Allison Trammell, LCSW Chief of Quality Management & Utilization Management Behavioral Health Link & Wendy Mart

1. www.behavioralhealthlink.com Crisis and Access Services:  Innovative Solutions to a Linking Individuals with Behavioral Health Needs to Appropriate Resources and Notthe Emergency Room. Allison Trammell, LCSW Chief of Quality Management & Utilization Management Behavioral Health Link & Wendy Martinez Schneider, LPC Chief Clinical Officer Behavioral Health Link

2. Learning Objectives At the conclusion of the session, attendees will be able to: • Have an understanding of BHL’s role within the system • Describe why risk assessment, linkage to care and follow-up are essential in suicide prevention • Describe new services in place as a result of the Department of Justice Settlement Agreement with the State of Georgia • Identify resources available to facilitate referrals to appropriate resources for individuals in need of behavioral health, substance abuse, or developmental disability services • Describe Crisis and Access Services developed to facilitate referrals to State providers and maximize the utilization of available resources

3. The Georgia Crisis & Access Line • The Georgia Crisis & Access Line (GCAL) went live on July 1, 2006 • It provides brief clinical triage of callers seeking services throughout Georgia’s 159 counties • GCAL can schedule real-time appointments with over 100 behavioral health providers among over 200 behavioral health sites across the state • Dispatches mobile crisis teams throughout the state • Operates mobile crisis teams in Metro Atlanta and Southeast Georgia

4. Programs Call Center Mobile Crisis Teams 24/7 Availability Call Center dispatched Probate court requests Community response ER Response • 24/7 Availability • 20,000 Calls per month • Active rescue response • Real time appointment scheduling

5. Assessment - Linkage Licensed clinicians assess: • Presenting problems and clinical issues • Substance use issues • Risk of lethality • Medical issues • Screening for persons with Developmental Disabilities Based on the assessment, a linkage to a service is determined that best meets the needs of the caller

6. The Importance of a Lethality Assessment • In the U.S., there were 38,364 suicides in 2010, ais the 10th leading cause of death • More than 90% of people who die by suicide have a diagnosable mental illness and/or substance abuse disorder • 11th ranking cause of death • 1,133 Georgia residents died by suicide in 2010 • Georgia is ranked #40 among all 50 states • South Atlantic region rates hold that 13% of all deaths are by suicide

7. Challenges • Resources!!!!!!!! • Many more individuals are entering the system without insurance • Bed access to ERF’s are CSU are limited based their capacity

8. Please Know We Understand the Struggles • BHL has been referring individuals for behavioral health care since for over 10 years. • We aim to be part of the solution, but in no way do we mean to imply that we have the answer or that we are perfect • Resources are indeed limited so our approach is to do the very best we can with the resources we have and to keep individuals with behavioral health needs safe • We are not a managed care company nor do we have control over access to services • Our job is to assess the immediate need as best we can and link the individual to the most appropriate service available

9. Trying to Change the Front Door to Care • 911 Transfers to GCAL • Use of Urgent Appointment Slots Live- Access 24/7 • Mobile Crisis in the Community • Direct Referrals to Psychiatric Inpatient Facilities and Crisis Stabilization Units (Medical Clearance by Definition) • EMS Partnerships • DBHDD Emergency Receiving (ER), Evaluation (E), Treatment (T) Facilities- are you really on the list? • If you are not a designated ERF (Emergency Receiving Facility), a 1013/2013 or probate order written to your facility is not valid • A “ER” is not automatically an ERF!!!!

12. 1013/2013 Basics WHO CAN COMPLETE THE FORM 1013   The Form 1013 (Attachment A) can be completed by a licensed Physician, licensed Psychologist, licensed Clinical Social Worker, or Psychiatric Clinical Nurse Specialist. STEPS PRIOR TO COMPLETION OF THE FORM 1013 • Determine that the individual does in fact meet criteria of mental illness AND ‘imminent risk’. For more information regarding ADMISSION CRITERIA, see Policy 03-502, Criteria for Mental Health Admissions of Adults to DBHDD Hospitals. • Contact the Emergency Receiving Facility (ERF); provide clinical information to the facility and determine if the facility has the capacity to admit the individual, if admission is necessary. • Providing the clinical information will help determine if the individual has signs or symptoms of a medical condition that would warrant urgent medical intervention prior to transport to the ERF. Individuals should not be referred to Emergency Rooms for ‘medical clearance,’ but for a specific complaint that would normally be seen in an emergency department (chest pain, delirium, shortness of breath). For more information re: MEDICAL CLEARANCE see Policy 03-520, Medical Evaluation Guidelines and Exclusion Criteria for Admissions to State Hospitals and Crisis Stabilization Units.

