2015
Crisis Protocols for Santa Cruz
County
Cenpatico Crisis Protocols for Santa Cruz County
Table of Contents
Overview & Purpose ................................................................................................................................ 1
Goals of the Crisis System ....................................................................................................................... 1
Definitions ................................................................................................................................................ 2
Crisis During Business Hours................................................................................................................... 6
Notes on Medical Clearance .................................................................................................................... 7
Crisis Services ......................................................................................................................................... 7
The NurseWise crisis line (NW) ............................................................................................................ 7
Crisis Mobile Teams ............................................................................................................................. 7
What is considered a crisis? ................................................................................................................. 7
Crisis Mobile Team Response in the Community ..................................................................................... 8
Services available ................................................................................................................................ 8
Involuntary Treatment for Children ........................................................................................................... 8
Involuntary Persons in Need of Mental Health Treatment (Legal Adults Only) ......................................... 8
A person in a Santa Cruz County ED ................................................................................................... 8
Steps to Petition ................................................................................................................................... 9
A person admitted to a medical floor at a Santa Cruz County Hospital ................................................. 9
Special Questions ................................................................................................................................ 9
A person in the community ................................................................................................................. 10
A person at an outpatient clinic during office hours ............................................................................. 10
When law enforcement is involved ..................................................................................................... 10
A person who is incarcerated at the Santa Cruz County Detention Center and involuntary for treatment 11
Voluntary Crisis Services for incarcerated persons ................................................................................ 12
At the Santa Cruz County Detention Center ....................................................................................... 12
At a Juvenile Detention Center ........................................................................................................... 12
Revocation of the outpatient treatment portion of an Existing COT ........................................................ 12
NOTE: Do not assume that medical clearance will be required. See Notes on Medical Clearance
section for more information. During Regular Business Hours ........................................................... 12
After Hours ......................................................................................................................................... 14
Direct Admission to a Hospital or Behavioral Health Inpatient Facility (Formally Level 1 Inpatient, Sub
Acute or RTC) ........................................................................................................................................ 14
Cenpatico Crisis Protocols for Santa Cruz County
By Intake Care and Coordination Agencies (ICC Agencies) (voluntary only) ...................................... 14
By crisis mobile teams (voluntary only) ............................................................................................... 15
By another hospital (ED or medical floors).......................................................................................... 15
Coordination of Care with local hospitals ............................................................................................... 15
Coordination with the ER on Enrolled Persons ................................................................................... 15
Coordination with the ED on NON-enrolled persons ........................................................................... 15
Coordination with Santa Cruz County Hospitals for voluntary medically admitted patients in an active
episode of care with an outpatient provider ........................................................................................ 16
Meeting Attendance ............................................................................................................................... 16
The Santa Cruz County Crisis System Meeting .................................................................................. 16
Crisis Team Meetings ......................................................................................................................... 16
Problem Resolution Process .................................................................................................................. 16
Drug and/or Alcohol Use ........................................................................................................................ 17
Signature Pages for Santa Cruz County Protocols ................................................................................. 18
Cenpatico Crisis Protocols for Santa Cruz County
Arizona’s Children Association (AZCA)
Cenpatico
Community Bridges
Community Intervention Associates (CIA)
Corazon Integrated Healthcare Services
US Customs
US Border Patrol
Department of Public Safety
Holy Cross Carondelet Hospital
Nogales Police Department
NurseWise
Patagonia Marshal’s Office
Pinal Hispanic Council (PHC)
Santa Cruz County Adult Detention Center
Santa Cruz County Attorney’s Office
Santa Cruz County Health DepartmentCorrectional Health
Santa Cruz County Probation (Adult and
Juvenile)
Santa Cruz County Sheriff’s Office
Overview & Purpose
The Protocols are guidelines that describe how we will all work together to ensure that behavioral
health services are delivered in Santa Cruz County. The Purpose is to enhance the network and
response capability to address behavioral health crisis in Santa Cruz County through ongoing
communication and collaborative agreements between community stakeholders and intake and care
coordination agency (ICC agency) 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 ICC agencies and identified Santa Cruz
County Community Stakeholders agree to coordinate activities to facilitate the implementation of crisis
services in Santa Cruz 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 ICC agencies and identified Santa Cruz 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.
