ACCESS MHMR
CRISIS SERVICES PLAN
Submitted: October
31, 2007
Revised 12-31-2007
Revised 3-1-2010
Table of Contents
OVERVIEW
.3
CRISIS SERVICES PLANNING INITIATIVES
4
CURRENT SERVICE GAPS AND COMMUNITY NEEDS
5
EXISTING CRISIS RESPONSE SYSTEM
...9
§
TYPE AND QUANTITY
OF SERVICES PROVIDED
DESCRIPTION OF EXISTING CRISIS
RESPONSE SYSTEM
.
10
§
EMERGENT CARE
CALLS DURING BUSINESS HOURS
§
EMERGENT CARE
CALLS DURING EVENINGS/WEEKENDS/HOLIDAYS
§
EXISTING CRISIS
FACE-TO-FACE ASSESSMENT/INTERVENTION SYSTEM
§
EXISTING CRISIS
RESPONSE SYSTEM STAFF MAKE-UP
§
EXISTING CRISIS
RESPONSE SYSTEM STAFF TRAINING
DESCRIPTION OF NEW CRISIS SERVICES
..
.
..13
§
CRISIS RESPONSE
SYSTEM STAFF MAKE-UP
§
CRISIS RESPONSE
SYSTEM TRAINING REQUIREMENTS
CRISIS RESPONSE SYSTEM INTEGRATION
BETWEEN
MH
AND SA SERVICES
.
..17
OVERSIGHT OF CRISIS REDESIGN
IMPLEMENTATION
..18
Attachment
A
.
..
19
Attachment B
....20
Attachment
C
..
.22
Attachment
D
..
.23
Attachment
E
..
.24
Attachment
F
..
.25
Attachment G
.
..
26
Attachment
H
.
.....27-28
Attachment
I
.......29-30
Attachment
J
...31
Attachment
K
.....32-33
Attachment
L
.34-35
OVERVIEW
In response to concerns about
serious gaps in the mental health and substance abuse crisis response systems
and in recognition that the growing numbers of individuals seeking mental
health crisis services in hospital emergency rooms, as well as the numbers
incarcerated due to lack of viable and responsive treatment alternatives were a
direct consequence of those gaps, the Texas Department of State Health Services
(DSHS) implemented an initiative to identify and address those deficits. Through identification and inclusion of
important stakeholders, and the establishment of a Crisis Services Redesign
Committee, specific gaps in services along with best practices in mental health
and substance abuse crisis service delivery were identified.
Efforts from these groups
resulted in the September 2006 report Texas Mental Health and Substance Abuse
Crisis Services Redesign. That report
established a blueprint for addressing requisite changes and developed costing
models to approximate the additional funding required to implement those
changes. As a direct result of those efforts, the 80th Session of
the Texas Legislature allocated 82 million dollars to DSHS to distribute among
the States local mental health authorities (LMHAs) during the FY 2008-2009
biennium to begin the process of ameliorating the most serious deficiencies in
the States mental health crisis services delivery system.
DSHS, in turn, has developed a
process for distributing those funds to the LMHAs for actual implementation of
strategies designed to address those critical deficiencies. Core services identified for implementation
were the use of Crisis Hotlines, Mobile Crisis Outreach Teams, Crisis
Outpatient Services, 23-48 Hour Observation, Community Crisis Residential
Services, Law Enforcement Crisis Intervention Teams (CITs) and MH Deputy
Programs, with Crisis Hotlines and Mobile Crisis Outreach Teams determined to
be most critical for first implementation.
LMHAs have been directed to fully implement those two core services
within the 2nd Quarter of FY2008 and through extensive local
planning initiatives, and with significant stakeholder input, to develop plans
for addressing other unmet mental health and substance abuse crisis needs in
their communities as additional funds become available.
Pursuant to its contract with
DSHS, ACCESS has initiated implementation of an AAS accredited Crisis Hotline
and a Mobile Crisis Outreach Team during FY2008. In addition to expanding its
local planning efforts to enhance the success of the crisis redesign project,
ACCESS also is committed to expanding these services with only new dollars
(i.e. not supplanting existing crisis dollars) and engaging in collaborative
efforts to maximize the use of local and State resources.
Update (3-1-2010): Additional crisis funds were allocated by the
Texas Legislature during its 81st Session in recognition of the
exponentially increased utilization of crisis mental health services during the
previous biennium. These dollars were used by ACCESS to provide more intensive
supports to persons in crisis and to pay for additional bed days at local
psychiatric hospitals.
Crisis
Service Planning Initiatives
In order to develop ACCESS
Crisis Service Redesign Plan, a process to meet the needs and priorities of the
two (2) County Community was implemented.
Stakeholders for each County (Anderson and Cherokee) were identified per
DSHS recommendations, through Jail Diversion Task Force meetings, and through
recommendations from staff at the Center who suggested client representatives
and families. At a minimum, stakeholders
identified for each County were: client
representatives; client family member representatives; child and family
advocates; mental health service providers; emergency healthcare providers
(i.e. hospital emergency room personnel); local public healthcare providers;
law enforcement representatives from each jurisdiction in the Local Service
Area (LSA); probation and parole department representatives; judicial
representatives from each county in the LSA; regional Outreach Screening and
Referral (OSAR) representative; and, other concerned citizens and service
providers. (Attachments A & B).
