Cenpatico Crisis Protocols for Greenlee County

Cenpatico Crisis Protocols for Greenlee County

Table of Contents

Involved Parties

Overview & Purpose

Goals of the Crisis System

Definitions

Crisis During Business Hours

Notes on Medical Clearance

Crisis Services

The NurseWise Crisis Line

Crisis Mobile Teams

Intake Care and Coordination Agencies (ICC Agencies)

What is considered a crisis?

Crisis Mobile Team Response in the Community

Services available

Involuntary Persons in Need of Mental Health Treatment

A Greenlee County Resident at the Mt Graham Emergency Department (ED) OR the Gila Health Resources Urgent Care (UC) facility

Steps to Petition

Special Questions

A person in the community

A person at an outpatient clinic during office hours

When law enforcement is involved

A person who is incarcerated and involuntary for treatment at the Greenlee County Jail

Non-Emergency Requests for Involuntary Evaluation (PAD or GD)

Voluntary Crisis Services for incarcerated persons

At the Greenlee County Jail

At the Eastern Arizona Regional Juvenile Detention Center

Revocation of the outpatient treatment portion of an Existing COT

During Regular Business Hours

Revocation of the outpatient treatment portion of a court order by a medical director

Revocation of the outpatient treatment portion of a court order by a Judge

After Hours

Direct Admission to a Licensed Hospital or Behavioral Health Hospital Facility (Psychiatric Inpatient Facility)

By outpatient providers (voluntary only)

By crisis mobile teams (voluntary only)

By Gila Health Urgent Care (UC)

Coordination of Care in the ER/UC

Coordination with the ER/UC on Enrolled Persons

Coordination with the ER/UC on NON-enrolled persons

Coordination with Hospitals for medically admitted patients enrolled with an outpatient service provider

Meeting Attendance

The Greenlee County Crisis System Meeting

Regular Crisis Team Meetings

Problem Resolution Process

Drug and or Alcohol Use

Services Available for Substance Use

Transfers of Care

Referrals to Community Bridges, Inc.

Mountain Health and Wellness-Mountainside Psychiatric Acute Care (PAC)

Detoxification Admission Criteria

Signature Page

Cenpatico Crisis Protocols for Greenlee County

Involved Parties

1 | Page

Cenpatico Crisis Protocols for Greenlee County

Arizona Counseling and Treatment Services

Cenpatico

Clifton Police Department

Eastern ArizonaRegionalJuvenileDetentionCenter

Gila Health Resources Urgent Care

Greenlee County Adult & Juvenile Probation Department

Greenlee County Attorney’s Office

Greenlee CountyJail

Greenlee County Sheriff’s Office

Mt GrahamRegionalMedicalCenter

NurseWise

SEABHS outpatient

1 | Page

Cenpatico Crisis Protocols for Greenlee County

Overview & Purpose

The Protocols are guidelines that describe how we will all work together to ensure that behavioral health services are delivered in GreenleeCounty. The Purpose is to enhance the network and response capability to address behavioral health crisis in GreenleeCounty through ongoing communication and collaborative agreements between community stakeholders and behavioral health provider agencies developing an environment where there is no wrong door.

Cenpatico Behavioral Health of Arizona, LLC and Cenpatico of Arizona, Inc. dba Cenpatico Integrated Care (herein referred to as Cenpatico) and their contracted providers and identified Greenlee County Community Stakeholders agree to coordinate activities to facilitate the implementation of crisis services in Greenlee County. The elements of the Crisis System (including referral, assessment and service implementation processes) and the roles and responsibilities of each agency are outlined below.

Cenpatico and their contracted providers and identified Greenlee County Community Stakeholders agree to work in partnership on behalf of persons experiencing a behavioral health crisis to ensure they receive the appropriate services and level of care that promote resiliency and protect the community.

This guideline will be active from date of signature until modified by the involved parties. This guideline does not create or delegate financial responsibility. This guideline is not a legal and binding contract or Memorandum of Understanding. These guidelines should never override the obligation to provide the most clinically appropriate intervention based on each individual situation nor should they override law or professional responsibility to clients. Agencies are encouraged to have adequate clinical supervision and guidance to support such actions.