Goals 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, support individuals in their recovery, promote
resiliency and protect the community.
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Definitions
An active episode of care-means they have been opened with and are 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 T 21 (kids)
o SMI only
o Medicare and T19
o Medicare and SMI
Note: Cenpatico will be the health plan for persons designated with a serious mental illness (SMI)
enrolled as Title XIX -Admitting Officer –Per ARS 36-501.1 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.
Admitting Officer Pick Up Order-This is a document pursuant to ARS 36-525-A that states a peace
officer shall on the advice of the admitting officer of the evaluation agency pursuant to section 36-524,
subsection E apprehend and transport a person to an evaluation agency.
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 prepetition 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.
Authorization for Apprehension and Transport (Form A91) - Pursuant to A.R.S. §§ 36-524(E) and
36-525 which allows a peace officer to transport a person to a screening or evaluation agency.
Behavioral Health Inpatient Facility (Formerly referred to as Level I Inpatient, Level 1 SubAcute, 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.
Business Hours- Monday through Friday from 8:00am to 5:00pm.
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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 department, 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 ICC agencies 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 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.
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.
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 University of Arizona Medical Center-South Campus (UAMC-South). 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, in Sierra Vista, is also an evaluation agency.
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
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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)- ICC Agencies are a 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 Care 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 Santa Cruz County include
Arizona’s Children Association (AZCA), Corazon Integrated Health Care Services, Pinal
Hispanic Council (PHC,) and Community Intervention Associates (CIA).
Natural supports- Refers collectively to support commonly identified as:
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
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understanding of the alternatives to the particular treatment offered after the advantages,
disadvantages and alternatives are explained to that person.
Petition-A mental health petition is the paperwork that must be completed and filed with the court in
order to place a person under court ordered evaluation.
Revocation of the outpatient treatment portion of a court order by a medical director
(emergency process)-The process outlined in ARS 36-540-E(5) in which the medical director of the
mental health treatment agency can order a person court ordered to outpatient treatment back into
inpatient treatment.
Revocation of the outpatient treatment portion of a court order by a Judge (non-emergency)The process outlined in ARS 36-540-E(4) in which the medical director requests that the person be
admitted back into an inpatient setting. This must be approved by the judge
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, selfcare, employment and recreation. Persons who are deemed SMI are eligible for RBHA covered
services.
Title 36- Arizona’s state law for involuntary mental health commitment for legal adults. The law is
located in the Arizona Revised Statutes, Title 36 (Public Health and Safety) Chapter Five (Mental
Health Services).
Title 36 pre-petition screening-The review of an application 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. Note: CIA currently
provides Title 36 pre-petition services for Santa Cruz County.
Specialty Provider- a provider type required to deliver specialized programs and treatment services
in treatment facilities, the community, member homes or specified offices to meet the unique needs of
special populations. Required service hours, locations, populations served and special treatment
programs are outlined in their contract with Cenpatico.
Warm Line Transfer – a live transfer where the call is introduced to and accepted by the recipient
before the call is transferred.
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WRAP Plan-Wellness Recovery Action Plan-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 member. 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 Intake Care and Coordination Agencies (ICC Agencies) will provide
crisis intervention to enrolled members who are in a crisis and in the presence of their ICC Agency.
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 a 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 coordinating with an ICC Agencies 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 may 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 avoided if recent health assessment
documentation can be provided to the receiving facility or a doc to doc can help rule out medical
concerns.
ICC Agencies 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
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agreements between Cenpatico and ICC Agencies 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.
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. These labs can be completed at any facility
that can complete sufficient medical information (i.e. Jail, urgent care, outpatient clinic, local primary
care physician).
Crisis Services
The NurseWise crisis line (NW)
NW is available 24 hours a day, 7 days per week by calling 866-495-6735. 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 in Santa Cruz County is Community Intervention Associates (CIA). Crisis
Mobile Team assessment and intervention services are available to any person in the County
regardless of insurance or enrollment status.