A public forum was held in each
County, in Anderson County on October 15th , 2007, and in Cherokee County on
October 16th. Announcements of the
forums (Attachment C) were placed in the local newspapers, including a local
Spanish newspaper (Attachment D) and invitations were mailed to 67 individuals
representing the above listed stakeholder groups (Attachments E & F). Input
from other stakeholders occurred during Jail Diversion Committee meetings
(Attachment G), meetings of the East Texas Behavioral Network (ETBHN) Regional
Planning Network Advisory Committee (RPNAC), and during meetings of the
Cherokee County Care Collaboration and Anderson County Interagency
Collaboration. ACCESS also is a member of the Partners in Health Advisory Board
in Cherokee County as part of a federal grant addressing significant health
issues in the County, including concerns about mental health and substance
abuse crises.
Update (3-1-2010): Public Forums and Stakeholder Meetings were
held in each County in 2008. In addition to other stakeholder meetings held in
2009, Public Forums were held on May 26th in Anderson County and on May 27th
in Cherokee County to elicit feedback regarding multiple planning initiatives.
Forums and Stakeholder Meetings for the 2010 planning cycle are scheduled to
take place during the months of March through May and feedback on the crisis
response system elicited through those meetings will be incorporated into the
final Crisis Plan to be submitted in July, 2010. In addition to meetings,
surveys will be mailed/distributed to community stakeholders during the months
of March and April and that feedback will also be included in the final Crisis
Plan.
Although the Forums were well
publicized, stakeholder attendance and participation was limited. Because ACCESS considers their input
essential to the crisis redesign process, additional efforts to engage and
involve the community stakeholders were implemented. Upper level management contacted stakeholders
not in attendance by phone and in person to solicit constructive feedback into
the local planning process. In this manner, ACCESS was able to expand the
communities participation.
Each County does have an active
collaboration group comprised of members from various social service agencies
(APS, CPS, Juvenile and Adult Probation, Red Cross, school district officials,
Crisis Center, etc.), local hospitals, church aid groups, medical
professionals, and concerned citizens.
ACCESS staff participate in both of these collaboration efforts and
input regarding the best use of the additional funding for development of
crisis services was also elicited from these groups.
Update (3-1-2010): ACCESS now participates in the East Texas
Suicide Coalition and the Child Fatality Review Team to identify and reduce
stressors affecting children and adolescents. ACCESS staff have been
instrumental in revitalizing the CRCGs in both Counties and the CRCGs have been
particularly effective in trying to prevent out of home placements and TYC
referrals for children and adolescents
in Anderson and Cherokee Counties.
ACCESS plans to continue to use
public forums, the existing network of collaboration committees in each County,
the ETBHN RPNAC, as well as other approaches and formats to increase feedback
and to expand upon and continue this stakeholder base. In addition to contacting stakeholders by
phone, a questionnaire will be mailed to stakeholders soliciting feedback about
the current crisis system and requesting ideas for future enhancements. ACCESS believes continuance of these
processes will strengthen the Centers ability to meet changing consumer, community
and stakeholders needs.
Current Service Gaps & Community
Needs
From community stakeholder
meetings, direct face-to-face post-hoc meetings with law enforcement officials,
ER leadership, and juvenile justice leadership, as well as this MHAs own
experiences, a number of service gaps and community needs related to the
delivery of crisis services have been identified. The issues identified apply to adults,
adolescents and children, as well as to gaps related to the delivery of crisis
services for individuals with co-occurring psychiatric and substance use
disorders. As expected, the gaps and
needs identified are consistent across both Counties of this MHAs catchment
area. Several common regional themes
coalesced around law enforcement crisis transportation needs and the need for
law enforcement to have additional options and/or resources available in order
to make appropriate diversions. Finally,
issues involving the variability of face-to-face response times of the crisis
workers surfaced repeatedly.
Transportation of clients in need
of rapid stabilization has been a resource repeatedly identified as lacking by
community stakeholders. The factors
which make this an issue are that the private hospitals are often outside the
jurisdiction of law enforcement or that law enforcement does not possess the
manpower necessary to remain with clients needing medical clearances for state
hospital admissions. On-duty peace
officers frequently report spending a considerable amount of time in the ERs
waiting for an alternative transportation plan to emerge or until the peace
officers can make other arrangements within their chain of command.
Although not specifically
identified by stakeholders as a gap, law enforcement officials and emergency
room leadership voiced their frustration that the dependability of the MHA to
rapidly respond for a face-to-face evaluation is inconsistent. The variable
response time for a face-to-face crisis evaluation by a QMHP-CS, is
understandable given that the workers notified to respond to these calls are
already engaged with clients in the community. Emergent care during regular
business hours in the community is handled by trained QMHP-CS field
staff. When there is an emergent need
in the community for an evaluation, these staff are diverted from direct,
ongoing client care on a scheduled, rotating basis.
Therefore, when a worker is
notified of the need for an evaluation, they must first obtain closure with
their client. This may involve simply
excusing themselves from the clients home to having to drive the client back
to their home which may be some distance from the location of crisis. Both counties served maintain a rotation
schedule rotating list of employees designated to respond to community based
crises. Nevertheless, workers in both
counties face the same dilemma in meeting crisis response times while also
trying to meet the demands of those individuals on their existing caseloads.
