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Final Thoughts heading to Appropriations. HOPEFULLY the various Committee and Subcommittee members have read and followed comments as concerns were registered statewide. Caution has been provided in how the BH System will be affected if moved forward. This would have been extremely important for Legislators patroning bills for SB34 and HB608 to have spoken to constituents expressing concern, their CSB who could have provided ACCURATE and INSIGHTFUL information that would have aided in understanding concern and the right thing. Contact your STAKEHOLDERS WHO WILL BE impacted by proposed bills and despite instead providing or supporting messages as if it is a relief for their benefit. They certainly know the landscape and who works for their interest. They would have appreciated being contacted about their TRUE pressure points with plenty of opportunity to do so. True partners work toward mutual interests and our community – not one system’s. Those not willing to have conversations or demonstrate transparency burden our law enforcement, emergency departments and citizens every day. Yet – messages are that it is for their benefit. Without the willingness to meet with stakeholders – or to demonstrate transparency – will not lead to the change needed. Misleading and inaccurate information to support an initiative – does not move toward meeting public interests. I trust that those governing and supporting our citizens have done their due diligence on the facts, issues and impacts. If so, moving forward with such a bill, a monumental shift in public policy would NOT HAVE weighed public interests --- but rather demonstrate favor = not for those systems, the behavioral health, public policy and not in alignment with other GA interests. Not in consideration of the liberties of your citizens. Moving forward ignores the caution identified in Financial Impact Statements and TDO Evaluator Workgroup report that was legislature directed. All expect burden to the system if such a bill were enacted. Certainly, that could not be ignored. Certainly – if so repercussions to citizens – to community. It would erode trust. The conflict of interest should worry those moving this forward, if the case. It impacts private providers who value transparency and partnerships will be impacted both initially and long term. Immediately it further undermines other hospital systems who are investing in the community. Also, with the budget request Item296#4h – further incentive while controlling a process for one provider. Any decision moving forward ignores important recommendations of JLARC – but remember – liberties are at stake. I’m hoping this is read and no decision to enact would move forward without having done so. Trust your gut. --- how would sacrificing all the principals make since here? It would not.

The CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services. I am actively opposed to this as it does nothing to speed up the process or get law enforcement “back out on the streets” but instead will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospital

This bill would drastically change the current structure of our mental health system and not in a positive way. CSBs work diligently to provide services that advert psychiatric hospitalizations by providing additional services that provide a least restrictive alternative. I believe this change would lead to an increase in unnecessary TDOs which is not in the best interest of the individual, but also puts an unnecessary strain on resources such as law enforcement and state facilities that are already operating at maximum capacity.

This does nothing to speed up the process or get law enforcement “back out on the streets”, but instead, will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospital. The CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services.

This bill would require significant adjustments or exceptions for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ liberties. The CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services.

We respectfully request that you do not enact SB34. This bill authorizes a single private behavioral health hospital to evaluate individuals in a behavioral health crisis to determine whether they meet the criteria for a Temporary Detention Order for involuntary psychiatric hospitalization. Community Services Boards are opposed to this bill, as are experts in the field who have studied this issue for decades. See expert letter and from Dr. Richard Bonnie, Dr. Heather Zelle, and Attorney John Oliver on this issue. They also strongly oppose SB34. Doesn’t anyone care that this bill have a conflict of interest? The inpatient provider would also determine where the patients would be hospitalized, which could be their own facility. As per the Code, the evaluator should be independent and have no financial interest. If the evaluator is employed by the hospital, that is a clear conflict of interest and we ask that you to not support this, or at least obtain a legal opinion before changing the code of Virginia for a single provider, even as a pilot! Allowing the provider to absorb the financial impact of this bill in order to move it forward seems like another conflict of interest. Allowing the provider to use their financial resources to pay for the cost of implementing the bill seems to be yet another conflict! Another fiscal impact noted in the proposed bill, is that this change to the code will increase the state hospital census. It has been suggested that in order to prevent this, the bill could be amended to require the CSB to complete a second prescreening evaluation whenever the Psych ED determines that someone needs to be hospitalized. This modification would require fragile individuals who are experiencing a mental health crisis to undergo TWO evaluations, thereby increasing the time spent in the ED. This also places an additional burden on your CSB to carry out all of the required duties of the bed search and placement if the individual is indeed in need of hospitalization, while relieving the Psych ED of that responsibility. This does not help the patient nor the system. Ask yourself why this is necessary. Whom does it serve? It serves the private behavior health provider, not your public CSB and above all not the individual patient lingering in the ED. PLEASE DO NOT SUPPORT THIS BILL. PLEASE SEND IT TO THE BEHAVIORAL HEALTH COMMISSION WHERE IT CAN BE FURTHER STUDIED.

Greetings members of the Health and Human Services Committee, Please oppose this bill as it does not address psychiatric bed availability or streamline care for those in need of acute behavioral health treatment. What has been working to streamline care and treatment is the CSB system operating as an objective party with extensive knowledge of community resources and specializing in strategies to link individuals in crisis to the least-restrictive alternatives. Thus avoiding hospitalization whenever possible. This also serves to maximize linkage to the General Assembly funded STEP-VA mandates and Crisis Now community-based services. Please see attached and thanks for your consideration.

