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.