Who should conduct Temporary Detention Orders Evaluations in Virginia? A VACEP-supported report gets published.

Last year, under orders from the General Assembly, the Department of Behavioral Health and Developmental Services (DBHDS) was tasked with reviewing the current process for conducting temporary detention order (TDO) evaluations and developing a comprehensive plan to expand those who may conduct them. The final report, authored in part by members of VACEP, was published earlier this month.

For more than two decades under the Code of Virginia, individuals who are under an emergency custody order (ECO) or are believed to require involuntary psychiatric hospitalization must be evaluated by a Certified Preadmission Screening Clinician (CPSC) to determine if they meet criteria for a TDO.

But could this process be streamlined? Could other trained, qualified professionals conduct these evaluations? The TDO Evaluator Workgroup, which included members of VACEP, was asked 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. 

The group also made six recommendations to improve the process.

Recommendation #1: Prioritize and continue the development of a comprehensive system of care, through STEP-VA and Medicaid Behavioral Health Enhancement in Virginia.

Recommendation #2: Integrate principles of continuous quality improvement to ensure that any implemented system changes are standardized, monitored, and periodically revised as needed.

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 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

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.

Recommendation #6: Conflict of interest on the part of the evaluator should be avoided at all times.

You can access the full report here, along with more background on the TDO evaluation and commitment process. The 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.

Special thanks to VACEP’s Bruce Lo, MD, MBA, FACEP; Jared Goldberg, MD, FACEP; Jonathan D’Souza, MD, MBA, FACEP; and our longtime lobbyist Aimee Perron-Seibert for serving on the TDO Evaluator Workgroup. Additional workgroup representatives included professionals from the Medical Society of Virginia, Psychiatric Society of Virginia, Virginia Hospital and Healthcare Association, and many more.