2015
Cenpatico Crisis Protocols for
Graham County
Cenpatico Crisis Protocols for Graham County
Table of Contents
Involved Parties ................................................................................................................................... 3
Overview & Purpose ............................................................................................................................ 3
Goal of the Crisis System .................................................................................................................... 4
Definitions............................................................................................................................................ 4
Crisis During Business Hours .............................................................................................................. 8
Notes on Medical Clearance ................................................................................................................ 9
Crisis Services ..................................................................................................................................... 9
The NurseWise Crisis Line ............................................................................................................... 9
Crisis Mobile Teams......................................................................................................................... 9
Intake Care and Coordination Agencies (ICC Agency) ................................................................... 10
What is considered a crisis? ........................................................................................................... 10
Crisis Mobile Team Response in the Community............................................................................... 10
Services available .......................................................................................................................... 10
Crisis Mobile Team Response on the Reservations ....................................................................... 10
Involuntary Persons in Need of Mental Health Treatment .................................................................. 11
A person in the Graham County Emergency Department (ED) .......................................................... 11
Steps to Petition ............................................................................................................................. 11
Special Questions .......................................................................................................................... 12
A person admitted to a medical floor at Mount Graham Medical Center ......................................... 12
A person in the community ............................................................................................................. 13
A person at an outpatient clinic during office hours ........................................................................ 13
When law enforcement is involved ................................................................................................. 13
A person who is incarcerated and not voluntary for mental health evaluation .................................... 14
At the Graham County Jail ............................................................................................................. 14
Non-Emergency Requests for Involuntary Evaluation (PAD or GD) ................................................... 15
Voluntary Crisis Services for Incarcerated Persons ........................................................................... 15
At the Graham County Jail ............................................................................................................. 15
At the Eastern Arizona Regional Juvenile Detention Facility .......................................................... 15
Revocation of the outpatient treatment portion of an Existing COT .................................................... 15
During Regular Business Hours ..................................................................................................... 16
Revocation of the outpatient treatment portion of a court order by a medical director ........................ 16
Cenpatico Crisis Protocols for Graham County
Revocation of the outpatient treatment portion of a court order by a Judge ....................................... 17
After Hours ........................................................................................................................................ 17
Direct Admission to a Licensed Hospital or Behavioral Health Hospital Facility (Psychiatric Inpatient
Facility) .............................................................................................................................................. 18
By outpatient providers (voluntary only) ......................................................................................... 18
By crisis mobile teams (voluntary only) .......................................................................................... 18
By another hospital (ED or medical floor) ....................................................................................... 18
Coordination of Care with Local Hospitals ......................................................................................... 19
Enrolled Persons ............................................................................................................................ 19
NON-enrolled persons ................................................................................................................... 19
Medically admitted patients enrolled with an outpatient service provider ........................................ 19
Meeting Attendance ........................................................................................................................... 19
The Graham County Crisis System Meeting................................................................................... 20
Regular Crisis Team Meetings ....................................................................................................... 20
Problem Resolution Process.............................................................................................................. 20
Drug and or Alcohol Use ................................................................................................................ 20
Services Available for Substance Use ............................................................................................... 21
Transfers of Care ........................................................................................................................... 21
Referrals to Community Bridges, Inc. ............................................................................................. 21
Mountain Health and Wellness-Mountainside Psychiatric Acute Care (PAC) ................................. 22
Detoxification Admission Criteria .................................................................................................... 22
Signature Page .................................................................................................................................. 23
Cenpatico Crisis Protocols for Graham County
Involved Parties
Arizona Counseling and Treatment Services
Cenpatico
Community Bridges
Eastern Arizona Regional Juvenile
Detention
Graham County Attorney’s Office
Graham County Jail
Graham County Sheriff’s Office
Graham County Adult & Juvenile Probation
Department
Graham County Health Department
Mt Graham Regional Medical Center
NurseWise
Pima Police Department
Safford Police Department
San Carlos Police Department
SEABHS outpatient
Thatcher Police Department
Overview & Purpose
The Protocols are guidelines that describe how we will all work together to ensure that
behavioral health services are delivered in Graham County. The Purpose is to enhance the
network and response capability to address behavioral health crisis in Graham County through
ongoing communication and collaborative agreements between community stakeholders and
behavioral health provider agencies developing an environment where there is no wrong door.
Cenpatico Behavioral Health of Arizona, LLC and Cenpatico of Arizona, Inc. dba Cenpatico
Integrated Care (herein referred to as Cenpatico) and their contracted providers and identified
Graham County Community Stakeholders agree to coordinate activities to facilitate the
implementation of crisis services in Graham County. The elements of the Crisis System
(including referral, assessment and service implementation processes) and the roles and
responsibilities of each agency are outlined below.
Cenpatico and their contracted providers and identified Graham County Community
Stakeholders agree to work in partnership on behalf of persons experiencing a behavioral health
crisis to ensure they receive the appropriate services and level of care that promote resiliency
and protect the community.
This guideline will be active from date of signature until modified by the involved parties. This
guideline does not create or delegate financial responsibility. This guideline is not a legal and
binding contract or Memorandum of Understanding. These guidelines should never override the
obligation to provide the most clinically appropriate intervention based on each individual
situation nor should they override law or professional responsibility to clients. Agencies are
encouraged to have adequate clinical supervision and guidance to support such actions.
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Cenpatico Crisis Protocols for Graham County
Goal of the Crisis System
The goal of the crisis system is to ensure persons receive the appropriate services and level of
care; stabilize persons in the community whenever possible and individuals in their recovery;
and promote resiliency and protect the community.
Definitions
Active episode of care- the member has been opened with and are currently receiving
services at a contracted RBHA funded agency. The person may have any of the following
eligibility and entitlements:
o T19 (AHCCCS or SSI/MAO)
o SMI only
o Medicare and T19
o Medicare and SMI
o T 21 (kids)
Note: Cenpatico will be the physical health plan for persons designated with a serious mental
illness (SMI) enrolled as Title XIX .
