Individuals who are subject to an emergency custody order (ECO) are required to be evaluated by a Certified Preadmission Screening Clinician (CPSC) to determine if they meet criteria for a temporary detention order (TDO). Individuals who are not under an ECO, but are believed to require involuntary psychiatric hospitalization, may also be evaluated by a certified CPSC to determine if they meet criteria for a TDO. Under current Virginia code, a TDO cannot be issued until it is determined that a) the individual meets civil commitment criteria and b) a willing treatment facility is identified. Certified CPSCs in Virginia are mental health professionals who are employees or designees of the community services boards (CSB), and are responsible for performing a comprehensive evaluation of a person experiencing a mental health crisis, establishing a preliminary diagnosis, recommending the disposition of the individual – including establishing crisis plans, identifying community resources for outpatient treatment, and identifying a willing treatment facility for inpatient psychiatric treatment – and subsequently, if a TDO is issued, participating in the accompanying legal process. The CPSCs serve as a principal access point to the public mental health system. This has been the established process for more than two decades, with a few changes over the years. This report examines the current process for conducting evaluations and identifying a willing facility; assesses opportunities to expand the workforce that can conduct such evaluations to include other qualified professionals in light of both the vision for where the system is headed and where it is now; explores potential short- and long-term positive and negative impacts associated with possible changes; and recommends necessary legislative changes, funding, and additional resources required to implement any changes.

The TDO Evaluator (HB 1699/SB 768) Workgroup was tasked to:

• Review the current process for conducting evaluations, including any challenges or barriers to timely completion;

• Develop a comprehensive plan to expand the individuals who may conduct Preadmission screenings, and consider other states’ experiences; and

• Include specific recommendations for legislative or budget actions necessary to implement the plan.

With extensive input from the workgroup, DBHDS developed comprehensive plans for two potential pathways for expanding who can perform preadmission screenings: 1) new categories of professionals with sufficient experience within the community services board/behavioral health authority system; and 2) physicians and licensed mental health professional (LMHP) emergency department staff. These two pathways are described in more detail within the report. It is important to note that expanding to allow preadmission screenings to be performed by physicians and LMHP emergency department staff would, for the first time in decades, permit a private entity to be a point of entry into the public psychiatric hospital system. The workgroup acknowledged the valuable training and expertise of the professionals who dedicate their careers to working with individuals experiencing a mental health crisis, and so the question of which professions have training and expertise to assess risk should be allowed to conduct preadmission screenings did not render much controversy. Open questions remained, however, around operationalizing the procedural aspects in Virginia Code related to involuntary commitment and the potential or perceived negative consequences of allowing preadmission screenings to be performed by professionals outside of the CSB system. In trying to address these issues, it was acknowledged that the current process is strained. In some cases, this may be due to workforce shortages at CSBs and is also due to inadequacies in the bed finding process, which adds a significant administrative burden in an already cumbersome process.

Involuntary commitment is one of the most complex clinical and legal processes in mental health care. The Substance Abuse and Mental Health Services Administration (SAMHSA) has reported that an apparent shortage of psychiatric beds and other services- primarily community based, early intervention services- in many areas has created a situation in which involuntary commitment may be seen as a way to prioritize intensive mental health services for individuals who would have difficulty accessing services otherwise, or for situations where a lack of access to comprehensive community services obligate an overreliance on high cost, high acuity services like inpatient hospitalization. Constraints on access greatly influence involuntary commitment practice and policy.1 Virginia has experienced this firsthand as the state mental health hospitals frequently operate at or above capacity throughout the year. This continues to drive resources towards hospital operations, instead of into the community where comprehensive, high quality, evidence-based outpatient services are sorely needed. The community behavioral health workforce is also depleted, not only because there are not enough licensed mental health professionals and other mental health professionals, but also because the reimbursement for services in lower levels of care is not sufficient compared to compensation in acute inpatient care and even lines of work outside of healthcare.

Lastly, the workgroup agreed that expanding the categories of professionals who can conduct preadmission screenings would not solve all of the challenges with the screening process, including lack of consistent quality monitoring, consideration of the patient experience, and time-consuming administrative aspects such as the bed search process. Recommendations were developed to identify opportunities for improvements across the overall behavioral health system of care.

Recommendations

Recommendation #1: Prioritize and continue the development of a comprehensive system of care, through STEP-VA and Medicaid Behavioral Health Enhancement in Virginia. This continuum of care across the lifespan should focus on high quality, evidence-based community services to prevent the need for more costly acute care and reduce overreliance on institutional care. There is a critical shortage of licensed behavioral health workforce and all professionals with the skills, training, and knowledge in various aspects of the evaluation and treatment of mental illness should be employed to their fullest potential, work collaboratively with each other, and optimize resources across the system. While workforce shortages are an issue regardless of payor source, they are magnified in the Medicaid population because many licensed health professionals accept few or no Medicaid members due to low Medicaid reimbursement rates. Thus Medicaid Behavioral Health Enhancement is a critical strategy to build workforce capacity to deliver high quality services, particularly those to prevent the need for mostly costly acute care and reduce overreliance on institutional care.

Recommendation #2: Integrate principles of continuous quality improvement to ensure that any implemented system changes are standardized, monitored, and periodically revised as needed. Quality management processes should be included in a plan for any system changes. Quality oversight across a public and private system may benefit from a broad data management and integrated care coordination process and should include the healthcare triple aim:

• Improve the patient experience: regardless of who conducts the preadmission screening, in order to help ease any resulting trauma, requirements should be considered to have peer support specialists present during the evaluation.

• Improve health outcomes: optimizing and expanding the behavioral health workforce facilitates people accessing other needed services.

• Improve cost efficiency: promote emergency room avoidance and diversion from inpatient services when appropriate.

Recommendation #3: Current processes, such as completion of TDO-related paperwork and bed searches, are lengthy and take away from time spent with an individual in crisis in need of support. Therefore, any changes to who may prescreen should be paired with efforts to streamline the administrative elements of the process for all prescreeners.

Recommendation #4: Investment in an enhanced bed registry tool, which was considered by the HB1453/SB739 workgroup, is critical to expediting the bed search process as well as facilitating a potential handoff from private provider to CSB if a private provider were conducting the initial preadmission screening or even requesting a preadmission screening. (*2) This would also lower the threshold for information the CSB must provide over the phone to hospitals while in search of a bed, as information could be securely uploaded into the registry and shared with inpatient facilities with available beds.

Recommendation #5: Changes to current processes must give special consideration to the impact on inpatient psychiatric bed capacity, especially the impact to the state mental health hospitals given their frequent operation at or above capacity. Evaluators should demonstrate due diligence in diverting individuals from involuntary inpatient treatment and towards least restrictive settings whenever appropriate.

Recommendation #6: Conflict of interest on the part of the evaluator should be avoided at all times.
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(*1) Substance Abuse and Mental Health Services Administration: Civil Commitment and the Mental Health Care Continuum: Historical Trends and Principles for Law and Practice. Rockville, MD: Office of the Chief Medical Officer, Substance Abuse and Mental Health Services Administration, 2019.
(*2) RD513 - Acute Psychiatric Bed Registry Workgroup Report – November 6, 2020. Available at: https://rga.lis.virginia.gov/Published/2020/RD513