Crisis Services Redesign Implementation Overview for LMHA’s Presenter: Mike Maples, Director MHSA

1. Crisis Services RedesignImplementation Overview for LMHA’sPresenter: Mike Maples, Director MHSA

2. Overview In December 2005, then Commissioner of Texas Department of State Health Services (DSHS), Eduardo Sanchez established the Crisis Services Redesign Committee to develop recommendations for mental health and substance abuses crisis services that are delivered throughout the local mental health authorities in the State of Texas.

3. Purpose of Redesign The charge to the Crisis Redesign Committee and the purpose of redesign was to develop recommendations for a comprehensive array of specific services that will best meet the needs of Texans who are having a mental health and/or substance abuse crisis.

4. Goals of Crisis Redesign A consistent state of the art system of crisis services across Texas with improved: • Accessibility • Standards of care • Community involvement • Consumer choice • Less restrictive treatment environments • Lessening burden on hospitals, jails & law enforcement

5. Crisis Services Redesign Committee This committee was formed with representation from: The recommendations from this group are guiding the course for Crisis Redesign now in it’s Implementation Phase.

6. Crisis Services Funding • REQUESTED: DSHS requested $82 million from the 80th Legislature to make significant progress toward improving the response to behavioral health crises. • AWARDED: Through the Legislature and Rider 69, the full $82 million was granted over fiscal years 2008/ 2009 to redesign and improve the mental health crisis system across Texas.

7. Crisis Services Funding, cont. • $27.3 million will be allocated in FY 08 • $54.7 million will be allocated in FY 09 • Additional funds will be requested from the 81st Legislature • It is required that new crisis redesign general revenue funds will be used to improve crisis services provided and not replace the current crisis services.

8. Allocation of Funds • Consistent with the proposed use of funds described in the Legislative Appropriation Request (LAR), the new crisis funds will be divided into five portions: • EQUITY • PROPORTIONAL • COMMUNITY INVESTMENT INCENTIVE • COMPETENCY RESTORATION ALLOCATION • STATE EXPENDITURES

9. Equity • To address inequities that have developed over time among funding for LMHA’s • Allocates 32% (approximately $27million) to bring under-funded LMHAs up to the current state average of per capita funding

10. Proportional • Allocates 36% (almost $30 million) to be divided proportionally. However under this simple per capita distribution, many Centers would not receive sufficient dollars to allow full implementation of initial services. Thus DSHS will first assure that all Centers receive enough funding to for Crisis Hotline and Mobile Crisis Outreach Teams (MCOTs) and then will divide the remaining funds on a per capita basis.

11. Community Incentive • Additionally, there will be community investment incentive funds which will allow LMHAs (including NorthStar) or groups of LMHAs who provide 25% local match to compete for extra dollars to create the following: • Psychiatric Emergency Service Centers (PESCs) • Projects for jail diversion or alternatives to State hospitalization

12. Competency Restoration Funds • $3 Million over the FY08-09 biennium will be available to LMHAs including NorthStar • LMHAs and NorthStar may apply for these additional funds to provide outpatient competency restoration services to individuals who are incompetent to stand trial but are eligible to receive mental health outpatienttreatment

13. State Expenditures • 1.5% or about 1.2 million will be used by DSHS to support the crisis redesign initiative over the biennium including: • Hotline training by AAS (American Association of Suicidology) • Four DSHS staff positions • An independent evaluation of the project at a later date

14. Crisis Services StandardsPresenter: Jennifer Edwards, DSHSCommunity MHSA Program Services Section

15. Crisis Services Standards • DSHS has promulgated Standards for all services in the crisis service array. Standards address: • Description of service • What acuity is served in each service • Plant/facility requirements • Staff credentials and training requirements • Assessment parameters • Services provided and time frames for delivery • Continuity of care

16. Initial Crisis Services: Hotline • Every LMHA will be required to provide a continuously available telephone hotline staffed by trained hotline workers who provide information, screening and assessment, intervention and support to callers 24 hours per day, 7 days per week. What’s new about hotline? • Hotlines must be accredited by the American Association of Suicidology (AAS) • Thorough training and adherence to standards will ensure consistency