Goals of the Crisis System

To ensure persons receive the appropriate services and level of care; stabilize persons in the community whenever possible and individuals in their recovery; and promote resiliency and protect the community.

Definitions

An active episode of care-means they have been opened with and are receiving services at a contracted RBHA funded agency. The person may have any of the following eligibility and entitlements:

• T19 (AHCCCS or SSI/MAO)
• T 21 (kids)
• SMI only
• Medicare and T19
• Medicare and SMI

Note: Cenpatico will be the health plan for persons designated with a serious mental illness (SMI) enrolled as Title XIX --

Admitting Officer- Per ARS 36-501 an admitting officer is a psychiatrist or other physician or psychiatric and mental health nurse practitioner with experience in performing psychiatric examinations who has been designated as an admitting officer of the evaluation agency by the person in charge of the evaluation agency.

Amendment of the outpatient portion of a court order- The process outlined in ARS 36-540. Section I in which the medical director of the mental health treatment agency can order a person court ordered to outpatient treatment back into inpatient treatment.

Application for Emergency Admission for Evaluation (Form A3)- Paperwork completed to initiate an emergency evaluation of a person who, based on probable cause, is believed to be, a danger to self or others and that during the time necessary to complete the pre-petition screening procedures the person is likely without immediate hospitalization to suffer serious physical harm or serious illness or to inflict serious physical harm on another person.

Application for Involuntary Evaluation (Form A2)- Paperwork completed to initiate a request for an evaluation of a person who is alleged to be Persistently or Acutely Disabled (PAD), or Gravely Disabled (GD), or Danger to Self (DTS) or Danger to Others (DTO), or any combination of these. This process of requesting an involuntary evaluation is for situations that are considered non-emergency requests for an evaluation.

Authorization for Apprehension and Transport (Form A91) - Pursuant to A.R.S. §§ 36-524(E) and 36-525 which allows a peace officer to transport a person to a screening or evaluation agency.

Business Hours- Monday through Friday from 8am to 5pm.

Crisis - An acute, unanticipated, or potentially dangerous behavioral health condition, episode or behavior.

Crisis Intervention Services (Mobile, Community Based) - Crisis intervention services provided by a mobile team or individual who travels to the place where the person is experiencing the crisis (e.g., person’s place of residence, emergency department, jail, community setting) to:

• Stabilize acute psychiatric or behavioral symptoms;
• Evaluate treatment needs; and
• Develop plans to meet the needs of the persons served.

Depending on the situation, the person may be transported to a more appropriate facility for further care (e.g., a crisis services center).

Crisis Intervention Services (Telephone)- Crisis intervention (telephone) services provided by qualified service providers within the scope of their practice to triage, refer and provide telephone-based support to persons in crisis. This is often the first place of access to the behavioral health system. This service may also include a follow-up call to ensure the person is stabilized.

Danger to Others (DTO)- The judgment of a person who has a mental disorder is so impaired that he is unable to understand his need for treatment and as a result of his mental disorder his continued behavior can reasonably be expected, on the basis of competent medical opinion, to result in serious physical harm to others.

Danger to Self (DTS) - (a) Behavior which, as a result of a mental disorder, constitutes a danger of inflicting serious physical harm upon oneself, including attempted suicide or the serious threat thereof, if the threat is such that, when considered in the light of its context and in light of the individual's previous acts, it is substantially supportive of an expectation that the threat will be carried out.

(b) Behavior that, as a result of a mental disorder, will, without hospitalization, result in serious physical harm or serious illness to the person, except that this definition shall not include behavior that establishes only the condition of gravely disabled.

Evaluation Agency- Per ARS 36-501 (13) “a health care agency that is licensed by the department and that has been approved pursuant to this title, providing those services required of such agency by this chapter.” There are several evaluation agencies located in Tucson including Palo Verde, Sonora and Banner – University Medical Center South Campus. There are also 2 sub-acute facilities that are evaluation agencies located in Apache Junction and Yuma (Mountain Health and Wellness). Canyon Vista Medical Center is also an evaluation agency in Cochise County.

