We in Virginia have had a lot of discussion in relation to Mental Health with shootings and terrible stories that are linked to either poor coverage by Mental Health organizations or people dropping the ball. I want to in this blog explain a little about the system as it works in the private sectors. I will also explain in my opinion how things could improve in the overall mental health sector. I want you to know that this is how I see things as my opinion may not be appropriate.
Mental Health Therapy:
This is the area I know the least about as I have only had limited experience in this field. In the public sector this is typically controlled by the insurance companies. Long term therapy isn't really considered Viable due to the payment standards set. Each therapy set is divided into a certain number of sessions usually around 12-13. If additional sessions are required new authorization is needed and this can be a difficult endeavor. In the public sector there are several types of therapy that are quite effective on the short term including Cognitive Behavioral Therapy which is very effective in most cases yet not for everyone. If longer term therapy is needed or the original Therapy didn't take then they can reapply in a few weeks and the system is repeated. This does work in its own way with the resources available. I is not always preferable but as the public system will allow you to have brief therapy for little to no money this is a great deal.
Mental Health Crisis:
The next are of business is Mental Health Crisis. This is one of the areas that has been in the spotlight regularly when people say “why don’t we just lock them up”. When someone is having a mental health crisis they can start to receive treatment by calling their local crisis line. The individual on the other end is supposed to not only be able to provide brief levels of crisis counseling but also give recommendations and treatment options for the individual to help them again once they get back out into the community.
If a Person comes in seeking voluntary hospitalization they can either do so by going directly to the hospital ER where they are required to find a bed if the individual reports being in need of hospitalization or they can come to the local crisis office for assistance in finding a bed. 90% of the time if you are seeking voluntary hospitalization through a local ER they will find a bed for you just keep in mind no state funding is usually utilized on hospitalizations that are voluntary so you may end up with a very large bill in the end.
One case where a person will have the local Community pay for their treatment is the Crisis Stabilization Unit. If you have one of these in your community (we have one here in Richmond ) then going voluntary through the local Community Services Board Crisis team can be beneficial. If a bed is available, the Consumer has around 1-2 weeks of medications on hand and the individual is not an immediate threat to themselves or others this can be an option. The Crisis Stabilization unit provides a similar level of treatment to that provided in the hospital setting with a psychiatrist readily available to change medications. The Crisis stabilization is more active in their treatment through groups and therapy which makes for a more effective environment for those that want to work hard to improve their symptoms. The Crisis Stabilization Unit is not a locked facility so like any Voluntary Admission the Consumer can leave when they wish to do so.
The above examples are of things that happen on circumstances that usually have resolution and are not typically in the public eye. The type of Crisis many wish to learn about is the type that tends to start in an ECO and end in a TDO.
First an ECO (Emergency Custody Order) is the legal means to getting a Consumer evaluated for hospitalization against their will. There are two ways that an ECO is administered. The Paper ECO is done when a family member or member of the community approaches the Magistrate with their issues explaining why the Consumer requires a Mental Health Evaluation. If the Magistrate agrees then the individual is brought in or detained at home to be evaluated by a Certified Pre-Screener for hospitalization. A Paperless ECO occurs when law enforcement is called due to a disturbance involving Mental Health and they take the individual into custody so that they can be evaluated for potential hospitalization. This type is usually initiated from a 911 call. Once the individual is in law enforcement custody the Consumer can be held up to 4 hours (with an optional 2 hour extension) while the Consumer is evaluated and a bed is found.
A TDO (Temporary Detention Order) is a legal means of hospitalizing an individual against their will. This process requires the consensus between a Pre-Screener and the Magistrate to execute. To qualify for the TDO the Pre-Screener has to determine if an Consumer is a harm to themselves, a harm to others or unable to care for themselves. After this is determined a hospital bed must be found that is willing to take the individual and after that point the person is taken in up to 72 hours. On the next available instance the Consumer is brought before a Judge where it is determined if the Consumer requires continued treatment or is allowed to stay or go voluntarily.