Intake and Care Coordination Agencies (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 and can conduct crisis assessment, brief intervention and treatment for clients at
their facility who are in crisis.
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 other 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
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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 Department unless there is a medical emergency.
NOTE: Crisis Mobile Teams are required to have vehicles to facilitate transportation and field
interventions as well as laptops and cell phones for communications.
Involuntary Treatment for Children
Arizona Revised Statutes, Title 8 contains provisions that allow for the involuntary evaluation and
treatment of children. If a youth needs involuntary treatment and the parents or legal guardians are
not willing to admit the youth for evaluation or treatment, DCS should be contacted.
Involuntary Persons in Need of Mental Health Treatment (Legal Adults
Only)
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].
In Santa Cruz County, the County contracts with Community Intervention Associates (CIA) Crisis
Mobile Team (CMT) for pre-petition screening services. The Crisis Mobile Team is accessed through
NurseWise, the 24 hour crisis line for the County (1-866-495-6735).
A person in a Santa Cruz County ED
Note: ED staff requesting a Crisis Mobile Team (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 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:
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Steps to Petition
1. The CMT will ensure that the Application for Emergency Admission for Evaluation (Form A3)
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 staff the petition with their respective agencies and receive approval to do a bed
search.
4. The CMT will conduct a bed search for the person.
5. NOTE: Do not assume that medical clearance will be required. See Notes on Medical
Clearance section for more information. Once a bed is located, 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 fill out the “Admitting Officer Pick Up Order” form
b. The CMT staff will call the appropriate law enforcement agency and advise them they need
a peace officer transport for a T36 emergency evaluation.
c. Law enforcement arrives on scene and gets the original “Admitting Officer Pick Up Order”
and transports the person to the evaluation agency. CIA should keep a copy for the
record.
d. At the time of pick up, law enforcement will also obtain a copy of the petition packet (Forms
A1, A2, and A3) and will deliver it to the evaluation agency.
6. The CMT will ensure that the original petition paperwork is filed with the County Attorney’s
Office within 24 business hours of the admission. Paperwork must also be faxed to the
County Attorney’s Office (attention: Charlene LaPlante) in real time at 520-375-7909.
7. 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.
A person admitted to a medical floor at a Santa Cruz County Hospital
If a medically admitted patient is involuntary for treatment and meets the criteria for an emergent
(Danger to Self/Danger to Others) 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 Crisis Mobile Team will follow the process outlines in
Steps to Petition.
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 evaluation agency there must be a clinically
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appropriate safety plan developed for the person. The Crisis Mobile Team can develop this plan or be
called back to the scene if they have cleared 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. If the application
is declined after the person has arrived at the evaluation agency, the agency will assess and pursue
the most clinically appropriate safety plan for the person.
NOTE: A screening should not be declined solely due to the person being under the influence of a
substance. T36 does require evidence of a mental illness but this does not preclude the presence of
a co-occurring disorder.
What if the person is found to be petitionable on a non-emergent basis (PAD and/or GD)? The
CIA Crisis Mobile Team will facilitate the Title 36 process on a non-emergency basis for all persons
who are not enrolled in an active episode of care. These petitions would need to be staffed with the
CIA doctor. For those enrolled in an active episode of care, the clinical team at the ICC agency
should complete the non-emergency petition and their doctor would complete the petition paperwork.
In this situation only a judge can order a mental health pick up and the paperwork is filed with the
court for this authorization. In these situations, safety plans must be put in place until the paperwork
is approved. If a clinical team is pursuing a non-emergency petition, they will need to contact the
Deputy County Attorney (Charlene LaPlante) and notify her that the team is starting this process.
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 sent. 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 Steps to Petition and Special Questions.
A person at an outpatient clinic during office hours
During regular business hours service ICC agencies will provide crisis intervention to enrolled
members if a crisis occurs while the ICC 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 Steps to Petition and Special Questions.
