Behavioral Health Task Force Emergency Department Mental Health Services Survey April 9, 2009 Wisconsin Hospital Associa

1. Behavioral Health Task Force Emergency Department Mental Health Services Survey April 9, 2009 Wisconsin Hospital Association

2. Purposes of Survey • Gain an understanding of: • Accessibility and availability of mental health services. • Trends in county-provided mental health services. • Trends in emergency detention/involuntary admission issues. • Survey was only intended to measure impressions. • Not intended to be a precise measure of mental health services.

3. Development of Survey • Initial draft of survey sent to Task Force members for comment. • Survey revised based on Task Force comments. • Online survey sent to CNOs and ER managers on Mar. 29. • Requested that ER managers complete the survey. • Survey closed on April 8.

4. Survey Results • 63 out of 127 hospitals responded (49.6%) • 34 out of 63 respondents were CAHs (53.9%)

5. Survey Comments Psychiatric care is sadly lacking for the chronically ill in this county. Case management should be strongly enforced so the patients get treatment instead of jail when making bad decisions. The mental health access issues seem to have improved in Milw Co. over the past year. There needs to be a way to provide appropriate follow up for these patients. Many are repeat visitors, there seem to be very few treatment options available to them in a timely manner, and/or within an appropriate access location or time of day. It has become increasingly difficult to find facilities to transfer these patients Every time a suicidal individual comes to the ER it is problematic to find a transfer facility It usually takes 4-5 hours to find placement and then it is always over 50 miles away. For teens it is close to 100 miles away. I have seen at trend that officers are unwilling to ED patients after they call the County Agency Director. We provide treatment for health needs, and have contracted psych screening for patients in need. Biggest barrier to care is finding a facility with room and service as they are too few and very far away!

6. What was Learned? Survey Results • Are Mental Health Services Available? • Chapter 51 issues • Non-Emergency Detention County Services • Emergency Detention/Involuntary Admission Issues

7. 1. Are Mental Health Services Available? Hypotheses: Accessing services is nearly impossible for patients with Medicaid or no insurance. There are a lack of MH services in Wisconsin, especially in rural areas. Did the survey confirm the hypotheses?

8. 1. Are Mental Health Services Available? • Accessibility of MH services for individuals with private insurance • Accessibility of MH services for individuals with Medicaid • Accessibility of MH services for individuals with no insurance

9. Accessibility of MH services for individuals with insurance Generally Accessible Generally Inaccessible Nearly Unavailable No response/no hospital

10. Accessibility of MH services for individuals with Medicaid Generally Accessible Generally Inaccessible Nearly Unavailable No response/no hospital

11. Accessibility of MH services for individuals with no insurance Generally Accessible Generally Inaccessible Nearly Unavailable No response/no hospital

12. 1. Are Mental Health Services Available? Are psychiatric CONSULT SERVICES available in your Emergency Department? Is a psychiatrist ON CALL for your Emergency Department?

13. Psychiatric Consult Services in ER Pscyhiatric Consult Service IS available in ER Psychiatric Consult Service IS NOT available in ER No response/no hospital

14. 1. Are Mental Health Services Available? • Nearest available psychiatrist: • Accessibility of MH services for individuals with Medicaid • Nearest available other physician providing mental health services:

15. 1. Are Mental Health Services Available? • Nearest available PRIVATE OUTPATIENT PSYCHIATRIC services: • Nearest available COUNTY FUNDED outpatient psychiatric services:

16. 1. Are Mental Health Services Available? Hypotheses: Accessing services is nearly impossible for patients with Medicaid or no insurance. There are a lack of MH services in Wisconsin, especially in rural areas. Did the survey confirm the hypotheses? Is more study warranted?

17. 2. Chapter 51 Issues • Counties have responsibilities under Chapter 51 for emergency detention/involuntary admission needs AND general mental health care needs for indigent. • Non-Emergency Detention County Services • Are the counties meeting their responsibilities to provide mental health care to indigent? • Emergency Detention/Involuntary Admission Issues • Are the counties meeting their emergency detention/involuntary admission duties?

