Workgroup Considering Improvements to Involuntary Commitment Process

September 9, 2021

A workgroup convened by the Department of Behavioral Health and Developmental Services to consider potential expansion of the categories of professionals who may conduct evaluations of individuals for Temporary Detention Orders (TDOs) has concluded its meetings for the year and released a draft report. Currently, these evaluations, which occur when an individual is subject to an Emergency Custody Order, are performed by professionals employed or contracted by a Community Services Board (CSB) who meet certain training and licensure or education requirements, and determine whether an individual meets the criteria for inpatient commitment. If the individual meets the criteria, the evaluator conducts a search for an available bed; if no bed is available before the expiration of the eight-hour Emergency Custody Order, the state hospital is designated as the “bed of last resort.”

A 2020 workgroup on the subject was directed by legislation enacted during the 2020 General Assembly session, which required the workgroup to review the current process for conducting evaluations, including barriers to timely completion of evaluations, and to develop a plan to expand the categories of individuals who may complete the evaluations. The 2020 workgroup considered two potential approaches – adding new categories of CSB employees who could be eligible to conduct evaluations, or expanding the pool of evaluators beyond CSBs by allowing emergency department clinicians to conduct the evaluations. There was no consensus on recommendations; although members of the workgroup expressed interest in expediting the evaluation process, in reviewing data from previous studies of the evaluation process, it appeared that the evaluation process is not typically the factor causing delays in the issuance of TDOs, as the vast majority of evaluations begin within two hours of notification. There were also concerns about non-CSB staff’s familiarity with community resources and whether they may rely more heavily on hospitalization as a result, and the ability of non-CSB staff who may conduct an evaluation to fulfill the remaining elements of the process, including the bed search and attendance at commitment hearings.

Language in the 2021 Appropriation Act directed the Department of Behavioral Health and Developmental Services to continue the workgroup and report its implementation plan by December 1, 2021. This year, workgroup participants considered the two pathways discussed in the 2020 workgroup – expansion of evaluators within CSBs, and expansion of evaluators to emergency room clinicians – and also proposals to improve the quality of the ECO/TDO process (to include improving the patient experience), as well as enhancing administrative efficiency. The draft report includes the following recommendations from the workgroup:

  • Improving the use of peer support services for individuals undergoing TDO evaluations, with a goal of improving the experience for the individual in crisis.
  • Establishing a quality review committee for TDO evaluations, based on some concern about variability in the evaluation process at the local level.
  • Developing crisis services that offer specialized care, such as alternative services for individuals with a primary diagnosis of dementia or individuals with intellectual or developmental disabilities. A separate workgroup is examining ways to divert individuals with dementia from hospitalization.
  • Considering ways to enhance psychiatric treatment in emergency departments as a potential strategy to reduce TDOs or minimize time spent in inpatient hospitalization.
  • Continuing improvements to the psychiatric bed registry system, which is intended to track available beds and is in the process of being redesigned.

The workgroup also discussed potentially allowing additional CSB staff to qualify as pre-screeners, provided that these individuals met certain criteria for education and experience. There was limited interest during this round of study in allowing emergency department clinicians to perform evaluations at this time.

A final report is due by December 1.

VACo Contact: Katie Boyle

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