Crisis Triage Center (CTC): This is something fairly new to the state. This is a center that responds to calls for the county or counties it is set up for. This is a central area where law enforcement by bring individuals in on an ECO and leave them with a paid CTC officer and not be tied up for the time it takes to evaluate and find a bed. These units are designed largely to allow for law enforcement to be free to do more work within the community while not being tied up keeping watch on an ECO.
On the expense of the TDO: The Consumer is still left with any charges made by the ER even if they were taken to an ER against their will for a medical evaluation. Today most hospitals require Medical clearance (meaning that the Consumer is healthy) before they will be willing to take the person into their custody. This can end with a sizable bill even if all the rest is paid for. The state chips in for the duration of the TDO itself but it is the local Community Services Board that pays for the hospitalization if the judge decides that continued care is needed and this is called Grant Funding.
I will briefly talk about the decision making process shown to end in a TDO as this tends to be the biggest thing that comes up in the support group I run.
Threat to Self: This is pretty self explanatory, the person is threatening to harm themselves significantly due to irrationality. In these cases it is evaluated if the individual is suicidal so the Pre-Screener has to tease out through information given by family, friends and the individual if the Consumer plans to do harm in the near future. If an individual comes in after a suicide attempt it is highly likely that a TDO will be issued. This situation tends to be the hardest to tease out in cases where a suicide attempt has not been made but the Consumer had made a threat heard only by family. Many will avidly deny it and each Pre-Screener works differently on building their case with some leaning to a greater or lesser degree towards hospitalization.
Threat to Others: This is also pretty self explanatory, the person is threatening to assault or has already assaulted another individual. Usually the threat comes from an attempt to kills someone and the means are teased out to do it. In many cases it becomes one person’s word against another in this situation. There are also situations where one has to determine if the assault was the result of mental illness or if it was an actual assault where the police are required.
Failure to Care for Self: This is the one that tends to get the least amount of coverage in the medial. If you are unable to care for your ADLs (Activities of Daily Living) which are to do things such as make a simple meal, bath, dress, bathroom or even eat then this comes into play. This issue takes on a new meaning if you have a caregiver involved. For instance if you have someone that cannot bath themselves or eat without assistance due to severe depression and you have an aid bathing the person and feeding them then they cannot be hospitalized under this area. If that caregiver says that they are no longer supporting the Consumer, then the person can go under this. When looking at this area one has to make the choice as to weather the Consumer’s inability to provide for ADLs threatens their life and livelihood.
Problems: One of the initial issues that I have found with the above can be the response time. Many of the individuals that call a crisis line are directed to an answering service that then is supposed to connect them to a Crisis Therapist. This process of call and connection can take a lot longer than needed. During my time as a pre-screener I would be addressed by the police after only taken 5 minutes to come to my destination that the original call had been made over an hour previous. This issue I believe is in the works to be resolved and from what I am hearing is much quicker all the way round.
The Clock: This is one of the biggest issues that comes from an evaluation. As stated above the Pre-Screener has up to 6 hours after the Consumer is taken into custody to evaluate the individual, find the bed and obtain the TDO. Once the 6 hours has run out the Consumer is free to go even if they still have plans to do harm to themselves or others. Many people will look at the 6 hours and think that this is more than enough time but let me break down the process to you. The first part is to keep in mind that this clock starts after the individual is taken into custody and not from the start of the evaluation. The time taken into custody to the time the evaluation is able to start can at times take between 15 minutes and 2 hours depending on the location of the Consumer and the ability of law enforcement to transport.
The evaluation and the paperwork that goes along with it can take anywhere between 15 minutes to 1 hour depending on the paperwork level involved. Making the decision can take a long time compounding on the time above. This is especially true if the choice is a tough one and relatives, friend or even co-workers need to be called in order to be able to make a full decision. The evaluation process should at the longest takes can take up to 2 hours in a really hard to read one.