Admitting Officer- Per ARS 36-501 an admitting officer is a psychiatrist or other physician or
psychiatric and mental health nurse practitioner with experience in performing psychiatric
examinations who has been designated as an admitting officer of the evaluation agency by the
person in charge of the evaluation agency.
Amendment of the outpatient portion of a court order- The process outlined in ARS 36-540.
Section I in which the medical director of the mental health treatment agency can order a person
court ordered to outpatient treatment back into inpatient treatment.
Application for Emergency Admission for Evaluation (Form A3)- Paperwork completed to
initiate an emergency evaluation of a person who, based on probable cause, is believed to be, a
danger to self or others and that during the time necessary to complete the pre-petition
screening procedures the person is likely without immediate hospitalization to suffer serious
physical harm or serious illness or to inflict serious physical harm on another person.
Application for Involuntary Evaluation (Form A2)- Paperwork completed to initiate a request
for an evaluation of a person who is alleged to be Persistently or Acutely Disabled (PAD), or
Gravely Disabled (GD), or Danger to Self (DTS) or Danger to Others (DTO), or any combination
of these. This process of requesting an involuntary evaluation is for situations that are
considered non-emergency requests for an evaluation.
Business Hours- Monday through Friday from 8am to 5pm.
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Crisis - An acute, unanticipated, or potentially dangerous behavioral health condition, episode
or behavior.
Crisis Intervention Services (Mobile, Community Based)- Crisis intervention services
provided by a mobile team or individual who travels to the place where the person is
experiencing the crisis (e.g., person’s place of residence, emergency room, jail, community
setting) to:
 Stabilize acute psychiatric or behavioral symptoms;
 Evaluate treatment needs; and
 Develop plans to meet the needs of the persons served.
Depending on the situation, the person may be transported to a more appropriate facility for
further care (e.g., a crisis services center).
Crisis Intervention Services (Telephone)- Crisis intervention (telephone) services provided by
qualified service providers within the scope of their practice to triage, refer and provide
telephone-based support to persons in crisis. This is often the first place of access to the
behavioral health system. This service may also include a follow-up call to ensure the person is
stabilized.
Danger to Others (DTO)- The judgment of a person who has a mental disorder is so impaired
that he is unable to understand his need for treatment and as a result of his mental disorder his
continued behavior can reasonably be expected, on the basis of competent medical opinion, to
result in serious physical harm to others.
Danger to Self (DTS)- (a) Behavior which, as a result of a mental disorder, constitutes a danger
of inflicting serious physical harm upon oneself, including attempted suicide or the serious threat
thereof, if the threat is such that, when considered in the light of its context and in light of the
individual's previous acts, it is substantially supportive of an expectation that the threat will be
carried out.
(b) Behavior that, as a result of a mental disorder, will, without hospitalization, result in serious
physical harm or serious illness to the person, except that this definition shall not include
behavior that establishes only the condition of gravely disabled.
Evaluation Agency- Per ARS 36-501 (13) “a health care agency that is licensed by the
department and that has been approved pursuant to this title, providing those services required
of such agency by this chapter.” There are several evaluation agencies located in Tucson
including Palo Verde, Sonora and Banner – University Medical Center South Campus. There
are also 2 sub-acute facilities that are evaluation agencies located in Apache Junction and
Yuma (Mountain Health and Wellness). Canyon Vista Medical Center is also an evaluation
agency in Cochise County.
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Gravely Disabled (GD)- A condition evidenced by behavior in which a person, as a result of a
mental disorder, is likely to come to serious physical harm or serious illness because he/she is
unable to provide for his/her basic physical needs.
Guardian- A guardian is a person who has the legal authority to make personal decisions for
the ward relating to living arrangements, education, social activities, and authorization or
withholding of medical or other professional care, treatment, or advice. The guardian must
always make decisions that are in the best interests of the ward. The guardian must always
make sure that the ward is living in the least restrictive environment in which the ward can
remain safe. Under §14-5312.01 (a) a guardian is able to consent to medical treatment outside
a Licensed Hospital or Behavioral Health Hospital Facility. A mental health guardian is given
under §14-5312.01 (b) for placement in Licensed Hospital or Behavioral Health Hospital Facility.
It is based on evidence produced from a licensed mental health expert that the ward is in need
of such hospitalization due to a mental disorder as listed in §36-501. It is renewed every year
with an affidavit from a mental health expert stating that it is likely that the ward will need to be
placed in a Licensed Hospital or Behavioral Health Hospital Facility.
Intake and Care Coordination Agency (ICC Agency)- (Also referred to as Outpatient
Treatment Agencies or Provider Agencies). ICC Agencies are contracted provider type
requiring full execution of Intake Provider functions and requirements. ICC Agencies must
accept all requests for services for eligible populations and are required to manage members’
care by performing the following roles: intake, assessment, service planning, clinical oversight of
all services, service tracking and data reporting, enrollment and demographic submissions,
education, engagement activities, psychiatric services and ensure adequate treatment service
availability to all enrolled members.
ICC Agencies are further divided into High Needs Recovery (HNRC) and Low to Moderate
Needs Recovery Centers (LMNRC). ICC Agencies are required to screen members and refer
them to either an HNRC or an LMRC. ICC Agencies in Graham County include ACTS &
SEABHS.
Jail Hold- A Jail Hold is defined as a situation where an incarcerated person is sent to the
inpatient psychiatric facility for inpatient care (voluntary or involuntary) but remains ‘in custody’
and must be returned to the jail upon release from that facility. The Sheriff’s Department will
transport the patient in this situation.