17. Crisis Hotline Training • The American Association of Suicidology (AAS) was selected by DSHS as the accrediting body for hotlines across the state. Their curriculum involves extensive training and demonstration of competency. • Two key training objectives: • Immediate access to quality hotline training • Development of a sustainable training infrastructure

18. Crisis Hotline Training, cont. • DSHS will host four regional AAS hotline training events in FY 08: • Dallas • Houston • Austin • Corpus Christi • Two tracks will be provided—three days for hotline workers and two additional days for Train-the-Trainer

19. Crisis Hotline Training, cont. • Trainers completing the Train-the-Trainer course may train other hotline workers for the future • Additional DSHS staff will become certified trainers and will be available to provide future training

20. Initial Crisis Services:Mobile Crisis Outreach Teams Mobile Crisis Outreach Teams provide a combination of crisis services including emergency care, urgent care, and crisis follow-up and relapse prevention to the child, adolescent, or adult in the community.

21. Mobile Crisis Outreach What’s new about Mobile Outreach? • Greater accessibility to Mobile Crisis Outreach Teams (MCOTs) • Specific MCOT Standards regarding delivery of services and training & experience required of MCOT Staff

22. Mobile Crisis Outreach Teams • Staffing Patterns: Availability 24/7 in all communities • Urban LMHAs:Minimum of one MCOT on duty during LMHA-designated “peak hours” totaling 84 hours per week • One additional Urban MCOT on call 24/7 • Rural LMHAs:One MCOT on duty during LMHA-designated “peak hours” totaling 56 hours per week • MCOT capability is maintained throughout the Local Service Area (LSA) 24/7

23. Mobile Crisis Outreach Teams • Not every county in the LSA needs an MCOT; however the ability to meet face-to-face within one hour remains a Community Standard • Team Composition: A MCOT, at a minimum, is comprised of 2 QMHP-CSs or where appropriate, 1 QMHP-CS and law enforcement • Urban LMHAs: QMHP-CS is deployed with an RN, LPHA, or physician, preferably a psychiatrist, on every emergent care call

24. Mobile Crisis Outreach Teams • Rural LMHAs: It is recommended that a QMHP-CS is deployed with an RN, LPHA, or physician, preferably a psychiatrist. If not deployed as part of the MCOT, a physician, LPHA, or RN must be available to provide face-to-face assessment as needed or clinically indicated. • Location: MCOT services are designed to reach individuals in their place of residence, school, and/or other community-based safe locations • Services Provided:Crisis assessment, crisis intervention services, and crisis follow-up and relapse prevention

25. Roll-out of Crisis Redesign Initial Services to be Implemented: • Hotline • Mobile Crisis Outreach Team These are the initial services expected for implementation and adherence to standards. Any remaining funds post-implementation of hotline and MCOT will be available to LMHAs to spend on “Enhanced Services”

26. Enhanced Services • Crisis Outpatient Services • Extended Observation Services (up to 48 hours) • Crisis Stabilization Units (CSUs) • Crisis Residential (Child or Adult) • Crisis Respite (Child or Adult) • Mental Health Deputies/Crisis Intervention Teams • Transportation • Purchase of additional inpatient hospital beds

27. Enhanced Crisis Services Crisis Outpatient Services: Office-based outpatient services for adults, children and adolescents providing immediate screening and assessment and brief, intensive interventions focused on resolving a crisis and preventing admission to a more intensive level of care Staffing Requirements: All crisis services staff are trained physicians, preferably psychiatrists, RNs, LPHAs, QMHP-CSs, or Paraprofessionals (Behavioral Health Technicians)

28. Crisis Outpatient Services • Screening and Assessment Timeframes: • Face to Face triage or screening by QMHP-CS within 15 minutes of presentation • LPHA or RN completes crisis assessment within 1 hour of referral from the screening process • Location: • Crisis Outpatient Services are office-based outpatient services • Community Mental Health Centers (CMHCs) may provide extended hours or time on weekends to deliver walk-in crisis services

29. Crisis Outpatient Services • Continuity of Care: Upon resolution of the crisis, every eligible individual shall be transitioned into Service Packages 1-4 if determined to be medically necessary, or receives Crisis Follow-Up (SP5) throughout a 30-day period until he/she is stabilized and/or transitioned to appropriate behavioral health services.

