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 State’s local mental health authorities (LMHAs) during the FY 2008-2009 biennium to begin the process of ameliorating the most serious deficiencies in the State’s 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 Center’s 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 MHA’s 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 MHA’s 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 ER’s 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 client’s 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 ETCADA’s OSAR after-hours phone line are routed to ACCESS’s 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 MHA’s 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 group’s 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 ACCESS’s 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 ACCESS’s 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 Center’s 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 clinic’s 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 caller’s 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 ER’s, 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 caller’s 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 hotline’s 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 ER’s, 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 MHA’s 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 ER’s 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 County’s 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 ETCADA’s OSAR after-hours phone line are routed to ACCESS’s 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.


 

ATTACHMENT A

 

ANDERSON COUNTY STAKEHOLDERS

 

a

Client Representatives

b

Family Members

c

C & A Advocates

d

MH Service Providers

e

Emergency HC Providers

f

Local Public HC Providers

g

Law Enforcement

h

Probation & Parole Reps

i

Judicial Reps

j

OSAR

k

Others

 

 

 

 

 

 

 

 

 

 

 

Ch.G.

L. D.

Anderson County Crisis Center

PRMC Psychiatric Services

 

PRMC Director

Ms. Cynthia Harty, Indigent Health Care Anderson Cty

 

Charlotte Moore, Dir., Juv. Prob.

Doug Lowe, Esq.

And. Cty. D.A.

Susan Erwin, Executive Director, ETCADA

State Rep. Byron Cook, District 8

M.L.

 

 

 

Ms. Deb Walker, Clinic Coord., VA

 

Constable Larry Bennett

Precinct 1

Roy Drewett, Dir.

Adult Prob.

 

 

 

 

 

 

 

 

 

Constable Doug Lightfoot

Precinct 2

 

County Judge Linda Ray

 

 

 

 

 

 

 

 

Constable Kim Dickerson, Precinct 3

 

JP Gary Thomas, Precinct 1

 

 

 

 

 

 

 

 

Constable Gary Briley

Precinct 4

 

JP Carl Davis, Precinct 2

 

 

 

 

 

 

 

 

Police Chief Larry Coutorie

 

JP Jones Todd,

Precinct 3

 

 

 

 

 

 

 

 

Sheriff Greg Taylor;

Troy Black, Chief of Deputies

 

JP James Westley, Precinct 4

 

 

 

 

 

 

 

 

Captain Sharp

Sheriff’s Dept

 

County Judge Jeff Doran

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTACHMENT B

 

 

CHEROKEE COUNTY STAKEHOLDERS

 

a

Client Representatives

b

Family Members

c

C & A Advocates

d

MH Service Providers

e

Emergency HC Providers

f

Local Public HC Providers

g

Law Enforcement

h

Probation & Parole Reps

i

Judicial Reps

j

OSAR

k

Others

C. G.

L.G.

Cherokee Cty Crisis Center

RSH:

TMFH-Jville:

Cherokee Cty Health Dept.

Chief C.E. Barron, Alto PD

Nancy Scruggs, Probation Dept.

Craig Caldwell, Esq.

Jana Elmore, ETCADA

State Rep Chuck Hopson District 11

 

 

 

Lynda Roberson

Dianne Adelfio

 

Officer Jeremy Jackson, Alto PD

Andretta White, Probation Dept.

Judge Chris Davis

 

State Senator Robert Nichols District 3

 

 

 

Ed Bruce

Shannon Rice

 

Sgt. James Green, Alto PD

Cindy Montgomery, Probation Dept.

Brenda Dominy, JP, Prct. 1

 

 

 

 

 

Ladora Carter

Angela Marsh

 

Brad George, Rusk PD

 

Teresa Pfifer, JP, Prct. 2

 

 

 

 

 

Yolanda Rodriguez

 

 

Chief Ronny Miller, Rusk PD

 

James Morris, JP, Prct. 3

 

 

 

 

 

Ted Debbs

ETMC-Jville:

 

Roy Cavazoz, Asssitant Chief Rusk PD

 

Vera Foreman, JP, Prct 4

 

 

 

 

 

Brenda Matsler

J.P. Bradford

 

Sheriff James Campbell

 

Sue Schulze

 

 

 

 

 

 

Jason Foster

 