Behavioral Health Inpatient Facility (Formerly referred to as Level I Inpatient, Level 1 Sub
Acute, or RTC)--A facility licensed per 9 A.A.C. 20 and includes a psychiatric acute hospital
(including a psychiatric unit in a general hospital), a residential treatment center for persons
under the age of 21, or a sub-acute facility.
Natural supports- Refers collectively to support commonly identified as:
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a. "Informal Support " (support provided by those individuals who know or are related to the
individual/family, but do not provide a paid service, such as a grandparent or neighbor
who is connected to the individual/family) and
b. "Community Support" (those supports that are part of the individuals/family's community,
such as faith community, neighborhood or community organizations).
Persistently and Acutely Disabled (PAD)-A severe mental disorder that meets all the
following criteria:
(a) If not treated has a substantial probability of causing the person to suffer or continue to
suffer severe and abnormal mental, emotional or physical harm that significantly impairs
judgment, reason, behavior or capacity to recognize reality.
(b) Substantially impairs the person's capacity to make an informed decision regarding
treatment and this impairment causes the person to be incapable of understanding and
expressing an understanding of the advantages and disadvantages of accepting treatment and
understanding and expressing an understanding of the alternatives to the particular treatment
offered after the advantages, disadvantages and alternatives are explained to that person.
Petition for Court-Ordered Evaluation [Pursuant to A.R.S. § 36-523] (Form A6)- The
prescribed form used to request a petition for court-ordered evaluation.
Revocation of the Outpatient Portion of a Court Order- The process outlined in ARS 36-540.
Section I in which the medical director of the mental health treatment agency can order a person
court ordered to outpatient treatment back into inpatient treatment.
Serious Mental Illness (SMI)- A condition of persons who are eighteen years of age or older
and who, as a result of a mental disorder as defined in A.R.S. 36-501, exhibit emotional or
behavioral functioning which is so impaired as to interfere substantially with their capacity to
remain in the community without supportive treatment or services of a long -term or indefinite
duration. In these persons mental disability is severe and persistent, resulting in a long-term
limitation of their functional capacities for primary activities of daily living such as interpersonal
relationships, homemaking, self-care, employment and recreation. Persons who are deemed
SMI are eligible for RBHA covered services.
Title 36 Pre-petition Screening- The review of the paperwork requesting court-ordered
evaluation, including an investigation of facts alleged in such application, an interview with each
applicant, and an interview, if possible, with the proposed patient. The purpose of the interview
with the proposed patient is to assess the problem, explain the application and, when indicated,
attempt to persuade the proposed patient to receive, on a voluntary basis, evaluation or other
services. In Graham County pre-petition screenings are conducted by Arizona Counseling and
Treatment Services (ACTS).
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Warm Line Transfer – a live transfer where the call is introduced to and accepted by the
recipient before the call is transferred.
WRAP Plan-Wellness Recovery Action Plan- WRAP is a self-management and recovery
system developed by a group of people who had behavioral health difficulties and who were
struggling to incorporate wellness tools and strategies into their lives. WRAP plans are
developed by the consumer. The plan helps people to monitor uncomfortable and distressing
symptoms and identify ways to help reduce, modify or eliminate those symptoms by following
plan strategies. The plan includes an outline of who can help and how they can help as well as
preferred management strategies and treatments.
Wrap Services- Also referred to as ‘wrap around services;’ these are supportive services
provided to a person at home or in the community designed to provide additional support to a
person in crisis or to prevent a crisis. Planned services are available 24/7/365. Wrap services
include an array of professional, community, and natural (i.e., family, friends) supports and are
individualized based on the needs of the person and the family.
Crisis During Business Hours
During regular business hours outpatient service providers will provide crisis intervention to
enrolled members who are in a crisis and in the presence of their treatment provider. Crisis
intervention services include assessment, de-escalation techniques and crisis counseling as
well as crisis and follow up planning by a case manager, clinical liaison, behavioral health
professional, or prescriber. In some situations crisis intervention may include need for an
evaluation for a medication change by a prescriber followed by close monitoring by the clinical
team.
Other times, the intervention may involve providing wrap around services to the person in the
community such as accessing the person’s support system, activating the person’s WRAP plan
and or advance directive, seeking respite services, or arranging generalist agency services to
provide the necessary wraps.
If there are no other safe alternatives, placement in a psychiatric facility may be needed on an
emergency basis. In these situations, the prescriber can do a direct admission to a receiving
psychiatric facility. If hospitalization is needed, the prescriber must have knowledge of and be
able to attest to the need for an inpatient admission. Case managers and other direct service
staff will conduct bed searches and make arrangements for admission. The prescriber will be
required to complete a doc to doc phone call to the admitting agency. In these situations, there
is no need to send the member out for medical clearance unless the receiving facility (or
sending prescriber) has a symptom generated concern that must be evaluated medically. If
medical clearance is requested the outpatient team must find out the reason for the request and
document this in the clinical record. In some cases, unnecessary medical clearance may be
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avoided if recent health assessment documentation can be provided to the receiving facility. A
doc-to-doc can also help rule out medical concerns. It should be noted that if the admitting
physician of a receiving hospital has requested medical clearance, medical clearance must be
obtained prior to admission.
Outpatient providers will ensure there is sufficient staff coverage including protocols outlining
the chain of command when a member is in crisis and in need of immediate intervention. In
addition, contractual agreements between Cenpatico and intake providers require all contracted
agencies have urgent and emergency appointments available to ensure that enrolled members
can be seen at the agency when an emergency arises.
Please refer to the “Process Guide: Facilitating Level One Placements “Guide for more details
on this process.