30. Extended Observation Services • Extended Observation Services: Emergency and crisis stabilization services are provided to individuals in a secure and protected, clinically staffed (including medical and nursing professionals), psychiatrically supervised treatment environment with immediate access to urgent or emergent medical evaluation and treatment. Individuals who cannot be stabilized within 48 hours would be linked to the appropriate level of care (inpatient hospital unit or CSU).

31. Extended Observation Services • Staffing Requirements: Physicians, (preferably psychiatrists) RNs (APNs), LPHAs, QMHPs (PAs), and Paraprofessionals (Behavioral Health Technicians) • Screening and Assessment Timeframes: Triage by RN or Physician within 15 minutes of presentation • Individuals who are not referred for care elsewhere after triage receive a full assessment (psychosocial, psychiatric and as ordered medical) initiated within one hour of the individual’s presentation to the extended observation services

32. Extended Observation Services • Screening and Assessment Timeframes, cont.: Staffing patterns should allow individual reassessment at least every 15 minutes for behavioral health technicians, two hours for nursing, four hours for QMHPs, and 12 hours for physicians, preferably psychiatrists

33. Extended Observation Services • Continued care Staffing: • A physician preferably a psychiatrist on call 24 hours/day to evaluate individuals face to face or via telemedicine as needed; • At least one LPHA on site 24 hours/day, seven days/week; • At least one RN on site 24 hours/day, seven days/week; and • Behavioral health technician(s) on site 24 hours/day, seven days/week

34. Extended Observation Services • Location: Secure location with immediate access to urgent or emergent medical evaluation and treatment • If services are provided for children and adolescents, the physical plant must have separate child, adolescent, and adult observation areas.

35. Extended Observation Services • Coordination of Care: Consists of identifying and linking the individual with all available services necessary to stabilize the crisis and ensure transition to routine care, providing necessary assistance in accessing those services, and conducting follow-up to determine the individual’s status and need for further service. This includes contacting and coordinating with the individual’s existing services providers in a timely manner and in conformance with applicableconfidentiality requirements.

36. Crisis Stabilization Units (CSU) • Short-term residential treatment designed to reduce acute symptoms of mental illness provided in a secure and protected clinically staffed, psychiatrically supervised, treatment environment that complies with a crisis stabilization unit licensed under Chapter 577 of the Texas Health and Safety Code and Title 25, Part 1, Chapter 411, Subchapter M of the Texas Administrative Code.

37. Crisis Residential Child and Adult: • Provide short-term, community-based residential, crisis treatment to persons with some risk of harm who may have fairly severe functional impairment. These facilities provide a safe environment with clinical staff on site at all times however they are not designed to prevent elopement and individuals must have at least a minimal level of engagement to be served in this environment. The recommended length of stay is from 1-14 days.

38. Crisis Residential • Staffing Patterns: There is an on-call roster of clinical (QMHP-CS and above) and nursing (RN and LVN) staff. There is a process for assessing and anticipating staffing needs to ensure clinical or nursing staff are on-site at all times. Behavioral health technicians and nursing staff may used on the overnight shift.

39. Crisis Residential • Screening and AssessmentTimeframes: Prior to admission to the Crisis Residential Unit individuals receive a full psychiatric assessment within 24 hours of the individual’s presentation to the service if not referred directly from an active inpatient unit or psychiatric emergencyservice.

40. Crisis Residential • Screening and AssessmentTimeframes, cont.: Individuals, not currently in services or for whom the health status is unknown, receive a comprehensive nursing assessment by an RN within 1 hour of presentation • If ordered, individuals receive a physical health assessment by an RN, within two hours of entering a crisis residential unit unless already conducted within the last week. This evaluation includes assessment of medical and psychiatric stability, self- administration of medication capability, vital signs, pain, and danger to self or others.

