Crisis Best Practices Workgroup

1. Crisis Best Practices Workgroup October 24, 2017

2. Today’s Agenda • Welcome • Program Spotlight: RHD(Philadelphia, PA • Content Overview: Managing Admissions & the Milieu • Review Survey Results/Discussion • Review Project Plan and Timeline • Adjourn Purpose: To develop a comprehensive Best Practice Toolkit for Crisis Residential Services, informed by Crisis Residential providers across the country.

3. Crisis Best Practices Workgroup TBD Solutions is proud to sponsor the Crisis Best Practices Workgroup. • Crisis Program Development • Metrics Development • Middle Management Training • Interactive Data Visualization • Quality & Process Improvement • Integrated Care Coordination • Research & Analysis • Software Procurement Consulting www.TBDSolutions.com @TBDSolutions

4. Crisis Services Map

5. Workgroup Participants • 164 participants • 138 Crisis Residential Providers • 10 Crisis Providers, Psych Hospitals, or Peer Respites • 6 State Behavioral Health Administrations Represented (MN, NY, TX, VA, WA, WI) • 43 states • Plus D.C., England and Costa Rica • Approximately 410 crisis homes exist nationwide • Welcome new participants from MN, OK, MA, GA

6. Resources for Human Development Crisis Services Hope House and New Perspectives Michael Usino, Crisis Services Director

7. Brief History • Resources for Human Development is a national human services nonprofit with the broadest possible service mission, and specializes in creating innovative, quality services that support people of all abilities and any challenges wherever the need exists. Founded in 1970, RHD supports more than 160 human service programs across the country, serves tens of thousands of people every year with caring and effective programs addressing intellectual and developmental disabilities, behavioral health, homelessness, addiction recovery and more.

8. Our Reach Programs in: • Connecticut • Delaware • Florida • Iowa • Louisiana • Massachusetts • Missouri • Nebraska • New Jersey • North Carolina • Pennsylvania • Rhode Island • South Dakota • Tennessee • Virginia

9. Our Mission RHD’s mission is to provide caring, effective, and innovativeservices that empower people of all abilities as they work to achieve the highest level of independence possible and build better lives for themselves, their families and their communities.

10. Crisis Programs Hope House • Founded in 1995 • Provides short-term residential accommodations and continuous supervision for eight individuals in psychiatric crisis. • Licensed by the commonwealth of Pennsylvania Department of Public Welfare, the program provides mental health and stabilization services as a voluntary alternative to hospitalization. • Individuals enter the program for up to a maximum of ten days until they stabilize or other arrangements can be made for them. • Primarily funded through contracts with Magellan Behavioral Health, Northampton County MH/MR/D&A, and Lehigh County MH/MR/D&A.

11. Crisis Programs (Cont.) New Perspectives: • Eight-bed, short-term residential program for adults in Carbon, Monroe and Pike counties. • Provides supervised mental health stabilization services as an alternative to psychiatric hospitalization for individuals who are in psychiatric crisis, or who may need to be removed from a stressful environment while supports are identified to ensure stability. • Founded in 1998

12. What We Do and Where We Do It • In PA, we have two Crisis Residences serving a total of 5 counties. • Carbon • Monroe • Pike • Lehigh • Northampton

13. Our Services • Crisis Residence – 8 bed; short term (5-7 days) • Mobile Crisis Interventions (medical, team and individual) • Facilitation of Petitions for Involuntary Commitments (302s) • Crisis Phones

14. What we are proud of… • Trauma Informed Care • Seeking Safety • TREM • Crisis Resolution Plans • 72 hour post admission meeting • Trainings • Sign Language • De-escalation Techniques • DBT & CBT

15. What we are proud of (cont.) • Staff Recognition and training • Our Corporate Values • Community Relationships and Continuity of Care • RHD Values • Respect for the dignity and worth of each individual • Multi-level thinking • Empowerment of groups • Decentralization of authority • Safe and open environment • Creativity • Honesty and trust • Diversity • Organizational integrity • Ongoing growth and development • Personal and professional enrichment • Quality service