Notes on Medical Clearance
It should not be assumed that medical clearance is needed for every admission. There may be
exceptions and alternatives to taking a person to the Emergency Department. For example,
Medical Clearance may not be required for an admission to the Mountain Health and Wellness
Behavioral Health Hospital Facility (the SAF in Yuma or the PAC in AJ) or by Community
Bridges Detox or Substance Abuse Transitional Facility. The only exceptions would be upon
request by the admitting physician due to a symptom generated concern that must be evaluated
medically. Some Licensed Hospitals will also accept an admission without medical clearance
(Cenpatico keeps an updated list of these facilities). If medical clearance is required, it may be
possible to obtain labs and a clearance without using the ED and this option should be
explored.
Crisis Services
The NurseWise Crisis Line
The Nurse Wise Crisis Line is available 24 hours a day, 7 days per week by calling 866-4956735. If a crisis mobile team (CMT) is needed the request must be made to NurseWise who will
triage and dispatch CMTs.
Crisis Mobile Teams
The Crisis Mobile Team provider in Graham County is Arizona Counseling and Treatment
Services (ACTS). Crisis Mobile Team assessment and intervention services are available to
any person in the County regardless of insurance or enrollment status. CMT response times
are one hour in town and 2 hours outside of town.
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Intake Care and Coordination Agencies (ICC Agency)
All ICC Agencies are also available to members for intensive wrap (supportive) services
providing the necessary supports to avoid crisis and or out of home placement. High Need
Recovery Centers may also available after hours if this is part of the person’s treatment plan.
Intake Provider Agencies in Graham County include Arizona Counseling and Treatment
Services (ACTS) and South Eastern Arizona Behavioral Health Services (SEABHS).
What is considered a crisis?
A crisis is measured by the person experiencing it. If the situation exceeds the person’s coping
skills, the person is in crisis. Can the crisis system take calls for people diagnosed with a
developmental disability, Alzheimer’s or dementia? Yes. There are no medical conditions that
exclude a person from receiving crisis services. The crisis line and or crisis team can assess,
intervene and make recommendations for any person in crisis. It is important to note that in
order for the person to be admitted to a psychiatric facility under his or her insurance, he or she
must have a treatable psychiatric condition.
Crisis Mobile Team Response in the Community
Services available
A Crisis Mobile Team is available to all persons in the community to assist them in overcoming
a crisis situation, assessing the need for an out-of-home placement, and coordinating safety
planning. Crisis Mobile Teams are committed to responding to the community including but not
limited to places such as the home, school, church, the streets, and jails. There is no need to
bring a person in crisis to the Emergency Room unless there is a medical emergency. NOTE:
CMTs are required to have vehicles to facilitate transportation and field interventions as well as
cell phones and laptops for communications.
Crisis Mobile Team Response on the Reservations
Cenpatico serves the entire county and is obligated to provide crisis services to any person who
requests services in the county. Community Bridges (out of the Globe location) serves the San
Carlos Indian Community. CMTs are permitted to provide mental health services on reservation
land. Police escorts can be arranged on reservations as needed. In Graham County, the
reservations served include the Graham County portion of the San Carlos Reservation. In San
Carlos, the CMT will generally respond to the ER, the Bylas Health Center, or the Detention
Center but they are permitted to respond to the community as well.
Note: Neither Cenpatico nor its contracted agencies have the authority to remove a Native
American person involuntarily from tribal land or petition a Native American person under a Title
36 on Tribal land. In these situations, the Tribal Police should be contacted to ensure the safety
of the tribal member.
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Involuntary Persons in Need of Mental Health Treatment
Per ARS 26-545.06 “Each county… shall provide directly or by contract the services of a
screening agency and an evaluation agency for the purposes of this chapter” [Title 36 Chapter
5]
The CMT must ensure the safety of persons they are petitioning under title 36 until such time as
safe transport is provided to an inpatient facility. This can be provided by the team members
themselves or through a clinically appropriate safety plan utilizing natural supports.
In Graham County the Arizona Counseling and Treatment (ACTS) Crisis Mobile team (CMT) will
conduct pre-petition screenings on behalf of the County until the County secures a contract for
these services. Pre-petition screening services are not a RBHA covered service. The Crisis
Mobile Team is accessed through NurseWise, the 24 hour crisis line for the County (1-866-4956735).
A person in the Graham County Emergency Department (ED)
Note: ED staff requesting a CMT DO NOT need to wait until the person is medically cleared
before requesting a CMT. The only exception would be if the person is unable to communicate
or is severely medically compromised.
If a person is in need of mental health treatment but not voluntary, please call NurseWise.
NurseWise will triage the situation and dispatch a Crisis Mobile Team (CMT) as necessary. The
CMT will meet with the person in the ED and attempt to engage the person in treatment
voluntarily. If the CMT is unable to do so, and the person is dangerous to self or others the
mobile team can facilitate an emergency petition for involuntary treatment by following the steps
outlined below:
Steps to Petition
1. The CMT will ensure that the Application for Emergency Admission for Evaluation
(Form A3), witness statements and a behavioral health assessment are completed and
available for review. The person that witnessed the petitionable behavior will need to
fill out the Application for Emergency Admission for Evaluation (Form A3). Note: The
CMT must ensure that witnesses are aware that they will be required to testify in court.
2. The CMT will complete a pre-petition screening and the Application for Evaluation
(Form A2).
3. The CMT will fax the paperwork to the receiving evaluation agency for review.
4. The admitting officer of the evaluation agency will decide if the person meets criteria to
be admitted for an evaluation and either accept or deny the patient. If the evaluation
agency does not have a bed, the CMT would complete a bed search for a receiving
agency and would staff the petition with the admitting officer of that receiving agency.
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5.
6.
7.
8.
NOTE: Do not assume that medical clearance will be required. See Notes on Medical
Clearance section for more information
Once the bed is secured, the CMT will facilitate transportation to the evaluating agency.
Per statute, a peace officer shall, upon the advice of the admitting officer (the
psychiatrist, medical doctor or mental health nurse practitioner at the evaluation
agency) apprehend and transport the person to an evaluation agency. Transportation
will be facilitated as follows:
a. The CMT staff will call local law enforcement and advise them they need a
peace officer transport for a T36 emergency evaluation.
b. Law enforcement will arrive on scene and transport the person to the evaluation
agency.