13. Recent Changes to the 1013 Document I ________________(staff at referring facility) have communicated with ______________________(staff at receiving facility) at _________________(name of receiving facility), ______________ (telephone number), who stated that the facility has a bed available for this individual. This certificate authorizes the peace officer or other person to deliver the individual named on this 1013 to the named facility for examination to determine whether admission is necessary. ____________________________________________________________________________________________ SIGNATURE AND PRINTED NAME of staff at Referring Facility Date_______ 20____ Time ________m

14. Transporting 1013s/2013s As soon as possible, but within 72 hours after receiving this certificate, the Peace Officer shall make diligent efforts to take the above-named Individual into custody. Thereafter, the Peace Officer shall transport the above-named Individual to the emergency receiving facility serving the county where such person is found, as named above. This certificate expires 7 days after it is executed. This certificate and the Report of Peace Officer are to be delivered by the Peace Officer to the emergency receiving facility and are to be made a part of the above-named Individual's clinical record. If private transportation by family, friends, or other means is deemed safe, it shall be encouraged and authorized. This does not relieve the county governing authority from its responsibility to arrange for transportation when needed or requested.

15. We hold the individual’s hand until they are safely in the hands of a provider The most important thing you can do to prevent suicide is to make sure individuals are assessed appropriately (risk assessment)and that they get appropriate follow-up based on their clinical need. It doesn’t necessarily mean putting them in the hospital. Continuity of care is key. Allison is going to tell you about some recent research on follow-up on continuity of care that really emphasizes the importance of follow-up and dispels some myths about inpatient psychiatric care.

16. The President’s New Freedom Commission on Mental Health recommended: • Fundamentally transforming how mental health care is delivered in America.” Continuity of care should be a critical com­ponent of the foundation for any transformed system. Continuity of care is an underutilized suicide prevention strategy. • Continuity-of-care strategies need to target individuals that are at high risk both for suicide and for non-adherence to the recommended treatment plan.”

18. Report Summary • Published in 2011 through a joint project between the Suicide Prevention Resource Center (SPRC), AAS, SAMSHA, and the University of Michigan, this report “highlights a critical area for suicide prevention efforts, one that holds promise for reducing the number of suicides in America. • The accumulating research in suicide had made it increasingly clear that for those who experience suicidal crises and receive acute care interventions in hospitals and Emer­gency Rooms, suicide risk does not end at the moment of discharge. Rather, their elevated risk continues or is easily rekindled in the days and weeks that follow, leading to heightened rates of suicide during this post -acute care period. • However, as is noted in the National Strategy for Suicide Prevention, “All too often the assump­tion is that individuals are no longer at risk for suicide once they are discharged from inpatient hospital or institutional settings.” • Yet, despite the fact that those who attempt suicide and others experiencing a suicidal crisis who are seen in the health care system are a high risk population going through a clear high risk period, there have been few systematic suicide prevention efforts in the United States that have focused on this population during this time pe­riod.

19. Report Summary Continued • Elevated post discharge rates of death by suicide, suicide attempts, and readmissions to acute care services have been repeatedly documented, but this has not been matched by proportionate prevention efforts. • Moreover, as this report makes clear, not only has the need been shown to be unmistakable, but there are also promising interventions that can be utilized. In fact, the only two randomized controlled trials in the suicide prevention literature that have shown a reduction in the number of deaths by suicide have both involved following up with high risk populations after discharge from acute care services (Motto and Bostrom, 2001; Fleischmann et al., 2008)” • Another Goal of The National Strategy for Suicide Prevention is to “increase the proportion of patients treated for self-destructive behavior in hospital emergency departments that pursue the proposed mental health follow-up plan.” • Since discharge from a psychiatry inpatient unit is so strongly associated with subsequent suicide death, this report concerns suicide attempts and suicide deaths subsequent to discharge from an emergency department or from a psychiatry inpatient unit.”

20. Efficacy of Inpatient Hospitalization to Ameliorate Suicide Risk Alarmingly and a piece of research that few mental health professionals are even aware of, is that inpatient hospitalization hasnotbeen shown to be a statistically significant intervention in and of itself to prevent suicide. • “Rather than having a supporting role, psychiatric hospitalization plays a decidedly central role in America’s mental health care provision system. Despite the centrality of hospital­izing seriously ill psychiatric patients, the research base for inpatient hospitalization for suicide risk is surprisingly weak. This review could not identify a single randomized trial about the effectiveness of hospitalization in reducing suicide acts after discharge. “ • Huey and his research team found an intensive outpatient intervention superior to emergency inpatient treatment and, perhaps, more rapidly effective. • Two other randomized trials, one led by van der Sande and the other by Waterhouse and Platt, compared inpatient admission to alternative treatment controls; neither demonstrated a reduction in suicide acts. Consequently, beyond usual care, there are no evidence-based, psychiatric inpatient treatments that have been found to reduce the frequency of suicidal acts or suicide attempts subsequent to discharge.

