www.behavioralhealthlink.com
Crisis and Access Services:
Innovative Solutions to a Linking Individuals with Behavioral Health
Needs to Appropriate Resources and Not the Emergency Room.
Allison Trammell, LCSW
Chief of Quality Management & Utilization Management
Behavioral Health Link
&
Wendy Martinez Schneider, LPC
Chief Clinical Officer
Behavioral Health Link
Learning Objectives
At the conclusion of the session, attendees will be able to:
– Have an understanding of BHL’s role within the system
– Describe why risk assessment, linkage to care and follow-up are
essential in suicide prevention
– Describe new services in place as a result of the Department of Justice
Settlement Agreement with the State of Georgia
– Identify resources available to facilitate referrals to appropriate
resources for individuals in need of behavioral health, substance abuse,
or developmental disability services
– Describe Crisis and Access Services developed to facilitate referrals to
State providers and maximize the utilization of available resources
The Georgia Crisis & Access Line
• The Georgia Crisis & Access Line (GCAL) went live
on July 1, 2006
• It provides brief clinical triage of callers seeking
services throughout Georgia’s 159 counties
• GCAL can schedule real-time appointments with
over 100 behavioral health providers among over
200 behavioral health sites across the state
• Dispatches mobile crisis teams throughout the state
– Operates mobile crisis teams in Metro Atlanta and
Southeast Georgia
Programs
Call Center
•
•
•
•
24/7 Availability
20,000 Calls per month
Active rescue response
Real time appointment
scheduling
Mobile Crisis Teams
• 24/7 Availability
• Call Center dispatched
• Probate court requests
• Community response
• ER Response
Assessment - Linkage
Licensed clinicians assess:
–
–
–
–
–
Presenting problems and clinical issues
Substance use issues
Risk of lethality
Medical issues
Screening for persons with Developmental Disabilities
Based on the assessment, a linkage to a service is
determined that best meets the needs of the caller
The Importance of a Lethality Assessment
– In the U.S., there were 38,364 suicides in 2010, a is the 10th
leading cause of death
– More than 90% of people who die by suicide have a diagnosable
mental illness and/or substance abuse disorder
– 11th ranking cause of death
– 1,133 Georgia residents died by suicide in 2010
– Georgia is ranked #40 among all 50 states
– South Atlantic region rates hold that 13% of all deaths are by
suicide
Challenges
• Resources!!!!!!!!
• Many more individuals are entering the
system without insurance
• Bed access to ERF’s are CSU are limited based
their capacity
Please Know We Understand the Struggles
– BHL has been referring individuals for behavioral health care since for over
10 years.
– We aim to be part of the solution, but in no way do we mean to imply that
we have the answer or that we are perfect
– Resources are indeed limited so our approach is to do the very best we can
with the resources we have and to keep individuals with behavioral health
needs safe
– We are not a managed care company nor do we have control over access to
services
– Our job is to assess the immediate need as best we can and link the
individual to the most appropriate service available
Trying to Change the Front Door to Care
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911 Transfers to GCAL
Use of Urgent Appointment Slots Live- Access 24/7
Mobile Crisis in the Community
Direct Referrals to Psychiatric Inpatient Facilities and Crisis
Stabilization Units (Medical Clearance by Definition)
EMS Partnerships
DBHDD Emergency Receiving (ER), Evaluation (E), Treatment
(T) Facilities- are you really on the list?
If you are not a designated ERF (Emergency Receiving Facility),
a 1013/2013 or probate order written to your facility is not valid
A “ER” is not automatically an ERF!!!!
1013/2013 Basics
WHO CAN COMPLETE THE FORM 1013 The Form 1013 (Attachment A) can be completed by a licensed
Physician, licensed Psychologist, licensed Clinical Social Worker, or Psychiatric Clinical Nurse Specialist.
STEPS PRIOR TO COMPLETION OF THE FORM 1013
• Determine that the individual does in fact meet criteria of mental illness AND ‘imminent risk’. For
more information regarding ADMISSION CRITERIA, see Policy 03-502, Criteria for Mental Health
Admissions of Adults to DBHDD Hospitals.
•
Contact the Emergency Receiving Facility (ERF); provide clinical information to the facility and
determine if the facility has the capacity to admit the individual, if admission is necessary.