When law enforcement is involved
Note: Numbers 1 and 2 below represent options for law enforcement and in a crisis; either
option can be accessed based on the discretion of the officer.
Option 1: 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
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others, PAD or GD the mobile team can facilitate a petition for involuntary treatment by Steps to
Petition or Special Questions.
Note: The officer involved will need to complete a witness statement and supply it to the CMT. The
officer may also be called to testify in court.
OR
Option 2: 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 prepetition 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 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.
A person who is incarcerated at the Santa Cruz County Detention Center
and involuntary for treatment
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 Crisis Mobile Team
(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 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: Before a person in the jail can be transported to an evaluation facility, there must be a
court order in the criminal case for the release of the person. Jail personnel can contact the
County Attorney’s Office during regular business hours and the County Attorney after hours.
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Voluntary Crisis Services for incarcerated persons
At the Santa Cruz County Detention Center
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. If a judge orders a release then safety will
dictate whether or not the transfer will be done through crisis mobile team or a peace officer. If a judge
orders a transfer, then transfer will be done by a peace officer.
At a Juvenile Detention Center
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.
NW can provide information about bed availability in Arizona, and the CMT/clinical team will assist as
well.
NOTE: 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 member returns to an
inpatient setting under a COT amendment, 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, if needed, to the inpatient facility. The clinical team will be responsible for locating a bed. If the
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person on COT has Medicare or other third party coverage, a thorough Medicare/TPL 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)) These are completed for persons who are in a
psychiatric crisis and need immediate hospitalization due to danger to self or danger to others.
1. The clinical team/CMT 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/NW 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. The clinical team/CMT will make 3 copies of the request for revocation of an outpatient
treatment plan form. One to be ‘copy stamped’ for the agency 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/CMT/NW will arrange for transportation to the receiving
facility as follows:
a. The Clinical Team/CMT will prepare the Order to a peace officer to apprehend and
transport which is signed by the Medical Director. (Only a medical director can order a
peace officer to transport a person on COT to a psychiatric inpatient facility.)
b. The Clinical Team/CMT will call the appropriate law enforcement agency and advise them
they need a peace officer transport for a T36 revocation.
c. Law enforcement arrives on scene and gets the original pick up order and transports the
person to the receiving inpatient facility. The team should keep a copy.
5. The request for revocation scanned and emailed to the County Attorney's Office: Attention:
Charlene LaPlante at claplante@santacruzcountyaz.gov with a copy
pluna@santacruzcountyaz.gov).
6. The medical director’s request for revocation of an outpatient treatment plan along with an
updated outpatient treatment plan will be filed by the Clinical Team no later than the next
working day.
Revocation of the outpatient treatment portion of a court order by a Judge (non- emergency
ARS 36-540(E)(4): 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 non-emergency situations and
would be facilitated by the Clinical Team in conjunction with the approval of the outpatient ICC Agency
Medical Director.
1. Once the team decides a revocation is needed, they 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).
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2. Once a bed is found, 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.
3. 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 form C2 and bring it before the court.
5. If the court agrees, the judge will sign an order to pick up and transport the person to an
inpatient psychiatric facility. The order will be sent to County Attorney’s Office and the County
Attorney’s Office will send the order 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 facility, and one to show law enforcement at the time of pick up).
7. The Clinical Team will contact the local law enforcement agency and advise that they have a
court order for a pick up and transfer to an inpatient psychiatric facility. Note: these are nonemergency situations and therefore should be coordinated with the appropriate law
enforcement agency. There should be coordination between the outpatient provider and law
enforcement about the time of pick up and the clinical team should be available to meet the
officer at the time of pick up. If the team has any difficulty with this process, contact Charlene
LaPlante for assistance.
8. Law Enforcement will pick the person up and transport them to the receiving inpatient facility.
The Clinical Team will have a copy of the court order and request for revocation, and the Pick
Up Order in case law enforcement requests it.
After Hours
If a member on court ordered treatment is in need of an emergency revocation and it is after hours
(Danger to Self and Danger to Others only), the CMT can coordinate the placement in an inpatient
setting and assist in the revocation process. CIA’s medical director will be available after hours to
sign off on the revocation documentation.
