Northwest Connections Emergency Mental Health Services WI Statute Review

1. Northwest ConnectionsEmergency Mental Health Services WI Statute Review

2. Emergency Mental Health Services WI DHS 34

3. DHS 34 • Emergency Mental Health Services(aka Crisis Services)-a coordinated system of mental health services which provides an immediate response to assist a person experiencing a mental health crisis. • This statute was created in 1996 to provide an outline of expected service provision in all WI counties • All counties in Wisconsin are required to provide DHS 34 services

4. Initial Training Requirements • Pertinent parts of DHS Chpt 34 • The program’s policies and procedures. • Job responsibilities for staff and volunteers in the program. • Applicable parts of Chs. 48, 51 and 55, Stats., and any related administrative rules. • The provisions of s. 51.30, Stats., and DHS 92 regarding confidentiality of treatment records. • The provisions of s. 51.61, Stats., and DHS 94 regarding patient rights.

5. Initial Training Requirements • Basic mental health and psychopharmacology concepts applicable to crisis situations. • Techniques and procedures for assessing and responding to the emergency mental health service needs of persons who are suicidal, including suicide assessment, suicide management and prevention. • Techniques for assessing and responding to the emergency mental health service needs of persons who appear to have problems related to the abuse of alcohol or other drugs. • Techniques and procedures for providing non−violent crisis management for clients, including verbal de−escalation, methods for obtaining backup, and acceptable methods for self−protection and protection of the client and others in emergency situations.

6. Training Requirements • 40 hours of documented orientation training within 3 months after beginning work with the program (staff person who has less than 6 months of experience in providing emergency mental health services) or 20 hours of documented orientation training within 3 months after beginning work with the program (staff person who has had 6 months or more of prior experience in providing emergency mental health service)-Administration will determine trainings based on experience and need. • 20 hours of additional training in providing mental health services to children/adolescents within 3 months after being hired (staff person who has not had one year of experience providing mental health services to young children or adolescents)

7. Ongoing Training • Ongoing training requirement-8 hours per year of In-service training • How this is met: • 1:1 Training • Group Training(usually during supervision) • Assignment to attend a training • All training is tracked in a training log

8. What is a crisis? WI Chapter 34 defines Crisis as “a situation caused by an individual’s apparent mental disorder which results in a high level of stress or anxiety for the individual, persons providing care for the individual or the public which cannot be resolved by the available coping methods of the individual or by the efforts of those providing ordinary care or support for the individual.”

9. What is a Response Plan? “Response plan” means the plan of action developed by program staff under s. DHS 34.23 (5) (a) to assist a person experiencing a mental health crisis. • Staff of the program shall prepare and initiate a response plan consisting of services and referrals necessary to reduce or eliminate the person's immediate distress, de-escalate the present crisis, and help the person return to a safe and more stable level of functioning. • Response planning should be a risk assessment based determination.

10. Required Emergency Mental Health Service Components • 24-Hour Telephone service:provides information, support, counseling, intervention, emergency service coordination • Mobile crisis service:provides onsite, in−person intervention • Walk−in service:provides face−to−face support and intervention at set location on an unscheduled basis • Short-term voluntary or involuntary hospitalization: when less restrictive alternatives are not sufficient to stabilize an individual who is in crisis • Linkage and coordination service:assistance during the period of transition from emergency to ongoing mental health services • Services for children/adolescents and their family: meet the unique needs • OptionalStabilization service: temporary transitional setting for crisis services

11. Telephone Services-Definition “Telephone services” means telephone response services to provide callers with immediate information, counseling, support and referral and to screen for situations which require in−person responses. • Must be available 24/7 • The person answering must be able to assist • Be provided by staff qualified under s. DHS 34.21 (3) (b) 1. to 19. Staff qualified under s. DHS 34.21 (3) (b) 9. to 19., a mental health professional qualified under s. DHS 34.21 (3) (b) 1. to 8. shall be on site or constantly available by telephone to provide supervision and consultation.

12. Telephone Services Process(NWC Specific) Call is received by the call center “Hello NWC how may I help you” Identification of identified “client” Identify any previous contacts/crisis plan Yes-review items as information is being provided and proceed with an initial assessment No- proceed with initial assessment Formulate a response plan

13. Telephone Services Only-Outcomes • Information Only • Medical Treatment Primary • Home Individually • Home individually with telephone stabilization phone call(s) • Community Supports – Support / supervision by / with family / friends at home or alternative residence • Crisis Bed • Voluntary Hospital Admission

14. Telephone Services Only-Outcomes Continued • Voluntary Detox Admission – In counties this is an option • 51.45 : Incapacitated by Alcohol • 55: This would only be used if an Emergency Protective Placement (55) was the outcome. • 51:15 Emergency Detention(ED) • Jail • JDC • Send Mobile(face to face response)

15. Mobile Services-Definition “Mobile crisis service” means a mental health service which provides immediate, on−site, in−person mental health service for individuals experiencing a mental health crisis. • Must be available 8 hours per day • Staff providing mobile services shall be qualified under s. DHS 34.21 (3) (b) 1. to 15 A mental health professional qualified under s. DHS 34.21 (3) (b) 1. to 8.shall either provide in−person supervision or be available to provide consultation by phone.