The CMT will ensure that the original petition paperwork is filed with the County
Attorney’s Office within 24 business hours of the admission.
The CMT and/or applicant will be available as a witness for the Title 36 petition if
needed. The County Attorney’s Office will notify potential witnesses at their earliest
convenience.
At the time of pick up, law enforcement will also obtain the original Application for
Emergency Admission (Form A3) and will deliver it to the evaluation facility.
Special Questions
What if the Application for Emergency Admission for Evaluation is declined?
An Application for Emergency Admission for Evaluation can be declined after a review by an
Admitting Officer. If this occurs prior to the person being transported to the evaluating agency
there must be a clinically appropriate safety plan developed for the person. The CMT can
develop this plan or be called back to the scene if they have cleared the scene. If a team needs
to be called out, the response time is a maximum of one hour in the city limits and 2 hours
outside the city limits.
What if the person is found to be petitionable on a non-emergent basis (PAD and/or GD)?
Refer to Non-Emergency Requests for Involuntary Evaluation (PAD or GD).
A person admitted to a medical floor at Mount Graham Medical Center
If a medically admitted patient is involuntary for treatment and meets the criteria for an emergent
(DTS/O) or non-emergent petition (PAD, GD), please contact the NW and request a Title 36
screening. There is no statutory reason why the petition process cannot be facilitated on a
medical floor; however, the patient must be medically stable so the patient can be discharged
from the hospital. In this case, the CMT will follow the process outlines in the section entitled
Steps to Petition.
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A person in the community
If a person in the community is in need of mental health treatment but not voluntary, NurseWise
will be contacted and a Crisis Mobile Team (CMT) will be requested. The CMT will meet with
the person where they are and attempt to engage the person in treatment voluntarily. If the
CMT is unable to do so, and the person is dangerous to self or others, PAD or GD the mobile
team can facilitate a petition for involuntary treatment by following the process outlined in the
sections entitled Steps to Petition and Special Questions. In this case, the CMT would need to
fax a copy of the petition paperwork to the evaluating agency before the patient arrives.
A person at an outpatient clinic during office hours
During regular business hours service providers will provide crisis intervention to enrolled
members if a crisis occurs while the provider agency is providing services (in the office or in the
community). If the team is unable to engage the person in treatment, and the person is danger
to self or others, the team will contact NurseWise and ask for a CMT for a Title 36 screening.
The CMT will follow the process outlined the sections entitled Steps to Petition and Special
Questions. In this case, the CMT would need to fax a copy of the petition paperwork to the
evaluating agency before the patient arrives.
When law enforcement is involved
If law enforcement comes across a person in the community who is in need of mental health
treatment but not voluntary, they can contact NurseWise (866-495-6735) and request a Crisis
Mobile Team (CMT). The CMT will meet with the person where they are and attempt to engage
the person in treatment voluntarily. If the CMT is unable to do so, and the person is dangerous
to self or others, PAD or GD, the mobile team can facilitate a petition for involuntary treatment
by following the sections entitled Steps to Petition and Special Questions. Note: The officer
involved may need to complete a witness statement and supply it to the CMT. The officer may
also be called to testify in court.
Per ARS 36-525 (B) “a peace officer may take into custody any individual he has probable
cause to believe, based on his own observations, is, as a result of mental disorder, a danger to
self or others, and that during the time necessary to complete the pre-petition screening
procedures set forth in sections 36-520 and 36-521 the person is likely without immediate
hospitalization to suffer serious physical harm or serious illness or to inflict serious physical
harm on another person…” If the peace officer determines this to be the situation, the peace
officer can transport the person to the -evaluating agency. The person that observed the
petitionable behavior will need to fill out the paperwork to initiate an Application for Emergency
Admission for Evaluation (Form A3). The evaluating agency will assist law enforcement and/or
the applicant as needed in determining the standard by which the person will need to be
petitioned, the proper forms to complete, and they will file the paperwork with the County
Attorney’s Office. NOTE: The original Application (Form A3) must be delivered to the evaluating
agency along with the person being petitioned.
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What if probable cause cannot be established?
If probable cause cannot be established and there appears to be a behavioral health crisis, law
enforcement should follow internal departmental protocols. If department protocols allow AND if
it is safe to do so, a CMT can be called to assess and intervene in the crisis.
A person who is incarcerated and not voluntary for mental health
evaluation
At the Graham County Jail
If the inmate is refusing all treatment offered and is dangerous to self or others, persistently and
acutely disabled or gravely disabled, the jail will contact NurseWise and request a CMT for a
Title 36 screening.
The jail staff shall give a verbal summary of the presenting issues to the CMT including the
results of any recent assessments and any other pertinent information needed for a Title 36
assessment and for subsequent discharge planning. The person that observed the petitionable
behavior will need to fill out the paperwork to initiate an evaluation for involuntary treatment.
The CMT will assist the jail staff in determining the standard by which the person will need to be
petitioned as well as the proper forms to complete. The jail staff may also need to be available
as a witness for the Title 36 petition. The County Attorney’s Office should notify any potential
witnesses at their earliest convenience if they are to be named as a witness.
Note: If a person needs to be released for treatment this happens generally one of two possible
ways:
1)
The jail works with the court system to obtain a release of the inmate. Charges may be
dropped or the person may be released OR on their own recognizance. In this case, the
CMT coordinates with jail personnel to assure the release has been legally granted and
then can assist in placement of the person.