•
Providing the clinical information will help determine if the individual has signs or symptoms of a
medical condition that would warrant urgent medical intervention prior to transport to the ERF.
Individuals should not be referred to Emergency Rooms for ‘medical clearance,’ but for a specific
complaint that would normally be seen in an emergency department (chest pain, delirium,
shortness of breath). For more information re: MEDICAL CLEARANCE see Policy 03-520, Medical
Evaluation Guidelines and Exclusion Criteria for Admissions to State Hospitals and Crisis
Stabilization Units.
Recent Changes to the 1013 Document
I ________________(staff at referring facility) have
communicated with ______________________(staff at receiving
facility) at _________________(name of receiving facility),
______________ (telephone number), who stated that the
facility has a bed available for this individual. This certificate
authorizes the peace officer or other person to deliver the
individual named on this 1013 to the named facility for
examination to determine whether admission is necessary.
____________________________________________________
________________________________________ SIGNATURE
AND PRINTED NAME of staff at Referring Facility Date_______
20____ Time ________m
Transporting 1013s/2013s
As soon as possible, but within 72 hours after receiving this certificate, the
Peace Officer shall make diligent efforts to take the above-named Individual
into custody. Thereafter, the Peace Officer shall transport the above-named
Individual to the emergency receiving facility serving the county where such
person is found, as named above. This certificate expires 7 days after it is
executed. This certificate and the Report of Peace Officer are to be delivered
by the Peace Officer to the emergency receiving facility and are to be made a
part of the above-named Individual's clinical record.
If private transportation by family, friends, or other means is deemed safe, it
shall be encouraged and authorized. This does not relieve the county
governing authority from its responsibility to arrange for transportation when
needed or requested.
We hold the individual’s hand until they are
safely in the hands of a provider
The most important thing you can do to prevent suicide is to make
sure individuals are assessed appropriately (risk assessment)and that
they get appropriate follow-up based on their clinical need.
It doesn’t necessarily mean putting them in the hospital. Continuity of
care is key.
Allison is going to tell you about some recent research on follow-up on
continuity of care that really emphasizes the importance of follow-up and
dispels some myths about inpatient psychiatric care.
The President’s New Freedom Commission
on Mental Health recommended:
• Fundamentally transforming how mental health care is delivered in
America.” Continuity of care should be a critical component of the
foundation for any transformed system. Continuity of care is an
underutilized suicide prevention strategy.
• Continuity-of-care strategies need to target individuals that are at
high risk both for suicide and for non-adherence to the
recommended treatment plan.”
Report Summary
•
Published in 2011 through a joint project between the Suicide Prevention Resource Center
(SPRC), AAS, SAMSHA, and the University of Michigan, this report “highlights a critical area
for suicide prevention efforts, one that holds promise for reducing the number of suicides
in America.
•
The accumulating research in suicide had made it increasingly clear that for those who
experience suicidal crises and receive acute care interventions in hospitals and Emergency
Rooms, suicide risk does not end at the moment of discharge. Rather, their elevated risk
continues or is easily rekindled in the days and weeks that follow, leading to heightened
rates of suicide during this post -acute care period.
•
However, as is noted in the National Strategy for Suicide Prevention, “All too often the
assumption is that individuals are no longer at risk for suicide once they are discharged
from inpatient hospital or institutional settings.”
•
Yet, despite the fact that those who attempt suicide and others experiencing a suicidal
crisis who are seen in the health care system are a high risk population going through a
clear high risk period, there have been few systematic suicide prevention efforts in the
United States that have focused on this population during this time period.
Report Summary Continued
•
Elevated post discharge rates of death by suicide, suicide attempts, and readmissions to
acute care services have been repeatedly documented, but this has not been matched by
proportionate prevention efforts.
•
Moreover, as this report makes clear, not only has the need been shown to be
unmistakable, but there are also promising interventions that can be utilized. In fact, the
only two randomized controlled trials in the suicide prevention literature that have shown a
reduction in the number of deaths by suicide have both involved following up with high
risk populations after discharge from acute care services (Motto and Bostrom, 2001;
Fleischmann et al., 2008)”
•
Another Goal of The National Strategy for Suicide Prevention is to “increase the
proportion of patients treated for self-destructive behavior in hospital
emergency departments that pursue the proposed mental health follow-up
plan.”