16. Mobile Services Process(NWC Specific) Call Center calls and indicates they have a case to respond to Call Center provides information including previous contacts/crisis plan Mobile proceeds to location –completes assessment Formulate a response plan

17. Mobile Services-Outcomes • Home Individually • Home individually with telephone stabilization phone call(s) • Community Supports – Support / supervision by/with family/ friends at home or alternative residence • Crisis Bed • Voluntary Hospital Admission • Voluntary Detox Admission – In counties this is an option • 51.45: Incapacitated by Alcohol • 55: Emergency Protective Placement • 51:15 Emergency Detention(ED) • Jail • JDC

18. When to consider sending mobile • Juvenile cases tend to be more complicated and benefit from mobile worker contact more frequently. Additionally, many times the 25-30 minutes for a mobile worker to respond to the location will allow de-escalation to begin. • If the consumer is unwilling to speak with a worker via phone • Forced cooperativeness (consumer is being told they have to talk with you via phone or a predetermined outcome will occur) • When the telephone worker is receiving conflicting information/reports • When you are struggling to implement a response/safety plan that all parties are comfortable with

19. Stabilization-Defined “Stabilization services” means optional emergency mental health services under s. DHS 34.22 (4) which provide short−term, intensive, community−based services to avoid the need for inpatient hospitalization. • Reducing or eliminating an individual’s symptoms of mental illness so that the person does not need inpatient hospitalization. • Assisting in the transition to a less restrictive placement or living arrangement when the crisis has passed. • Staff providing stabilization services who are qualified under s. DHS 34.21 (3) (b) 1. to 19., with those staff qualified under s. DHS 34.21 (3) (b) 9. to 19. supervised by a person qualified under s. DHS 34.21 (3) (b) 1. to 8.

20. Stabilization Services • Via phone • At a community location • Hospital diversion facility (Crisis/Respite Bed) • Medication Monitoring • Symptom Monitoring • Case Management

21. Walk In Services-Defined “Walk−in services” means emergency mental health services provided at one or more locations in the county where a person can come and receive information and immediate, face−to−face counseling, support and referral. • Must be available 8 hours a day, 5 days a week excluding holidays • Be provided by persons qualified under s. DHS 34.21 (3) (b) 1. to 14. However, persons qualified under s. DHS 34.21 (3) (b) 9. to 14. shall work under the supervision of a mental health professional qualified under s. DHS 34.21 (3) (b) 1. to 8.

22. Walk In Services-Goals • Immediate relief of distress and reducing the risk of escalation in pre−crisis and crisis situations. • Referral to or arrangement for any additional mental health services which may be needed. • Self−directed access to mental health services.

23. Follow Up and Linkage-Defined After a response plan has been implemented and the person has returned to a more stable level of functioning, staff of the program shall determine whether any follow−up contacts by program staff or linkages with other providers in the community are necessary to help the person maintain stable functioning.

24. Follow Up and Linkage -Process • Contacting the person via phone • Contacting the person’s ongoing mental health providers or case manager • Conferring with family members or other persons providing support for the person to determine if the response and follow−up are meeting the client’s needs. • Developing a new crisis plan under sub. (7) or revising an existing plan to better meet the person’s needs based on what has been learned during the mental health crisis. • Setting up a face to face crisis appointment Each county has their own policy and practices on follow up and linkage

25. Clinical Consultation • Available via phone at all times the program is in operation. • First 5 calls • When/if staff encounter a situation that is more unusual or complex or higher risk and you would like to problem solve, seek guidance, or achieve concurrence on your plan. • Provided by WI Licensed Clinicians (LCSW, LPC, MFT, PhD)

26. Clinical Supervision • Program staff who are not qualified under sub. (3) (b) 1. to 8., receive a minimum of one hour of clinical supervision per week or for every 30 clock hours of face to face mental health services they provide. • Program staff who are qualified under sub. (3) (b)1. to 8., participate in a minimum of one hour of peer clinical consultation per month or for every 120 clock hours of face−to−face mental health services they provide. • Provided by-A mental health professional qualified under s. DHS 34.21 (3) (b) 1. to 8

27. Clinical Supervision • Individual sessions • Individual side−by−side sessions • Group meetings • Other professionally recognized methods of supervision

28. State Alcohol, Drug Abuse and Developmental Disabilities ActWI Chapter 51

29. State Alcohol, Drug Abuse, Developmental Disabilities and Mental Health Act • WI Statute 51 • Created in 1975 • Created toassure the provision of a full range of treatment and rehabilitation services in the state for all mental disorders and developmental disabilities and for mental illness, alcoholism and other drug abuse • Protect personal liberties: “no person who can be treated adequately outside of a hospital, institution or other inpatient facility may be involuntarily treated in such a facility.”