41. Crisis Residential • Treatment Interventions: An array of treatment interventions may exist in the crisis residential setting and may include individual or group psychotherapy or psychoeducation, crisis intervention and crisis psychotherapy, family therapy, advocacy, help with obtaining community supports and housing, help developing social skills and a social support network, substance abuse treatment, and relapse prevention. A minimum of 4 hours per day of such programming should be provided. Individuals who have significant substance abuse comorbidity receive counseling designed to motivate the patient to continue with substance abuse treatment following discharge from the program.

42. Crisis Residential • Location: Crisis residential services units provide a safe environment; however they are not designed to prevent elopement. They are to provide as normalized of an environment as possible, with 16 beds or less. All medications are securely stored.

43. Crisis Residential • Coordination of Care: Coordination of emergency services is provided for every individual. Coordination of emergency services consists of identifying and linking the individual with all available services necessary to stabilize the crisis and ensure transition to routine care, providing necessary assistance in accessing those services, and conducting follow-up to determine the individual’s status and need for further service.

44. Crisis Respite Child and Adult: • Provide short-term, community-based residential, crisis treatment • Individuals in a crisis respite have no risk of harm to self or others and may have some functional impairment and require direct supervision and care but do not require hospitalization • Generally serves individuals with housing challenges or assist caretakers who need short-term housing for the persons for whom they care to avoid a mental health crisis. • Utilization of these services is managed by the LMHA based on medical necessity. • The recommended length of stay is 1-7 days.

45. Crisis Respite Child and Adult: • Staffing Patterns: There is a defined process for on-site staff to obtain supervision, consultation, and evaluation when needed and for medical and psychiatric emergencies 24 hours a day from a physician, preferably a psychiatrist, APN, or PA. • Mental health aide(s)/behavioral health technician(s) are on site 24 hours a day, with numbers, qualifications, and training sufficient to ensure patient and staff safety and the provision of needed services. • Staff members providing in-home crisis respite services to children or adolescents are Qualified Mental Health Professionals competent to provide crisis services to children and adolescents.

46. Crisis Respite Child and Adult: • Screening and Assessment Timeframes:Prior to admission to Crisis Respite Services, individuals receive a full crisis assessment by a physician, preferably a psychiatrist, LPHA, RN or other Qualified Mental Health Professional. • Treatment Interventions:Individual and group skills training are provided at the crisis respite site and are based on the needs of the individual and the goals of their individual crisis plans. • A stable therapeutic environment exists in facility-based crisis respite units that includes assigned personnel and scheduled activities.

47. Crisis Respite Child and Adult: • Location:Contracted assisted living facilities used for crisis respite units are subject to licensing regulations of the Department of Aging and Disability Services (DADS) as Assisted Living Facilities. • These services can occur in houses, apartments, or other community living situations

48. Crisis Respite Child and Adult: • Coordination of Care: Coordination of emergency services is provided for every individual. Coordination of emergency services consists of identifying and linking the individual with all available services necessary to stabilize the crisis and ensure transition to routine care, providing necessary assistance in accessing those services, and conducting follow-up to determine the individual’s status and need for further service.

49. Psychiatric Emergency Service Centers (PESCs) • Available as part of Community Investment Incentive Funding • Provide immediate access to assessment and a continuum of stabilizing treatment for individuals presenting with behavioral crises. • These units are co-located with licensed hospitals or Crisis Stabilization Units (CSUs) and have the ability to manage the most severely ill individuals at all times, including immediate access to emergency medical care. • PESCs must be available to individuals who walk in, and contain a combination of service types including Extended Observation and Inpatient Hospital Services or a CSU.

50. Psychiatric Emergency Service Centers (PESCs) • Staffing Patterns:A physician, preferably a psychiatrist on call 24 hours/day to evaluate individuals face to face or via telemedicine as needed; • At least one LPHA on site 24 hours/day, seven days/week; • At least one RN on site 24 hours/day, seven days/week; and • Behavioral health technician(s) on site 24 hours/day, seven days/week.