18. Non-Emergency Detention County MH Services Hypothesis: Counties are not providing adequate mental health care for the indigent, consequently, more patients are coming to the Emergency Department with acute needs. Did the survey confirm the hypotheses?

19. Non-Emergency Detention County MH Services • Accessibility of MH services for individuals with no insurance: • Nearest available COUNTY FUNDED outpatient psychiatric services: • Is there variation by region or county? • Are there any trends?

20. Accessibility of MH services for individuals with no insurance Generally Accessible Generally Inaccessible Nearly Unavailable No response/no hospital

21. Are Counties Providing Adequate Mental Health Care? • Changes over last 5 years in frequency of people seeking treatment for a mental health problem in your Emergency Department: • Changes over last 5 years in frequency of people coming to Emergency Department that are candidates for emergency detention: • Visits to ER with life threatening mental illness growing somewhat slower than visits to ER for mental illness in general.

22. Non-Emergency Detention County MH Services • Visits to ER with life threatening mental illness growing somewhat slower than visits to ER for mental illness in general. • Trends show more individuals coming to ER for mental health reasons. • However: • Survey did not differentiate between patients with insurance and those without. • Is there simply more willingness to be treated for mental health issues? • 3. Any rural or urban trends?

23. Changes over last 5 years in frequency of people seeking treatment for a mental health problem in your Emergency Department Substantial decrease Some decrease Insignificant change Some increase Substantial increase No response/no hospital

24. Changes over last 5 years in frequency of people coming to Emergency Department that are candidates for emergency detention Substantial decrease Some decrease Insignificant change Some increase Substantial increase No response/no hospital

25. Non-Emergency Detention County MH Services Hypothesis: Counties are not providing adequate mental health care for the indigent, consequently, more patients are coming to the Emergency Department with acute needs. Did the survey confirm the hypotheses? Is more study warranted?

26. Emergency Detention: County Responsibilities Hypothesis: Counties are not fulfilling their emergency detention/involuntary admission responsibilities. Did the survey confirm the hypotheses?

27. Emergency Detention: County Responsibilities Is your hospital experiencing chronic administrative difficulties relating to emergency detention/involuntary admission issues? • Any self-selection bias in the survey?

28. Hospitals Reporting Chronic Emergency Detention and Involuntary Commitment Difficulties All responding hospitals in the county indicated chronic administrative difficulties Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties

29. Hospitals Reporting Chronic Emergency Detention and Involuntary Commitment Difficulties(Hospitals with Inpatient Psychiatric Units Shown) All responding hospitals in the county indicated chronic administrative difficulties Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties

30. Hospitals Reporting Chronic Emergency Detention and Involuntary Commitment Difficulties(Hospitals with Inpatient Psychiatric Units Shown) • In the counties in which all of the hospitals reported chronic Emergency Detention difficulties: • What arrival problems are occurring? • What problems are occurring after arrival? • For all counties: • Any problems with patient transport? • Did the survey confirm the hypotheses? All responding hospitals in the county indicated chronic administrative difficulties Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties

31. How do Emergency Detention eligible individuals arrive at the ER? • Law enforcement brings an individual exhibiting a substantial probability of physical harm to self or others to the ER: • How often pursuant to s. 51.15 emergency detention? • Any change in frequency of such arrivals?

32. How do Emergency Detention eligible individuals arrive at the ER? • Law enforcement brings an individual exhibiting a substantial probability of physical harm to self or others to the ER: • How often pursuant to s. 51.15 emergency detention? • Any change in frequency of such arrivals? Are these results good or bad?

