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DDES Memo Series 2005-04

March, 2005

STATE OF WISCONSIN
Department of Health and Family Services
Division of Disability and Elder Services

To: 
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
Administrator

Re: Providing Intoxication Monitoring Services to Persons in Crisis

Document Summary

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 service.

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 individual.

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 83.

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

Service Guideline

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 appropriate. 

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

Intoxicated (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)

May provide intoxication monitoring in accordance with the 5 practices listed above. 

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; delirium tremens)

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.

ACTION SUMMARY:
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 monitoring service.

REGIONAL OFFICE CONTACT: 
Area Administrators

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
e-mail: hulicgh@wisconsin.gov or quirkma@wisconsin.gov

MEMO WEB SITE: 
http://www.dhs.wisconsin.gov/partners/local.htm

cc: 
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

_____________________________________________________
Attachment 1

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 crisis.

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 services.

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 standards prescribed.

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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