DDES Memo Series 2005-04
STATE OF WISCONSIN
Department of Health and Family Services
Division of Disability and Elder Services
Area Administrators/Assistant Area Administrators
Bureau Directors/Section Chiefs
County Departments of Community Programs Directors
County Departments of Developmental Disabilities Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
County Mental Health Coordinators
County Substance Abuse Coordinators
HFS 34 Agency Directors
Tribal Chairpersons/Human Services Facilitators
From: Sinikka Santala
Intoxication Monitoring Services to Persons in Crisis
This memo provides guidance to agencies
certified under HFS 34, emergency mental health service programs,
pertaining to the provision of intoxication monitoring services to
persons in a crisis who are admitted to a crisis stabilization bed.
HFS 34 agencies providing frequent (25 or more intoxicated
persons/year) intoxication monitoring services are to seek dual
certification under HFS 75.09, residential intoxication monitoring
From 25 to 50 percent of persons receiving services for mental
illness also have alcohol or other drug use issues. Consumers with both
substance abuse and mental illness experience frequent psychiatric
crises. Research has shown that these persons are at least twice as
likely to attempt suicide as persons with mental illness who do not use
substances. The prevalence of substance abuse among persons with severe
mental illness challenges all service providers to view co-occurring
disorders as the rule, rather than the exception. As such, the Division
of Disability and Elder Services desires to promote best practices in
the provision of emergency mental health services to persons who have
both mental health and substance use issues. The development of this
memo was a joint effort of the Bureau of Mental Health and Substance
Abuse Services and the Crisis Network and has been approved by the
Wisconsin Counties Human Services Association.
Emergency mental health service programs (crisis centers) certified
under chapter HFS 34 and providing 24-hour stabilization services in
either a CBRF or some other residential arrangement have a long history
of providing services when a client in crisis has also been drinking or
using other mood-altering substances. The purpose of this memo is to set
forth guidelines for the provision of 24-hour intoxication monitoring
services to persons in crisis centers.
This memo will also identify when an HFS 34 crisis agency providing
24-hour stabilization services will need to seek dual certification
under HFS 75.09, residential intoxication monitoring service, and what
those requirements are. The intent is not to encumber crisis centers
with unnecessary certification requirements but to ensure that quality
services are provided. Not all 24-hour crisis centers will need to be
dually certified under chapters HFS 34 and HFS 75. Crisis centers which
frequently (25 or more intoxicated persons/year) provide 24-hour
monitoring for intoxicated persons in crisis will need to be dually
certified under chapters HFS 34 and HFS 75.09. The provisions of this
memo will not affect revenue streams.
Regulatory references are attached for information purposes only
(Attachment 1). It is the intent of HFS 34 to allow a crisis agency to
provide services to persons in crisis who have been drinking or are
intoxicated (see the chart on the next page). However, persons
incapacitated by alcohol are to be conveyed to a certified medical detox
facility, or, if appropriate, to an inpatient mental health facility
that can also monitor and treat withdrawal.
It is also important to note that the citations related to alcohol
and other drug abuse services in ch. HFS 34 are not permission to
provide services that were meant to be provided by an agency certified
under ch. HFS 75. Chapter 51 Wis. Stats., makes it clear that HFS 34
agencies providing 24-hour services for intoxicated individuals need to
also be certified under substance abuse service standards, HFS 75.
The following are best practice guidelines for emergency mental
health service programs providing 24-hour monitoring services to
intoxicated persons in crisis:
1. Intoxicated individuals should be screened by medical staff (e.g.
physician, psychiatrist, or nurse under medical supervision) using the
Clinical Institute Withdrawal Assessment (CIWA) or the Selective
Severity Assessment (SSA) prior to admission and should be determined
not to be in need of medical care.
2. The agency should have written agreements with medical facilities for
referrals should the need arise.
3. There should be around-the-clock observation of the intoxicated
4. The client should have the opportunity for a consultation from a
certified AODA counselor prior to discharge. The AODA counselor should
evaluate the client's current substance use and substance use history,
administer UPC or ASAM placement criteria, encourage the client to seek
additional services, if needed, and contribute to the discharge plan.
There should be an AODA component in the discharge plan as determined by
the AODA counselor.
5. The facility should be licensed as a CBRF or meet the physical
environment, safety, and structural requirements of subchapters V and VI
of ch. HFS 83, Community-Based Residential Facilities. Facilities having
more than 20 beds/residents should also meet subchapter VII of ch. HFS
The table below provides guidelines for when a 24-hour service under
HFS 34 admits a client to a crisis stabilization bed who also has
substance use issues:
Client's Level of Alcohol/Drug Involvement
Been drinking or using drugs - no substance abuse
history (i.e., had a few drinks or used drugs w/in past 24
hours; no signs of intoxication or incapacitation; no known
history of substance abuse)
Provide crisis services as appropriate.
