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premise describing the appropriate location to provide services for an individual under and ECO or a TDO is both out of date and flawed.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.