Variable response times were also
reported by stakeholders during evening hours/holidays/weekends. The after-hours crisis services are staffed
by the same employee base that provides in-vivo psychiatric rehabilitative
skills training services during the day.
The system is currently such that budget constraints afford only one
worker to cover both counties. The
system works well as long as the worker can resolve one call at a time. This, however, is not always the case as the
worker may be notified of the need for another evaluation before the first one
is resolved. Unfortunately, this circumstance does happen, extending the length
of time between the call to the hotline and the face-to-face presence of the
crisis worker. Further complicating the issue is the distance the worker may
have to travel between and within the Counties unless the crisis events are
located within proximity to one another.
Input from the regional OSAR during a meeting of the Anderson
County Interagency Collaboration pointed out a gap in crisis workers awareness
of the availability of substance abuse treatment resources. Also identified was the crisis workers
general lack of knowledge of the substance abuse response system, indicating a
need for more cross-training and collaboration between the mental health and
substance abuse systems, particularly when addressing the complicated needs of
individuals with co-occurring disorders.
Update:
ACCESS and OSAR regional staff have begun discussions around needed
cross-training, as well as having OSAR staff available to the 24/7 crisis
hotline for individuals presenting with substance abuse issues.
Update (3-1-2010): ACCESS and East Texas Council on Alcoholism
and Drug Abuse (ETCADA), the regional OSAR, have entered into a Memorandum of
Agreement to collaborate in their efforts to provide substance abuse outreach,
screening, assessment and referral services to individuals in Anderson and
Cherokee Counties. ETCADA provides a
Licensed Chemical Dependency Counselor to conduct screening and evaluation
services in Anderson and Cherokee Counties for individuals referred by ACCESS
who are seeking substance abuse services. ACCESS provides office space in its
Mental Health Clinics and staff support for the LCDC. In addition and beginning in January, 2010,
persons in need of mental health crisis services who have contacted ETCADAs
OSAR after-hours phone line are routed to ACCESSs crisis hotline provider,
AVAIL, to initiate the appropriate crisis services response.
The development and
implementation of crisis redesign elements requiring the hotlines to be
staffed, structured, and have processes that are AAS certified creates a gap in
ACCESS crisis services array and reflects a need for additional staff
training. While the Center currently
contracts with an AAS certified hotline for evening/holiday/weekends, during
business hours urgent or emergent calls come through support staff to QMHP-CS
case managers who are not AAS certified crisis workers. Although AVAIL will pick up all hotline
services on 12/1/2007, there remains a need to train crisis workers and support
staff who will also be taking calls directed to the local clinic business
numbers. Additional training for other MHA
staff in crisis response and referral is also needed.
Update (3-1-2010): ACCESS contracted for 24/7 crisis hotline
coverage provided by AVAIL and all crisis calls are routed to that hotline.
However, LPHAs, QMHP-CSs, and support staff all have received initial and
ongoing crisis response and referral training to ensure their ability to
respond appropriately to individuals presenting in crisis.
As ACCESS is already over serving
adults and children and adolescents, there is a concern that there are no ready
referral resources for individuals in crisis but not meeting the priority
population diagnosis. Lack of available
community resources to serve as a front or as a back door to services could
create significant service capacity issues. The relatively extreme poverty in
its two Counties has hampered efforts by the community to do more than apply a
band-aid approach to crisis mental health and substance abuse services. There
is a need for increased access to substance abuse services for all and for
crisis mental health and substance abuse services specifically directed to the
needs of children and adolescents. Some community stakeholders and ACCESS staff
also identified a real need for transitional housing options for individuals no
longer in need of more intensive supervision but still needing housing to
prevent or reduce additional crisis.
Update (3-1-2010): ACCESS also
has partnered with the Cherokee County Juvenile Probation Department in a
Commitment Reduction Program Grant funded through TCOOMMI to divert youth from
TYC. ACCESS will receive $35,900 to
provide 18 scheduled (emergency) psychiatric assessments, to include service
coordination, treatment planning, medication-related services and any other
appropriate and needed behavioral health services. ACCESS has hired a QMHP-CS to work as a team
with a Juvenile Probation Officer to provide intensive in-home services
approximately 24 family units, utilizing the TCOOMMI Special Needs Diversionary
Program as a model. The goal is to reduce the number of juveniles placed in
residential treatment by providing intensive community based services to the
entire family and to provide intensive counseling to help parents change when
the juvenile does require placement. The ultimate goal is to divert at least 2
youths from being placed at TYC during the grant period.
Update:
ACCESS staff participate on the Partners in Health Advisory Board in
Cherokee County which is now evaluating options available for obtaining a
Federally Qualified Health Center (FQHC), either as a stand-alone or as a satellite
location, for the County to address the physical and emotional needs of its
residents. Mental health and substance abuse issues will be included within
whatever proposal eventually goes forth and ACCESS staff will participate in
the development and implementation of those programs. A FQHC will also provide
much needed medical and dental services to the population ACCESS serves.
