It appears 23 hour beds are only billable in a TDO Facility.
If this were to remain as it is written, it would require CITACs with 23 hour beds available now or coming online to ALSO be licensed as a TDO facility.
At the moment, only inpatient psych units are licensed as TDO facilities (as I understand it), which would require private psychiatric units to develop and implement 23 hour beds as part of their psych units, which is problematic because again, we’re trying to avoid inpatient hospitalization. It seems like the better place for private 23 hour beds might be EDs.
It also appears 23 hour beds are only billable within the context of the civil commitment process, specifically the ECO and TDO time periods.
This is counter to the clinical recommendation for use of this service. In general, the intervention would be to admit an individual to a 23 hour bed voluntarily to allow time and space for the crisis to de-escalate, to find community supports and work through a thorough safety plan to avoid the hospital—and avoid a TDO.
It is also counter to our code-driven responsibility to avoid a TDO through less restrictive community treatment options. While a 23 hour bed is a less restrictive treatment option than an inpatient psych facility, the TDO is the most restrictive way in which to provide treatment.
A 23 hour bed to which a person could be TDO’d would require a person to be transferred from the 23 hour bed to an inpatient TDO facility in the event they are in need of an inpatient level of care following the 23 hour intervention. This is often infeasible because there are so few inpatient psychiatric beds available. The current average period of psychiatric boarding varies but can be upwards of 30 hours.
It appears there is an assumption that people will move from a 23 hour bed to a RCSU, which is a service line that does not currently exist. If that is true, then after the 23 hour period, the service cannot be billed when there are no RCSU beds available (which is most of the time). In that case, individuals would board in 23 hours beds for indeterminate amounts of time awaiting an RCSU bed or an inpatient psych bed, while the facilities receive no reimbursement for the service. Programs could struggle to remain open under those circumstances, resulting in many existing TDO facilities lack of interest in establishing a service like this under these circumstances.
Currently, the statute requires the Director of the TDO facility to discharge an individual prior to hearing in the event the individual no longer meets the criteria for a full commitment. In the event there were 23 hour beds in a CITAC/CSB and the individual could be discharged prior to hearing, who would be the deciding facility director? Would it be the Department Head; Medical Director of the agency; or a Medical Director of the program itself? In general, these resources do not all currently exist in CITACs/CSBs.
Recommendations to prevent loss of existing and upcoming services, promote private sector service development, and provide for appropriate billing/reimbursement for services provided.
Revise regulations so 23 hour bed services can be provided voluntarily or involuntarily, in CITACs, CRCs, EDs, and/or inpatient psych facilities (TDO facilities), as needed.
Consider specific regulations to govern CITACs with 23 hour beds to allow for both voluntary and involuntary admission, so as not to require licensing as a full TDO facility.
Revise regulations to include reimbursement for individuals who are still in need of psychiatric placement after the initial 23 hours.
Consider interim regulations that better suit the current system, with a plan to revise when the community infrastructure exists to better support these requirements.