Keith Radcliff, Chief Deputy, SO

 

 

 

 

 

 

 

 

Donna Watson

 

Chief Ledford

Cuney Police Department

 

 

 

 

 

 

 

 

Janet Blue

 

Reece Daniel, Jville Chief of Police

 

 

 

 

 

 

 

 

Rodney Caldwell, MD

 

 

 

 

 

 

 

 

 

 

ETMC Physicians Office, Rusk

 

 

 

 

 

 


ATTACHMENT C

 

ACCESS

 

OPEN FORUM

 

CRISIS RESPONSE SYSTEM

 

TUESDAY, OCTOBER 16, 2007

2:00 P.M.

 

5656 North Jackson

Jacksonville, Texas 75766

 


ACCESS

 

OPEN FORUM

 

CRISIS RESPONSE SYSTEM

 

MONDAY, OCTOBER 15, 2007

2:00 P.M.

 

3320 South Loop 256

Palestine, Texas 75801

 

 

Update: 2010 Public Forums/Stakeholder Meetings were held in each County during April and May, 2010                                                                    

 

 

ATTACHMENT D

 

MEDIA

(2010 Ads to run in April and May)

 

Palestine Herald-Press

519 Elm Street

Palestine, TX  75802

Tel. 903-729-0281

Adv. Fax: 903-729-1057

N120 = Public Announcements

 (Ad ran Sunday, 10/14/2007)

 

Jacksonville Daily Progress 525 E. Commerce Jacksonville, TX  75766

Tel. 903-586-2236

Ad Contact:  Sarah Minter

(Ad ran Sunday, 10/14/2007)

 

Cherokeean Herald

618 N. Main

Rusk, TX 75785-1144

Tel. 903-683-2257

(Ad ran Sunday, 10/14/2007)

 

La Opinion

402 College Avenue

Jacksonville, TX 75766

Tel. 903-586-7106

(Ad ran Sunday 10/14/2007)

 

 

 

 

 

 

 

 

 

ATTACHMENT E

 

Anderson-Cherokee Community Enrichment ServiceS

Your Community Mental Health/Mental Retardation Center

(– Letter will be updated and re-issued prior to 2010 Forums)

 

October 4, 2007

 

 

Ladies and Gentlemen:

 

The 80th Legislature has appropriated money to improve the local community crisis response system.  ACCESS is holding an open public forum to give local stakeholders an opportunity to provide input in the improvement of the crisis response system of Anderson County.  This meeting will be held on Tuesday, October 16, 2007 at 2:00 p.m. in the Jacksonville Clinic located at 5656 No. Jackson, Jacksonville, Texas. 

 

Stakeholders who have been invited to attend include the following groups: Client Representatives; Client Family Member Representatives; Child and Adult Advocates; Mental Health Service Providers; Emergency Healthcare Providers (i.e., hospital emergency room personnel); Local Public Healthcare providers (i.e., Federally Qualified Health Centers, local Health Departments, etc.); Law Enforcement Representatives from each jurisdiction; Probation and Parole Department Representatives; Judicial Representatives from each county; and Outreach, Screening and Referral (OSAR) provider(s) serving the counties (concerned citizens, representatives from the private sector); as well as those who can provide input to overcome barriers to this service. 

 

Please RSVP to Claudia Lydick or Sarah Bostwick at 903-589-9000 if you plan to attend.

 

Very truly yours,

 

 

 

Steve Kahn, Ph.D., LPC

Director, Authority Services

 

 

 

 

ATTACHMENT F

 

Anderson-Cherokee Community Enrichment ServiceS

Your Community Mental Health/Mental Retardation Center

– Letter will be updated and re-issued prior to 2010 Forums)

 

 

October 4, 2007

 

 

Ladies and Gentlemen:

 

The 80th Legislature has appropriated money to improve the local community crisis response system.  ACCESS is holding an open public forum to give local stakeholders an opportunity to provide input in the improvement of the crisis response system of Anderson County.  This meeting will be held on Monday, October 15, 2007 at 2:00 p.m. in the Palestine Clinic located at 3320 S. Loop 256, Palestine, Texas. 

