Baker Act The Florida Mental Health Act FLORIDA STATUTES CHAPTER 394

1. Baker Act The Florida Mental Health ActFLORIDA STATUTES CHAPTER 394

2. Main Legal/Societal Principles Parens Patriae Police Power Protect Citizens • Parent of Country – English Common Law

3. The Case of Mrs. Elizabeth Packard - 1860 • Hospitalization was needed due to an “unclean spirit” Moral Insanity . • ( Parens Patriae) • After 3 years , she had lost custody of her children and lost property to her clergy husband • She sued and won for wrongful commitment.

4. BayCare Hospital Baker Act Receiving Facilities • Saint Anthony’s Hospital • Saint Joseph’s Hospital Behavioral Health Center • Morton Plant Hospital • Mease Dunedin Hospital • Morton Plant North Bay Hospital Recovery Center • Winter Haven Hospital • These hospitals are designated by DCF as Baker Act receiving facilities.

5. Important Case Law and Impact on Today • 1966 - Lake versus Cameron- Washington D.C. • Court determined that if not dangerousness must find • “ least restrictive treatment” • 1975 -Supreme Court - O’Connor versus Donaldson Case • ( 15 years) – dangerousness required for hospitalization • 1978 - Addington versus Texas • mother asked that her son be hospitalized due to repeated dangerousness • Standard of proof • Beyond a reasonable doubt • Clear and Convincing Evidence • Preponderance of Evidence – decision is more likely to be correct than non-correct

6. BayCare Integrated Stabilization Unit (ISU) TheISU is the ONLY combined Baker Act and Addictions Receiving Facility (ARF) in BayCare Health System. • Adult Facility • Approximately 30 beds What does that mean? • Accepts both voluntary and involuntary patients under the Baker Act and Marchman Act. • Can involuntary confine a patient pending an involuntary examination under both the Baker Act and Marchman Act.

7. Baker Act Initiation Criteria • There is reason to believe the individual has a mental illness/ mental health diagnosis. • Not a substance abuse impairment • Because of mental illness:

8. Baker Act Status • Voluntary Admission (BA40) • Involuntary Examination (BA52) • Continued Involuntary Confinement (BA32) • Petition to the Court • Continued Involuntary Placement (BA8) • Ordered by the Court • An individual may not be placed in a secured receiving facility unless they are under a baker act status.

9. Voluntary Admission (BA40)

10. Request for Baker Act Voluntary Admission • What You Need to Know: • A competent adult with the capacity to make well-reasoned, willful, and knowing decisions, • Does not have a legal guardian or healthcare surrogate/ proxy currently making their health care decisions, • Has been provided a written explanation of their rights, • Prior to consent and signature, understands they can be detained without consent for up to 24 hours after a request for discharge (Right to Release).

12. Right to Release in Baker Act Voluntary Status • An individual requests a Right to Release(either written or verbal). • What is Required: • Face-to-face assessment by psychiatrist/psychologist within 24 hours of request. • Improved condition; no longer meets Baker Act criteria – DISCHARGE • Continues to meet Baker Act criteria (Needs to Stay) • Refusal to or revocation of continued voluntary consent, • Petition for continued involuntary confinement (BA32) initiated and filed with the Court. • Baker Act status changed to involuntary pending Court hearing/decision.

14. Involuntary Examination (BA52)

15. Initiation of an Involuntary Examination (BA52) • Who Can Initiate a Baker Act Involuntary Examination? • Law Enforcement Licensed Clinical Social Worker • Physician Licensed Mental Health • Psychiatrist Counselor • Clinical Psychologist Licensed Marriage and Family • Certified Psychiatric ARNP Therapist • The Court (Ex Parte) • A Physician’s Assistant (PA) or medical ARNP may not initiate a Baker Act in the State of Florida.

16. Baker Act Involuntary Examination (BA52) • What you should know: • MAY be confined involuntarily up to 72 hours as long as BA criteria is met. • While medical clearance is determined, the 72 hour clock STOPS: • BA status continues; only the clock stops; • 72 hour clock starts when the physician order for “medically cleared” is written. • MAY NOT be released without documented approval of a psychiatrist, clinical psychologist, or emergency department physician. • A competency evaluation is performed by a psychiatrist/clinical psychologist within 24 hours of medical clearance or direct admission to a BA receiving facility. • Determination of competency designates continued BA status.

