Cenpatico Crisis Protocols for Pinal County
Table of Contents
Overview & Purpose
Definitions
Crisis During Business Hours
Crisis Services
The NurseWise crisis line (NW)
Crisis Mobile Teams
What is considered a crisis?
Crisis Mobile Team Response in the Community
Services available
Services available to private psychiatrists (in office)/persons at a local psychiatrist’s office
Crisis Mobile Team Response on the Reservations
Crisis Mobile Team Services at an inpatient psychiatric facility
Crisis Mobile Team Services at the Arizona Regional Medical Center ER (ARMC)
Involuntary Persons in Need of Mental Health Treatment
A person in a Pinal County ER
Steps to Petition
A person in the community
A person at an outpatient clinic during office hours
When law enforcement is involved
A person who is detained At the Pinal County Jail
Non-Emergency Requests for Involuntary Evaluation (PAD or GD)
Voluntary Crisis Services for detained persons
At the Pinal County Jail
At a Juvenile Detention Center
At the Ak-Chin Detention Center
Revocation of the outpatient treatment portion of an Existing COT
During Regular Business Hours
After Hours
Emergent Revocations
Non-Emergent Revocations
Direct Admission to a Level One (Acute or Sub-Acute) Psychiatric Inpatient Facility
By outpatient providers (voluntary only)
By crisis mobile teams (voluntary only)
By another hospital (ED or medical floors)
Coordination of Care at in-county Hospitals
Coordination with the ER on Enrolled Persons
Coordination with the ER on NON-enrolled persons
Coordination with in-county Hospitals for medically admitted patients enrolled with an outpatient service provider
Coordination of care with County Border Hospitals
Coordination with the ER on Enrolled Persons (in an active episode of care)
Coordination with the ER on NON-enrolled persons or enrolled persons NOT in an active episode of care
Coordination with a County Border Hospital for medically admitted patients enrolled with an outpatient service provider
Meeting Attendance
The Pinal County Mental Health Crisis Systems Meeting
Regular Crisis Team Meetings
Problem Resolution Process
Drug and/or Alcohol Use - Services Available for Substance Use
Community Bridges (CBI)
Mountain Health & Wellness Mountainside Psychiatric Acute Care (PAC)
Signature Pages
Cenpatico Crisis Protocols for Pinal County
Ak-Chin Police Department
Apache Junction Police Department
Arizona Counseling and Treatment Services (ACTS)
Arizona’s Children Association (AZCA)
Banner Goldfield Medical Center
Casa Grande Police Department
Casa Grande Regional Medical Center (CGRMC)
Cenpatico
Community Bridges
Coolidge Police Department
Corazon Behavioral Health
Eloy Police Department
EMPACT
Florence Police Department
Florence Anthem ER
Gila River Indian Community Police
Hayden-Winkelman Police Department
Helping Associates
Horizon Health and Wellness
Kearny Police Department
Mammoth Police Department
Maricopa Police Department
NurseWise (NW)
Pinal County Attorney’s Office
Pinal County Adult Probation
Pinal County Juvenile Detention
Pinal County Public Fiduciary
Pinal County Sheriff’s Office (PCSO)
Pinal Hispanic Council
Southwest Behavioral Health
Superior Police Department
Tohono O’Odham Nation Police Department
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Cenpatico Crisis Protocols for Pinal County
Overview & Purpose
The Protocols are guidelines that describe how we will all work together to ensure that behavioral health services are delivered in Pinal County. The purpose is to enhance the network and response capability to address mental health crisis in Pinal County through ongoing communication and collaborative agreements between community stakeholders and mental 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 Pinal County Community Stakeholders agree to coordinate activities to facilitate the implementation of crisis services in Pinal 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 Pinal 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.
These guidelines will be active from date of signature until modified by the involved parties. These guidelines do not create or delegate obligations or financial responsibilities. These guidelines are 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 members. 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, support individuals in their recovery, 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-means “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.”