 

Stakeholders who have been invited to attend include the following groups: Client Representatives; Client Family Member Representatives; Child and Adult Advocates; Mental Health Service Providers; Emergency Healthcare Providers (i.e., hospital emergency room personnel); Local Public Healthcare providers (i.e., Federally Qualified Health Centers, local Health Departments, etc.); Law Enforcement Representatives from each jurisdiction; Probation and Parole Department Representatives; Judicial Representatives from each county; and Outreach, Screening and Referral (OSAR) provider(s) serving the counties (concerned citizens, representatives from the private sector); as well as those who can provide input to overcome barriers to this service. 

 

Please RSVP to Claudia Lydick or Sarah Bostwick at 903-589-9000 if you plan to attend.

 

Very truly yours,

 

 

 

Steve Kahn, Ph.D., LPC

Director, Authority Services

 


 

 

ATTACHMENT G

 

LSA Community Stakeholders

 who provided input to development

of the crisis response system

Name

Title

Organization

Donald Hammock

Executive Director

Crisis Center of Anderson & Cherokee Counties

Jana Elmore

Program Director, Region 4

OSAR/ETCADA

Larry Coutorie

Chief of Police

Palestine, TX

James Westley

Justice of the Peace, Pct. 4

Anderson County

Charlotte Moore

Chief Probation Officer & Director of Detention

Palestine, TX

Judy Beck

Cherokee County Health Dept.

Cherokee County

 

Brian Kempton, MD

Area Medical Director for ETMC ER Group

ETMC, Jacksonville, TX

Ben Beathard

Charge Nurse, Emergency Care Center

Trinity Mother Francis Hospital, Jacksonville, TX

Greg Taylor

Sheriff, Anderson County

Anderson County

James Campbell

Sheriff, Cherokee County

Cherokee County

Brenda Dominey

Justice of the Peace, Pct.1

Cherokee County

Teresa Phifer

Justice of the Peace, Pct. 2

Cherokee County

Roy Cavazoz

Assistant Chief of Police

Rusk, TX

Craig Caldwell

County Attorney

Cherokee County

LaDora Carter

Rusk State Hospital

Cherokee & Anderson Counties

Carl Davis

Justice of the Peace, Pct. 2

Anderson County

Gary Thomas

Justice of the Peace, Pct. 1

Anderson County

Linda Ray

County Judge

Anderson County

Ron Safford

Chief Administrator, Palestine Regional Medical Hospital

Palestine, TX

John Paige

Assistant Chief of Police

Jacksonville, TX

John Burns

Chief Probation Officer

Cherokee County

Susan Erwin

Executive Director, ETCADA

Cherokee & Anderson Counties

SFG Steve Smart                

 

Texas Army National Guard

Anderson County

Jim Payne

 

Anderson County Veteran Service Officer

 

Anderson County

David Thomason

 

Cherokee County Veteran Service Officer

 

Cherokee County

Laura MacClain

 

Facility Administrator

Palestine CBOC

Central Texas Veterans Health Care System

 

Anderson County

Gordon Brett

 Adjutant

American Legion

 

Anderson County

ATTACHMENT H                                                                                                     (revised flowchart on next page)

(Draft 2010 flowchart currently being revised for inclusion in final

2010 Crisis Services Plan)



ATTACHMENT I

Crisis Response Systems for ACCESS MHMR

 

Current Crisis Response System (FY2006-2007)

Revised Crisis Response System (FY 2008-2009)

(Draft –pending final revision for FY2011-2012)

  Initial Crisis Call comes to local center during business hours (8-5 M-F). 

  Initial Crisis Call comes to Avail Solutions weekends, evenings, holidays, and after hours.

  Dedicated Crisis Hotline – Avail Solutions (Accredited by American Association of Suicidology) – 24/7, 365 days per year.

  Dedicated 1-800 number for both counties (Anderson/Cherokee)

  Local center staff respond to crisis during normal business hours (8-5 M-F). 

  After hours, on call staff member is contacted (QMHP-CS).

  On-call staff contact management staff by phone for supervision.

  Psychiatrist back-up by phone

  Mobile Crisis Outreach Team

  1 QMHP and MHPO and LPHA may (respond together as a team).

  “On-duty” from 10a – 7p daily (covering crisis peak hours) = faster response time. Update: Peak hours changed to 8a – 5p daily.

  Supervised by LPHA at all times (LPHA on-call 24/7)

  LPHA available for telephone or F-F consultation as needed.