2) The person is released on a Jail Hold. In this case, an incarcerated person is in jail, in a
psychiatric crisis and determined to be manageable at an evaluation agency for
Psychiatric Services. The inmate is transported to the evaluating agency by the Sheriff’s
Department on a Jail Hold with a Detainer from the Court. The inmate is treated at an
evaluation agency and returned to Jail by the Sheriff’s Department. If the Jail Hold has
been dropped a “release from Custody” Order is received from the Court. Appropriate
discharge planning then occurs with the assigned outpatient provider.
Before a person in the jail can be transported to an evaluation agency, there must be a court
order in the criminal case for the release of the person. The CMT should coordinate with the
Jail personnel in order to facilitate this.
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Non-Emergency Requests for Involuntary Evaluation (PAD or GD)
All non-emergency petitions for persons who are NOT enrolled should be coordinated by
calling NW.
All non-Emergency petitions for persons who are enrolled in an active episode of care with a
local provider should be facilitated by the person’s clinical team.
In these situations, safety plans must be put in place until the paperwork is approved.
Voluntary Crisis Services for Incarcerated Persons
At the Graham County Jail
If an inmate in the jail is in a psychiatric crisis the jail can call NurseWise and request a Crisis
Mobile Team (CMT). The CMT can provide crisis assessment and short term crisis intervention
as well as recommendations to detention staff. The CMT can only make recommendations to
the jail and cannot remove a person from the jail to facilitate further treatment, unless a judge
orders a release. If the jail wishes to release the person for treatment, they would follow internal
protocols to obtain a release for the person and to ensure placement in an appropriate
treatment setting.
At the Eastern Arizona Regional Juvenile Detention Facility
If a juvenile in detention is in a psychiatric crisis the detention center can call NurseWise and
request a Crisis Mobile Team (CMT). The CMT can provide crisis assessment and short term
crisis intervention as well as recommendations to detention staff. The CMT can only make
recommendations to the detention center and cannot remove a person from the center to
facilitate further treatment. If the CMT does recommend a higher level of care for a juvenile in
detention, the detention center will follow internal protocols to ensure placement in an
appropriate treatment setting. The detention center can call NurseWise at 866-495-6735 to get
bed availability information.
Contractual agreements between Cenpatico and local ICC Agencies require all said agencies to
coordinate care of enrolled members with jails and detention centers. Coordination of care can
be achieved by visiting the person or participating in treatment and release planning for enrolled
members.
Revocation of the outpatient treatment portion of an Existing COT
If all attempts at outreach and engagement and crisis planning have failed to re-engage a
member under court ordered treatment, a revocation of outpatient treatment may be necessary.
A revocation would result in re-hospitalization of the member. Per ARS 36-540 (E) when a
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member returns to an inpatient setting under a COT revocation, the member must be informed
of their right to judicial review and the right to consult with counsel pursuant to section 36-546.
This must be documented in the clinical record.
NOTE: Do not assume that medical clearance will be required. See Notes on Medical
Clearance section for more information.
During Regular Business Hours
Revocations are the responsibility of the member’s clinical team. The team will ensure
the proper paperwork is filled out and filed with the court and they will coordinate
transportation by a peace officer to the inpatient facility. The clinical team will be
responsible for locating a bed. If the person on COT has Medicare, a thorough Medicare
bed search must be completed.
Revocation of the outpatient treatment portion of a court order by a
medical director (emergency process per ARS 36-540(E)(5))Non-emergent revocations are completed for persons who are non-adherent to treatment and
not currently DTO/DTS. These would not be completed by the CMT as these are nonemergency situations and would be facilitated by the Clinical Team.
1. The clinical team will complete the Request for Revocation of an Outpatient Treatment
Plan (Form C1) and ensure it is signed by the agency’s medical director. The medical
director can sign the form by the next business day after a member is admitted to an
inpatient facility.
2. The clinical team will locate a bed for the person. (If the person is on COT has
Medicare or other third party coverage, a thorough Medicare/TPL bed search must be
completed). The receiving hospital will need a copy of the original court order and
Request for Revocation as well as clinical documentation.
3. The clinical team will make 3 copies of the Request for Revocation of an Outpatient
Treatment Plan form. One to be ‘copy stamped’ for the facility’s medical record, one
copy for law enforcement to show at the time of pick up, and one for the receiving
inpatient facility.
4. Once a bed is found, the clinical team will arrange for transportation to the receiving
facility as follows:
a. The Clinical Team will contact the appropriate law enforcement agency and
advise that they have a person under a COT revocation who requires
transportation to a receiving psychiatric facility.
b. Law enforcement will arrive on scene and transport the person to the receiving
inpatient facility. The Clinical Team will have a copy of the court order and
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request for revocation, in case law enforcement requests it. They should also
keep a copy for the chart.
5. The request for revocation must be filed with the County Attorney's Office no later than
the next working day.
Revocation of the outpatient treatment portion of a court order by a
Judge (non-emergency process per ARS 36-540(E)(4))
Non-Emergency revocations are completed for persons who are non-adherent to treatment, and
not currently DTO/DTS. These would be completed by the Clinical Team.
1. The clinical team will fill out the Request for Revocation of an Outpatient Treatment
Plan (Form C1) and ensure it is signed by the agency’s medical director.
2. The Clinical Team will locate a bed for the person. (If the person on COT has Medicare
or other third party coverage, a thorough Medicare/TPL bed search must be
completed). The receiving hospital will need a copy of the original court order and
request for revocation as well as clinical documentation.
3. Once a bed is found, the Request for Revocation of an Outpatient Treatment Plan
must be delivered to the County Attorney's Office to begin the process.
4. The County Attorney will prepare a cover sheet and bring the request for revocation
before the court.
5. If the court agrees, the judge will sign and order to pick and transport the person to an
inpatient psychiatric agency. The order will be sent to the identified staff member at
the outpatient treatment agency.
6. Once the Clinical Team receives the order from the judge, they will make copies of the
original court order and the order to pick up and transfer the person (one for the client
chart, one for the receiving psychiatric agency, and one to show law enforcement at
the time of pick up).