The calls to the hospitals are by far the longest part of the pre-screening process. In central Virginia the Pre-Screener must call most hospitals in the state before to see if a bed is available. A Hospital without any beds can some times take as long as an hours to confirm that there are no available beds. A Hospital with an available bed will typically not just come out and say that they will take the Consumer. The Hospital must gain a copy of the pre-screen, run the insurance and then discuss the issue with the lead psychiatrist to decide if they are appropriate for the bed available. This process can take from 30 minutes to 3 hours depending on the hospital and the psychiatrist in charge that day. If all of the hospital options are exhausted then the state hospital is called for a bed. The Pre-screener must prove that all other hospitals were called and then build a very strong case for admittance as the State Hospital works hard to deny all that they can and will work hard to find any chinks in your argument for hospitalization. The State hospitals also tend to require extra medical tests before entry. The State process tends to take 1-3 hours depending on what is needed. Of course if the Consumer has multiple medical issues the State hospital can refuse and you are without a bed at all.
Available Bed: There is a difference between “no beds” and “no appropriate beds”. If a hospital reports “no beds” then they are full up and have nothing available. When a hospital says “no appropriate beds” there are multiple things that could be the case. The hospital may have a bed in a unit with 10 year olds per say and you are looking for a 32 year old. The hospital may have a bed in a calm unit that requires less care and you are attempting to refer an individual needed 1 to 1 care (this is typically the case). Last is that the hospital looks at the record and decides for one reason or another that they do not feel that this individual will be satisfactory for their program at this time.
The Wait: One of the main things done to fix the ECO process is to extend the time. There are two main issues that take place when it comes to this. The first issue is police presence necessary to hold an ECO. With this you are taking an officer off of the beat for 1-6 hours sometimes even longer. The CTC works to help take some of the stress off but this is still a problem. The second is ER space. A person being evaluated in the hospital is taking up a bed in the ER this is a real problem when it comes to space when the ER is busy.
Mental Health Case Management:
This is an area that I have a lot of experience in. I have been working Case Management for the last 10 years and there are many overlaps between Community Services Boards when it comes to the services. The basic task of a Case Manager is to utilize resources within the community in order to better increase a Consumer's independence. The case manager also works in different capacities to monitor symptom changes and arrange through resource allocation, supportive counseling and encouragement to better prevent an individual from getting to the point where they are in a Mental Health Crisis.
A Case Manager in the past typically would have a caseload of 30-45 consumers that they would keep on their caseload provide services face-to-face at least once every 90 days and preferably more often than that. The typical contacts tend to be on the phone providing information for available resources or work towards trying to collaborate with other service providers such as the psychiatrist so in order to head off symptom changes or getting the Consumer connected to crisis treatment if required.
The Bad: The reality of what is done is typically far more than what was originally intended. The typical Case Load is actually 50-70 people some of which are high intensity and others that are low intensity with a hopefully equal mix. The current load in addition is different depending on where they are employed. In the instance I am reporting the case manager must participated in an annual update in paperwork which typically takes 1-3 hours a quarterly report each month, a review of their financial and insurance statues at least every month. During this time the case manager is keeping in contact with the psychiatrist and other collateral contacts such as police, probation, outpatient therapist or the day program staff. During each month each Consumer needs to be checked on depending on their insurance status. If the person is Medicaid then the case manager needs to at least have two phone contacts if they don't do a Face-to-Face meeting. While keeping up with all of these items the less a Case Manager has to review their caseload and at times items don't get done and slip past which is a worry for the community. Case Management is the first line defense when it comes to prevention of crisis and hope of getting people back into society as high functioning adults.
The Community Service Board system is also very hard to navigate. To enter in you have to go through a very detailed paperwork process that can take anywhere from 2-5 hours and then go on a wait list of sometimes up to 3 months before seeing a psychiatrist that does an hour long review asking the same questions done in the previous assessment. This is a frustrating slow system that many high level cases glide under.
My Thoughts on How to Improve the System:
Case Management: I believe that this system can be improved greatly by developing a tiered system. Right now you have two types essentially of Case Management which deal with the majority of consumers and those that see the high intensity consumers. I believe that we need to have three tiers of case management.
