Emergency
Services Program Recommendations
ATTACHMENT 2
In the year 2000 the Department of Health and Family Services (DHFS),
Office of Program Review and Audit (OPRA), in cooperation with the Bureau
of Community Mental Health, conducted a program and financial review of
four counties that have a high incidence of emergency detentions of
non-Wisconsin residents. The review was requested by the Division of
Supportive Living (DSL) to determine if these counties were directing
non-Wisconsin residents who are emergency detained to the appropriate
treatment resources, providing appropriate clinical services prior to
discharge, and accurately securing reimbursement from DHFS for these
services. The following are selected recommendations from that review
which should be implemented by each county in relation to its current
practices for emergency detention and other emergency services for
Wisconsin residents and non-Wisconsin residents.
- Crisis intervention services.
Counties should strive to develop
and/or improve crisis intervention services because it is clinically,
programmatically and economically beneficial for counties and their
clients who can benefit from crisis intervention services. Even if
budgetary restraints preclude the development of comprehensive crisis
intervention services for a particular county, the Department’s review
indicates that it would benefit counties to develop predominantly
non-hospital based crisis intervention services that may include one or
more of the following:
- Telephone service
under HFS 34.22 (3) (a) that provides support,
counseling, intervention, emergency service coordination and referral.
- Mobile crisis services
under HFS 34.22 (3) (b) that provides
crisis services onsite and in-person intervention for persons
experiencing a mental health crisis. These services have demonstrated
their effectiveness in diverting persons with a mental disorder from
unnecessary hospitalization and resolving the problems related to the
mental health crisis.
- Walk-in services
under HFS 34.22 (3) (c) that provides
face-to-face support and intervention at an identified location or
locations on an unscheduled basis.
- Short-term voluntary or involuntary hospital care
under HFS
34.22 (3) (d) when less restrictive alternatives are not sufficient to
stabilize a person experiencing a mental health crisis.
- Crisis stabilization services
under HFS 34.22 (4) (a) that
provides stabilization services to a person for a temporary transition
period in a setting such as a crisis hostel, Community Based Residential
Facility, Adult Family Home or other settings.
- Medically monitored residential detoxification services
under
HFS 75.07 that provides medically monitored detoxification services and
monitoring 24-hours per day in a residential setting. Care is provided
by a multi-disciplinary team of service personnel, including 24-hour
nursing care under the supervision of a physician.
- Residential intoxication monitoring services
under HFS 75.09
that provides 24-hour per day observation by staff to monitor the safe
resolution of alcohol or sedative intoxication, and to monitor for the
development of alcohol withdrawal for intoxicated patients who are not
in need of emergency medical or psychological care. This service may be
provided in a hospital, Community Based Residential Facility or an Adult
Family Home.
It is important that the county provide some screening mechanism to
insure that persons detained in less restrictive community based
programs do not need hospital level inpatient services. Programs that
meet the applicable standards contained in the above referenced
administrative codes may claim Medicaid reimbursement for these
services.
To find out more about the crisis intervention services under HFS 34
for persons with a mental illness, please contact George Hulick, CICSW,
Clinical Consultant, Bureau of Community Mental Health at (608)
266-0907. To find out more about crisis intervention services under HFS
75 for persons with substance abuse issues, please contact Vince Ritacca,
Interdepartmental Program and Systems Liaison, Bureau of Substance Abuse
Services at (608) 266-2754. Messrs. Hulick and Ritacca can provide
information and consultation about crisis intervention services in their
respective fields, and technical assistance in developing such programs.
See Reimbursement to County Agencies, Statutory basis for
reimbursement on pages 6 through 13 of this Memo Series that
identifies the types of Emergency detention services eligible for
reimbursement from DHFS, including non-hospital based crisis
intervention and community based services for emergency detentions of
non-Wisconsin residents.
- Mental health triage with law enforcement officials.
Some
hospitalizations occur because police bring people directly to a
hospital ER, bypassing any available crisis services. At other times,
police initiate an emergency detention to decrease their perceived
liability risk, even when the involved clinicians do not think
hospitalization is necessary. Counties should work cooperatively with
local law enforcement officers on mental health triage that may serve to
avoid emergency detentions in the first place, use non-hospital based
crisis interventions when appropriate, and establish more appropriate
police procedures (such as less or no use of handcuffs) for persons with
a mental illness. The mental health triage should include a crisis
intervention worker who is on call to respond quickly to emergency
detentions, preferably while the detention is occurring, and work with
police to determine if the person needs emergency detention and if so,
is detained at the least restrictive setting needed. The mental health
triage should also include the law enforcement dispatch center to assure
that the dispatchers know that a county agency has a crisis intervention
worker, who that person is, and how to notify him or her of a crisis
situation. Dispatchers can play an important role of assisting in the
coordination of law enforcement officers and crisis intervention workers
to the benefit of persons being detained.
- Monitoring inpatient hospitalizations.
Counties should develop
written policies and procedures to clinically monitor inpatient
hospitalizations following an emergency detention to ensure that the
patient’s length of stay is appropriate and that needed court orders
are obtained on a timely basis. If a crisis intervention worker is not
able to participate in mental health triage at the time of the
detention, then clinical monitoring should include, but not be limited
to, a face-to-face visit with the client no later than the next working
day following detention to assure that the client is in the appropriate
setting. The Department’s review indicated that there are significant
benefits in counties where there is monitoring of clinical care and
length of stay. The benefits include assurance that the client is in, or
is transferred to, the appropriate setting, and that the client is
discharged when clinically appropriate; i.e., not retained in the
facility longer than necessary to achieve clinical stability. These
measures tend to reduce the length of stay of a client, make good use of
scarce resources, and reduce the overall cost of care. Such monitoring
also helps to avoid violations of client rights under HFS 94.07,
"Least restrictive treatment and conditions," and HFS 94 08,
"Prompt and adequate treatment."
- Border county agreements with neighboring states.
Wisconsin
counties bordering neighboring states should take the initiative to
develop agreements with counties and law enforcement agencies in
neighboring states on the use of Wisconsin hospitals by out-of-state
residents for emergency detention and non-emergency detention
situations. These agreements should, at a minimum, address the payment
for such services from sources in the patient’s home state, and that
patients who cannot be retained in the Wisconsin hospital for any reason
(such as, but not limited to, behavioral issues or unusual treatment
needs) are transferred to an appropriate hospital in the patient’s
home state, not to Mendota or Winnebago Mental Health Institute.
- Discharge of clinically stable patients.
Patients who have been
emergency detained and for whom the county has established probable
cause under s. 51.20 (7), Stats., may be discharged from the treatment
setting and returned to their home state before the final commitment
hearing if the person has stabilized clinically and is ready for
discharge into the community. In these instances, it is not necessary
that the case go to a final commitment hearing. An adequate discharge
plan should be developed identifying needed outpatient services the
person should receive in their home state. See the section Reimbursement
of transportation and related expenses beginning on page 11
regarding Department reimbursement to return a person to his or her home
state or to another state of his or her choosing.
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NMemo02-19
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