21. Study Recommendations Manage and treat each patient making a suicide attempt and/or having suicidal ideation as if the next suicide attempt will result in suicide death. Having this rec­ommendation as a goal will motivate improved continuity-of-care policies and proce­dures in health care systems. Streamline the gathering of corroborating information for bona fide emergencies. Contacting knowledgeable others are one means clinicians have of getting help for characterizing a patient’s suicide risk profile. Clinicians seeking to gather corrobo­rating information regarding potentially suicidal individuals confront an assortment of federal, state, and regulatory issues about privacy. recipient rights concerns add additional complications.

22. Recommendations Continued • Support fellowship training in emergency psychiatry. Emergency psychiatry re­quires a specialized blend of psychiatric and general medical knowledge and skills. • Fund studies that pertain to “contracting for safety” and “safety planning.” Despite their extensive use, these clinical tools have been understudied and have not been subjected to randomized methods. At some point, clinicians have to accept the word of the patient, but little is known about the procedures that make this acceptance reasonable or unreasonable. • Reimburse extended suicide assessment procedures. If a comprehensive suicide risk assessment cannot be completed in the emergency department, permit and encourage reimbursement for a 24 to 48-hour hospitalization during which time such assessments can be accomplished.

23. Recommendations Continued Patients should be seen by certified professionals that have mastered suicide assessment and prevention skill sets. Define a nationally recognized set of the minimum essential skills and core competen­cies necessary for suicide risk assessment and management. Physician education in depression recognition and treatment reduces suicide rates. Consequently, there is every reason to believe that improved education and training pertaining to the management of suicide attempts and suicide ideation will have similar results. “Assessing and Managing Suicide Risk: Core Competencies for Mental Health Professionals” (AMSR), developed by the American Association of Suicidology (AAS) for the Suicide Prevention Resource Center (SPRC) and AAS’ “Recognizing and Responding to Suicide Risk: Essential Skills for Clinicians” (RRSR) each contain modules that teach core competencies and related skill sets.

24. Recommendations Continued • Essential skills and competencies. Certification is one means to improve overall quality of care provided to individuals at risk for suicide. • Find the best means for most efficiently and effectively teaching and disseminating the nationally recognized set of minimum essential skills and competencies. Not every­one will attend sit-down courses. A variety of means for teaching and dissemination needs to be considered. • Support fellowship training in emergency psychiatry. Emergency psychiatry requires a specialized blend of psychiatric and general medical knowledge and skills. • Promote pilot studies of interventions designed to reduce discrimination found in emergency departments in association with suicide risk and mental illness. There are numerous good hypotheses (e.g., skill deficits, unrealistic fears, inadequate collaboration with mental health professionals) that could be tested immediately.

25. Follow-up is Key Follow-up with Referrals to Ensure Services: BHL makes every effort to ensure that individuals followed through with recommendations for outpatient services. With a goal of diverting individuals to community services, maintaining family and community supports, providing treatment in the community at the lowest necessary level of care and preventing emergency room visits and contact with law enforcement. Research Based Crisis Planning Stanley Brown Crisis Plan: The most comprehensive discharge planning guidance for high-risk inpatients comes from the United States Department of Veterans Affairs (VA). Examples include weekly evaluations dur­ing the first 30 days after discharge and specific follow-up for missed appointments. Barbara Stanley and Gregory Brown have developed a “Safety Plan Treatment Manual to Reduce Suicide Risk;” there is a version of this made specifically for the VA.

26. SAMSHA Follow-Up Grant BHL Experience with SAMSHA Follow-up Research and Initial Results: BHL was one of 6 crisis centers nation-wide to receive a SAMSHA follow-up grant award in 2008. We participated in a three year study on the efficacy of follow-up. Though the results are still in press at this time, our initial results as an agency were excellent and several other agencies had a similar experience. Several agencies used specific follow-up consent forms for both MCRS responses and Call Center calls that can be modified to include text follow-up.

27. Initial Study Results

28. Permission for Mobile Crisis Follow-up

29. Georgia is Cutting-Edge

30. Methods of Follow-up Our experience with the SAMSHA follow-up project gave us a lot of ideas about efficient ways to follow up. Follow ups were generally more successful in the evening (we are having the CPS work second shift). We also found that telephonic follow-up isn’t always sufficient or effective. With the Disaster Distress Helpline project, BHL learned that using text and chat to communicate is extremely effective- particularly with younger consumers. We are working to utilize these as methods for follow-up and get permission from consumers during our contact for the method(s) of follow-up the consumer is agreeable to receiving. Kaiser Permanente uses Mosio chat/text for appointment reminders. BHL has used Mosio for the Disaster Distress Helpline with great success. It is HIPPA compliant and easy to use. With the consumer’s permission, ultimately our goal is to do live follow up via phone, chat or text and then send a reminder for the follow-up outpatient appointment via text.

