows, in the locations where the model is functional, for any individual in crisis to be admitted at any time regardless of the legal status – voluntary, under and ECO or under a TDO. 
• The close working relationship with the local CSB-ES team permits immediate engagement and assessment for any individual regardless of their type of entry (walk-in or law enforcement drop=off)
• One of the significant benefits is a marked reduction in lime any member of law enforcement must be taken from their regular duties and similarly a significant reduction in the time (hour or days) that an individual spends in an Emergency Room with little or no treatment.
• However, with no restrictions on entry, facilities must utilize all of their capacity to provide safe and effective assessment and treatment. 

If the restriction on placing someone who is on a TDO (TDO issued to the facility in question) is based upon the need for “security” and clinical capability – then the facility should be judged on that basis and the TDO “stipulation” attached to their licenses should reflect that.

If, however, the restriction is based on the fact that the 23-hour program is not intended to “house” someone for the 72 hour duration of a TDO then the CSB should note that placement will be made in the attached CSU as soon as a bed becomes available.  If it is unlikely that a bed will be available in the specified amount of time, the CSB may choose to seek a different location.

While it within the purview of Medicaid to set limits on payment this seems to be contrary to the State’s intent to improve the functionality of the Community Crisis System.  As we read these restrictions:

• If someone enters a Crisis Now facility on an ECO and is transferred to the custody of the facility for immediate intervention and further assessment (in the 23-hour Obs Unit) and is a Medicaid recipient, payment must end if the CSB determines that a TDO is warranted and a TDO for detention to that same facility is issued. 
• The restrictions also seem to include that if the individual enters the facility on a TDO it may only occur if there is a bed available in the CSU.  This severely limits the functionality of the facility to meet the community needs it was designed to meet.

I would encourage further discussion regarding the role of 23-hour crisis receiving centers in serving individuals under a TDO, particularly when the crisis receiving center is co-located with a Crisis Stabilization Unit and has clinical staffing, infrastructure, and capacity to safely manage individuals at that level of acuity.

If a facility is equipped to manage the needs commonly associated with individuals under a TDO, including the ability to safely respond to significant behavioral escalation and utilize seclusion, physical restraint, or medication for behavioral emergencies when clinically indicated, it should be permitted to provide care while an individual awaits an appropriate inpatient bed. This could include transition to the facility's attached CSU when a bed becomes available or transfer to another appropriate facility elsewhere in the Commonwealth.

The alternative is often not a more therapeutic or safer level of care. It is an emergency department. Individuals may spend prolonged periods in an ED awaiting psychiatric placement, frequently remaining under law-enforcement custody and, at times, in restraints, while receiving limited psychiatric treatment during that wait. Emergency departments serve an essential role in addressing medical emergencies, but they are generally not designed or staffed to provide the same level of specialized behavioral health crisis intervention available within a crisis receiving center.

Virginia has invested significantly in developing a crisis continuum intended to provide individuals experiencing behavioral health emergencies with care in the most appropriate and least restrictive setting possible. A blanket exclusion of individuals under TDOs from otherwise capable crisis receiving centers risks working against that goal.

I would encourage DBHDS to consider a model based on facility capability and clinical appropriateness rather than TDO status alone. Where a crisis receiving center and attached CSU can demonstrate the staffing, safety infrastructure, clinical capabilities, and regulatory requirements necessary to manage this population, those facilities should have the flexibility to serve individuals under a TDO while they await definitive placement.

Ultimately, the question should be: Where can this individual safely receive the most appropriate psychiatric care while awaiting placement? When a behavioral health crisis facility is equipped to provide that care, requiring the individual to remain in an emergency department simply because of their legal status may not produce the safest or most clinically appropriate outcome.