16. Questions

17. Content Review: Clinical Services & Training July: The Safety Net August: Regulations & Governance September: Clinical Services & Training • October: Managing Admissions & the Milieu December 2016: Staffing January 2017: Scope & Function February: Metrics & Outcomes March: Taxonomy & Community Relations April: Treatment Philosophy & Approach May: Intake June: Funding

18. Managing Admissions & the Milieu

19. Managing Admissions & the Milieu • Medical Clearance • Handling Complex Medical Needs • Approving Referrals • Exclusionary Criteria • Legal System Involvement • Safety Plans

20. Medical Clearance “Recent overdose or poor vitals.” “Untreated medical conditions—seizure, blood pressure, diabetes.” “If there is a communicable disease and medications have not been started.” “Drowsiness, confusion, or cognitive impairment; acute cardiac symptoms; active PICA diagnosis; major organ dysfunction that could present as psych symptoms” n=31

21. Medical Clearance Specifics Journal of Psychosocial Nursing, 2010

22. Medical Clearance Specifics “We typically do the Urine Drug Screen on site, but request it anyway.” “Preferrably a PPD/TB test.” “Labs only required if the patient needs a withdrawal bed.” “We tell the ERs that we require no labs, but ER MDs typically order the usual panels n=26

23. Where Medical Clearance is Provided n=28

24. Handling Complex Medical Needs “Accepted as long as individuals can tend to ADLs.” “We will facilitate a more appropriate referral to a psychiatric hospital.” “Our licensing board prohibits certain types of complex medical conditions, such as requiring a medical device to stabilize conditions.” n=29

25. Handling Complex Medical Needs n=24

26. Approving Referrals “A team approach, which may include the program director, nursing staff, or program psychiatrist, depending on nature of concern, happens with every admission” “Our psychiatrist approves ALL referrals.” “Individuals with a history of sexual impropriety in our program.” “History of suicide attempts.” n=26

27. Exclusionary Criteria for Crisis Services “For sexual perpetrators, we make a clinical decision related to the nature of the offense and the clinical make-up of the house at the time.” “Client must sign release to Parole Officer or we will not admit them.” “Only exclude if violence or CSC occurred within the past month.” n=21

28. Legal System Involvement “We do not confirm or deny the presence of a client. We then approach the client and ask them to speak to the officers, leaving the choice up to them.” “We cooperate fully and do not hinder but do not inform without consent.” “We only communicate with law enforcement if given permission by client.” n=25

29. Creating Safety Plans “Restrict access to items and increase safety checks.” “Safety planning informing by zero suicide initiatives.” “Clients are stepped up to psych hospital or discharged.” “Increased safety checks.” n=28

30. Managing Admissions • “We are able to transfer clients between our 3 locations if the milieu issue is directly related to conflicts between certain clients.” • “We keep a record of all denials and review them monthly with leadership to see patterns where more education and training may be needed for the unit. After a year we’ve seen a major decrease in denials, and a 99% drop in denials that we should have accepted.” • “Focusing on frequent utilizers to our walk-in crisis services, as these individuals also frequent jails, hospital ED’s, and shelter system. We’re working to address the root cause (homelessness, SUD, etc.)” • “We have been able to move people to other parts of our building with staff support, if there are issues or challenges that cannot be managed within another part of the unit (sexual inappropriateness, language barrier, matching clients based on gender, etc).” • “Our personal, trauma-informed approach results in clients respecting the rules and the CSU, even when extremely sick. We assist in getting them to the appropriate level of care. It is unethical for us to treat someone beyond our scope of practice.”

31. Survey Participation & Incentives • Missing surveys will be sent to you by 10/31/17 • Please complete missing surveys within 30 days of receiving request • Email Claudia at claudiav@tbdsolutions.com with any questions

32. Crisis Services Database • Surveying for all Crisis Services in each State • Crisis Residential • 23 Hour Crisis Stabilization • Mobile Crisis • Psychiatric Hospitals • State Psychiatric Hospitals • CIT Teams • Peer Respites • Email claudiav@tbdsolutions.com

33. Next Steps Next Conference Calls: Friday, November 17th @1pmEDT/10am PDT Group Listserv: CrisisResidentialNetwork@TBDSolutions.com Website: www.CrisisResidentialNetwork.com (Meeting Slides stored here) Questions: TravisA@TBDSolutions.com