Gravely Disabled (GD)- A condition evidenced by behavior in which a person, as a result of a mental disorder, is likely to come to serious physical harm or serious illness because he/she is unable to provide for his/her basic physical needs.

Guardian- A guardian is a person who has the legal authority to make personal decisions for the ward relating to living arrangements, education, social activities, and authorization or withholding of medical or other professional care, treatment, or advice. The guardian must always make decisions that are in the best interests of the ward. The guardian must always make sure that the ward is living in the least restrictive environment in which the ward can remain safe. Under §14-5312.01 (a) a guardian is able to consent to medical treatment outside a Licensed Hospital or Behavioral Health Hospital Facility. A mental health guardian is given under §14-5312.01 (b) for placement in Licensed Hospital or Behavioral Health Hospital Facility. It is based on evidence produced from a licensed mental health expert that the ward is in need of such hospitalization due to a mental disorder as listed in §36-501. It is renewed every year with an affidavit from a mental health expert stating that it is likely that the ward will need to be placed in a Licensed Hospital or Behavioral Health Hospital Facility.

Intake and Care Coordination Agency (ICCAgency) - (Also referred to as Outpatient Treatment Agencies or Provider Agencies). ICCAgencies are contracted provider type requiring full execution of Intake Provider functions and requirements. ICCAgencies must accept all requests for services for eligible populations and are required to manage members’ care by performing the following roles: intake, assessment, service planning, clinical oversight of all services, service tracking and data reporting, enrollment and demographic submissions, education, engagement activities, psychiatric services and ensure adequate treatment service availability to all enrolled members.

• ICCAgencies are further divided into High Needs Recovery (HNRC) and Low to Moderate Needs Recovery Centers (LMNRC). ICC Agencies are required to screen members and refer them to either an HNRC or an LMRC. ICCAgencies in Greenlee County include ACTS & SEABHS.

Licensed Hospital (Formerly referred to as Level I Inpatient Facility)-- A facility licensed per 9 A.A.C. 20 and includes a psychiatric acute hospital (including a psychiatric unit in a general hospital), a residential treatment center for persons under the age of 21, or a sub-acute facility. For the purposes of this protocol, a Level one facility does not include residential treatment.

Natural supports-Refers collectively to support commonly identified as:

1. "Informal Support " (support provided by those individuals who know or are related to the individual/family, but do not provide a paid service, such as a grandparent or neighbor who is connected to the individual/family) and
2. "Community Support" (those supports that are part of the individuals/family's community, such as faith community, neighborhood or community organizations).

Persistently and Acutely Disabled (PAD)-A severe mental disorder that meets all the following criteria:

(a) If not treated has a substantial probability of causing the person to suffer or continue to suffer severe and abnormal mental, emotional or physical harm that significantly impairs judgment, reason, behavior or capacity to recognize reality.

(b) Substantially impairs the person's capacity to make an informed decision regarding treatment and this impairment causes the person to be incapable of understanding and expressing an understanding of the advantages and disadvantages of accepting treatment and understanding and expressing an understanding of the alternatives to the particular treatment offered after the advantages, disadvantages and alternatives are explained to that person.

Petition for Court-Ordered Evaluation [Pursuant to A.R.S. § 36-523] (Form A6)- The prescribed form used to request a petition for court-ordered evaluation.

Revocation of the Outpatient Portion of a Court Order- The process outlined in ARS 36-540. Section I in which the medical director of the mental health treatment agency can order a person court ordered to outpatient treatment back into inpatient treatment.

Serious Mental Illness (SMI) - A condition of persons who are eighteen years of age or older and who, as a result of amental disorder as defined in A.R.S. 36-501, exhibit emotional or behavioral functioningwhich is so impaired as to interfere substantially with their capacity to remain in thecommunity without supportive treatment or services of a long -term or indefinite duration.In these persons mental disability is severe and persistent, resulting in a long-termlimitation of their functional capacities for primary activities of daily living such asinterpersonal relationships, homemaking, self-care, employment and recreation. Persons who are deemed SMI are eligible for RBHA covered services.

Behavioral Health Inpatient Facility (Formerly referred to as Level I Inpatient, Level 1 Sub Acute, or RTC)--A facility licensed per 9 A.A.C. 20 and includes a psychiatric acute hospital (including a psychiatric unit in a general hospital), a residential treatment center for persons under the age of 21, or a sub-acute facility.