•
Since discharge from a psychiatry inpatient unit is so strongly associated with subsequent
suicide death, this report concerns suicide attempts and suicide deaths
subsequent to discharge from an emergency department or from a psychiatry
inpatient unit.”
Efficacy of Inpatient Hospitalization
to Ameliorate Suicide Risk
Alarmingly and a piece of research that few mental health professionals are even aware of, is that
inpatient hospitalization has not been shown to be a statistically significant intervention in and of
itself to prevent suicide.
•
“Rather than having a supporting role, psychiatric hospitalization plays a decidedly central role in
America’s mental health care provision system. Despite the centrality of hospitalizing seriously ill
psychiatric patients, the research base for inpatient hospitalization for suicide risk is surprisingly
weak. This review could not identify a single randomized trial about the effectiveness of
hospitalization in reducing suicide acts after discharge. “
•
Huey and his research team found an intensive outpatient intervention superior to emergency
inpatient treatment and, perhaps, more rapidly effective.
•
Two other randomized trials, one led by van der Sande and the other by Waterhouse and Platt,
compared inpatient admission to alternative treatment controls; neither demonstrated a reduction
in suicide acts.
Consequently, beyond usual care, there are no evidence-based, psychiatric inpatient
treatments that have been found to reduce the frequency of suicidal acts or suicide
attempts subsequent to discharge.
Study Recommendations
Manage and treat each patient making a suicide attempt
and/or having suicidal ideation as if the next suicide attempt
will result in suicide death. Having this recommendation as a goal
will motivate improved continuity-of-care policies and procedures in
health care systems.
Streamline the gathering of corroborating information for
bona fide emergencies. Contacting knowledgeable others are one
means clinicians have of getting help for characterizing a patient’s
suicide risk profile. Clinicians seeking to gather corroborating
information regarding potentially suicidal individuals confront an
assortment of federal, state, and regulatory issues about privacy.
recipient rights concerns add additional complications.
Recommendations Continued
• Support fellowship training in emergency psychiatry.
Emergency psychiatry requires a specialized blend of psychiatric and
general medical knowledge and skills.
• Fund studies that pertain to “contracting for safety” and
“safety planning.” Despite their extensive use, these clinical tools
have been understudied and have not been subjected to
randomized methods. At some point, clinicians have to accept the
word of the patient, but little is known about the procedures that
make this acceptance reasonable or unreasonable.
• Reimburse extended suicide assessment procedures. If a
comprehensive suicide risk assessment cannot be completed in the
emergency department, permit and encourage reimbursement for a
24 to 48-hour hospitalization during which time such assessments
can be accomplished.
Recommendations Continued
Patients should be seen by certified professionals that have
mastered suicide assessment and prevention skill sets. Define a
nationally recognized set of the minimum essential skills and core
competencies necessary for suicide risk assessment and
management.
Physician education in depression recognition and treatment reduces
suicide rates. Consequently, there is every reason to believe that improved
education and training pertaining to the management of suicide attempts
and suicide ideation will have similar results. “Assessing and Managing
Suicide Risk: Core Competencies for Mental Health Professionals” (AMSR),
developed by the American Association of Suicidology (AAS) for the Suicide
Prevention Resource Center (SPRC) and AAS’ “Recognizing and Responding
to Suicide Risk: Essential Skills for Clinicians” (RRSR) each contain modules
that teach core competencies and related skill sets.
Recommendations Continued
• Essential skills and competencies. Certification is one means to improve
overall quality of care provided to individuals at risk for suicide.
• Find the best means for most efficiently and effectively teaching and
disseminating the nationally recognized set of minimum essential skills
and competencies. Not everyone will attend sit-down courses. A variety of
means for teaching and dissemination needs to be considered.
• Support fellowship training in emergency psychiatry. Emergency
psychiatry requires a specialized blend of psychiatric and general medical
knowledge and skills.
• Promote pilot studies of interventions designed to reduce discrimination
found in emergency departments in association with suicide risk and
mental illness. There are numerous good hypotheses (e.g., skill deficits,
unrealistic fears, inadequate collaboration with mental health
professionals) that could be tested immediately.
Follow-up is Key
Follow-up with Referrals to Ensure Services: BHL makes every effort to ensure that
individuals followed through with recommendations for outpatient services. With a goal
of diverting individuals to community services, maintaining family and community
supports, providing treatment in the community at the lowest necessary level of care and
preventing emergency room visits and contact with law enforcement.