As a certified prescreener I oppose SB34. Our issues with placement have nothing to do with the evaluation response times. It has everything to do with psychiatric hospital acceptance who ultimately are the ones who determine if they accept or do not accept our individual’s. We complete multiple bed searches per shift. Individuals who do not fit the “perfect” psychiatric criteria (meaning they are acute, have ID issues, or any physical limitations) may sit in the ED for days until state hospitals have an available bed. Again, this has nothing to do with assessment response times. Our agency responds within an average of minutes after an evaluation is requested. This bill will UNDERMINE everything that we have done to reduce TDO’s as we have so many less restrictive options that hospitals are unaware of. Our last resort is always a TDO. Private hospitals do not have the options that we have to ensure the best and least restrictive options. This bill Would be a monumental shift in public policy enacted decades ago to ensure that the least restrictive alternative is always considered and avoiding inappropriate TDOs; Ignores and circumvents the concerns and recommendations of the legislature-directed TDO Evaluator Workgroup which just presented their findings on December 29, 2021; Directly contradicts efforts and General Assembly’s investments in STEP-VA; and counters recommendations in the JLARC Study issued in Dec. 2023 and is inconsistent with goals of moving Virginia toward a Crisis Now System; Ignores caution identified in the Financial Impact Statements for both SB34 and HB608 which anticipates enactment would increase the number to TDO admissions to the state hospital. Delays in the system are due to individuals being unable to access an accepting bed, not for an evaluation. Hospitals maintain control whether they will admit or not admit; Does nothing to speed up the process or get law enforcement “back out on the streets” but instead will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospital; Would require significant adjustments or exceptions for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ liberties; Provides a private hospital, with financial interest in the outcome, authority to determine facility of TDO, whether to their own facility or direct access to State Hospital Bed; The CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services.

The amount of opposition is a testament to the inappropriateness of measures proposed to be taken. First, it appears to disregard research designed to promote best practices regarding this area of concern. Second, it appears to be in direct opposition to the goals set forth by the Commonwealth to ensure concerns are addressed in a comprehensive manner. Third, it seems to provide a limited view of challenges it is designed to address. Thus, the bill does not accurately or adequately address its intended purpose, and does not need to be supported.

I strongly oppose SB 34 for the following reasons: This would be a monumental shift in public policy enacted decades ago to ensure that the least restrictive alternative is always considered and avoiding inappropriate TDOs. It ignores and circumvents the concerns and recommendations of the legislature directed TDO Evaluator Workgroup which just presented their findings on December 29, 2021. Passing of SB 34 directly contradicts efforts and General Assembly’s investments in STEP-VA, counters recommendations in the JLARC Study issued in Dec. 2023, and is inconsistent with goals of moving Virginia toward a Crisis Now System. It would also cause delays in the system are due to individuals being unable to access an accepting bed, not for an evaluation. Hospitals maintain control whether they will admit or not admit. Unfortunately, this will do nothing to speed up the process or get law enforcement “back out on the streets” but instead will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospital. Passing SB 34 would also require significant adjustments or exceptions for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ liberties. This would also provide private hospitals, with financial interest in the outcome, authority to determine facility of TDO, whether to their own facility or direct access to State Hospital Bed. As you are aware, CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services.

I am responding to voice strong opposition to SB34. Enabling this legislation to move forward would be a monumental shift in public policy enacted decades ago to ensure that the least restrictive alternative is always considered and avoiding inappropriate TDOs. This also provides a private hospital, with financial interest in the outcome, authority to determine facility of TDO, whether to their own facility or direct access to State Hospital Bed. It has been suggested that the magistrate is the one that determines whether or not a TDO is recommended and choice of placement; however, it is the CSBs responsibility as an unbiased party, to assess, make the recommendation, and determine placement location. SB34 ignores and circumvents the concerns and recommendations of the legislature-directed TDO Evaluator Workgroup which just presented their findings on December 29, 2021. It also directly contradicts efforts and General Assembly’s investments in STEP-VA; and counters recommendations in the JLARC Study issued in Dec. 2023 and is inconsistent with goals of moving Virginia toward a Crisis Now System. It ignores caution identified in the Financial Impact Statements for both SB34 and HB608 which anticipates enactment would increase the number to TDO admissions to the state hospital. It is important to note that delays in the system are due to individuals being unable to access an accepting bed, not difficulties obtaining an evaluation or waiting extensive times for those evals. Hospitals maintain control whether they will admit or not admit and an individual to be placed on a waiting list. This does nothing to speed up the process or get law enforcement “back out on the streets” but instead will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospital. This also would require significant adjustments or exceptions for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ rights. In conclusion, the CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services. Part of the success of these programs that have been stood up to assist in decreasing hospitalization rates by DBHDS is that there are staff working in the CSB who are knowledgeable of the resources and who are committed to referring to those programs to avoid hospitalization.

***Please disregard the previously submitted version of this letter (dated 2/20/24) which was inadvertently sent on UVA letterhead. The signatories are submitting this letter in their personal capacities. It does not reflect the positions or policies of the University. The prior submission on UVA letterhead on February 20, 2024 was unintended. *

I am the Divisional Director of our CSB's Crisis Services. I STRONGLY OPPOSE this legislation (SB34). It is misguided in its efforts that it will reduce the wait time for evaluations and obtaining a hospital bed and will somehow quickly return officers back to their intended duties of law enforcement. Delays in the system are due almost exclusively to individuals being unable to access an accepting bed, not for an evaluation. Hospitals have the ultimate authority and maintain control whether they will admit or not admit the individual. This Bill will not change that process. The proposed legislation does nothing to speed up the process or get law enforcement “back out on the streets” but instead will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospitals. There should only be one access point to the state hospital system. This would override that process. This Bill will provide a private hospital, with financial interest in the outcome, authority to determine choice of facility for the TDO, whether to their own - or by having direct access to State Hospital Bed. This flies in the face of the General Assembly’s investments in STEP-VA; and counters recommendations in the JLARC Study issued in Dec. 2023.

The CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services. This Bill, if approved, would undermine the intent of "objective 3rd party" weighing in on need for compulsory inpatient psychiatric treatment and provide a private hospital, with financial interest in the outcome, authority to determine facility of TDO, whether to their own facility or direct access to State Hospital Bed. Furthermore, does nothing to speed up the process or get law enforcement “back out on the streets” but instead will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospital. Bad bill anyway you look at it.

•OPPOSE : Would be a monumental shift in public policy enacted decades ago to ensure that the least restrictive alternative is always considered and avoiding inappropriate TDOs; • Ignores and circumvents the concerns and recommendations of the legislature-directed TDO Evaluator Workgroup which just presented their findings on December 29, 2021; • Directly contradicts efforts and General Assembly’s investments in STEP-VA; and counters recommendations in the JLARC Study issued in Dec. 2023 and is inconsistent with goals of moving Virginia toward a Crisis Now System; • Ignores caution identified in the Financial Impact Statements for both SB34 and HB608 which anticipates enactment would increase the number to TDO admissions to the state hospital. • Delays in the system are due to individuals being unable to access an accepting bed, not for an evaluation. Hospitals maintain control whether they will admit or not admit; • Does nothing to speed up the process or get law enforcement “back out on the streets” but instead will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospital; • Would require significant adjustments or exceptions for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ liberties; • Provides a private hospital, with financial interest in the outcome, authority to determine facility of TDO, whether to their own facility or direct access to State Hospital Bed; • The CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services.

I strongly oppose SB34. I have outlined my opposition below. • Would be a monumental shift in public policy enacted decades ago to ensure that the least restrictive alternative is always considered and avoiding inappropriate TDOs; • Ignores and circumvents the concerns and recommendations of the legislature-directed TDO Evaluator Workgroup which just presented their findings on December 29, 2021; • Directly contradicts efforts and General Assembly’s investments in STEP-VA; and counters recommendations in the JLARC Study issued in Dec. 2023 and is inconsistent with goals of moving Virginia toward a Crisis Now System; • Ignores caution identified in the Financial Impact Statements for both SB34 and HB608 which anticipates enactment would increase the number to TDO admissions to the state hospital. • Delays in the system are due to individuals being unable to access an accepting bed, not for an evaluation. Hospitals maintain control whether they will admit or not admit; • Does nothing to speed up the process or get law enforcement “back out on the streets” but instead will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospital; • Would require significant adjustments or exceptions for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ liberties; • Provides a private hospital, with financial interest in the outcome, authority to determine facility of TDO, whether to their own facility or direct access to State Hospital Bed; • The CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services.

As you have seen in public comment for SB34 and previously HB608 - great concern is seen around the commonwealth. Please note the following. • Would be a monumental shift in public policy enacted decades ago to ensure that the least restrictive alternative is always considered and avoiding inappropriate TDOs; • Ignores and circumvents the concerns and recommendations of the legislature directed TDO Evaluator Workgroup which just presented their findings on December 29, 2021; • Directly contradicts efforts and General Assembly’s investments in STEP-VA; and counters recommendations in the JLARC Study issued in Dec. 2023 and is inconsistent with goals of moving Virginia toward a Crisis Now System; • Ignores caution identified in the Financial Impact Statements for both SB34 and HB608 which anticipates enactment would increase the number to TDO admissions to the state hospital. • Delays in the system are due to individuals being unable to access an accepting bed, not for an evaluation. Hospitals maintain control whether they will admit or not admit; • Does nothing to speed up the process or get law enforcement “back out on the streets” but instead will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospital; • Would require significant adjustments or exceptions for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ liberties; • Provides a private hospital, with financial interest in the outcome, authority to determine facility of TDO, whether to their own facility or direct access to State Hospital Bed; A budget amendment is being introduced to provide private hospitals incentive to take more TDOs. To share the burden of state hospitals - not circumstances such as this. to • The CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services.

This bill does nothing to speed up the process or get law enforcement “back out on the streets” but instead will enable the provider to assert additional control over the local publicly funded resources, including law enforcement and the state hospital.

I voice my strong opposition to Senate Bill 34. The issue of Behavioral Health is not a partisan issue. However, this bill would prove to be a monumental shift in public policy with significant immediate and future implications. The General Assembly enacted the current legislation decades, A recent workgroup (December 2021) evaluating such matter, comment on the preadmission evaluation, also noted that: “It is a pivotal point within the larger civil commitment process because if involuntary treatment is recommended and a TDO is issued, the individual in crisis is deprived of his or her liberty” and did not recommend such exception

We strongly oppose SB34! As the Executive Director of the Hampton-Newport News CSB, which is the CSB that represents this district, we are strongly opposed to this bill. In addition to what has already been written repeatedly from CSBs across the Commonwealth, there has been some misunderstanding or misrepresentation as to why this change is needed. It has been stated that due to the backlog at our CSB the ECOs are running out. That is untrue and easily verifiable. It was also stated that CSBs conduct prescreening evaluations on computer screens. Well, that is called telemedicine and is an approved clinical practice. If telemedicine is a concern, we can address that. It was also stated during testimony that there are duplicate assessments. While an individual may undergo multiple assessments, there is only one prescreening assessment and that is completed by the CSB. It was also stated that having a private entity conduct the prescreening assessment will get law enforcement back on the street faster. This is also untrue, law enforcement's obligation is under the TDO, regardless of who completes the prescreening assessment. Please question the information that is presented, and review the law and roles involved in the TDO process under the code of Virginia. It would be great to have the office of the Attorney General weigh in on the conflict of interest or legality of a process that allows for a provider who has a financial interest, conduct prescreening evaluations and bed searches. Thank you for your consideration.

Strongly oppose.

I am strongly opposed to SB34 due to conflation of interest between public and private entities. Please consider that referring clients to your own practice/hospital system is both a legal and ethical dilemma. Ability to detain their own clients to their own hospital system is a conflict of interest. This also allows ability to not detain 'problem' clients and risks the objectivity inherent in maintaining prescreeners as part of a public entity (e.g. CSB) with oversight of DBHDS.