Title 36 Pre-petition Screening- The review of the paperwork requesting court-ordered evaluation, including an investigation of facts alleged in such application, an interview with each applicant, and an interview, if possible, with the proposed patient. The purpose of the interview with the proposed patient is to assess the problem, explain the application and, when indicated, attempt to persuade the proposed patient to receive, on a voluntary basis, evaluation or other services. In Greenlee County pre-petition screenings are conducted by the Arizona Counseling and Treatment Services (ACTS).

Warm Line Transfer – a live transfer where the call is introduced to and accepted by the recipient before the call is transferred.

WRAP Plan-Wellness Recovery Action Plan- WRAP is a self-management and recovery system developed by a group of people who had behavioral health difficulties and who were struggling to incorporate wellness tools and strategies into their lives. WRAP plans are developed by the consumer. The plan helps people to monitor uncomfortable and distressing symptoms and identify ways to help reduce, modify or eliminate those symptoms by following plan strategies. The plan includes an outline of who can help and how they can help as well preferred management strategies and treatments.

Wrap Services- Also referred to as ‘wrap around services;’ these are supportive services provided to a person at home or in the community designed to provide additional support to a person in crisis or to prevent a crisis. Planned services are available 24/7/365. Wrap services include an array of professional, community, and natural (i.e., family, friends) supports and are individualized based on the needs of the person and the family.

Crisis During Business Hours

During regular business hours outpatient service providers will provide crisis intervention to enrolled participants who are in a crisis and in the presence of their treatment provider. Crisis intervention services include assessment, de-escalation techniques and crisis counseling as well as crisis and follow up planning by a case manager, clinical liaison, behavioral health professional, or prescriber. In some situations crisis intervention may include need for an evaluation for a medication change by a prescriber followed by close monitoring by the clinical team.

Other times, the intervention may involve providing wrap around services to the person in the community such as accessing the person’s support system, activating the person’s WRAP plan and or advance directive, seeking respite services, or arranging generalist agency services to provide the necessary wraps.

If there are no other safe alternatives, placement in a psychiatric facility may be needed on an emergency basis. In these situations, the prescriber can do a direct admission to a receiving psychiatric facility. If hospitalization is needed, the prescriber must have knowledge of and be able to attest to the need for an inpatient admission. Case managers and other direct service staff will conduct bed searches and make arrangements for admission. The prescriber will be required to complete a doc to doc phone call to the admitting agency. In these situations, there is no need to send the participants out for medical clearance unless the receiving facility (or sending prescriber) has a symptom generated concern that must be evaluated medically. If medical clearance is requested the outpatient team must find out the reason for the request and document this in the clinical record. In some cases, unnecessary medical clearance may be avoided if recent health assessment documentation can be provided to the receiving facility. A doc-to-doc can also help rule out medical concerns.It should be noted that if the admitting physician of a receiving hospital has requested medical clearance, medical clearance must be obtained prior to admission. Outpatient providers will ensure there is sufficient staff coverage including protocols outlining the chain of command when a participant is in crisis and in need of immediate intervention. In addition, contractual agreements between Cenpatico and intake providers require all contracted agencies have urgent and emergency appointments available to ensure that enrolled participants can be seen at the agency when an emergency arises.

Please refer to the “Process Guide: Facilitating Level One Placements“ for more details on this process.

Notes on Medical Clearance

It should not be assumed that medical clearance is needed for every admission. There may be exceptions and alternatives to taking a person to the Emergency Department. For example, Medical Clearance may not be required for an admission to the Mountain Health and Wellness Behavioral Health Hospital Facility (the SAF in Yuma or the PAC in AJ) or by Community Bridges Detox or Substance Abuse Transitional Facility. The only exceptions would be upon request by the admitting physician due to a symptom generated concern that must be evaluated medically. Some Licensed Hospitals will also accept an admission without medical clearance (Cenpatico keeps an updated list of these facilities). If medical clearance is required, it may be possible to obtain labs and a clearance without using the ED and this option should be explored.