18. Certification of Competency • Determined to be competent: • No longer meets baker act criteria, must be released; • Order written to allow patient to consent to voluntary status for continued treatment/confinement and patient agrees; • Patient does not agree to voluntary status but needs to stay, as determined by psychiatrist: • Convert [back to] involuntary status; • File a petition to the Court for continued involuntary confinement (BA32) prior to the expiration of the 72 hour maximum hold time; • Designate an appropriate health care proxy, using Florida Statute defined hierarchy, prior to baker act court hearing appointing a guardian advocate.

19. Certification of Competency • Determined to be incompetent: • Continues to meet baker act criteria, • Continue involuntary status; • Designate an appropriate health care proxy, using Florida Statute-defined hierarchy, prior to baker act court hearing appointing a guardian advocate; • File a petition to the Court for continued involuntary confinement (BA32) prior to the expiration of the 72-hour maximum hold time; • Electronically submit the BA32 petition to the Clerk of the Court.

20. Petition for Continued Involuntary Confinement (BA32)

21. Petition for Continued Involuntary Confinement • What are the requirements for a BA32: • Continues to meet the BA criteria for involuntary confinement; • After explanation of transition to voluntary status patient refuses; • 1st and 2nd opinions supporting recommendations of 2 psychiatrists or psychiatrist and clinical psychologist, • Based on face-to-face examination within the preceding 72 hours. • Petition completed and electronically filed prior to the expiration of the 72-hour maximum for involuntary confinement. • Public defender court-appointed to represent the patient (if not represented by private counsel).

23. Petition for Continued Involuntary Confinement • BA32 Court Proceedings: • Hearing held in facility unless continuance requested/granted; • 1 of the 2 psychiatrists/clinical psychologist who completed 1st or 2nd opinion must be a witness; • Patient may refuse to testify at the hearing; • If incompetent to consent, guardian advocate appointed. • Court Decisions: • Meets all involuntary inpatient placement criteria, • Appoints a guardian advocate whose duties terminate upon discharge, transfer to voluntary status, restoration of competency, or expiration of involuntary placement order; • Orders treatment at an appropriate receiving facility for a period of up to 6 months (BA8 status); • Orders transfer to a treatment facility (state hospital) (BA8 status); • Dismisses the petition based on technical filing error. • What Does it Mean: • If petition dismissed by court, patient must be discharged that day. • When no longer meets involuntary inpatient placement criteria, patient must be safely discharged.

24. Writ of Habeas Corpus • Each person (any age or legal status) admitted to a receiving facility must have written notice of the right to petition for Writ to the Court. • What can be challenged? • Cause and legality of detention • Unjustly denied a right or privilege • Abuse of procedure authorized in law • When? • Petition filed any time/without notice; • Facility files petition with the Clerk of the Court on next working day. • By Whom? • Individual (competent or incompetent) Relative Friend Guardian • Guardian Advocate Attorney DCF Representative

25. Restrictions to Consent by Legal Guardian • May not consent to: • Voluntarily confinement (adult), • Must be involuntary status if court-appointed guardian or healthcare surrogate/proxy • Continued involuntary confinement/placement, • Court-ordered with petition for continued involuntary confinement (BA32) • Electroconvulsive Treatment (ECT) • Petition submitted for Court approval with consent of legal guardian

27. Continued Involuntary Placement (BA8)

28. Continued Involuntary Placement (BA8) • BA8 Court Decisions: • Orders treatment at an appropriate receiving facility for a period of up to 6 months • Remains in the designated receiving facility for the defined period of time as long as continues to meet involuntary inpatient placement criteria. • Orders transfer to a treatment facility (state hospital) • Completes and submits appropriate paperwork for treatment facility placement to state hospital; • Assigned state hospital wait list designation; • Remains in designated receiving facility pending transfer to the state hospital as long as continues to meet involuntary inpatient placement criteria. • When no longer meets involuntary inpatient placement criteria: • Must be safely discharged; or • If under a criminal charge (warrant), with notice provided by law enforcement, transferred to the custody of law enforcement.