My name is Dean Barker and I have been a Preadmission Screener in Virginia for 32 continuous years now. In that time I have seen a number of legislative changes made. The value of a historical perspective is that changes are always made in reaction to circumstances or specific situations that may or may not be indicative of systemic changes. Often times, it's difficult to properly gauge what changes are necessary versus reactionary. I specifically recall a time in the early 1990s when entities other than the CSBs could request TDOs from magistrates. In those times, I recall multiple events of private hospitals asking for and being given TDOs on persons in their facilities when they were unable to verify insurance benefits. This specific circumstance occurred enough that it was the basis of the inclusion of language stating no person can request a TDO who has a financial interest in the case. I believe, the General Assembly at that time in its wisdom added that language to guard that the least restrictive alternative be utilized while diminishing the possibility of decisions being made out of convenience. I also recall, during this time Veterans at the VA Hospital being TDO'd by psychiatric residents when they were unsure of VA procedures to enroll someone in outpatient services. These cases were never handled this way out of malicious intent however, an involuntary detention for several days, a deprivation of liberty, a potential unwarranted restriction of gun rights are things to be taken into account with someone's choice and the assessment of their ability to make informed decisions. This bill opens the door for private entities to restrict rights with minimal oversight beforehand. The Magistrate's Office issues the TDOs and in testimony given the subcommittee, this was offered as a check-balance of the system. Part of the legislative changes of 2015 changed the Magistrate's portion from "MAY ISSUE" to "SHALL ISSUE". While this change addressed some of the issues from the Deed's tragedy it in the context of this bill opens the door to dangerous control being transferred from the State to Private individuals in direct and immediate response to a deprivation of liberty. Ideas are consistent, not convenient. I am strongly opposed to this bill.

Good morning. I am writing in opposition to SB 34 (Locke) which proposes to open TDO assessments to practitioners employed by Riverside Health System in Newport News and Hampton, Va. I am the retired Executive Director of the HNNCSB where my career began in 1979 and ended with my retirement in 2016. The conflict of interest by having a private practitioner, despite the role of a Magistrate, deciding on the competence of and possible commitment to their own facility is not acceptable. Please see my recent letter to Senator Deeds (attached) which identifies my other concerns about this bill.

I, as many others with whom I work in mental health STRONGLY OPPOSE this bill. It will not do the things it purports to do. Further, It directly contradicts efforts and General Assembly’s investments in STEP-VA It counters recommendations included in the last 2 JLARC studies It is inconsistent with the goals of moving Virginia toward a Crisis Now System & Gov. Youngkin’s Right Help Right Now legislation, the Prompt Placement Task Force & other investments in crisis services; Significant adjustments or exceptions would be required for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ liberties. It ignores and circumvents the concerns and recommendations of the legislature-directed TDO Evaluator Workgroup just providing findings on December 29, 2021. It ignores caution included in Financial Impact Statement of both SB34 and HB608 It provides a private hospital, with financial interest in the outcome, authority to determine facility of TDO, whether their facility or direct access to State Hospital Beds And enables a private hospital to direct and further tax local publicly funded resources Again, strongly opposed to this Bill. Gregory G Braund, LCSW

• I voice my strong opposition to Senate Bill 34. The issue of Behavioral Health is not a partisan issue. However, this bill would prove to be a monumental shift in public policy with significant immediate and future implications. The General Assembly enacted the current legislation decades, A recent workgroup (December 2021) evaluating such matter, comment on the preadmission evaluation, also noted that: “It is a pivotal point within the larger civil commitment process because if involuntary treatment is recommended and a TDO is issued, the individual in crisis is deprived of his or her liberty” and did not recommend such exception • SB34, submitted at the request of a private hospital ignores and circumvents the concerns and recommendations that a legislature-directed Workgroup studying this very matter had just issued their findings, Dec. 29, 2021. The Workgroup studying, “Who Should Conduct TDO Evaluations in Virginia”, consisting of “representatives from Virginia’s community services boards (CSB), community hospitals, law enforcement, mental health advocates, and other stakeholders”[3], like those previous workgroups evaluating this matter, did not make recommendations to allow a non-CSB clinician to conduct a preadmission evaluation. Instead, the Workgroup identified a number of the concerns, as previous studies had, including how such allowances would not account for complexities of the system and may unwind decades old legislation, which has been referred to as the “bedrock of the public behavioral health system”, including areas needing consideration when evaluating any code changes which would expand who could conduct preadmission evaluations to include: Conflict of interest – including “any potential for real or perceived bias” Connection to community resources, noting “the critical role of the CSB connecting individuals to alternatives to inpatient hospitalization”. “Potential increase in TDO admissions. Evaluators who work in private hospital settings may not be fully aware of all the community alternatives to the state psychiatric hospitals, and the workgroup expressed that this could inadvertently lead to an increase in TDO disposition. This would put additional strain on the state mental health hospital system, which is already suffering significant census pressures and staffing shortages” • The Report, like SB34 and HB608 Financial Impact Statements,, anticipates that enactment of either Bill would increase the number to TDO admissions to the state hospital. Despite CSBs playing such a critical role at all aspects of the Behavioral Health system, at no time were we consulted on the needs, of any concerns nor was the potential impact on stakeholders considered.

