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Emergency Services Program Recommendations

ATTACHMENT 2

In the year 2000 the Department of Health and Family Services (DHS ), 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 DHS 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.

  1. 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 Departmentís 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 DHS , including non-hospital based crisis intervention and community based services for emergency detentions of non-Wisconsin residents.

  1. 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.
  2. Monitoring inpatient hospitalizations. Counties should develop written policies and procedures to clinically monitor inpatient hospitalizations following an emergency detention to ensure that the patientís 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 Departmentís 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."
  3. 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 patientís 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 patientís home state, not to Mendota or Winnebago Mental Health Institute.
  4. 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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