  Psychiatrist or MD Consult available by phone.

  Most frequent response location is center office or ER

 

  Response location will occur in field, with peace officer whenever possible.

  A total 85 “face-to-face evaluations of risk” and coordination of emergency services occur per month.

  Current crisis calls to clinics during business hours average 30 calls per month.

  Evening/holidays/and weekends contracted crisis hotline indicated an average of 85 calls per month.

 

  Due to more rapid response time and response in-vivo, it is anticipated that quantity of crisis calls and face-to-face evaluations will also increase. It is also anticipated that diversions from incarcerations and inpatient psych hospitalizations will increase.

  Staff make-up: (13) QMHP-CSs and three (3) LPHAs for clinical backup.

  Calls are responded to individually.  No “team approach.”

  Crisis duties are an  “add-on” to primary job duties

  Supervision is provided by management staff (some licensed, some not.)

  Staff Makeup: Dedicated MCOT Team – 2 QMHP-CSs, 2 MHPOs, and 1 LPHA – may respond to calls in pairs per county during peak crisis hours. Update: 4 QMHP-CSs (1 as Team Leader, and 1 as Continuity of Care worker), 2 MHPOs, w/on-call supervision from LPHA.

  Crisis is primary job duty – only “caseload” are clients receiving crisis follow-up.

  Supervision is provided by dedicated MCOT LPHA. Update: Supervision provided by QMHP-CS, w/on-call supervision from LPHA.

  Existing staff provide back-up to MCOT during peak hours and primary crisis response during “off-peak” hours.

  Training: Receive all TAC required training.  Training on crisis service delivery, R&DM modules, UM guidelines. Competency is assessed; in-vivo mentoring of crisis service delivery occurs.

 

  Training: Training:  Staff to attend Train the Trainer Hotline training. Update: Training completed.

  Staff will attain competency in all DSHS required crisis training components. Update: Training completed.

  MH  Peace Officers will attain TCLEOSE certification & demonstrate competency in all DSHS required training. Update: Training completed.

 

  No transportation by center is available

 

  Transportation of non-violent individuals will be available & provided in accordance with state laws & regulations by law enforcement personnel or when appropriate by qualified staff.

Budget:   Overtime/on-call pay for staff = $16,000.00 per year.

  Avail Solutions = $12,000.00 per year.

  Estimated mileage costs = $13,500.00 per year.

  Crisis inpatient psychiatric (“local generals”) = $186,200.00

Total Yearly Budget: $227,700.00/One Qtr = $56,925.00

Draft Budget: (see attached revised line-item budget)

Update:  Source of funds for Crisis Hotline, MCOT, crisis inpatient psychiatric beds, crisis flexible funds, and pending Crisis Respite Program are funded first by the Crisis Allocation dollars, augmented by Medicaid Rehab, and required Local Match.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

ATTACHMENT J

 

Crisis Services Implementation Timeline

 

12/1/2007…………..…………………..……Accredited Crisis Hotline Operational 24/7

 

1/31/2008……………………………………………………….…....MCOT Staff Hired

 

2/1/2008……………………………………………………MCOT Staff Training Begins

 

3/1/2008……………………………………………………….MCOT Fully Operational

 

Summer, 2010…………………………………..10 Bed Crisis Respite Unit Operational

 

 

 

 

 


ATTACHMENT K

 

ACCESS MHMR

Crisis Redesign Plan Required Addendum

12-31-2007

 

Per  November 21, 2007 instructions, the following describes items in the ACCESS Crisis Services Plan that have been updated or revised:

 

I. OSAR and DSHS Stakeholder Involvement:

Participation by OSAR representatives has been bolded within the Plan to make finding those references easier.  They 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.

 

In addition, 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.

 

II. Detail on MCOT meeting response requirements in each County:

Additional detail describing how the MCOT can meet the response requirements in each County has been added to the body of the Crisis Plan, with additions italicized.  In brief, one QMHP-CS will be stationed in each County during peak hours, with clinical direction and oversight provided by the Team Leader. 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 emergent timeframe and within 8 hours to meet the urgent timeframe during peak hours. Additional “safe” locations are also being sought to decrease the amount of travel time within the two Counties. Currently, the Sheriffs in each County have offered space at their facilities for this purpose, to be utilized in addition to the hospital emergency rooms, and jail facilities.