I am greatly concerned that SB34 and HB608 Financial Impact Statements anticipates that enactment of either Bill would increase the number to TDO admissions to the state hospital. In my Region, forensic evaluations take up most of my state hospital admissions, causing individuals to be further displaced from their homes. Isn't the goal of hospitalization to return individuals to the community in the most person centered way where they can connect with local services to reduce the need for restrictive services? It also seems that there has not been much consideration for another major player in the current TDO process, the CSBs. Despite CSBs playing such a critical role at all aspects of the Behavioral Health system, to my understanding they have had limited consultation on any of their concerns nor the potential impact on stakeholders considered. I strong opposition to Senate Bill 34.

On behalf of Portsmouth Behavioral Healthcare Services, we strongly oppose SB34.

I strongly opposed SB34. John Konkel, LPC Emergency Services Coordinator CIT Coordinator Marcus Alert Coordinator Eastern Shore CSB Cell: 757-693-3653 Office: 757-442-3636 ext 330

Strongly oppose on behalf of Harrisonburg-Rockingham Community Services Emergency Services Department

Good morning, I have worked in Emergency Services for over 30 years and have seen many changes in code relating to the Emergency Custody and Temporary Detention processes. I am also aware that the mental health "system" has current challenges, none of which will be resolved by this bill. This bill, if passed, would change decades-worth of improvements to the "system". Allowing a private facility to detain to their own facility is a blatant conflict, does not adhere to current code, and will not resolve any of the challenges that currently exist. I want to add that I work with many wonderful staff at Riverside Mental Health and Recovery Center and some I consider friends. My position is not against them in any way, but against this bill, that will not help the challenged mental health system in ANY way, and only hinder it.

I voice my strong opposition to Senate Bill 34. The issue of Behavioral Health is not a partisan issue. However, this bill would prove to be a monumental shift in public policy with significant immediate and future implications. The General Assembly enacted the current legislation decades, A recent workgroup (December 2021) evaluating such matter, comment on the preadmission evaluation, also noted that: “It is a pivotal point within the larger civil commitment process because if involuntary treatment is recommended and a TDO is issued, the individual in crisis is deprived of his or her liberty” and did not recommend such exception

I voice my strong opposition to Senate Bill 34. The General Assembly enacted the current legislation decades ago to protect individuals and their liberties. SB34, submitted at the request of a private hospital ignores and circumvents the concerns and recommendations that a legislature-directed Workgroup studying this very matter had just issued their findings, Dec. 29, 2021. The Workgroup studying, “Who Should Conduct TDO Evaluations in Virginia”, consisting of “representatives from Virginia’s community services boards (CSB), community hospitals, law enforcement, mental health advocates, and other stakeholders”, like those previous workgroups evaluating this matter, did not make recommendations to allow a non-CSB clinician to conduct a preadmission evaluation. Instead, the Workgroup identified a number of the concerns, as previous studies had, including how such allowances would not account for complexities of the system and may unwind decades old legislation, which has been referred to as the “bedrock of the public behavioral health system”, including areas needing consideration when evaluating any code changes which would expand who could conduct preadmission evaluations to include: Conflict of interest – including “any potential for real or perceived bias” Connection to community resources, noting “the critical role of the CSB connecting individuals to alternatives to inpatient hospitalization”. In addition to changes in the codes and other regulatory, local, state, and regional protocols this action directly contradicts Other Critical Investments in VA's Behavioral Health System: Directly contradicts efforts and General Assembly’s investments in STEP-VA; Counters recommendations included in the last 2 JLARC studies; Inconsistent with the goals of moving Virginia toward a Crisis Now System & Gov. Youngkin’s Right Help Right Now legislation, the Prompt Placement Task Force & other investments in crisis services; Significant adjustments or exceptions required for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ liberties; Ignores and circumvents the concerns and recommendations of the legislature-directed TDO Evaluator Workgroup just providing findings on December 29, 2021; Provides a private hospital, with financial interest in the outcome, authority to determine facility of TDO; Enables a private hospital to direct and further tax local publicly funded resources. Do not allow the role of the preadmission evaluation to be minimized, devalued or to be regarded as “duplicative”. It is not a duplicative assessment, but rather a determination if an individual may lose their liberties, and as the legislation enacted must ensure that least restrictive alternatives must always be considered for the Commonwealth's most vulnerable citizens. Delays in the system are due to individuals being unable to access an accepting bed, not for an evaluation. CSBs responsiveness is not an issue and we strictly adhere to performance contract standards.

I voice my strong opposition to Senate Bill 34.  This bill would prove to be a monumental shift in public policy with significant immediate and future implications. SB34, submitted at the request of a private hospital, ignores and circumvents the concerns and recommendations that a legislature-directed Workgroup issued in their findings, Dec. 29, 2021.    The Workgroup studying, “Who Should Conduct TDO Evaluations in Virginia”, consisting of “representatives from Virginia’s community services boards (CSB), community hospitals, law enforcement, mental health advocates, and other stakeholders”[3],  did not make recommendations to allow a non-CSB clinician to conduct a preadmission evaluation. Instead, the Workgroup identified a number of the concerns, as previous studies had, including how such allowances would not account for complexities of the system and may unwind decades old legislation. Evaluators who work in private hospital settings may not be fully aware of all the community alternatives to the state psychiatric hospitals, and the workgroup expressed that this could inadvertently lead to an increase in TDO disposition.  This would put additional strain on the state mental health hospital system, which is already suffering significant census pressures and staffing shortages. Despite CSBs playing such a critical role at all aspects of the Behavioral Health system, at no time were we consulted on the needs or any concerns, nor was the potential impact on stakeholders considered. SB34, like HB608, would authorize newly designated “certified evaluators”, employed by a private facility, to recommend issuance to the magistrate for a TDO.  It enables the private hospital to identify the TDO facility, whether their own facility or now with direct access to state hospital beds.  Fundamentally, this poses the position of a private entity’s financial interests being a consideration, real or perceived, in the outcome of this determination, while simultaneously dismissing the importance of an individual’s civil liberties.  The Financial Impact Statements for both Bills and the Dec. 2021 TDO Evaluator Workgroup Study (pg. 16), all anticipate that if enacted, would increase the number of individuals evaluated and TDO’d. Delays in the system are due to individuals being unable to access an accepting bed, not for an evaluation.  The provider and VHHA’s testimony were misleading and did not demonstrate an appreciation for civil liberties being discussed.  Testimony indicating that such an allowance would lead to more timely access to an evaluation is inaccurate and characterized patients as waiting for CSB to evaluate, delaying care, which is also inaccurate.  Current waits are  related to securing an accepting bed, which this bill does nothing to address.  CSBs strictly adhere to performance contract standards with regard to evaluation times. This allowance does nothing to speed up the process or get law enforcement “back out on the streets”.  Instead, it will enable the provider  to assert additional control over the local publicly funded resources and the state hospital. The Code is also very clear on matters related to financial consideration, noting in §37.2-817.01, regards to the evaluator,  - (g) have no financial interest in the admission, treatment, or denial of admission of the person being evaluated; (h) have no investment interest in the facility detaining or admitting the person under this article;[9].