The first tier would be a low intensity workload. These case managers work with the individuals who have little to no needs coming in about once every 2-3 months mainly just seeing the doctor. The case manager would be present to solve some issues as they come up and to monitor symptom changes to try and keep them at this level. The case manager would see the Consumers at least once every 90 days and try and make phone contacts to update every month. The paperwork light would be light with trimmed down annual and quarterly papers so as to move through quickly and easily. The caseload for the manager would be between 60-100 individuals and they would have a relatively low pay rate in the community asking for reduced reimbursement rates.
The second tier would have a higher amount of need as these people tend to have a level of need that requires them to be seen face to face at least once every 1-2 months and their symptoms remain fairly unstable. This case manager would help to coordinate care for medical and psychiatric resources as well as work on detailed treatment planning for independent living. This tier would be the area where independence would be the major focus hoping to eventually aim for the goal to move the people down to the first tier level or out of the area of mental health completely. These case managers would be required to be at the masters level and be trained as certified pre-screeners so that they can handle emergency situations as they develop with their consumers giving an added level of personalized care. This group of case managers would be paid at a higher level for the added care and education that they have. The case loads would be 35-50 people so that the personal level can remain manageable. The paperwork would be the most detailed as it would rely heavily on goal oriented care.
The third tier would mimic the current high intensity systems concentrating on groups of people who are highly unstable with a high risk of harm to self and others. This group of case managers would be at the Licensed Clinician level so that they can provide emergency therapy as well as being a pre-screener to provide personalized crisis care. These individuals would be in touch with the hospital system and the psychiatrists keeping a high level of care seeing the individuals at least 1-3x monthly. These individuals would also include people that have a high level of medical care need that requires a large amount of assistance coordinating with hospitals and Primary Care Physicians. The paperwork load would be light with the focus plainly on reduction of symptoms and allowing for speedy entry into care. The case loads due to this would be no more than 10 Consumers per clinician. For both the second and third tier levels on call services would have to be made available.
Mental Health Crisis: This is the one that everyone wants to try and fix. I know that there are many ways that have been made available and discussed. The likely change would be to increase the ECO time table to 8 hours or greater giving the Crisis worker more time to find a bed. The problem with increasing the time is that you are tying up police and an ER bed when you normally would not. I have an expensive solution and a less expensive solution that would solve the issue.
I would continue to do the evaluation process as it normally falls with a 4 hour ECO in place to get the evaluation done. When it is determined that the individual requires a TDO to a crisis facility then a bedless TDO would be executed allowing for the person to remain in police care until the bed can be found.
A facility can be build in most cities to house individuals who are waiting on a bed to come available. This facility would be similar to many intake facilities with individual rooms, security and a small medical staff there to medially clear the individual. This would allow for police to get back on the street and for medical staff and ER staff not having to be used in such situations. This would also allow for the Pre-screener to more quickly get to any additional situations that might occur.
For a less expensive solution I know that other states such as Maryland tend to utilize hospital security and police tend to leave not long after dropping the person off. This may be a system worth looking into.
With the bed issues. I feel this can be automated as it already is being done. Right now a system is being tested that will automatically tell a crisis worker what beds are available in the community. I feel that this can be tweaked to make it a little more friendly allowing for a more detailed breakdown showing the number of beds available for gender, age and intensity so that the crisis worker can quickly go through the list without having to wait a long time. A system added so that a pre-screen can be attached and sent electronically for review directly by the psychiatrist with a yes or no answer box would make this process not only run quickly but could end the need for the above.
The Crisis Triage centers could be expanded as well to lower costs adding a few more security officers and crisis personnel to hold on to more people at one time.
Finally speaking of automation. I feel that the pre-screening process should be separated out from all of the different Community Services Board operating systems and made into a universal program that can be accessed all over the state. This would make for very quick access by all parties that needed to know about the process and instead of faxing the pre-screen all over the place all contact can be done with a few quick emails.
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