7. The Clinical Team will contact the appropriate local law enforcement agency and
advise that they have a court order for a pick up and transfer to an inpatient psychiatric
facility.
8. Law Enforcement will apprehend and transport the person to the receiving inpatient
facility. The Clinical Team will have a copy of the court order, the request for
revocation, and the order to pick up and transfer the person in case law enforcement
requests it.
After Hours
The CMT can be called to intervene in a crisis and will take necessary steps to assure the
safety of the person and the community. If the Medical Director/Designee of the treatment
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agency cannot be located and the person remains involuntary, AND is DTS or DTO the CMT
can fill out an Application for Emergency Admission and will contact NurseWise about getting
the person screened and admitted under an emergency COE. (See section entitled Involuntary
Persons in Need of Mental Health Treatment).
Note: In this case, the assigned outpatient treatment agency would be contacted during the first
regular business hour of the business week so they can complete a COT revocation and the
new COE would be dropped. They would follow the process outlined above and omit the bed
search and transportation steps.
Direct Admission to a Licensed Hospital or Behavioral Health Hospital
Facility (Psychiatric Inpatient Facility)
Note: A direct admission can occur without medical clearance barring any symptom driven
reasons requiring a medical screening.
By outpatient providers (voluntary only)
Outpatient providers serving enrolled Cenpatico members are able to seek direct admissions to
level one facilities for their enrolled voluntary members if they determine that an emergency
admission is needed during regular business hours. In these situations, there is no requirement
for pre-authorization or a CON. (See section I: Crisis During Business Hours for more details.)
By crisis mobile teams (voluntary only)
CMTs can refer persons in a behavioral health crisis who are voluntary for treatment to a level
one facility for direct admission. NurseWise can assist the CMT with bed searches in these
situations. Once a bed is located, the CMT should call the facility to staff the situation and get
approval for the person to be admitted. In these situations there is no reason to take the person
to the ER prior to admission. The admitting psychiatrist may request, based on symptom driven
concerns that the person be medically screened prior to admission. If medical clearance is
requested, NurseWise or the CMT, or both will gather information about the specific medical
symptoms or concerns that require medical clearance and will ensure this is documented. This
information will also be clearly relayed to ER staff. Once accepted to a facility, NW can assist
the CMT in arranging transportation or the CMT can transport the member if the transport does
not interfere with crisis call response.
By another hospital (ED or medical floor)
Any medical hospital has the capability of transferring a person from the ED or a medical floor
directly to another medical facility that can address the psychiatric condition of the patient. In
general, this practice would require a doc to doc and would not require a call to NW or to the
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CMT. This may be beneficial for persons who have private insurance, no insurance, or those
who need medical detoxification services.
Coordination of Care with Local Hospitals
Per the ADHS/DBHS Provider Manuel, coordination and communication should occur with any
known medical provider of a RBHA enrolled member. (Please see Emergency Department
Guide for Persons Receiving Crisis Services from Cenpatico and the IHS guide for persons
receiving crisis services for more detailed information about crisis services in the ER.)
Enrolled Persons
In order for NurseWise and the CMT to place a person in an inpatient psychiatric level of care
(level one or sub-acute), the person must be either:
o
o
o
Active with AHCCCS (Title 19)
Active w/ Indian Health Services AHCCCS
Active with KidsCare (Title 21)
In any
T/RBHA
NON-enrolled persons
Any person presenting in the emergency department (ED) in a behavioral health crisis is eligible
for crisis services. For those who arrive at the ED and have private insurance, the person’s
private insurance should be accessed to assist the person.
Medically admitted patients enrolled with an outpatient service provider
1. If a person who is enrolled with an outpatient provider is admitted to the hospital
for medical reasons, a member of the clinical team should be available to
coordinate care with hospital staff within 24 hours of admission. The clinical
team should also be involved in the discharge plan for the admitted member to
ensure behavioral health needs are met.
2. Hospital staff facilitating discharge plans are able to access NurseWise for well
checks for persons being discharged and at risk. This can be accomplished only
with the agreement and participation of the patient. Hospital staff will need to
clearly outline the clinical reasons for a wellness check and will need to allow the
patient to speak to NurseWise about the plan. Note: these services are available
for both enrolled and non-enrolled persons.
3. CMTs are unable to respond to medical floors.
Meeting Attendance
The strength of the crisis system is in part dependent upon the level of participation of involved
stakeholders, the RBHA and local agencies. Successful meetings will also require a focus on
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systems issues. Specific complaints about individual situations should be handled as outlined in
the Problem Resolution Process. All parties agree to have representation at meetings and
agree to participate actively in the process.
The Graham County Crisis System Meeting
This meeting has been established to identify areas in which there is a need for procedures or
improved communication between the behavioral health system, law enforcement, the courts,
the jail and local providers. Attendance is encouraged since this meeting is a primary means for
stakeholders, the RBHA and RBHA contracted agencies to discuss and examine the current
procedures to address and intervene during a behavioral health crisis. The group represents a
collaborative effort to identify barriers and strengths in the crisis system and to develop
agreements and processes to build on strengths and resolve barriers.
Regular Crisis Team Meetings
Cenpatico holds meetings on a bi-weekly basis to follow up with Crisis Mobile Team providers
and NurseWise staff on how the crisis system is working.
Problem Resolution Process
Conflicts between specific agencies or regarding specific situations should be handled between
the agencies involved. Cenpatico is always willing to assist in this process if called upon to do
so. It is agreed that problem resolution is best completed in real time by following the chain of
command.
It is agreed upon that for effective problem solving, system issues that present a problem will be
discussed in the Graham County Crisis System Meeting.
The Cenpatico Stakeholder Liaison is also a resource for Graham County when concerns arise.
The Liaison can help resolve problems related to specific situations as they relate to the crisis
system and can also help file official complaints with Cenpatico Customer Service if necessary.
