slides gte mental health webinar may 2013 for posting pre event

May 29 Live Webinar: The TDO Process 5/21/2013

2013, Sarah Bisconer & Jim Martinez 1



Current statutes and procedures governing when and how the TemporaryDetention and involuntary admission process may occur

How to initiate the Preadmission Screening and Temporary Detention process

Practical considerations to keep in mind when initiating the Temporary Detentionand involuntary admission process (e.g., helpful documentation, timing, medicalclearance, transportation, readmission to facility after treatment and stabilization)

• ALF – Assisted Living Facility

• BHA – Behavioral Health Authority

• CSB – Community Services Board

• DBHDS – Department of Behavioral Health andDevelopmental Services

• DSM-IV-TR – Diagnostic and Statistical Manual of MentalDisorders (will be replaced by DSM-V in May 2013)

• ECO – Emergency Custody Order

• ISP – Individualized Service Plan

• MOT – Mandatory Outpatient Treatment

• TDO – Temporary Detention Order



This presentation includes material aboutVirginia’s involuntary treatment process for peoplewith mental illness, which is based on Virginia law.

Individual states all have their own involuntarytreatment laws.

State laws in this area are often similar, but rarelyidentical, and some individual state’s laws are verydifferent from those in other states.

The situations discussed here are relevantanywhere, so it’s important to know the laws ofyour state.

Involuntary admission is the court process bywhich a petition is filed to initiate involuntarypsychiatric treatment for a person who needs carebut who is unwilling, or incapable of volunteeringfor treatment (Code of Virginia, §37.2-808, et. seq)

The petition (the case) is adjudicated by a judge orspecial justice at a formal court hearing.

Due process protections are important, butbalancing rights of individuals with communityinterests and public safety can be difficult.Treatment resources are limited and controversiesabound.



* Operational procedures vary considerably from locality to locality

CSB CrisisContact

EmergencyCustody (ECO)

TemporaryDetention (TDO)

Petition FiledCourt Hearing(on petition)

Release orDismissal

MandatoryOutpatientTreatment

VoluntaryInpatient

Treatment

InvoluntaryInpatient

Treatment

• Emergency custody and temporary detention are not requiredfor every involuntary admission (i.e., ECO is not required fortemporary detention, TDO is not required for commitment).

• But, both procedures are needed for due process andpractical reasons, for example:

• Emergency custody allows an in-person examination, toconfirm the need for temporary detention.

• Temporary detention allows time to organize a fairinvoluntary admission court hearing.



be issued by a magistrate on a petition or his/her own motion,

or

be initiated by a law enforcement officer on his/her ownobservations or the reports of others(“officer-initiated” or “paperless” ECO).

AnECOmay:

PROBABLE CAUSE is the evidentiary standard for emergency custody to be used.

“Under an ECO, the person is taken into custody and brought to a “convenientlocation”, if needed, so that CSB can complete the “in-person” evaluation required

for temporary detention. TDO may result.

TemporaryDetention

• May be ordered if the “in-person” CSB evaluation(i.e., the ECO evaluation) has occurred,* criteriaare met and TDO is needed.

• Occurs in a safe clinical setting, (usually ahospital) where treatment can be started.

• During temporary detention, the hearing isscheduled, participants are organized andrelevant information is gathered.

* There are some exceptions to the requirement for prior in-person evaluation.

TEMPORARY DETENTION IS A BRIEF PERIOD OF CONFINEMENTORDERED BY A MAGISTRATE (TDO) PRIOR TO THE COURT HEARING.



“…. person

(i) has a mental illness and …. there exists a substantial likelihood that,as a result of mental illness, the person will, in the near future,

(a) cause serious physical harm to himself or others as evidenced by recentbehavior causing, attempting, or threatening harm and other relevantinformation, if any, or

(b) suffer serious harm due to his lack of capacity to protect himself from harmor to provide for his basic human needs,

(ii) is in need of hospitalization or treatment, and

(iii) is unwilling to volunteer or incapable of volunteering forhospitalization or treatment.”

* Other specific findings and determinations are associated with each procedure.

A preadmission screening report is required to be presented,by the appropriate CSB, at the involuntary admission courthearing.

The requirements for preadmission screening report aredifferent from ECO/TDO evaluation requirements, but

In almost all instances, when a CSB performs an exam for aTDO, that evaluation also serves as the CSB’s preadmissionscreening report for the subsequent court hearing.



Only qualified CSB employees or designees may perform ECOevaluations for TDO, and preadmission screening for commitmenthearings. Requirements are:

› Master’s degree in a clinical field recognized by the VirginiaDepartment of Health Professions (e.g., Counseling,Psychology, Social Work, Rehabilitation Counseling).

› Licensed Registered Nurse with 36 months professionalwork experience with a psychiatric population.