Update (3-1-2010): Unfortunately,
and despite the poverty and lack of resources in the County, Cherokee County
does not qualify as a Medically Underserved Area (MUA) so does not meet the
requirements for a FQHC. The Partners in Health Advisory Board has had several
meetings with consultants but has been unable to obtain the required MUA
designation. The Advisory Board is now investigating other options to expand
needed services in the County.
As a rural MHA, there is a lack
of readily available and appropriately degreed staff. In particular, finding and retaining the
services of psychiatrists to meet the MHAs regular service array, much less
meeting the face-to-face and consultative requirements of the crisis response
system, has been, and will continue to be, a real challenge for most rural
MHAs. In addition, ACCESS must compete
for physicians, nurses, and other licensed staff with the local State Hospital
and the cities of Tyler and Longview.
Update (3-1-2010): Due to its
continuing inability to hire and retain a sufficient number of psychiatrists,
ACCESS has entered into contracts with the Burke Center and UTMB for telepsychiatry
services for children and adolescents. ACCESS pays the Burke Center for
telepsychiatry time but the UTMB contract provides telepsychiatry services
under a grant it has which relieves the Center of significant costs it would
otherwise have to expend for these services.
Lack of participation by
consumers, family members, and advocates was particularly troubling and efforts
to increase interaction with these groups will be a primary focus of future
planning initiatives. Traditionally,
participation from these groups has been lacking in the ACCESS catchment area
and is further exacerbated by the complete lack of public transportation, yet
another community need frequently cited by stakeholders. Several attempts to establish a NAMI group
have failed, and recent problems in maintaining the local Texas Mental Health
Consumers (TMHC) group have further limited consumer and family input.
Update:
The Cherokee County Peer Support Group has recently formed and is
holding regular meetings. This groups
input has been solicited into the further development of ACCESS crisis
redesign services and their ongoing evaluation of the services efficacy should
prove very helpful as the program evolves.
Update (3-1-2010): Membership and participation in the Cherokee
County Peer Support Group has grown substantially. The group has also started a
NAMI group that meets weekly and both of these groups have provided input into
ACCESSs crisis planning processes. The
group asked for, and received, training on how to assist their peers who might
be in crisis and have proved very adept at connecting such persons with needed
crisis services.
Another gap identified has been
the need for this MHA to begin the recruitment process for a Community
Champion. Several prospective Champions
have been identified. It is expected
that the assistance of a judge or other champion to bring together the
stakeholders for further planning will be highly beneficial to the continued
development and success of the crisis redesign process.
Finally, ACCESS recognizes the
importance of community input in the ever-changing structure and process in
crisis services. ACCESS will continue
collaborative meetings with stakeholders to plan for the future, and to keep
apprised of the need for possible changes to the ongoing crisis redesign
process and in response to emerging needs in the Counties it serves.
Update:
In addition to discussions with OSAR staff about their inclusion in the 24/7 crisis hotline, another community
crisis hotline need has been identified.
The Crisis Center that also serves Anderson and Cherokee Counties has
experienced a recent cut in funding and is also interested in collaborating
with ACCESS in utilizing its 24/7 Crisis Hotline. It is believed that this will
reduce duplication, costs, and some of the confusion that occurs when there are
multiple crisis hotlines in one area. The three entities will continue to
explore this option to determine its feasibility.
Update (3-1-2010): Utilization of ACCESSs crisis hotline
through AVAIL has been extended to OSAR staff for after-hours crisis
calls. After consideration, the Crisis
Center decided that it was not yet ready to collaborate in a joint crisis
hotline response system.
Existing
Crisis Response System
Types and Quantity
of Services Provided:
ACCESS existing crisis response
system provides a number of services, including a crisis hotline, crisis
screenings, crisis interventions, emergent/urgent pharmacological management,
and inpatient psychiatric hospitalizations.
A retrospective look at the types
and quantity showed the
following:
1)
The data from the crisis call logs maintained by
support staff which notes the date, time and name of crisis calls to clinics
during business hours showed an average of 30 calls per month.
2)
The data from evening/holidays/and weekends contracted
crisis hotline indicated an average of 85 calls per month were received. Of these 85 calls per month, an average of 33
per month were activated for a face-to-face evaluation.
3)
ACCESS averaged 85 face-to-face evaluations of risk
and the coordination of emergency services per month when crisis data from
business hours was included with after-hours data.
4)
ACCESS averages 24 emergent medication adjustment
issues per month with existing clients during business hours.
5)
Regarding crisis stabilization events, data showed an
average of 17 admissions to private hospitals and 16 admissions to State
Hospitals per month.
Update (3-1-2010): Calls to the Crisis Hotline have increased
from an average of 85 a month to 112.5 but it should be noted that the average
number activated for a face to face evaluation only increased to 36 from
33. The trend for some time has been
that the percentage of face to face interactions with the crisis response
system is decreasing in inverse proportion to the numbers of crisis calls. This seems to indicate that the system is
becoming more efficient at diverting individuals from more restrictive crisis
interactions but further study of the trend will indicate whether that is the
case or whether other factors are responsible.