Drug and or Alcohol Use
Per ADHS Practice Protocol Co-occurring Psychiatric and Substance Disorders, “Assessment
begins at the point of clinical contact, regardless of the member’s clinical presentation. Initiation
of assessment should not be made conditional on arbitrary criteria such as length of abstinence,
non-intoxicated alcohol level, negative drug screen, absence of psychiatric medication, and so
on.”
Thus, a person under the influence who self identifies as being in crisis is eligible for the array of
crisis services offered by the RBHA. There is no requirement for the person to reach a certain
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level of sobriety before being assessed. The only requirement is that the person must be able to
physically participate in an interview.
The Title 36 statute does not preclude a person under the influence of substances from being
petitioned for involuntary treatment. The statute does require that there be evidence of a “mental
disorder” as defined in ARS 36-501.25.
Services Available for Substance Use
Community Bridges: CB has several Substance Abuse Transitional Facility drug and alcohol
treatment facilities. SRU facility accepts any person who has used alcohol or other addictive
substances (opiates, barbiturates, tranquilizers and stimulants) within the previous 7 days or a
benzodiazepine with the last thirty days. A person can stay at CB for up to 5 days based on
clinical need. They also have outpatient substance use services and can get people enrolled for
long term services if this is desired.
Transfers of Care
As a result of the ‘no wrong door’ philosophy, once assessed, persons in crisis may need to be
transferred from one facility to another in order to receive the most appropriate treatment.
Transfers to CB - Benson (520-586-6171)
CB is available 24 hours per day, 7 days per week to take referrals.
A person may be a candidate for CB if:
1.
2.
3.
4.
The person is not medically compromised.
The person is voluntary for treatment.
The primary concern is drugs and or alcohol.
The person is currently under the influence of a substance or has used substances in
the last 7 days or a benzodiazepine in the last 30 days.
Referrals to Community Bridges, Inc.




Law enforcement can bring persons to CB;
A CMT can bring a person in
A case manager can bring a person in
A client can self-refer
Note: Community Bridges employs Emergency Medical Technicians (EMTs) who can conduct a
basic medical screening to identify any potential acute medical concerns. If medical care is
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needed, Community Bridges will request an ambulance to transport the person to the nearest
ED.
Mountain Health and Wellness-Mountainside Psychiatric Acute Care (PAC)
Mountainside PAC is a 14-bed free standing Behavioral Health Facility (formally Level One Sub
Acute capable of treating person in need of inpatient psychiatric treatment as well as
detoxification from alcohol and other drugs. Typical detox stays are 3-5 days for stabilization.
Mountainside PAC is available 24 hours per day 7 days a week. They have registered nurses to
triage for admissions. Mountainside PAC referrals are made by calling NurseWise.
Detoxification Admission Criteria
a) Must be 18 years or older.
b) Must have a health insurance benefit (private insurance is also taken)
c) History of alcohol/drug abuse or addiction with current use and /or recent
cessation of use, and in a state of intoxication or withdrawal.
d) Must be conscious and able to minimally participate in the evaluation process.
e) Patients must be medically stable, without the need for intravenous treatment or
internal medicine consultation for a medical condition, including alcohol
detoxification.
f) Need for opiate detoxification must not be so great as to require methadone
treatment.
Note: Referral to a more appropriate medical setting will be initiated for patients who do not
meet these admission criteria.
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Signature Page
Cenpatico and their contracted providers and identified Graham County Community
Stakeholders agree to work in partnership on behalf of persons experiencing a behavioral health
crisis to ensure they receive the appropriate services and level of care that promote resiliency
and protect the community.
This guideline will be active from date of signature until modified by the involved parties. This
guideline does not create or delegate financial responsibility. This guideline is not a legal and
binding contract or Memorandum of Understanding.
These guidelines should never override the obligation to provide the most clinically appropriate
intervention based on each individual situation nor should they override law or professional
responsibility to clients. Agencies are encouraged to have adequate clinical supervision and
guidance to support such actions.
The Graham County Crisis Protocols are a Collaborative Protocol between the following
agencies:
Arizona Counseling and Treatment Services
Cenpatico
Community Bridges
Eastern Arizona Regional Juvenile
Detention Facility
Graham County Attorney’s Office
Graham County Jail
Graham County Sheriff’s Office
Graham County Adult & Juvenile Probation
Department
Effective Date: 11/10/2011
Horizon Human Services
Mt Graham Regional Medical Center
NurseWise
Pima Police Department
Safford Police Department
San Carlos Police Department
SEABHS outpatient
Thatcher Police Department
Last Revision Date(s): 7/13/2015
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End Date (if applicable):
_____________________________________
___________________
To be reviewed in one year
Date:
Arizona Counseling and Treatment Services (ACTS)
____________________________________
___________________
Date:
Arizona Department of Public Safety
_____________________________________
___________________
Date:
Cenpatico
____________________________________
___________________
Date:
Community Bridges
___________________________________
Date: ___________________
Eastern Arizona Regional Juvenile Detention Center
___________________________________
Date: ___________________
Graham County Attorney’s Office
_____________________________________
___________________
Date:
Graham County Jail
___________________________________
Date: ___________________
Graham County Sheriff’s Office (GCSO)
___________________________________
Date: ___________________
Graham County Adult & Juvenile Probation Department
____________________________________
___________________
Date:
Horizon Human Services
____________________________________
___________________
Date:
Mt Graham Regional Medical Center
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____________________________________
___________________
Date:
NurseWise
____________________________________
___________________
Date:
Pima Police Department
___________________________________
Date: ___________________
Safford Police Department
____________________________________
___________________
Date:
San Carlos Police Department
____________________________________
___________________
Date:
SEABHS outpatient
___________________________________
Date: ___________________
Thatcher Police Department
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