33. Frequency law enforcement brings an Emergency Detention eligible individual to the ER pursuant to an s. 51.15 Emergency Detention(Hospitals with Inpatient Psychiatric Units Shown) Among counties in which ALL responding hospitals indicated chronic administrative difficulties Never 0-1 times per six months 2-5 times per six months About 1 time per month More than 1 time per month Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

34. Change in frequency law enforcement brings an Emergency Detention eligible individual to the ER pursuant to an s. 51.15 Emergency Detention(Hospitals with Inpatient Psychiatric Units Shown) Among counties in which ALL responding hospitals indicated chronic administrative difficulties Substantial decrease Some decrease Insignificant change Some increase Substantial increase Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

35. How do Emergency Detention eligible individuals arrive at the ER? • Law enforcement brings an individual exhibiting a substantial probability of physical harm to self or others to the ER: • How often under custody of law enforcement but not pursuant to s. 51.15 emergency detention? • Any change in frequency of such arrivals?

36. Frequency law enforcement brings an Emergency Detention eligible individual to the ER under custody but NOTpursuant to an s. 51.15 Emergency Detention Among counties in which ALL responding hospitals indicated chronic administrative difficulties Never 0-1 times per six months 2-5 times per six months About 1 time per month More than 1 time per month Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

37. Change in frequency law enforcement brings an Emergency Detention eligible individual to the ER under custody but NOTpursuant to an s. 51.15 Emergency Detention Among counties in which ALL responding hospitals indicated chronic administrative difficulties Substantial decrease Some decrease Insignificant change Some increase Substantial increase Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

38. Emergency Detention: County Responsibilities • In the counties in which all of the hospitals reported chronic Emergency Detention difficulties: • What arrival problems are occurring? • What problems are occurring after arrival? • For all counties: • Any problems with patient transport?

39. For Emergency Detention eligible individuals, what happens after arrival at the ER? • The individual leaves Emergency Department against medical advice: • Frequency • Change

40. Individual Leaves ER Against Medical Advice (Frequency) Among counties in which ALL responding hospitals indicated chronic administrative difficulties Never Rarely Sometimes Frequently Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

41. Individual Leaves ER Against Medical Advice (Change) Among counties in which ALL responding hospitals indicated chronic administrative difficulties Substantial decrease Some decrease Insignificant change Some increase Substantial increase Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

42. For Emergency Detention eligible individuals, what happens after arrival at the ER? • The individual remains in Emergency Department longer than 12 hours: • Frequency • Change

43. Individual remains in ER longer than 12 hours (Frequency) Among counties in which ALL responding hospitals indicated chronic administrative difficulties Never Rarely Sometimes Frequently Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

44. Individual remains in ER longer than 12 hours (Change) Among counties in which ALL responding hospitals indicated chronic administrative difficulties Substantial decrease Some decrease Insignificant change Some increase Substantial increase Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

45. For Emergency Detention eligible individuals, what happens after arrival at the ER? • The county agrees to transport to another hospital for involuntary admission: • Frequency • Change

46. The county agrees to transport to another hospital for involuntary admission (Frequency) Among counties in which ALL responding hospitals indicated chronic administrative difficulties Never 0-1 times per six months 2-5 times per six months About 1 time per month More than 1 time per month Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

47. The county agrees to transport to another hospital for involuntary admission (Change) Among counties in which ALL responding hospitals indicated chronic administrative difficulties Substantial increase Some increase Insignificant change Some decrease Substantial decrease Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

48. For Emergency Detention eligible individuals, what happens after arrival at the ER? • The individual leaves the ER against medical advice after county refuses to proceed with an involuntary admission: • Frequency • Change

49. Among counties in which ALL responding hospitals indicated chronic administrative difficulties Never 0-1 times per six months 2-5 times per six months About 1 time per month More than 1 time per month Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital

50. Leaves the ER against medical advice after county refuses to proceed with an involuntary admission (Change) Among counties in which ALL responding hospitals indicated chronic administrative difficulties Substantial decrease Some decrease Insignificant change Some increase Substantial increase Some responding hospitals in the county indicated chronic administrative difficulties No responding hospitals in the county indicated chronic administrative difficulties No response/no hospital