› Completed DBHDS Preadmission Screening on-lineCertification Training (a series of modules)

› CSB supervisory approval

Documentation of above (i.e., educational credentials, supervisory approvaland completion of on-line curriculum) is maintained in CSB personnel files.

See http://www.dbhds.virginia.gov/OMH-MHReform.htm.

TYPICAL CSBEVALUATOR

RESPONSIBILITIES

Conduct face-to-face assessments ofpersons in crisis foracute mental healthand substance use

disorders;

Collate informationfrom individuals

being served, familymembers, other

providers, medicaland other records

and any othersource;

Provide crisiscounseling,

outpatient andinpatient referrals.

Serve as primarygatekeepers to

communityhospitals, state

hospitals, & trainingcenters, including

locating andaccessing inpatientbeds for temporary

detention.

Documentassessment findingsand determinations

in the VirginiaPreadmission

Screening Reportform.

Implement Virginia’sinvoluntary

admission statutes,including attendance

at court hearings.



COURT HEARINGS

Court hearings must be held within 48 hours of TDO, or on the nextbusiness day if 48-hour period ends on Saturday, Sunday or holiday.

Persons receives explanation of rights, counsel, etc.

Independent examination required.

CSB preadmission screening report required.

Hearing attended by judge (usually special justice), individualand attorney, petitioner, as well as independent evaluator,*CSB screener* (both may participate by telecom), treating MD*or hospital representative, family or friends.

*may participate and/or report by electronic means.

Dismissal of thepetition, andrelease from

courtjurisdiction;

Voluntaryinpatient

admission for aminimum 72-

hour period, then48-hour notice if

leaving;

Involuntaryinpatient

admission (up to30 days on initial

order, 180 forrenewal or

recommitment);

MandatoryOutpatientTreatment

(MOT).

POSSIBLEHEARING

OUTCOMES



Voluntary alternative dispositions, at any stage,should always be encouraged, such as:

Release to care of self, or with family or friend support;

Voluntary admission to a regional crisis stabilization unit; or

Voluntary admission to a psychiatric hospital.

The involuntary admission process can be painful and traumatizing.

Many other important issues are covered ininvoluntary admission statutes, such as:

• Permitted disclosures;

• Transportation, including use ofalternative transportation;

• Mandatory outpatient treatment;

• Impact on right to purchase firearms, etc.

Also, be mindful of Advance Directives(§54.1-2981, Health Care Decisions Act)



Law permits agentappointed in anadvance directiveor a guardian toadmit anincapacitatedperson to apsychiatric facilityfor up to 10 daysif:

Physician fromadmitting facilityexamines person andfinds in writing that:

The person has mental illness, is incapable ofmaking an informed decision, and needsinpatient treatment;

Proposed facility is willing to admit ; and

The person’s AD authorizes admission byagent, or the guardianship order authorizesadmission by guardian.

CSB pre-admissionscreening is requiredfor state hospitaladmission.

Hospitalization may becontinued beyond 10days via “otherprovisions of law” (i.e.,involuntary admission).

Virginia involuntary admission and related statutes leave roomfor local variations in practice.

› It takes all partners working together to make emergencyservices work well.

› Collaboration and commitment to “customers first” isessential.

Too much variation can complicate the process, and reducetimely access to care for some.



Appearance (neat, clean, disheveled, unkempt, bizarre)

Behavior/Motor Disturbance (agitation, aggression)

Orientation (person, place, time, situation)

Speech (rapid, pressured, slowed, slurred)

Mood/Emotions/Impulse Control

Range of Affect (labile, flat, blunted, full range)

Thought Processes (disorganized, flight of ideas, tangential)

Thought Content (religious delusions, paranoid thoughts)

Sensory Perceptions (auditory, visual, tactile, olfactorygustatory)

Memory (immediate, recent, remote)

Appetite/Sleep

Insight and Judgment

Risk Assessment (suicide or homicide ideation, intention, plan,means)

A Mental StatusAssessment is a

systematic evaluation of aperson’s level of

functioning and helpsstaff monitor changesfrom baseline level of

functioning.

A person developspsychotic symptomsincluding delusionalthoughts or hallucinations.

A person develops manicor depressed moodsymptoms.

A person voices suicidal orhomicidal thoughts withintent to harm self orothers.

A person experiencescommand hallucinations orvoices telling him to harmself or others.

A person becomesdisorganized, confused,and disoriented in a matterof hours or days.

PSYCHOSIS

MANIA

SUICIDE

COMMANDHALLUCINATIONS

DELIRIUM



What aredelusionalthoughts?

• Paranoid (Believes CIA or FBIis monitoring him)

• Religious (Believes Jesus talksto with him)

• Somatic (Believes electronicdevise is implanted in his brain)

• Grandiose (Believes he ispresident of the U.S.)