Description of Existing Crisis Response System
The process by which initial
crisis calls are managed depends upon whether the call comes in during regular
business hours or in the evenings, weekends, or holidays. ACCESS current
crisis response system is divided into a business hours and an
evening/weekend/holidays system. (See Attachments H & I Flow Chart and
Side-by-Side Comparisons)
Emergent Care
Calls During Business Hours:
During regular business hours
(8:00A 5:00P), calls come through the Centers toll free number or through
the Clinics business numbers. These
calls are reviewed by support staff who determine whether there is an urgent or
emergent need, as well as whether the caller is a community stakeholder (e.g.
law enforcement personnel, ER staff, etc.) requesting a face-to-face
evaluation. If the support staff
believes that there is an urgent or emergent need, the call is transferred to
one of the clinics available case managers who is a QMHP-CS.
The QMHP-CSs in the clinic during
business hours also function as R & DM routine case managers and, thus,
serve in multiple capacities. The
QMHP-CSs determine the urgent/emergent need of the caller who may be any number
of community stakeholders (law enforcement, schools, emergency rooms, clients,
families). If the caller wants the
client seen in the clinic as a walk-in crisis, then the clinic case manager
will meet that need. Upon arrival at one
of the clinics by the client, the worker triages the case with all relevant
stakeholders (family, emergency medical providers, law enforcement, CPS,
juvenile justice, etc.) and the client.
If the caller believes the client
should be seen in the community and identifies the client to be medically stable,
then one of the field staff will be immediately notified of the nature of the
callers need and will travel to the location of the caller as long as the
environment is safe and secure for the worker.
Current safe locations include the ERs, jails, Juvenile Detention,
and State Hospital. Upon arrival, the
worker triages the case with all relevant stakeholders (family, emergency
medical providers, law enforcement, CPS, juvenile justice, etc.) and the client.
Emergent Care
Calls During Evenings/Weekends/and Holidays:
Calls during the evening/weekend
/and holidays are answered by AAS certified hotline staff. They are the first
point of contact for crisis in the community, providing triage to determine the
callers immediate need and mobilize emergency services for the caller, if
necessary. The AAS certified hotline is
answered by a trained QMHP-CS who assesses the nature of the call. Initial assessments may lead to a face to
face assessment by ACCESS staff and /or other appropriate referrals for
assistance or treatment. The hotline
provides referrals to 911, when indicated.
If an emergency is not evident after further screening, the hotlines
service includes referral to other appropriate resources within or outside the
LMHA. The hotline service works in close
collaboration with local law enforcement, 211, and 911 systems.
If the caller to the hotline
identifies the client to be medically stable, then the worker will travel to
the location of the caller as long as the environment is safe and secure for
the worker. Current safe locations
include the ERs, jails, Juvenile Detention, and State Hospital. Upon arrival, the worker triages the case
with all relevant stakeholders (family, emergency medical providers, law
enforcement, CPS, juvenile justice, etc.) and the client.
Existing Crisis
Face-to-Face Assessment/Crisis Intervention System:
Whether initiating a face-to-face
assessment for an individual referred by the crisis hotline or from MHA support
staff during regular business hours, the crisis worker completes the assessment
using selected dimensional elements of either the CA-TRAG or the adult
TRAG. The worker may also complete a
clinical suicide assessment. If the
assessment suggests the client is at imminent risk of danger to self or others
or risk of deterioration, the worker collaborates with all stakeholders to
facilitate the necessary crisis stabilization at either a local, private
psychiatric facility or a State Mental Health Hospital.
If the assessment suggests that
the client is not at imminent risk of danger to self or others or at risk of
deterioration, then the worker engages the client to ameliorate or reduce
distress and help the client cope with the immediate stressors which
precipitated the event. A collaborative
Safety Plan may also be created between the client and stakeholders. The plan may include strategies and
interventions to help the client, follow-up contact information, and
responsibilities of all involved.
If all stakeholders, including
the client, agree that the client could be treated on an outpatient basis, then
the following steps could be undertaken:
a)
If the client is an active client at the MHA, then
the client would be directed to come to one of the clinics the next business
day in order to be re-evaluated by medical staff, QMHP-CS, or a counselor.
b)
If the client is not an active consumer at this MHA,
then they may be directed to return to one of the outpatient clinics to be seen
by one of the clinics LPHAs to determine further needs and eligibilities.
c)
The client also at any time may be referred to schedule
a meeting with the regional OSAR representative to address substance abuse
concerns.
Existing Crisis
Response System Staff Make-Up:
The current crisis response
system staff is comprised of thirteen (13) QMHP-CSs and three (3) LPHAs. Of the thirteen (13) QMHP-CSs, ten (10) of
them are full-time psychiatric rehabilitative trainers and three (3) are clinic
case managers. The ten (10) QMHP-CS skills
trainers respond to community crises day or night, weekends and holidays based
on a rotating schedule. The crisis
response system has three (3) LPHAs who are credentialed to perform crisis
intervention, but whose job activities generally preclude them from functioning
as a face-to-face evaluator. The LPHAs
do serve as clinical back-up on an around the clock basis for those who are
crisis workers.
Additional elements of the crisis
response system staff make-up are the support staff that serve as the first
point of contact for calls to clinics during business hours. These staff are not credentialed mental
health personnel.
In the evening hours, weekends,
and holidays, the first point of contact for crisis calls is an ACCESS
contracted crisis hotline, AVAIL. AVAIL has recently obtained American
Association of Suicidology certification through that accrediting body.