Screen for substance abuse service needs and include a
referral to substance abuse services in discharge plan as
No need for HFS 75.09 certification.
Substance abuse history (i.e., no signs of
intoxication or incapacitation; may or may not have been using in
the past 24 hours; has a known history of abuse of illicit drugs,
non-medical prescription drugs, or alcohol)
Provide crisis services as appropriate.
Include a referral to substance abuse services in discharge
plan as appropriate.
No need for HFS 75.09 certification
(i.e., slurred speech; bloodshot eyes; sweating; sleepy; unsteady;
incoordination; swaying; odor of alcohol; disoriented; impaired
attention or memory; uncontrolled eye movement from side to side)
intoxication monitoring in accordance with the 5 practices listed
HFS 34 agencies
providing intoxication monitoring for 25 or more intoxicated
persons annually shall be dually certified under HFS 75.09
(residential intoxication monitoring service).
Incapacitated (i.e., at risk for withdrawal or in withdrawal as
evidenced by lack of appetite; itching; pins and needles; anxious;
restless; agitated; tremor; sweating; auditory and visual
disturbances; headache; nausea; disoriented; elevated temperature;
rapid and strong heartbeat; insomnia; seizure; hallucinations;
HFS 34 agencies should not be providing detox services to persons who
are incapacitated. Law
enforcement and other referral agents should be instructed to
convey these persons to a certified medical detox facility, or, if
appropriate, to an inpatient mental health facility that can also
monitor and treat withdrawal.
HFS 34 staff can provide outreach/mobile crisis services to these
persons while they are undergoing medical detox as appropriate.
This memo provides guidance to agencies certified under HFS 34,
emergency mental health service programs, as it pertains to the
provision of intoxication monitoring services to persons in a crisis who
are admitted to a stabilization bed. Agencies providing frequent (25 or
more intoxicated persons/year) intoxication monitoring services are to
seek dual certification under HFS 75.09, residential intoxication
REGIONAL OFFICE CONTACT:
CENTRAL OFFICE CONTACT:
George Hulick or Mike Quirke
Bureau of Mental Health and Substance Abuse Services
1 West Wilson Street, room 850
P.O. Box 7851
Madison, WI 53707-7851
George: (608) 266-0907 Mike: (608) 266-7584
Fax: (608) 266-1533
MEMO WEB SITE:
Members, Wisconsin Council on Mental Health
Wisconsin Family Ties
NAMI WI, Inc.
Milwaukee County Mental Health Association
Grassroots Empowerment Project
Wisconsin Association on Alcohol and Other Drug Abuse
Members, State Council on Alcohol and Other Drug Abuse
Wisconsin Alcohol and Drug Treatment Providers Association
Mark Hale, Bureau of Quality Assurance
Regulatory References Pertaining to the Provision
of 24-hour Intoxication Monitoring Services to Persons in Crisis
These citations are provided for reference only and to establish the
need and basis for the guidelines:
Chapter HFS 34.22(7), "Counties may choose to operate emergency
service programs which combine the delivery of emergency mental health
services with other emergency services, such as those related to the
abuse of alcohol or other drugs…"
Chapter HFS 34.23(6)(c)2, "If a person has been receiving
services primarily related to the abuse of alcohol or other drugs…contacting
a service provider in the area of related need in order to coordinate
information and service delivery for the person."
Chapter HFS 34.22(2)(d) allows for follow-up contacts, as
appropriate, in order to determine if needed services or linkages have
been provided or if additional referrals are required.
Chapter HFS 34.23(2)(e) requires that procedures be followed for
referral to other programs when a decision is made that a person's
condition does not constitute an actual or imminent mental health
Chapter HFS 34.21(8)(a)9 requires that crisis agencies have
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.
The following citations are from Ch. 51, Wis. Stats.:
51.42(7)(b) is the Department's rule promulgation authority and
provides for the distinction among the fields of community mental
health, developmental disabilities, and alcoholism and drug abuse
51.45(11) TREATMENT AND SERVICES FOR INTOXICATED PERSONS AND OTHERS
INCAPACITATED BY ALCOHOL. An intoxicated person may come voluntarily to
an approved public treatment facility for emergency treatment. (Note:
The emphasis is on "approved" public treatment facility"
under chapter HFS 75).
51.45(8)(a) states in part that the department shall establish
minimum standards for approved treatment facilities that must be met for
a treatment facility to be approved as a public or private treatment
facility (under HFS 75).
51.45(2)(c) "Approved public treatment facility" means a
treatment agency operating under the direction and control of the
department or providing treatment under this section through a contract
with the department…or with the county department…, and meeting the
51.42(3)(ar)(2) County departments shall enter into contracts for the
use of any facility as an approved public treatment facility under s.
51.45 for the treatment of alcoholics.
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