Research Based Crisis Planning
Stanley Brown Crisis Plan: The most comprehensive discharge planning guidance for
high-risk inpatients comes from the United States Department of Veterans Affairs (VA).
Examples include weekly evaluations during the first 30 days after discharge and specific
follow-up for missed appointments. Barbara Stanley and Gregory Brown have developed
a “Safety Plan Treatment Manual to Reduce Suicide Risk;” there is a version of this made
specifically for the VA.
SAMSHA Follow-Up Grant
BHL Experience with SAMSHA Follow-up Research and
Initial Results:
BHL was one of 6 crisis centers nation-wide to receive a SAMSHA follow-up
grant award in 2008. We participated in a three year study on the efficacy of
follow-up.
Though the results are still in press at this time, our initial results as an agency
were excellent and several other agencies had a similar experience. Several
agencies used specific follow-up consent forms for both MCRS responses and
Call Center calls that can be modified to include text follow-up.
Initial Study Results
Permission for Mobile
Crisis Follow-up
Georgia is Cutting-Edge
Methods of Follow-up
Our experience with the SAMSHA follow-up project gave us a lot of ideas about efficient
ways to follow up. Follow ups were generally more successful in the evening (we are
having the CPS work second shift). We also found that telephonic follow-up isn’t always
sufficient or effective. With the Disaster Distress Helpline project, BHL learned that using
text and chat to communicate is extremely effective- particularly with younger
consumers.
We are working to utilize these as methods for follow-up and get permission from
consumers during our contact for the method(s) of follow-up the consumer is agreeable
to receiving. Kaiser Permanente uses Mosio chat/text for appointment reminders. BHL
has used Mosio for the Disaster Distress Helpline with great success. It is HIPPA
compliant and easy to use.
With the consumer’s permission, ultimately our goal is to do live follow up via phone,
chat or text and then send a reminder for the follow-up outpatient appointment via text.
.
In October 2012, BHL became
one of the first crisis centers in
the U.S. accredited by Contact
USA for online/text emotional
support
Resources
– GCAL (Georgia Crisis and Access Line)
– Department of Justice Settlement Agreement
• Mobile Crisis
– Seen in home
– BHL teams not allowed to send someone to the ER
without supervisory approval unless it is a 911
emergency
– Medical Clearance reference policy
Department of Justice Settlement
Agreement
Interesting Research on Mobile Crisis
2002 Hugo,
Smout &
Bannister,
A Comparison
Hospitalization
Rates between
Communitybased Mobile
& Hospital
Emergency
Service
Australian
and New
Zealand
Journal of
Psychiatry
Hospital-based emergency service
contacts were found to be more
than three times as likely to be
admitted to a psychiatric inpatient
unit when compared with those
using a mobile community-based
emergency service, regardless of
their clinical characteristics.
Interesting Research on Mobile Crisis
2007
Cotton,
Johnson,
Bindman,
et al
Factors
BMC
Psychiatric Psychiatry
Admission
Despite
CRT
Presence
Location of assessment also
influences whether patients are
admitted to hospital. Those
assessed in casualty
departments (ER) were more
likely to be admitted after
adjustment for baseline
variables.
Interesting Research on Mobile Crisis
2001 Guo, Biegel, Communit Psychiatric A consumer in hospital-based intervention
Johsen &
y Based
Services
was 51 percent more likely to be
Dyches
Mobile
hospitalized than one in community-based
Crisis
mobile crisis intervention group.
Impact on
Preventing
Hospitaliza
tion
Interesting Research on Mobile Crisis
1993
Phillips, Comparison
British
Gadd, & of
Medical
England Community
Journal
Based Service
with Hospital
The community is as effective
as the hospital based service
and is preferred by relatives.
This approach may reduce the
use of acute beds by 80%. The
distress of family is greatly
decreased.
Effectiveness of Inpatient Care for Treating
Suicidal Ideation
1997
Sande R. et
al.
2004
Huey SJ. KJr.
et al
Intensive inpatient and
community
intervention
versus
routine care
after
attempted
suicide.