Existing Crisis
Response System Training:
Crisis response system training
requires that the crisis worker be a QMPH-CS.
The crisis worker, before they see clients in crisis are trained in
HIPAA Privacy & Security, ACCESS Mission & Vision, Consumer Rights,
Cultural Diversity, Documentation & Record Keeping, EEO, Infection Control,
ACCESS Professional Code of Conduct, Workplace Safety, Seizure Assessment, and
Principles of Crisis Intervention.
The crisis workers are also
trained in both State approved R & DM assessment tools the CA TRAG and
Adult TRAG and on the MH Community Center Standards, particularly those
relating to crisis services. Crisis
workers then are engaged in 2-3 hours didactic learning with the MHAs
Authority Director. Following the
training, the crisis worker demonstrates competency by taking exams assessing
their fundamental knowledge of the CA TRAG and Adult TRAG and factual issues
related to the delivery of crisis services.
The crisis response staff is also
required to be mentored in-vivo in the assessment and delivery of crisis
services. This part of the training
involves the new crisis worker being paired with an experienced crisis
worker. In the beginning of the
in-vivo training, the new crisis worker shadows the delivery of crisis
services by watching the experienced worker.
Gradually, over a 3 month period of time, these roles are reversed, and
the new crisis worker is then evaluated by informal peer review of competency
to deliver crisis services. If the new
crisis worker is judged to need further mentoring, then this will occur until
both the trainee and experienced crisis worker believe the trainee is
competent.
Description
of New Crisis Services
The new crisis funding will be
used to meet the following objectives of a rapid response mobile crisis
outreach team: provide for expedited
local stabilization; aid in diversion from incarceration; and, reduce the
burden on law enforcement and emergency health care resources. This will be accomplished by improved crisis
response team infrastructure, training, and response processes.
The types and projected quantity
of crisis services to be provided with new funding will be as follows:
New crisis funding will be used
to improve ACCESS crisis hotline service.
ACCESS currently contracts with an AAS accredited hotline service during
evenings, weekends, and holidays. ACCESS
will expand the utilization of the contractor to include the provision of
crisis hotline services during business hours.
Thus, ACCESS will be able to provide accredited hotline services 24/7.
Other new crisis dollars will
afford the creation of an improved crisis response team infrastructure through
the creation of a Mobile Crisis Outreach Team. This type of service will
generate 56 hours per week of dedicated crisis staff time.
Prior to new monies, community
based crises were handled by staff who had many other duties and
responsibilities. These other activities
handled by field staff frequently caused the crisis worker to be unable to
respond to a crisis call within the one hour timeframe.
Under this second generation
crisis system, ACCESS will employ 2 dedicated QMHP-CS crisis workers one per
County. While the details of their schedule will be fine tuned over time, a
crisis worker will be positioned in each County, ready to immediately respond
for a face to face evaluation and intervention with the one hour timeframe
during peak hours. In addition, existing staff will continue to be used as
back ups to the MCOT to ensure emergent and urgent timeframe requirements are
met. This will improve the consistency and timeliness of rapid responses in
the community. Furthermore, these
individuals will facilitate the enhanced provision of crisis services,
particularly crisis follow-up and crisis intervention. It is anticipated that the outcome will be a
reduction in jail incarceration, ER visits, and inpatient hospitalizations.
ACCESS will also strengthen the
crisis team infrastructure with the addition of an LPHA Mobile Crisis Outreach
Team leader. It is expected that this
dedicated individual, at a minimum, will be back-up for the QMHP-CSs, as well
as travel as a team member to locations in the community when appropriate. The team leader is to serve in a supervisory
capacity for the team, provide oversight of follow-up contacts to the crisis
hotline and community based crises, and creates an additional level of staffing
depth for the team. This team member
will also increase the capacity of this MHA to provide rapid assessment for
outpatient care if needed.
Update (3-1-2010): After a lengthy search, ACCESS was able to
hire a LPHA to serve as the Mobile Crisis Outreach Team Leader. Unfortunately, that individual decided to
return to her private practice and after another unsuccessful search, it was
decided to fill the Team Lead position with a highly qualified QMHP-CS, with
clinical support and back-up provided by the ACCESS Chief Program Officer, a
LCSW.
Redesign funding will also allow
the MHA to offset transportation costs incurred by law enforcement, as well as
costs incurred by their lengthy detainments at ERs, by underwriting a Mental
Health Peace Officer (MHPO) in each County.
The inclusion of a MHPO as part of the Mobile Crisis Outreach Team is
expected to result in a reduced burden on the ERs maintenance of a consumer
who is in need of transportation and rapid stabilization. ACCESS also expects that having a MHPO
working in conjunction with a mobile unit will contribute to increased
diversions from incarceration, and address, if needed, the security and safety
concerns involved with evaluations in the community.
Update (3-1-2010): Each County now has a trained MHPO available
to transport individuals needing crisis services, as well as providing security
and support to the MCOT and ACCESS on-call crisis staff.
To further facilitate the
implementation of the MHPO as part of its crisis response system, ACCESS also
plans to purchase a vehicle for use by the Anderson County MHPO for
transportation of individuals in crisis.