I voice my strong opposition to Senate Bill 34. This bill would prove to be a monumental shift in public policy with significant immediate and future implications. SB34, submitted at the request of a private hospital, ignores and circumvents the concerns and recommendations that a legislature-directed Workgroup issued in their findings, Dec. 29, 2021. The Workgroup studying, “Who Should Conduct TDO Evaluations in Virginia”, consisting of “representatives from Virginia’s community services boards (CSB), community hospitals, law enforcement, mental health advocates, and other stakeholders”[3], did not make recommendations to allow a non-CSB clinician to conduct a preadmission evaluation. Instead, the Workgroup identified a number of the concerns, as previous studies had, including how such allowances would not account for complexities of the system and may unwind decades old legislation. Evaluators who work in private hospital settings may not be fully aware of all the community alternatives to the state psychiatric hospitals, and the workgroup expressed that this could inadvertently lead to an increase in TDO disposition. This would put additional strain on the state mental health hospital system, which is already suffering significant census pressures and staffing shortages. Despite CSBs playing such a critical role at all aspects of the Behavioral Health system, at no time were we consulted on the needs or any concerns, nor was the potential impact on stakeholders considered. SB34, like HB608, would authorize newly designated “certified evaluators”, employed by a private facility, to recommend issuance to the magistrate for a TDO. It enables the private hospital to identify the TDO facility, whether their own facility or now with direct access to state hospital beds. Fundamentally, this poses the position of a private entity’s financial interests being a consideration, real or perceived, in the outcome of this determination, while simultaneously dismissing the importance of an individual’s civil liberties. The Financial Impact Statements for both Bills and the Dec. 2021 TDO Evaluator Workgroup Study (pg. 16), all anticipate that if enacted, would increase the number of individuals evaluated and TDO’d. Delays in the system are due to individuals being unable to access an accepting bed, not for an evaluation. The provider and VHHA’s testimony were misleading and did not demonstrate an appreciation for civil liberties being discussed. Testimony indicating that such an allowance would lead to more timely access to an evaluation is inaccurate and characterized patients as waiting for CSB to evaluate, delaying care, which is also inaccurate. Current waits are related to securing an accepting bed, which this bill does nothing to address. CSBs strictly adhere to performance contract standards with regard to evaluation times. This allowance does nothing to speed up the process or get law enforcement “back out on the streets”. Instead, it will enable the provider to assert additional control over the local publicly funded resources and the state hospital. The Code is also very clear on matters related to financial consideration, noting in §37.2-817.01, regards to the evaluator, - (g) have no financial interest in the admission, treatment, or denial of admission of the person being evaluated; (h) have no investment interest in the facility detaining or admitting the person under this article;[9].

I wanted to voice my strong opposition to SB 34. I am the emergency services director for one Virginia's 40 CSBs. While I understand this bill is intended to be very limited in scope, I wanted to give an example of just how many citizen's rights are likely to be infringed upon by this bill. In FY 2023, my team released 176 people that we were asked to evaluate by local psychiatrists in hospitals. These are 176 people that would, under SB 34, be placed into involuntary hospitalization unnecessarily, and this total represents just 1 of the 40 CSBs in the state. More alarmingly, our team found 75 people actually were voluntary for treatment after having the involuntary hospitalization system explained and hearing our recommendation. This is another 75 people who would have unnecessarily been TDO'd and had their rights removed, due largely to a lack of understanding of process, under SB 34. Again, this is 1 of 40 CSBs in the state, and this is just in the last fiscal year. The unnecessary infringement of rights this bill would cause for people seeking mental health help in the Commonwealth is an ethical nightmare. The hospital bed space situation in the state is already disastrous, consider what that would look like when you add these 251 people x40 CSBs across the state to the pool each year. The Right Help Right Now model that the commonwealth is pursuing is meant to increase community based services and lessen the need for emergency and psychiatric hospital treatment, it'sunclear to me why we are perusing a bill that is the antithesis of this goal.

