The workgroup to study who should conduct TDO evaluations met three times during the summer of 2020 with representatives from Virginia’s community services boards (CSBs), community hospitals, law enforcement, mental health advocates, and other stakeholders. The final report laid out two possible pathways to expansion of TDO evaluators in Virginia, including:

1. Adding new categories of eligible professionals within the CSB system; and

2. Expanding the categories of evaluators to include clinicians in emergency rooms.

In 2021, the workgroup focused on developing additional detail around both Pathway 1 and Pathway 2, addressing key areas such as eligibility for new CPSCs, required orientation and training, and the specific responsibilities of CPSCs. In order to address these topics, the workgroup first considered how to improve the administrative processes involved in TDO evaluations as well as quality management of these evaluations. These considerations served as a foundation to the subsequent discussions around the two pathways to expansion.

Discussions held by the workgroup over two years resulted in several actionable recommendations to improve and enhance the TDO evaluation process. These recommendations are independent of whether or not the General Assembly expands the pool of individuals eligible to conduct TDO evaluations.

Invest in peer support services.

The workgroup recommends that the General Assembly invest in a rate study, conducted by the Department of Medical Assistance Services, to enhance rates for peer supporters. The workgroup also recommends that specialized rates for their role as supporters in the TDO evaluation process be considered.

Establish a quality review committee for TDO evaluations.

The workgroup recommends that a multi-disciplinary, inter-agency committee with stakeholder participation be established to develop a statewide process for the standardization, monitoring, a quality assurance of TDO processes and outcomes.

Develop crisis services that meet the needs of populations that require specialized care.

For many individuals with a primary diagnosis of dementia, intellectual or developmental disability, or intoxication who are subjects of a TDO evaluation, civil commitment or inpatient hospitalization is not the best course of treatment/action. Alternative services should be developed to divert individuals from inpatient hospitalization and decrease the incidence of civil commitment.

Collaborate across stakeholders to enhance psychiatric treatment in the emergency room.

The prompt initiation of psychiatric treatment for individuals in crisis results in better outcomes for the individual and reduces the rate of TDO dispositions. While all emergency departments provide basic stabilizing services, there is significant variation in psychiatric resources. Inter-agency collaboration as well as collaboration with academic medical centers is needed to optimize emergency psychiatric care in the Commonwealth.

Continue investments in the acute psychiatric bed registry.

While the new bed registry platform is expected to come online in the fall of 2021, ongoing support for the maintenance of this platform as well as training for proper use of the platform is critical to maximizing its effectiveness.

Maintain the current eligible CPSC while investing in process enhancements.

To facilitate expanding TDO evaluators in the Commonwealth, the current processes should first undergo system enhancements to improve quality, oversight, and improve efficiencies. The TDO evaluation is a critical entry step into the behavioral health system which is being enhanced through the work of STEP-VA and Project BRAVO.