This will allay concerns expressed by the Anderson County Sheriff about
the availability of a vehicle for use by the MHPO during crisis response calls.
Anderson County has agreed to outfit the vehicle to meet safety concerns and
will also pay all maintenance and gas costs.
Update (3-1-2010): Vehicles have been purchased and currently
are in use each County by that Countys MHPO. The addition of the MHPOs, along
with their vehicles, has achieved the desired effect of reducing time spent in
ERs by individuals in crisis, as well as reducing the burden on local law
enforcement, with the additional benefit of strengthening the working relationships
between law enforcement and ACCESS.
New funding will also be used to
purchase additional local inpatient hospitalization capacity. ACCESS
anticipates the purchase of 50 additional bed days, providing local inpatient
hospitals have available space. This will assist in efforts to divert
individuals from the State Hospitals and provide greater flexibility to the MHA
in coordinating local intervention and support services.
Update (3-1-2010): The additional crisis funds were used to
augment funds set aside by ACCESS to purchase local inpatient psychiatric
beds - although these were in limited
supply as Centers in the East Texas area vied for available beds resulting from
lack of access to the local State Hospital. Due to the high utilization of its
beds by forensic patients, Rusk State Hospital spent much of the year on
diversion status. It became apparent
that other resources needed to be developed and ACCESS, along with the Andrews
Center and Community Healthcore, has entered into a contract with the Wood
Group to establish a 10 bed Crisis
Respite facility to be licensed by DSHS and located in Tyler. It is anticipated that it will open in the
Summer of 2010 and will provide opportunities for diversion from more
restrictive levels of care.
Update:
At this time, the allocation received by ACCESS only supports the
development of the two Core services, the 24/7 accredited Crisis Hotline and
establishment of a Mobile Crisis Outreach Team. If additional funding becomes
available, ACCESS will canvass its stakeholders again to determine which of the
other crisis services to implement in its two Counties.
Update (3-1-2010): Additional crisis funds were allocated by the
Texas Legislature during its 81st Session in recognition of the
exponentially increased utilization of crisis mental health services during the
previous biennium. These dollars were used by ACCESS to provide more intensive
supports to persons in crisis and to pay for additional bed days at local psychiatric
hospitals.
Crisis Response
System Staff Make-Up:
New crisis funding dollars will
be used to grow ACCESS crisis response systems staffing. ACCESS is projecting to recruit for three (3)
new ACCESS positions and to underwrite County expenditures for two (2)
additional positions. The outgrowth of
these five (5) positions will be a dedicated rapidly deployed crisis team
composed of two (2) QMHP-CSs, one (1) LPHA, and two (2) certified and trained
Mental Health Peace Officers who will be
able to respond to crises within one hour during peak times. In addition, the current crisis response
system staff, comprised of thirteen (13) QMHP-CSs and three (3) LPHAs, will
still provide crisis services during
off-peak hours and serve as backup to the MCOT during peak hours to ensure
emergent and urgent timeframe requirements are met.
Update: There have been few qualified applicants for
the QMHP-CSs and none for the Team Leader (LPHA) position. This has lengthened the time it will take to
fully implement the MCOT and this delay is reflected in the Implementation
Timeline. Salaries may have to be
adjusted and it may also be necessary to consider reposting the Team Leader as
a highly QMHP-CS to obtain the skilled staff necessary to run the MCOT program.
Update (3-1-2010): The MCOT is fully staffed, although the Team
Leader originally planned to be a LPHA, is now a QMHP-CS. Salaries were increased to attract more
qualified applicants. As part of its evolving Continuity of Care and Services
Program, ACCESS recently integrated its Aftercare/Continuity of Care functions
into the MCOT unit. This added another QMHP-CS position to the Team and
facilitates a seamless transition of care for individuals served, before,
during, and after psychiatric hospitalizations, strengthening the relationship
between the MCOT and State Hospitals and local psychiatric facilities.
Crisis Response
System Training Requirements:
Projected training requirements
of the crisis response system will adhere to the standards established by DSHS.
ACCESS will expand its contract
with an AAS certified hotline. However,
in the event that this hotline service becomes unavailable, ACCESS anticipates
having an employee attend a DSHS regional Train-the-Trainer Conference in order
to safeguard the hotline crisis element and maintain fidelity of the DSHS
program.
The LPHA and QMHP-CS staff will
attain competency in all federal, state and DSHS regulatory requisite areas in
order to serve in the capacity as a Mobile Crisis Outreach Team member.
The Mental Health Peace Officers
will have demonstrated competency in order to carry the certification
authorized by the Peace Officers credentialing body (TCLEOSE). In addition to
the Peace Officers certified training, ACCESS anticipates that these 2 law
enforcement officials will receive additional training regarding:
1)
Center Operations
2)
Co-occurring psychiatric and substance abuse disorders
3)
Community resources
4)
OSAR
5)
Understanding the nature of severe and persistent
mental illness and serious emotional disturbance
6)
Cultural competency
7)
Screening and crisis interventions
Update: MCOT staff and
MHPOs have received training in all requisite regulatory areas.
Crisis
Response System Integration Between Mental Health
& Substance Abuse Services
A common complaint from the
mental health side of DSHS and substance abuse side is the lack of integration
between these two entities crisis services.