What arehallucinations?

• Auditory (Hearing voices)• Visual (Seeing things)• Olfactory (Smelling things)• Gustatory (Tasting things)• Tactile (Feeling things on skin)

A personbecomes

psychotic.

What is a fixeddelusion?

• A fixed false belief that isresistant to reason or actual fact.

Who develops afixed delusion?

• People with schizophrenia andother psychotic disorders.

Is a fixeddelusion an

acute psychiatricemergency?

• Not necessarily!

Examples:

• Person believes she has 4000 babiesand is pregnant again.

• Person believes he was abducted bythe CIA as a baby.

• Person believes he is transmitting histhoughts via radar.



A personbecomes manic.

WHAT IS MANIA?

• Inflated self esteem or grandiosity• Decreased need for sleep• More talkative than usual• Flight of ideas or racing thoughts• Easily distracted• Increased activity or psychomotor agitation• Excessive involvement in pleasurable activities

A personbecomes

depressed.

WHAT IS DEPRESSION?• Sad, empty, tearful• Diminished interest or pleasure in activities• Sleeping too little or too much• Psychomotor agitation or retardation• Fatigue or loss of energy• Feels worthless or excessive or inappropriate guilt• Poor attention and concentration• Recurrent thoughts of death or suicide



A person wants tokill themselves.

WHAT ARE RISK FACTORS FOR SUICIDE?• Active psychosis (hallucinations, delusions)

• Self injurious, reckless, or impulsive behavior• Current alcohol or drug abuse

• Presently clinically depressed(hopelessness, anxiety)

• Chronic debilitating medical illness with poor pain management• Suffered recent major loss (death, divorce, home)

• Isolated from others socially• Thoughts or fantasies about suicide

• Unexpectedly giving gifts or giving away personal items• Unexpectedly writing a will or making funeral arrangements

A person wants tokill another

person.

WHAT ARE RISK FACTORS FOR HOMICIDE?

• Active psychosis (hallucinations, delusions)• Acute manic mood symptoms• Paranoid beliefs that others want to hurt him/her• Overt anger and hostility toward others• Verbal threats to hurt or kill others• Recent physical aggression toward others• Thoughts or fantasies about killing someone• History physical aggression toward others



What arecommand

hallucinations?

•Auditory hallucinations or voices telling you todo something.

•Acting on the command can be lifethreatening.

•Sometimes voices tell you to kill yourself or killsomeone else.

•Sometimes voices tell you to jump off abuilding because you can fly.

•Sometime voices tell you to do somethingmore neutral (e.g., brush your hair).

•All command hallucinations should be takenseriously.

Who mightexperiencecommand

hallucinations?

•Persons with schizophrenia or schizoaffectivedisorder.

•Persons with bipolar disorder during manic ordepressed mood phases.

•Persons with dementia.•Persons with acute delirium.

A personexperiencescommand

hallucinations.

Disorganizedspeech –

Change in theway a personcommunicates

•Odd or incoherent sentences•Forgetting words or names or makingup words

•Changing topics repeatedly and rapidly

Disorganizedbehavior –Change in

normalbehaviorpatterns

•Naked in public settings•Wearing costumes or many layers ofclothing

•Incontinent or voiding in inappropriateplaces

•Taking things that do not belong tothem

•Wandering into other person’s rooms

Confusion anddisorientation– person …

•Does not recognize well-known staff orfamily

•Cannot find his bedroom or the diningroom

•Does not know the time, day, month,year, season

•Does not know the name of the facility•Does not know the town, state, countrywhere he resides

•Cannot share his life history

A personbecomes

disorganized,confused,

disoriented ina matter of

hours or days.



Delirium is Always an Acute Medical Emergency.

Delirium is an acute, transient (comes and goes), reversible state of confusioncharacterized by disorganized thoughts and behavior, confusion,disorientation, poor attention and concentration, sleep disturbance, agitation,hallucinations and other psychotic symptoms.

Likelihood of developing delirium increases exponentially with age.

Delirium can becaused by thefollowing factors:

Alcohol or drug use or abuse

Over-the-counter drugs (laxatives, sleeping aids, antacids, pain relievers)

Polypharmacy adverse interactions

Acute physical illness (blood sugar, blood pressure, thyroid, kidney)

Brain injury, lesions, stroke

Vitamin B12 and folate deficiencies

Sodium and potassium imbalances

HIV/AIDS

Surgical procedures and anesthesia

Psychosocial stressors (family death, social isolation)