I voice my strong opposition to Senate Bill 34. In addition to code changes and other regulatory, local, state, and regional protocols, this action directly contradicts Other Critical Investments in Virginia’s Behavioral Health System as outlined below: o Directly contradicts efforts and General Assembly’s investments in STEP-VA o Counters recommendations included in the last 2 JLARC studies o Inconsistent with the goals of moving Virginia toward a Crisis Now System & Gov. Youngkin’s Right Help Right Now legislation, the Prompt Placement Task Force & other investments in crisis services; o Significant adjustments or exceptions would be required for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ liberties. o Ignores and circumvents the concerns and recommendations of the legislature-directed TDO Evaluator Workgroup just providing findings on December 29, 2021. o Ignores caution included in Financial Impact Statement of both SB34 and HB608 o Provides a private hospital, with financial interest in the outcome, authority to determine facility of TDO, whether their facility or direct access to State Hospital Beds o The Code is also very clear on matters related to financial consideration, noting in §37.2-817.01, regards to the evaluator, - (g) have no financial interest in the admission, treatment, or denial of admission of the person being evaluated; (h) have no investment interest in the facility detaining or admitting the person under this article;[9]. Similar concerns were addressed in the TDO Workgroup’s Report issued on Dec. 29, 2021. The fact is, Magistrates must have reliable, unbiased recommendation that evaluates least restrictive alternative.

I am strongly opposed to Senate Bill 34. This bill would prove to be a monumental shift in public policy with significant immediate and future implications. It would reverse strides made in the past by removing the previous protections enacted by the General Assembly and actually counters recommendations included in the last 2 JLARC studies. It would also circumvent the concerns and recommendations outlined in the findings of a legislature-directed Workgroup that studied these matters and subsequently did not make recommendations to allow a non-CSB clinician to conduct a preadmission evaluation. There are extremely clear conflict of interest concerns which should not be dismissed when making decisions regarding a process that impacts the civil liberties of individuals in crisis. As history has demonstrated and recent reports have indicated, enactment of this Bill would open the door to increasing TDO admissions to an already overburdened state hospital system. Delays in the system are due to individuals being unable to access an accepting hospital bed, not due to the timeliness of an evaluation. In fact, this legislation would most certainly make the situation worse by increasing bed utilization and thereby the number of available beds. The CSBs are an objective party with extensive knowledge of community resources and specialize in strategies to link individuals in crisis to the least-restrictive alternatives; thereby maximizing linkage to the General Assembly funded STEP-VA and Crisis Now community-based services. Any deviation from this centralized and specialized role will create system vulnerabilities and set a precedent for private access to precious public resources that will worsen citizen access to beds, not help it. In addition, the Code is very clear on matters related to financial consideration, noting in §37.2-817.01, in regards to the evaluator: (g) have no financial interest in the admission, treatment, or denial of admission of the person being evaluated; (h) have no investment interest in the facility detaining or admitting the person under this article;[9]. Similar concerns were addressed in the TDO Workgroup’s Report issued on Dec. 29, 2021. It is my sincere hope that you will take note of the lessons history has taught us, the undeniable conflict of interest issues, the advisory groups who advise against this change, and vote against this bill to avoid damaging repercussions with a long-lasting impact. Thank you for your service and commitment to the safety and liberties of Virginia citizens.

Senate Bill 34 allows a pathway for private hospitals to utilize the pre-screening process to select which people to accept and which ones will ultimately, most likely, end up in State hospitals. Although the private provider requesting this permission reduces this dialogue to "which organization is completing the pre-screening," the greater concern is the fact that the pre-screener also searches for the hospital bed for those who need one; having that pre-screener employed by the hospital who can decide whether or not to admit an individual is in fact a conflict of interest for multiple reasons. This is not just a concern about one specific provider, but rather about the system of protection that has existed for 30 years to ensure that when someone is at possibly the lowest point in their life, they receive equal access to the care and resources that they need, by having trained CSB pre-screeners to complete the pre-screening and conduct the bed search. Previous legislation was put in place to provide this protection. Of the flaws in our system, the pre-screening process is not one of them. This bill does not help CSB workforce or get law enforcement personnel back on the streets more quickly. These are buzz words and phrases that are not based on facts or studies. The term "pilot" is used to soften what is actually an "experiment" as this is not based on any facts that indicate a need to change how pre-screening is already occurring. Two years to pilot this might not seem like a long time to some, but it is too long to experiment with people's access to care. Had there been an interest in having a pre-screener onsite in the hospital, this could have been approached by having a conversation with the CSBs about how we could work together to accomplish this. This requires conversation, not legislation. A review of facts and studies will show that private hospitals have other ways to support the system; giving them access to the public system is not one of them. This is, in fact, at odds with all of the other positive things that are being done to support the behavioral healthcare system. We ask that you not take this step back when so much has been done to move us forward. Thank you.

Do not allow the role of the preadmission evaluation to be minimized, devalued or to be regarded as “duplicative”. That will not serve the individuals, families and public and private providers well in our collective efforts addressing the needs of some of Commonwealth’s most vulnerable citizens. It is not a duplicative assessment, but rather a determination if an individual may lose their liberties, and as the legislation enacted must ensure that least restrictive alternatives must always be considered. SB34, like HB608, would authorize newly designated “certified evaluators”, employed by a private facility to recommend issuance to the magistrate for a TDO. It enables the private hospital to identify the TDO facility, whether their own facility or now with direct access to state hospital beds. The Financial Impact Statements for both Bills (page #s) and the Dec. 2021 TDO Evaluator Workgroup Study (pg. 16), all anticipate that if enacted, would increase the number of individuals evaluated and TDO’d including the impact to the already overburdened state hospital system. Financial Impact Statements - Please note the concerns, cost, and anticipated fall-out identified in both the SB34 Financial Impact Statement and the HB608 Financial Impact Statement, which included some of those identified by the TDOO Workgroup Study in just Dec. 2021. This pilot is not only at a cost to the Commonwealth for this one provider’s benefit, a benefit clearly contrary to the text of CODE. It is notable that the HB608 provided more information about financial impact that SB34, however, clear that the substance of both bills has the same devastating effects and costs, those immediately estimated, but also others that will be costly for the Commonwealth which are indeterminate, but also recognize that increased state hospital admissions and pressure throughout the behavioral health system is anticipated. No doubt costly due to policy shift, a stark contrast to other current DBHDS and General Assembly directed efforts. Delays in the system are due to individuals being unable to access an accepting bed, not for an evaluation. The provider and VHHA’s testimony were misleading and did not demonstrate an appreciation for civil liberties being discussed. Testimony indicating that such an allowance would lead to more timely access to evaluation inaccurate, characterized patients as waiting for CSB to evaluate delaying care is inaccurate and misleading. CSBs responsiveness is not an issue, and we strictly adhere to performance contract standards.