This widely held view was mirrored recently in the discussion between
ACCESS and regional OSAR
leadership. An ongoing effort to close
this gap and pool resources is evidenced by the MOU between ACCESS and OSAR where ACCESS has provided an
in-kind match of office space in its clinics to facilitate the provision by
East Texas Council on Alcohol and Drug Abuse (ETCADA) of substance abuse counseling services to
clients with co-occurring psychiatric and substance abuse issues. By acting as a host site, ACCESS is taking
steps towards improving integration of the systems.
However, this crisis redesign
planning process has been the impetus to enhance ongoing activities between OSAR and ACCESS. In particular, both agencies will be engaged
in continuing collaborative efforts to cross train all staff to better
understand the structure and processes of each agency. Additionally, there will be ongoing
discussion of how each agency handles crisis calls. It was agreed that through combined effort
there could be greater efficiency of referrals and hotline transfers.
One other possible collaborative
enhancement may involve using the same Crisis Hotline to reduce costs and
better leverage local and State resources.
Update: Further dialogue has taken
place with the Executive Director of the Region IV OSAR, East Texas Council on
Drug and Alcohol Abuse (ETCADA). She has expressed an interest in adding her
licensed OSAR staff to the on-call staff of ACCESS 24/7 crisis hotline
contracted through AVAIL. This would
facilitate the availability of immediate substance abuse assessment referrals
from the hotline when such need is indicated.
Both entities recognize this as an opportunity to enhance services,
through earlier identification and interventions tailored to COPSD issues. Discussion also continues about ways the OSAR
staff can provide crisis support to the MCOT.
OSAR
representatives have been included in stakeholder discussions since the
inception of the Crisis Redesign process and their input will continue to be
solicited throughout the redesign process. It should be noted that there are no
DSHS funded providers in ACCESS two counties of Anderson and Cherokee who
provide services to the population ACCESS serves. However, administrative staff have contacted
providers of substance abuse services in the area to discuss possible
collaborative efforts.
Update (3-1-2010): ACCESS and East Texas Council on Alcoholism
and Drug Abuse (ETCADA), the regional OSAR, have re-issued the Memorandum of
Agreement affirming their continued desire to collaborate in their efforts to
provide substance abuse outreach, screening, assessment and referral services
to individuals in Anderson and Cherokee Counties. ETCADA provides a Licensed Chemical
Dependency Counselor to conduct screening and evaluation services in Anderson
and Cherokee Counties for individuals referred by ACCESS who are seeking
substance abuse services. ACCESS provides office space in its Mental Health
Clinics and staff support for the LCDC.
In addition and beginning in January, 2010, persons in need of mental
health crisis services who have contacted ETCADAs OSAR after-hours phone line
are routed to ACCESSs crisis hotline provider, AVAIL, to initiate the
appropriate crisis services response.
Oversight of Crisis Redesign
Implementation
Without the infusion of new
dedicated crisis dollars, development and expansion of desperately needed
community crisis response systems would have been impossible. Providing
verifiable assurances that the new funding allocated for crisis services is
being used as intended, and with significant community stakeholder involvement,
is essential to the continued success and funding of the crisis redesign
process. To that end, ACCESS will
establish continuous quality improvement processes to ensure oversight of its
planning and implementation processes.
Opportunities for improvements
will be identified through monitoring of outcomes to ensure benchmarks are met,
with particular attention paid to those indicators affecting the outcomes set
by the Legislative Budget Board (LBB).
Other key performance indicators will be established and monitored for
fidelity in the areas of staff training and competency, adherence to crisis
standards and utilization management guidelines, timeliness of crisis service
provision, and timeliness of documentation.
All staff will be appropriately credentialed. Quality Management and ACCESS MHA management
staff will also monitor and evaluate crisis documentation for resolution of
crisis services to ensure adequacy of follow-up. Crisis data found in the Data
Warehouse will be reviewed to ensure its accuracy and to resolve any
discrepancies. Oversight activities and
any identified trends, patterns, and/or other concerns will be reported through
the ACCESS Corporate Compliance Committee for further evaluation and
recommendations. Regional Crisis data
will also be reviewed by the ETBHN RPNAC to identify any regional anomalies,
trends, or patterns.
Stakeholder involvement will
continue to be solicited through additional public forums, Jail Diversion Task
Forces, meetings with various community collaboration groups, direct contacts
with stakeholders - either by phone or in person, and mailed questionnaires.
Periodic status assessments of stakeholder involvement will occur, with any
concerns relayed to the various planning entities by ACCESS to solicit
suggestions for improving participation. Additionally, efforts will be
increased to engage clients, family members, and advocates in more active roles
in the development and expansion of crisis redesign services.
Update (3-1-2010): Quality Management staff provide substantial
levesl of oversight and monitoring of crisis services at ACCESS, including
training and retraining of staff as changes have occurred in definitions and UM
Guidelines. Functional improvement has been noted in most areas, with the
exception of timely follow-ups for routine episodes. Recent meetings between QM and MCOT staff
have addressed these concerns, developing new process flows for tracking
follow-ups and some improvement has already been observed. The ACCESS Board of
Trustees receives regular reports on crisis oversight activities.