Sleep deprivation

Urinary tract infection / dehydration

Lack of sensory stimulation and immobilization



Drugscommonlyassociated withdelirium

AnticholinergicsArtane, Benadryl, Cogentin, Symmetrel

Anti-ParkinsonsLevodopa, Carbidopa

Anxiolytics –sedatives – hypnotics

Ativan, Klonopin, Ambien

Histamine-2 receptorblockers

Tagament, Zantac

Narcotic analgesicsDemerol, Dilaudid, Fentanyl, OxyContin,Percocet, Vicodin

Following is the DSM-IV-TR Diagnosis:

The development of multiple cognitive deficits manifested by both (a) memoryimpairment (impaired ability to learn new information or to recall previously learnedinformation) (MEMORY PLUS ONE):

one (or more) of the following cognitive disturbances:

Aphasia (language disturbance)

Apraxia (impaired motor functions)

Agnosia (failure to recognize or identify objects)

Disturbance in executive functioning (planning, organizing, sequencing,abstracting)



Asso

cia

ted

Featu

res

Learning Problems

Memory Problems

Dysarthria or Involuntary Movement

Hypo-activity

Hyper-activity

Psychosis

Depressive Mood

Sexual Dysfunction

Sexually Deviant Behavior

Odd or Eccentric or Suspicious Personality

Anxious or Fearful or Dependent Personality

Dramatic or Erratic or Antisocial Personality

Medical screening and assessment is an important part of screening forhospitalization.

“…psychiatric hospitals today justifiably emphasize the importance ofcareful medical screening and assessment prior to admission of anyperson, and most hospitals will not admit a person unless such screeninghas been completed.”

To bring more consistency to practice, Virginia developed MedicalScreening and Assessment Guidance Materials in 2007 (seehttp://www.dbhds.virginia.gov/documents/omh-reform-MedicalScreenGuide.pdf

These materials are in the process of revision and will likely be completedSummer 2013.



CAUSE

A first logical step inan acute psychiatricemergency is to ruleout a medical causefor changes in mentalstatus and behavior.

PHYSICAL

Physical exam, bloodand urine lab work,and other medicaltests are conductedto rule out a medicalproblem. Mentalstatus and behavioroften stabilizes withmedical treatment.

PSYCHIATRIC

Once a medicalcause is ruled out apsychiatric bed canbe obtained.

CLEARANCE

Medical clearance isalmost alwaysrequired by apsychiatric hospitalbefore accepting aperson for admissionspecifically to rule outmedical causes forchange in mentalstatus and behavior.

Elders with a dementia diagnosis can benefit from inpatient psychiatrictreatment if they have:

› Acute symptoms of psychosis

› Acute symptoms of depression or mania

› Acute symptoms of anxiety and agitation

› Current Alcohol or substance abuse

Medical Record should reflect systematic changes in mental status andbehavior.

Good documentation helps the Preadmission Screener with decision tohospitalize or not.



Inpatient psychiatric hospitalization is appropriate if there is reasonto believe that the acute psychiatric symptoms will IMPROVE withtreatment.

Chronic behaviors and symptoms should be managed by anoutpatient physician and by implementing behavioral interventionsin the residential setting.

Elders with adementia diagnosis

likely will not beaccepted for

inpatientpsychiatric

treatment if:Acute symptoms arenot dangerous to selfor others and can be

treated andmonitored by an

outpatient physician.

Symptoms orbehaviors are chronic

and persistent andhave not responded

to psychiatricmedication trials in

the past.

Symptoms orbehaviors are not

expected to improvewith psychiatric

medication.



Condition for admission to any hospital:

› Facility Administrator often must state in writing that theperson can return to the facility when the accepting hospitaldetermines the person is ready for discharge.

› Without a letter many hospitals will not admit the person.

› Average length of stay 3 to 14 days.

Anyone canrequest an

evaluation or aPreadmission

ScreeningAssessment:

Any person

Family or friendof person

PoliceHospital

Other careprovider



CSB office

Crisis center

Hospital

Assisted living setting

Jail or police department

Home or private location (per CSB policy)

Assessment iscompleted in a safesetting approved by theCrisis Counselor

If person is an acute danger,severely disorganized,uncooperative, assessment isdone under police supervisionin a secure setting

• Magistrate issued ECO• Officer initiated ECO

If person is cooperative andnot dangerous, assessment isdone without policesupervision at a locationdetermined by the CrisisCounselor.



SUMMARY

First and foremost you shouldalways feel free to callEmergency Services toconsult about a case.

Watch for, recognize, anddocument early symptoms

and early changes in mentalstatus and behavior.

Rule out medical causes forchanges in mental status and

behavior.

If you are a facility, considerimplementing an evidence based

behavior and environmentalmanagement program forpersons with challenging

behaviors..

Finally, and most importantly, developand nurture relationships with yourcommunity partners and work with

them to provide best practice care forpeople experiencing a psychiatric or

behavioral crisis.

slides gte mental health webinar may 2013 for posting pre event

Health & Medicine