Background

Connections Health Solutions was recently awarded a contract from Prince William County to provide crisis receiving and stabilization services for the County. The Company will support the crisis receiving center's design and buildout and will operate the center located in Woodbridge, Virginia. Connections currently operates two of the largest and most studied behavioral health crisis receiving centers in the country and has expanded operations to include both rural and urban communities.

Feedback on 23-Hour Crisis Stabilization Level of Care Guidelines as a whole

Connections recommends that the language throughout the 23-Hour Crisis Stabilization section referring to “up to 23 hours” be changed to “up to 23 hours and 59 minutes.” The 23-Hour Crisis Stabilization model is intended to provide services and be billable for any time less than 24 hours. So, there are instances where individuals will receive services for over 23 hours, but less than 24 hours and the Manual’s language should reflect that.

Feedback on 23-Hour Crisis Stabilization Medical Necessity Criteria

In Appendix G of the Mental Health Services Manual the exclusion criteria for 23-Hour Crisis Stabilization specifies that those with “a presence of sufficient severity to require acute psychiatric inpatient, medical, or surgical care” are not appropriate for 23-Hour Crisis Stabilization. Connections recommends removing “sufficient severity to require acute psychiatric inpatient” from the exclusion criteria.

All patients admitted to Connections’ 23-Hour Crisis Stabilization units (~20k annually) are suitable for admission to an inpatient level of care. Even so, 60 – 70% are released to the community in lieu of an inpatient stay. These outcomes are driven by a commitment to patient-centered care and the belief that even high acuity patients can improve clinically. As the clinical picture improves, Connections transfers patients to the least restrictive environment which will still support the patient’s needs. In essence, without a stay in a 23-Hour Stabilization unit for assessment and treatment, a determination cannot truly be made with respect to the need for psychiatric inpatient care.

The exclusion criteria as listed above runs the risk of violating the “no wrong door” policy. The “no wrong door” policy is in part successful due to the ease of communication with all stakeholders. Law enforcement understands that they can drop-off any patient for treatment. Individuals can walk in through the front door and know they can be treated. The exclusionary criteria as it stands now may open the door to crisis receiving centers refusing to accept certain high acuity patients. If law enforcement and the community aren’t clear on who is suitable for crisis receiving centers or meet challenges in gaining access to crisis receiving centers, they will be less likely to use the crisis receiving center and the system falls apart.

In addition, the Mental Health Services Manual stipulates individuals under a temporary detention order, who according to Virginia statute may need inpatient hospitalization, can receive treatment in 23-hour crisis stabilization. Virginia code §37.2-809 B states: “A magistrate shall issue, . . . a temporary detention order if it appears from all evidence readily available, . . . that the person (i) has a mental illness and that there exists a substantial likelihood that, as a result of mental illness, the person will, in the near future, (a) cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting, or threatening harm and other relevant information, if any, or (b) suffer serious harm due to his lack of capacity to protect himself from harm or to provide for his basic human needs; (ii) is in need of hospitalization or treatment; and (iii) is unwilling to volunteer or incapable of volunteering for hospitalization or treatment.” Thus, individuals under a temporary detention order that are treated in 23-hour crisis stabilization may be of “sufficient severity to require acute psychiatric inpatient, medical, or surgical care”—counter to the current exclusion criteria.

Feedback on Residential Crisis Stabilization Medical Necessity Criteria:

In Appendix G of the Mental Health Services Manual the exclusion criteria for Residential Crisis Stabilization states “the individual’s psychiatric condition is of such severity that it can only be safely treated in an inpatient setting due to violent aggression or other anticipated need for physical restraint, seclusion or other involuntary control.” This guidance is reflective of current Virginia administrative codes that do not provide for seclusion and restraint capabilities in 23-Hour Crisis Stabilization and Residential Crisis Stabilization. Regardless, Connections urges DMAS in cooperation with DBHDS to work to create a path to allow 23-Hour and Residential Crisis Stabilization to perform seclusion and restraint where necessary.

In order for a crisis center to be “no wrong door” and take the most behaviorally acute (e.g. agitated and violent) patients, it needs the ability to do seclusion and restraint. Otherwise, crisis centers will likely refuse to take anyone who might need seclusion or restraint, and then those patients end up in ERs or jails, where they are likely to be restrained because those settings are not equipped to treat behavioral health conditions.

Crisis receiving centers have the trained clinical staff (no security) and physical layout to have a better chance of de-escalating the patient (including the highly acute/agitated) without having to use seclusion or restraint. Connections tracks use of seclusion and restraint closely and our rates are at or below the Joint Commission’s national averages for inpatient units, despite the fact that patients come in highly agitated directly from the field.

Seclusion and restraint is a function of the level of care more than the license. Emergency rooms are outpatient and perform restraints. A primary care clinic is also an outpatient setting, however it wouldn’t be appropriate to perform restraints in that setting. For these reasons, Connections encourages revision of the exclusionary criteria to include patients requiring seclusion and restraint in both 23-Hour Crisis Stabilization and Residential Crisis Stabilization.