29. Quick References

33. Baker Act Reference Manual

34. Marchman Act The Florida Substance Abuse Impairment Act

35. Voluntary/Involuntary Admission Criteria • Informed Consent required for voluntary admission. • Disability of minority (under 18) removed solely for purpose of voluntary admission. • Good faith reason person is substance abuse impaired and because of the impairment: • Has lost power of self-control over substance use; and either… • Has inflicted, or threatened or attempted to inflict, or unless admitted is likely to inflict, physical harm on self or others, or • Is in need of substance abuse services and, by reason of substance abuse impairment, his/her judgment has been so impaired the person is incapable of appreciating the need for services and of making a rational decision in regard thereto. (Mere refusal to receive services not evidence of lack of judgment)

36. Marchman Act Protective Custody Protective Custody is used by law enforcement officers when a person is intoxicated/impaired in public or brought to the attention of the officer. Why and How is it used? • To take a person to a safe environment where the person can be assessed to determine the need for treatment. • The officer may take the person home, to a hospital, a detoxification center, or addictions receiving facility (ARF), or in certain circumstances, to a jail, whichever the law enforcement officer believes is most appropriate. Minors cannot be taken to jail. • A person can be held for assessment for up to 72 hours prior to release, unless converting to voluntary status or a petition for involuntary treatment filed with the court when in a designated addictions receiving facility.

37. Emergency Admissions under Marchman Act • What is necessary? • Meets involuntary admission criteria for emergency assessment and stabilization; • Admitted to either a hospital, an ARF or a detoxification facility; • Must be accompanied by a physician’scertificate and completed application. • Who can initiate? • For a minor: parent, legal guardian, legal custodian or licensed service provider • For adults: Certifying physician, spouse, guardian, any relative, a private practitioner, licensed service provider, or any three responsible adult who has personal knowledge of the person’s substance abuse impairment

38. Application for Involuntary Emergency Admission For Substance Abuse I, ____________________________ have personally observed the behavior of ________________________ (applicant) (person whose care is sought) And believe he/she meets the criteria for emergency admission for substance abuse assessment and stabilization under chapter 397.6791 F.S. (Marchman Act). INVOLUNTARY EMERGENCY ADMISSION CRITERIA: I believe the person is substance abuse impaired because: ________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ AND I believe that because of such impairment, the person has lost the power of self control with respect to substance abuse for these reasons: __________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________: AND EITHER I believe that the person has inflicted or is likely to inflict physical harm on himself/herself or others unless admitted because: _______________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________: OR, I believe that the persons refusal to voluntarily receive care is based on judgment so impaired by reason of substance abuse that the person is incapable of appreciating his/her need for care and of making a rational decision regarding his/her need for care because: ______________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________: Involuntary Emergency Admission Request: I request that the above named person be admitted for involuntary emergency admission due to substance abuse and a Physician’s Certificate is attached. The information given in this application is true and correct. Signature of Applicant: _________________________________Date: _______________Time ___________ Witness Signature:____________________________________ Date _______________ Time ___________ A signed copy of the Physician’s Certificate must accompany the person and shall be made a part of the person’s clinical record, together with a signed copy of the application. See back of form for Law Enforcement assistance

39. Application for Involuntary Emergency Admission for Substance Abuse (continued) TRANSPORTATION ASSISTANCE The applicant, the person’s spouse or guardian ( ) are able or ( ) are not able to provide transportation to deliver the person for emergency admission. The person may be found at: __________________________ ________________________________. The following information is provided if needed to find the person so they may be taken into custody for involuntary emergency admission: County of Residence:______________________ Street Address:___________________________________ Age:____________ Race:______________ Sex: ___________ SS# ________________________________ Height: _________ Weight _____________ Hair Color_______ Eye Color: __________ Does person have access to any weapons? yes no If yes, describe:___________________________________ Is the person violent now? yes no If yes, describe _____________________________________________ Does the person have any pending criminal charges against him/her? yes no If yes, describe_______ Does the person have a legal guardian? yes no If yes, who ___________________________________