Direct Admission to a Hospital or Behavioral Health Inpatient Facility
(Formally Level 1 Inpatient, Sub Acute or RTC)
A direct admission can occur without medical clearance barring any symptom driven reasons
requiring a medical screening.
By Intake Care and Coordination Agencies (ICC Agencies) (voluntary only)
ICC Agencies 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 preauthorization or a Certificate of Need. (See Crisis During Business Hours for more details.)
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By crisis mobile teams (voluntary only)
CMT’s can refer persons in a behavioral health crisis who are voluntary for treatment to a Hospital or
Behavioral Health Inpatient 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 for 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 floors)
Any medical hospital has the capability of transferring a person (voluntarily) 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 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 for more detailed information about crisis services in the
ER.)
Coordination with the ER on Enrolled Persons
In order for NurseWise and the CMT to place a person in a Hospital or Behavioral Health Inpatient
Facility the person must be either:
Active with AHCCCS (Title 19)
Active w/ Indian Health Services AHCCCS
In any
T/RBHA
Coordination with the ED on NON-enrolled persons
Any person presenting in the emergency department in a behavioral health crisis is eligible for crisis
services. For those who arrive at the emergency department and have private insurance, the
person’s private insurance should be accessed to assist the person.
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Coordination with Santa Cruz County Hospitals for voluntary medically admitted
patients in an active episode of care with an outpatient provider
If a person who is enrolled with an outpatient provider is admitted to the hospital for medical reasons,
a member of the outpatient 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.
Hospital staff facilitating discharge plans are able to access NurseWise for well checks for any person
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.
Crisis Mobile Teams are unable to respond to medical floors for voluntary patients.
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
systems issues. Specific complaints about individual situations should be handled as outlined in the
Problem Resolution Process as outlined in section X (below). All parties agree to have representation
at meetings and agree to participate actively in the process.
The Santa Cruz 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.
Crisis Team Meetings
Cenpatico facilitates regular meetings to follow up with Crisis Mobile Team providers and NurseWise
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.
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Cenpatico Crisis Protocols for Santa Cruz County
It is agreed upon that for effective problem solving, system issues that present a problem will be
discussed in the Santa Cruz County Crisis System Meeting.
The Cenpatico Stakeholder Liaison and Stakeholder Coordinator are also resources for Santa Cruz
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, nonintoxicated 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 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.
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Signature Pages for Santa Cruz County Protocols
Cenpatico and their contracted ICC agencies and identified Santa Cruz 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.
Effective Date: 11/29/2012
Last Revision Date(s): 5/8/2015
End Date (if applicable):
_____________________________________
Arizona’s Children Association (AZCA)
Date: ___________________
____________________________________
Date: ___________________
Arizona Department of Public Safety
____________________________________
Cenpatico
Date: ___________________
___________________________________
Community Intervention Associates
Date: ___________________
____________________________________
Corazon Integrated Healthcare Services
Date: ___________________
___________________________________
US Customs
Date: ___________________
___________________________________
US Border Patrol
Date: ___________________
____________________________________
Department of Public Safety
Date: ___________________
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Cenpatico Crisis Protocols for Santa Cruz County
____________________________________
Holy Cross Carondelet Hospital
Date: ___________________
____________________________________
Nogales Police Department
Date: ___________________
____________________________________
NurseWise
Date: ___________________
____________________________________
Patagonia Marshall’s Office
Date: ___________________
____________________________________
Pinal Hispanic Council
Date: ___________________
____________________________________
Santa Cruz County Attorney’s Office
Date: ___________________
____________________________________
Santa Cruz County Adult Detention Center
Date: ___________________
____________________________________
Santa Cruz County Adult Probation Department
Date: ___________________
____________________________________
Santa Cruz County Juvenile Probation Department
Date: ___________________
____________________________________
Santa Cruz County Sheriff’s Office
Date: ___________________
___________________________________
Santa Cruz Juvenile Detention Center
Date: ___________________
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