Multisystemic
therapy
effects on
attempted
suicide by
youths
presenting in
psychiatric
emergencies
Br. J of
Psychiatry
Compared inpatient admission to
alternative treatment controls; neither
demonstrated a reduction in suicide acts.
J Am Acad Child
Adolesc
Psychiatry
Found that intensive outpatient
intervention was superior to emergency
inpatient treatment and perhaps more
rapidly effective.
Electronic Resources
Electronic Pending Boards
• Live Census that Regional Offices and DBHDD can view in
real-time
• Real-time referrals with timing- out mechanism and reporting
capabilities for average minutes to disposition by facility
• Prioritize individuals waiting at home so they don’t have to go to the
ER for “holding”
Electronic Request Forms
• Mobile Crisis
• Discharge Appointments
• PARF- Pre-Admission Referral Form
Live Referral Status Board
Ok- So how does this help the ER?
•
We are strongly encouraging direct referrals to psychiatric facilities and
discouraging ER referrals
•
Individuals seen at home are much less likely to be hospitalized so with the
expansion of Mobile Crisis, more individuals are being seen at home.
•
Many people sent to the State Hospital from the ER are never admitted
•
The bottom line is that we are working diligently to avoid unnecessary ER visits
but it takes time to change the “front door.”
•
We are also working for more transparency in the system so individuals who
have been waiting the longest get beds first and the information is visible to
the State 24/7/365
Grady EMS Project
• In January 2013, Grady EMS developed a 90 day pilot partnership
with Behavioral Health Link (BHL) which operates the Georgia Crisis
and access Line (GCAL) to extend an integrated model of Emergency
Crisis Intervention “into the field” by deploying a co-response team
to the scenes of behavioral health 9-1-1 calls.
• The response team consisted of a Grady Paramedic and Licensed
clinical Social Worker (LCSW).
• The primary goal of this project was to determine the rate of nonhospital dispositions that could be safely achieved by providing
alternative behavioral health resources for individuals who initially
engaged EMS by calling 9-1-1 in the field.
Results
• During the fourteen week pilot, the team scheduled 34
appointments in the field, provided 36 referral cards, reconnected 6
Assertive Community Treatment (ACT) patients with their providers,
and transported 16 patients to in-patient psychiatric centers
(directly with no stop at an emergency department)
• This prevented 92 ambulance transports to the ED.
• The success of this program is not only measured in non-transports
or dispositions to alternate destinations but also as a community
service provided on behalf of a safety net hospital to patients who
suffer from mental illness whose situations are complicated and can
often involve physically violent encounters.
Results
• The crisis intervention team has assumed a critical role in deploying
expertise from the LCSW to de-escalate agitated and potentially violent
patients.
• This is reflective in the 45% decrease in the use of chemical restraints.
• This program projects to mitigate 1200 patients during the first year in
dispositions other than ambulance transport to the ED after full staffing
levels are achieved.
• The program will provide hospitals (65% GHS, 20% AMC, 15% Other) more
than 8400 hours of available bed space to improve ED throughput times
and prevent hospital cost loss.
Next Steps
Grady EMS created two additional FTE positions classified as ‘Paramedic- Crisis
Intervention’ to operate the crisis unit eighty hours per week at an expense of
$121,790. BHL-GCAL has agreed to continue funding the LCSW through grant funded
positions until June 2015.
http://www.gradyhealth.org/images/video/Gra
dyCIU.wmv
Resources
Link to Centers for Disease Control and Prevention, National Centers for Injury Prevention and Control. Webbased Injury Statistics Query and Reporting System (WISQARS) [online]. (2010) {2012 Nov28}. Available from:
www.cdc.gov/ncipc/wisqars
Link to the Continuity of Care for Suicide Prevention and Research 2011 Report
http://www.suicidology.org/c/document_library/get_file?folderId=266&name=DLFE-612.pdfAAS.org
Suicide Prevention Resource Center (SPRC)
http://www.sprc.org/
American Association of Suicidology
http://www.suicidology.org/about-aas
Link to DBHDD Medical Clearance Policy
https://gadbhdd.policystat.com/policy/176512/latest/
Link to DBHDD 1013/2013 Policy
https://gadbhdd.policystat.com/policy/211582/latest/
List of Emergency Receiving, Evaluating and Treating Facilities
http://dbhdd.org/bhlu/files/ERET%20Listing%20by%20County.pdf