32. Resources • GCAL (Georgia Crisis and Access Line) • Department of Justice Settlement Agreement • Mobile Crisis • Seen in home • BHL teams not allowed to send someone to the ER without supervisory approval unless it is a 911 emergency • Medical Clearance reference policy

33. Department of Justice Settlement Agreement

34. Interesting Research on Mobile Crisis

35. Interesting Research on Mobile Crisis

36. Interesting Research on Mobile Crisis

37. Interesting Research on Mobile Crisis

38. Effectiveness of Inpatient Care for Treating Suicidal Ideation

39. Electronic Resources Electronic Pending Boards • Live Census that Regional Offices and DBHDD can view in real-time • Real-time referrals with timing- out mechanism and reporting capabilities for average minutes to disposition by facility • Prioritize individuals waiting at home so they don’t have to go to the ER for “holding” Electronic Request Forms • Mobile Crisis • Discharge Appointments • PARF- Pre-Admission Referral Form

40. Live Referral Status Board

41. Ok- So how does this help the ER? • We are strongly encouraging direct referrals to psychiatric facilities and discouraging ER referrals • Individuals seen at home are much less likely to be hospitalized so with the expansion of Mobile Crisis, more individuals are being seen at home. • Many people sent to the State Hospital from the ER are never admitted • The bottom line is that we are working diligently to avoid unnecessary ER visits but it takes time to change the “front door.” • We are also working for more transparency in the system so individuals who have been waiting the longest get beds first and the information is visible to the State 24/7/365

42. Grady EMS Project • In January 2013, Grady EMS developed a 90 day pilot partnership with Behavioral Health Link (BHL) which operates the Georgia Crisis and access Line (GCAL) to extend an integrated model of Emergency Crisis Intervention “into the field” by deploying a co-response team to the scenes of behavioral health 9-1-1 calls. • The response team consisted of a Grady Paramedic and Licensed clinical Social Worker (LCSW). • The primary goal of this project was to determine the rate of non-hospital dispositions that could be safely achieved by providing alternative behavioral health resources for individuals who initially engaged EMS by calling 9-1-1 in the field.

43. Results • During the fourteen week pilot, the team scheduled 34 appointments in the field, provided 36 referral cards, reconnected 6 Assertive Community Treatment (ACT) patients with their providers, and transported 16 patients to in-patient psychiatric centers (directly with no stop at an emergency department) • This prevented 92 ambulance transports to the ED. • The success of this program is not only measured in non-transports or dispositions to alternate destinations but also as a community service provided on behalf of a safety net hospital to patients who suffer from mental illness whose situations are complicated and can often involve physically violent encounters.

44. Results • The crisis intervention team has assumed a critical role in deploying expertise from the LCSW to de-escalate agitated and potentially violent patients. • This is reflective in the 45%decrease in the use of chemical restraints. • This program projects to mitigate 1200 patients during the first year in dispositions other than ambulance transport to the ED after full staffing levels are achieved. • The program will provide hospitals (65% GHS, 20% AMC, 15% Other) more than 8400 hours of available bed space to improve ED throughput times and prevent hospital cost loss.

45. Next Steps Grady EMS created two additional FTE positions classified as ‘Paramedic- Crisis Intervention’ to operate the crisis unit eighty hours per week at an expense of $121,790. BHL-GCAL has agreed to continue funding the LCSW through grant funded positions until June 2015. http://www.gradyhealth.org/images/video/GradyCIU.wmv

46. Resources Link to Centers for Disease Control and Prevention, National Centers for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2010) {2012 Nov28}. Available from: www.cdc.gov/ncipc/wisqars Link to the Continuity of Care for Suicide Prevention and Research 2011 Report http://www.suicidology.org/c/document_library/get_file?folderId=266&name=DLFE-612.pdfAAS.org Suicide Prevention Resource Center (SPRC) http://www.sprc.org/ American Association of Suicidology http://www.suicidology.org/about-aas Link to DBHDD Medical Clearance Policy https://gadbhdd.policystat.com/policy/176512/latest/ Link to DBHDD 1013/2013 Policy https://gadbhdd.policystat.com/policy/211582/latest/ List of Emergency Receiving, Evaluating and Treating Facilities http://dbhdd.org/bhlu/files/ERET%20Listing%20by%20County.pdf