Address continuity of 23-hour crisis stabilization services

The proposed Supplement continues to reimburse 23-hour crisis stabilization through the TDO Program during an ECO but not after the individual becomes subject to a TDO. While this may create a discontinuity in care, we believe the issue warrants further evaluation before broadly extending reimbursement.

 Virginia’s psychiatric bed shortages make 23-hour crisis services an important diversion option. However, not all 23-hour settings are designed to safely manage individuals under a TDO. Some operate in open environments with recliners in close proximity and may lack secured egress, continuous observation, enhanced staffing, or other safety features associated with higher-acuity psychiatric care.

National models indicate that some high-acuity psychiatric emergency programs can safely serve involuntary patients when appropriate staffing, monitoring, security, and clinical infrastructure are in place. The key issue, therefore, is not merely whether a person under a TDO may remain in a 23-hour setting, but which individuals can be safely served, in which settings, and under what conditions.

 We recommend that DMAS and DBHDS further evaluate the clinical, safety, operational, capacity, and reimbursement implications before implementing a statewide change. This review should include patient outcomes, safety events, effects on 23-hour bed availability, impacts on inpatient and emergency department utilization, facility capabilities, and the potential for reimbursement policy to unintentionally influence level-of-care decisions.

 A reasonable path forward may be to establish clear clinical and facility criteria or to consider a limited pilot to continue 23-hour reimbursement after an ECO converts to a TDO. This would allow Virginia to balance continuity of care and psychiatric bed capacity with patient safety, risk management, and appropriate level-of-care decisions.