30. 51.15-Emergency Detention • Statute section that outlines specifically the requirements for removing a persons civil liberties and placing them in a locked inpatient unit • The purpose of this section is to provide, on an emergency basis, treatment by the least restrictive means appropriate to the individual’s needs • This is a legal hold

31. Different ways of saying the same thing • ED • Chapter • Emergency Detention • 51 • 51.15 • 72 hour hold • Involuntary Commitment • Commitment

32. 51.15-Specific Criteria • Person is mentally ill, drug dependent, or developmentally disabled. • Person is reasonably believed to be unable or unwilling to cooperate with voluntary treatment. • By act or omission the person is found to also be a • Danger to themselves • Danger to others • Unable to care for self • Judgement is impaired We will discuss this at more length in the Response Planning of training

33. Common Questions • How long is the person in the hospital for-this is dependent on the receiving facilities director • Can the person be released before 72 hours is up-yes once they arrive at the facility it is that facilities determination to proceed with a probable cause hearing

34. 51.20- Involuntary commitment for treatment • Within 72 hours of an ED a probable cause hearing must occur (excluding weekends and holidays) • During that probable cause hearing a few things can happen • Dropped • Settlement Agreement • Full Commitment(6 mo.)-however this would require a final hearing

35. 51.30-Records • “Treatment records” -all records that are created in the course of providing services to individuals for mental illness, developmental disabilities, alcoholism, or drug dependence and that are maintained • Treatment records are confidential and may only be shared in a crisis situation (need to know), with a release, or as further outlined in 51.30 (4) (b) and WI state statute 92 • Note-NWC is not the holder of record. Records requests must go through the county.

36. 51.42Community mental health, developmental disabilities, alcoholism and drug abuse services. • This section of the statute identifies the expectations of WI on how counties create and manage their mental health and AODA programs • “51.42 Board Authorizer”

37. 51.45- Prevention and control of alcoholism. • 51.45 outlines and addresses response specifically to alcoholism • The common section of this statute used by crisis staff is related to an incapacitation hold. This hold allows for any person deemed as incapacitated due to alcohol can be held until they are no longer incapacitated at a approved treatment facility

38. 51.61- Patients rights • Patient rights are outlined in this section of the statute • This will be covered more in the online portion of client rights training offered on the online section of our curriculum • Each program must have a rights and grievance process

39. 51.64- Reports of death required; penalty; assessment. • If a person who is receiving services in a treatment facility dies, that facility is required to report the death if: • There is reasonable cause to believe that the death was related to the use of physical restraint or a psychotropic medication. • There is reasonable cause to believe that the death was a suicide.

40. Protective Services SystemWI Chapter 55

41. Adult at Risk • “Adult at risk” means any adult who has a physical or mental condition that substantially impairs his or her ability to care for his or her needs and who has experienced, is currently experiencing, or is at risk of experiencing abuse, neglect, self−neglect, or financial exploitation.

42. Chapter 55 • This chapter outlines the requirements of each county department to provide adult protection services and how those services must be provided • Commonly crisis services during non business hours also addresses these concerns • Still must be viewed and addressed in the least restrictive way • Each county must have an approved facility to take those individuals that require immediate assistance under protective placement

43. Emergency Protective Placement • Emergency protective placements are a means of intervening in an emergency situation if it is probable that an individual, as a result of an impairment as defined in Chapter 55, is incapable of providing for his or her own care or custody so as to create a substantial risk of physical harm to himself, herself or others if protective intervention is not immediately taken. • This is a legal hold • May not be done to a locked inpatient unit

44. Confidentiality of Treatment RecordsDHS 92

45. WI DHS 92 • Mirrors 51.30 • Addresses confidentiality of records • Confidentiality may only be broken in a medical emergency and then only information pertinent to the current situation may be shared

46. Patient Rights and Resolution of Patient GrievancesWI DHS 94

48. Informed Consent in Crisis • DHS 94.03 (2m): In emergency situations or where time and distance requirements preclude obtaining written consent before beginning treatment and a determination is made that harm will come to the patient if treatment is not initiated before written consent is obtained, informed consent for treatment may be temporarily obtained by telephone from the parent of a minor patient or the guardian of the patient. • We want to obtain informed consent whenever possible. At the same time, the emergency allows you to work on the crisis and develop a plan prior to consent. The goal is to always work with the client in the process to obtain the plan and therefore, more easily gain consent.

49. WI DHS 48 – The Children’s Code

50. Children's CodeWI DHS 48