Application for Emergency Admission (Form MH-104)-Paperwork completed to initiate a request for evaluation of a person who, based on reasonable cause, is in such a condition that without immediate hospitalization he or she is in eminent danger and likely to harm himself/herself or others
Application for Evaluation (Form MH 100)-Paperwork completed to initiate a request for an evaluation of a person who is alleged to be Persistently or Acutely Disabled (PAD) and/or Gravely Disabled (GD) and may also be alleged to be Danger to Self (DTS) and/or Danger to Others (DTO). This form is required for both emergent and non-emergent requests for evaluation.
Behavioral Health 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 these protocols, a Behavioral Health Inpatient Facility does not include residential treatment.
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 room, 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 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 which, as a result of a mental disorder, will, without hospitalization, results 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.
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.
Intake and Coordination of Care Agency (ICCA)-(Also referred to as Outpatient Treatment Agencies or Provider Agencies). ICC Agencies are contracted provider type requiring full execution of Intake Provider functions and requirements. ICC Agencies 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.
ICC Agencies are further divided into High Needs Care 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.
ICC Agencies in Pinal County include Arizona’s Children Association (AZCA), Corazon, Community Bridges, EMPACT, Helping Associates, Horizon Health and Wellness, Pinal Hispanic Council (PHC,) and Southwest Behavioral Health Services.
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.
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-A mental health petition is the paperwork that must be completed and filed with the court in order to place a person under court ordered evaluation. The prescribed forms can be found on Cenpatico’s website.
Revocation of the outpatient treatment portion of a court order-The process outlined in ARS 36-540-E numbers 4 & 5 in which the medical director of the mental health treatment agency can request the court 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.
Specialty Provider- a provider type that delivers specialized programs and treatment services in treatment facilities, the community, member homes or specified offices to meet the unique needs of special populations. Required service hours, locations, populations served and special treatment programs are outlined in their contract with Cenpatico.
Title 36-Arizona’s state law for mental health commitments. The law is located in the Arizona Revised Statutes, Title 36 (Public Health and Safety) Chapter Five (Mental Health Services).
Title 36 pre-petition screening-The review of an application (MH 100 or MH 104) 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 Pinal County pre-petition screenings are conducted by the Horizon Health and Wellness. This is to be done only when the Application for Emergency Admission (MH 104) is not completed.
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-is a self-management and recovery system developed by a group of people who had mental 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 as well as 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 members 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 coordinating with a Generalist agency 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 member 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 or a doc to doc can help rule out medical concerns.
Outpatient providers will ensure there is sufficient staff coverage including protocols outlining the chain of command when a member 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 members can be seen at the agency when an emergency arises.
Crisis Services
The NurseWise crisis line (NW)
The NurseWise crisis line is available 24 hours a day, 7 days per week by calling 866-495-6735. If a crisis mobile team (CMT) is needed the request must be made to NurseWise who will triage and dispatch CMTs. NW will check enrollment status for every call.
Crisis Mobile Teams
There are twoCMT providers in Pinal County: Horizon Health and Wellness (HHW) and Arizona Counseling and Treatment Services (ACTS).All teams cover the County but in general, HHS will be the primary responder to Casa Grande,Arizona City, Stanfield, Toltec, Red Rock, Sacaton, Sif-Oidak, Eloy,and the Tohono O’odham Nation and Ak Chin reservations. MHW in AJ is the primary responder to Apache Junction, Duddlyville, Gold Canyon, Florence, Florence Village, Queen Creek, Superior, andCoolidge. MHW-Oracle is the primary responder to Hayden-Winkelman, Oracle, Kearny, Mammoth, San Manuel, Oro Valley, Sierra Tucson Hospital, Saddlebrooke, and a small portion of the San Carlos Apache Reservation that is in Pinal County. ACTS is the primary responder to the city of Maricopa. CMT assessment and intervention services in the community are available to any person in the county regardless of insurance or enrollment status. Private insurance plans should be accessed first for persons in an Emergency Department with private insurance.