 

In addition, existing staff will continue to be used as “back ups” to the MCOT to ensure emergent and urgent timeframe requirements are met as required during peak and “off peak” hours. This will also improve the consistency and timeliness of rapid responses in the community. 

 

 

III.             Flowchart Amended.

The flowchart was amended to more clearly indicate follow-up and relapse prevention services are performed by the MCOT within 24 hours.  The amended flowchart has been inserted into the updated Crisis Service Plan, replacing the previous flowchart.

 

IV.             Line-item Budget.

A line-item budget, with narrative, has been attached to the Crisis Service Plan.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTACHMENT L

 

ACCESS MHMR

Crisis Redesign Plan Required Addendum

3-1-2010

 

Per  Information Items A and I of the FY2010-2011 DSHS Performance Contract, the following describes items in the ACCESS Crisis Services Plan that have been updated or revised:

 

I. Crisis Services for Special Populations:

Services to Veterans - ACCESS has received a DSHS grant for to enhance and expand the availability of, access and outreach to, and awareness of community-based behavioral health supports and services for veterans in Anderson and Cherokee Counties in East Texas.   

Services and supports to be delivered through this grant will focus on identifying and coordinating available resources and, where possible, developing additional resources to meet any identified gaps in needed services. Public service campaigns, highly publicized outreach events, and outreach to community key stakeholders and veterans and their families will provide information on available resources and assistance in accessing those resources. Veterans will receive training to facilitate peer support groups and ACCESS has already sent the first of three teams to Bring Everyone In the Zone training.

 

In addition to the peer facilitated group activities, ACCESS has subcontracted with Grace After Fire, a 501(c )(3) to provide access to an online peer support network, electronic access to resources, and eLearning opportunities, including online webcasts developed in partnership with the VA featuring the latest veterans' news and updates, benefits changes, and eligibility. Media and video materials will be produced for easy access and viewing day or night. Grace After Fire will also produce marketing strategies to assist the peer-to-peer groups in reaching their intended audience and assist the peer-to-peer groups and community partners in locating resources and developing referral processes. Additionally, Grace After Fire will assist in data collection and ongoing program evaluation.

 

The peer-to-peer groups and Grace After Fire will coordinate with community partners to facilitate referrals of veterans to needed services, including access to needed substance abuse treatment through ETCADA.  Community service agency partners include programs for substance abuse screening, assessment, and treatment, contacts with the various county service officers and the Texas Veterans Commission, the various programs that support Texas military forces, particularly the Yellow Ribbon Program and other activities associated with the overseas deployment cycle, the Veteran’s Integrated Services Network, the TexVet Partners Across Texas program, programs that support housing and employment, jail diversion programs for veterans and active service members related to behavioral health services, the various local school districts, and other relevant service agencies that provide services needed by veterans.

 

ACCESS also, through an Interlocal Cooperation Contract with The Andrews Center, provides individual counseling, family counseling, anger management and/or substance abuse counseling for military personnel deployed, or returned from deployments, to Iraq and/or Afghanistan and/or their family members residing in Anderson and Cherokee Counties.

 

Services to Children/Adolescents and Victims of Trauma - ACCESS staff participate in the East Texas Suicide Coalition, the Child Fatality Review Team, and CRCGs in each County.  As noted previously, the CRCGs have been particularly effective in trying to prevent out of home placements and/or referrals to TYC.  ACCESS also has a Services to at Risk  (“STAR”) program that provides free services and training (funded by DFPS) to children and adolescents and their families.  Services focus on protecting the youth while supporting the family unit and address a range of issues, from family conflict to truancy, runaways, and substance abuse.

 

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.

 

            II. Flowchart Amended.

The flowchart is in draft form, pending any additional revisions resulting from stakeholder feedback received at Forums/Stakeholder Meetings and from Survey responses. The final flowchart for FY2010-2011 will be attached to the final Crisis Plan submitted with the LSAP in July, 2010.

 

III. Source of Funds for Crisis Services.

Crisis Hotline, MCOT, crisis inpatient psychiatric beds, crisis flexible funds, and the pending Crisis Respite Program (operational in Summer, 2010) are funded first by  Crisis Allocation dollars, and augmented by Medicaid Rehab and required Local Match.