Background

Connections Health Solutions (Connections) reviewed the Mental Health Services (formerly CMHRS) Manual, with particular focus on Appendix G: Comprehensive Crisis Services and the Supplement Temporary Detention Orders.

With the launch of 988 Virginia’s existing crisis infrastructure, jails, emergency departments and inpatient psychiatric units, will face unprecedented demand. As Virginia’s current system is already facing demand beyond its capacity, and significant staffing shortages, without immediate intervention the state risks exacerbating current challenges.

Crisis receiving centers can alleviate the pressure on state inpatient psychiatric units, EDs and jails, while providing immediate access to mental health care of patients. However, the success of a crisis receiving center depends on the ability to implement a “no wrong door” strategy.  'No wrong door' embodies the philosophy that individuals in crisis should be able to receive care no matter how they arrive at the center.  This requires the ability to accept individuals that may need to be evaluated for court-ordered treatment, that may appear to be higher acuity, but can be successfully managed, and the ability to use seclusion and restraint only when necessary and by trained personnel. 

Secondly, the success of crisis receiving centers also depends on the ability to ensure that patients are treated in the least restrictive setting of care. It is critical to ensure that patients are connected to the right resource, at the right time to provide them with the best opportunity on their road to recovery.

Connections has provided commentary below on the medical necessity criteria for 23-Hour Crisis Stabilization and Residential Crisis Stabilization, as well as the Supplement Temporary Detention orders, highlighting language that runs counter to the ‘no wrong door’ philosophy and the principle of least restrictive care. Many thanks to the Department of Medical Assistance Services for the opportunity to provide comment.

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 medical” from the exclusion criteria.

In Arizona, 100% of 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.   

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.

Feedback on the Supplement Temporary Detention Orders

Connections applauds the addition of 23-Hour Crisis Stabilization and Residential Crisis Stabilization to the Mental Health Services Manual Supplement Temporary Detention Orders. Connections noted the language that states “TDO facility admissions may occur in acute care hospitals, private and state run psychiatric hospitals and 23 hour crisis stabilization and residential crisis stabilization unit (RCSU) providers who are identified as Department of Behavioral Health and Developmental Services (DBHDS) licensed facilities of temporary detention.”

The ability to accept all acuities, both involuntary and voluntary in 23-Hour Stabilization/Residential Crisis Stabilization is critical to the success of crisis response centers. The addition of these levels of care to the Supplement Temporary Detention Orders underscores the importance of adjusting the medical necessity criteria highlighted above. For example, as per the regulations (listed below) individuals that meet criteria for temporary detention order have “a mental illness and [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 evidence by recent behavior causing, attempting, or threatening harm and other relevant information.” Given this definition, it is likely that individuals on TDO may require seclusion and restraint. Without the capability to do so in the 23-Hour Crisis/Residential Stabilization, it is difficult to imagine these sites of care will be able to accept TDO patients.

Does Virginia allow treatment providers to convert to voluntary so the commitment process can be avoided altogether? Connections’ current understanding is that the responsibility for ECO/TDO evaluations falls to community service boards. Core to the success of crisis receiving centers is the ability to discharge to the least restrictive setting of care as soon as the patient is ready and empowering the patient to take control of their own treatment by consenting to voluntary treatment. Based on our initial review and understanding of the Code of Virginia Title 37.2 Chapter 8 – Emergency Custody and Voluntary and Involuntary Civil Admissions treatment providers do not have the ability to educate and offer patients the option for voluntary treatment.  If patients must wait until the commitment hearing to be converted to voluntary treatment, there is a risk that patients may be held in a higher level of care longer than necessary which prevents other patients who need that chair or bed from getting placement and results in unnecessary patient boarding. Empowering an individual to take control of their own treatment early in the process positively impacts outcomes and prevents them from having to go through the commitment hearing all together. Connections recognizes that we have more to learn with respect to ECO/TDO processes but wanted to highlight this point.  

In closing, Connections is more than happy to provide further clarification to this commentary and assistance, if helpful, as DMAS (and DBHDS) continue their implementation of the crisis system in Virginia.

About Connections Health Solutions

Connections is the founder of the 23-Hour Crisis Stabilization model. Connections’ clinical leadership Drs. Carson and Williamson created the first crisis observation units in Texas in the 1990s. Following their success in Texas, Drs. Carson and Williamson founded Connections in 2009 in Phoenix, Arizona to take over the management of the Urgent Psychiatric Center (UPC). Under Connections’ leadership, the UPC was transformed from a struggling facility with high employee turnover and variable outcomes into the nation’s premier crisis care center. Connections has set the national standard for urgent and emergency psychiatric services: 65% of patients who enter our crisis centers, inclusive of high-acuity and involuntary admissions, are successfully stabilized in <24 hours and safely discharged to the community in lieu of an inpatient psychiatric admission. 

In 2014, Connections expanded in Arizona by assuming management of the Crisis Response Center (CRC) in Tucson. Joined by Dr. Margie Balfour, the CRC underwent a full-scale quality improvement process. Dr. Balfour’s pioneering work on defining crisis outcome measures, developed at the CRC, has been adopted as a national standard by SAMHSA. Additionally, thanks to concerted investment in law enforcement partnership, the CRC’s collaboration with the Tucson Police Department has been recognized as a model Law Enforcement Mental Health Collaboration Learning Site by the U.S. Department of Justice. It is a frequent stop for counties researching crisis best practices. 

Connections’ leadership has been integral to the creation of the nationally recognized Arizona model, often referred to as “CrisisNow.” Most recently our work has been profiled in Roadmap to the Ideal Crisis System, released by the National Council for Mental Wellbeing and the Group for the Advancement of Psychiatry in 2021 (co-authored by Dr. Balfour).

Connections’ centers are an essential community resource with the ability to quickly triage, assess, and initiate treatment in a safe and healing environment.  Law enforcement is treated as a “preferred customer” with drop-off times of 5-10 minutes, to incentivize transport to treatment instead of jail. An interdisciplinary team of psychiatrists, nurses, social services staff, behavioral health technicians, and peer supports focuses on early intervention, crisis stabilization, and discharge planning.