I voice my strong opposition to Senate Bill 34 which would be a monumental shift in public policy with significant immediate and future implications. The GA enacted the current legislation decades ago for reason. SB34, submitted at the request of a private hospital ignores and circumvents the concerns and recommendations that a legislature-directed Workgroup studying this very matter had just issued their findings, Dec. 29, 2021. The Workgroup studying, “Who Should Conduct TDO Evaluations in Virginia”, consisting of “representatives from Virginia’s CSBs community hospitals, law enforcement, mental health advocates, and other stakeholders, like those previous workgroups evaluating this matter, did not make recommendations to allow a non-CSB clinician to conduct a preadmission evaluation. Instead, the Workgroup identified a number of the concerns, as previous studies had, including how such allowances would not account for complexities of the system and may unwind decades old legislation, including areas needing consideration: Conflict of interest; CSB's critical role of the CSB connecting individuals to alternatives to inpatient hospitalization and the “Potential increase in TDO admissions which would put additional strain on the state mental health hospital system. The Report, like SB34 and HB608 Financial Impact Statements, anticipates that enactment of either Bill would increase the number to TDO admissions to the state hospital. Despite CSBs playing such a critical role at all aspects of the Behavioral Health system, at no time were we consulted on the needs, of any concerns nor was the potential impact on stakeholders considered. Financial Considerations - The Code is also very clear on matters related to financial consideration, noting in §37.2-817.01, regards to the evaluator, - (g) have no financial interest in the admission, treatment, or denial of admission of the person being evaluated; (h) have no investment interest in the facility detaining or admitting the person under this article;[9]. Similar concerns were addressed in the TDO Workgroup’s Report issued on Dec. 29, 2021.The fact is, Magistrates must have reliable, unbiased recommendation that evaluates least restrictive alternative. I ask you to consider that members of the General Assembly will likely have a future budget request before you which will provide additional financial incentives to private hospitals accepting more TDOs to relieve burdens of state hospitals, operating in crisis years following the well-intended “bed of last resort legislation”. In addition to changes in the codes and other regulatory, local, state, and regional protocols this action directly contradicts Other Critical Investments in Virginia’s Behavioral Health System: including efforts and GA investments in STEP-VA; Counters recommendations included in the recent 2 JLARC study; is Inconsistent with the goals of moving Virginia toward a Crisis Now System & Right Help Right. It requires significant adjustments or exceptions would be required for the orientation, training, oversight, & supervision of Certified Pre-screeners, initiated by the Deeds Commission in 2016, intended to safeguard an individuals’ liberties. It also provides a private hospital, with financial interest in the outcome, authority to determine facility of TDO, whether their facility or direct access to State Hospital Beds and enables a private hospital to direct and further tax local publicly funded resources.

I voice my strong opposition to Senate Bill 34. The issue of Behavioral Health is not a partisan issue. However, this bill would prove to be a monumental shift in public policy with significant immediate and future implications. The General Assembly enacted the current legislation decades, A recent workgroup (December 2021) evaluating such matter, comment on the preadmission evaluation, also noted that: “It is a pivotal point within the larger civil commitment process because if involuntary treatment is recommended and a TDO is issued, the individual in crisis is deprived of his or her liberty” and did not recommend such exception SB34, submitted at the request of a private hospital ignores and circumvents the concerns and recommendations that a legislature-directed Workgroup studying this very matter had just issued their findings, Dec. 29, 2021. The Workgroup studying, “Who Should Conduct TDO Evaluations in Virginia”, consisting of “representatives from Virginia’s community services boards (CSB), community hospitals, law enforcement, mental health advocates, and other stakeholders”[3], like those previous workgroups evaluating this matter, did not make recommendations to allow a non-CSB clinician to conduct a preadmission evaluation. Instead, the Workgroup identified a number of the concerns, as previous studies had, including how such allowances would not account for complexities of the system and may unwind decades old legislation, which has been referred to as the “bedrock of the public behavioral health system”, including areas needing consideration when evaluating any code changes which would expand who could conduct preadmission evaluations to include: Conflict of interest – including “any potential for real or perceived bias” Connection to community resources, noting “the critical role of the CSB connecting individuals to alternatives to inpatient hospitalization”. “Potential increase in TDO admissions. Evaluators who work in private hospital settings may not be fully aware of all the community alternatives to the state psychiatric hospitals, and the workgroup expressed that this could inadvertently lead to an increase in TDO disposition. This would put additional strain on the state mental health hospital system, which is already suffering significant census pressures and staffing shortages” Delays in the system are due to individuals being unable to access an accepting bed, not for an evaluation. Current waits are related to securing an ACCEPTING BED, which this bill does nothing to address. CSBs responsiveness is not an issue and we strictly adhere to performance contract standards. This in no way assists Law Enforcement in “getting back on the street” as suggested by provider in previous subcommittees. The allowance for a private hospital to conduct a preadmission evaluation has no relevance of waits. Will they admit, which this provider currently maintains control of whether they will admit or not admit, their timeframe to review, and regards to their efforts or lack of to provide the CSB clinical or medical documentation that would enable a search for an alternative bed. This allowance does nothing to speed up the process or get law enforcement “back out on the streets”. Instead, it will enable the provider to assert additional control over the local publicly funded resources and the state hospital.