40. Physician Certificate for Emergency Admission • I certify that I have personally examined ________________________________ • on _______________________ at ___________am/pm. Based on my examination, I conclude that the above • (date) (time) • named person is substance abuse impaired and is appropriate for emergency admission for substance • abuse. This examination was performed within 5 days of the date of the application for admission. • My relationship to the person is:__________________________________________________________ • My relationship to the applicant is:_________________________________________________________ • My relationship to the licensed service provider is:_____________________________________________ • The person named above meets the following criteria for emergency admission: • 1. The person named above is substance abuse impaired because:____________________________________ • __________________________________________________________________________________________ • AND • 2. Because of such impairment, the person has lost the power of self-control with respect to substance • abuse for these reasons: • ___________________________________________________________________________________________ • ___________________________________________________________________________________________ • AND EITHER • 3. The person has inflicted or is likely to inflict physical harm on himself or others unless admitted because: • __________________________________________________________________________________________ • OR • 4. The person’s refusal to voluntarily receive care is based on judgment so impaired by reason of substance abuse • that the person is incapable to appreciating his/her need for care or of making a rational decision regarding his/her • need for care because: _________________________________________________________________________ • Recommended Level of Care: • Hospital Detoxification Center Addiction Receiving Facility Less Restrictive (assessment only) • Signature of Physician:____________________________ Date:_______________ Time __________an/pm • Printed Name of Physician:_______________________ Phone #_____________License #______________ • A signed copy of the Physician’s Certificate must accompany the person and shall be made a part of the • person’s clinical record, together with a signed copy of the application. See back of form for Law • Enforcement assistance. • See 397.769, FS MARCHMAN ACT

41. Physician Certificate for Emergency Admission A law enforcement officer is requested to provide transportation assistance for the said person for emergency substance abuse admission to the following facility: ______________________ Located at __________________________________________________________________. The person’s present location is at: _______________________________________________ If the person’s present location is unknown, the following information is provided to assist law enforcement in finding the person so they may be taken into custody for involuntary emergency substance abuse admission: County of Residence:______________________ Street Address:_______________________ Age:____________ Race:______________ Sex: ___________ SS# _____________________ Height: _________ Weight _____________ Hair Color_______ Eye Color: __________ Does person have access to any weapons? yes no If yes, describe: _____________________ Is the person violent now? yes no If yes, describe ___________________________________ Does the person have any pending criminal charges against him/her? yes no If yes, describe_____________________ Does the person have a legal guardian? yes no If yes, who __________________________

42. FLORIDA MARCHMAN ACT….in the Emergency Department • Patient Jones is transported to the ED by law enforcement under an Marchman Ex Parte Order. An emergency medical examination is performed. Patient Jones is intoxicated with a BAL .537, incoherent and incapacitated unable to participate in his treatment at this time. Patient Jones remains in the ED for some time receiving treatment to stabilize his condition and decrease is BAL. He is re-evaluated and determined to be capacitated and clinically stable. Patient Jones is now safe for discharge. The ED is not a designated Marchman receiving facility. • What are the Emergency Department responsibilities under the Ex Parte Order?

43. FLORIDA MARCHMAN ACTEmergency Department Responsibilities YES NO Secure a discharge plan while the patient remains incapacitated and intoxicated. Once the patient has been medically cleared and determined to be safe for discharge, physically and/or mechanically restrain the patient to prevent them from leaving the facility. If the patient attempts to leave the facility pending discharge, the facility staff and/or security team can pursue and detain the patient against their will. If medically cleared and ready for discharge, notify law enforcement that the patient has eloped from the facility and must be returned. • Ensure the patient is competent and SAFE FOR DISCHARGE. • Ask patient if they are willing to voluntarily enter a Marchman receiving facility for treatment. • Attempt to secure acceptance for admission at a designated Marchman receiving facility. • If unable to obtain acceptance for inpatient admission, obtain an outpatient screening appointment at a designated Marchman receiving facility and provide information to patient with discharge instructions. • Discharge the patient. • Notify the County Clerk of the Court issuing the Ex Parte Order within 72 hours of the patient discharge.

44. Baker Act patients in the main ED • Patient’s that have capacity have the right to refuse psychotropic medications. • If based upon your assessment the patient is not capable of exercising voluntary control over his or her own symptomatic behavior and the behavior is an imminent threat to the patient or others and ETO supersedes the patient’s right to refuse. • When an ETO is administered to a minor we must document attempts to contact the legal decision maker as soon as possible. • ETO=immediate administration of a rapid response psychotropic medication.

45. Emergency Treatment Orders for the Administration of Psychotropic medications • The issuance of an ETO requites a physician’s review of the patients condition for causal medical factors. • An emergency treatment order may only be issued by a physician. • The need for an ETO must be documented in the patient’s medical record as an addendum to your physician note and as an order and must describe the specific behavior which constitutes a danger to the patient or others. To include the nature and extent the danger posed.

46. Nursing Documentation • Nurses must document a separate narrative if they request physician intervention for an ETO. • Document attempts to contact legal decision maker to inform of ETO given. Utilize case management if necessary to assist with identifying legal decision maker • Consider increasing observation level of patient • Within one hour of administration document the effectiveness of the medication.

47. Questions?