AACAP+CACAP Joint Annual Meeting

Workshop 37 Crisis Stabilization for Youth on An Involuntary Psychiatric Hold: Danger to Self, Danger to Others, or Gravely Disabled : 

Workshop 37 Crisis Stabilization for Youth on An Involuntary Psychiatric Hold: Danger to Self, Danger to Others, or Gravely Disabled

Slide 2: 

George H. Stewart, M.D. is a consultant to Seneca Center. He has received travel expenses from Seneca Center for this presentation. He will not receive an honorarium, is not on a Speaker’s Bureau, and has no conflicts of interest, financial or otherwise, regarding this presentation. Gary D. Zomalt Ed.D., L.C.S.W., L.V.N . is a consultant to Seneca Center. He has received travel expenses from Seneca Center for this presentation. He will not receive an honorarium, is not on a Speaker’s Bureau, and has no conflicts of interest, financial or otherwise, regarding this presentation.

Presented by: George H. Stewart, M.D., Chair and Gary D. Zomalt, Ed.D., L.C.S.W., L.V.N. Willow Rock Center, CSU 2050 Fairmont Drive San Leandro, CA 94578 510-483-3030 george_stewart@senecacenter.org: 

Presented by: George H. Stewart, M.D., Chair and Gary D. Zomalt, Ed.D ., L.C.S.W., L.V.N. Willow Rock Center, CSU 2050 Fairmont Drive San Leandro, CA 94578 510-483-3030 george_stewart@senecacenter.org

Seneca Center Family of Agencies Willow Rock Center CSU A Collaboration between Alameda County (CA), Seneca Center, and Telecare Corporation A Crisis Stabilization Unit for Youth on an Involuntary Psychiatric Hold: Danger to Self, Danger to Others, Gravely Disabled : 

Seneca Center Family of Agencies Willow Rock Center CSU A Collaboration between Alameda County (CA), Seneca Center, and Telecare Corporation A Crisis Stabilization Unit for Youth on an Involuntary Psychiatric Hold: Danger to Self, Danger to Others, Gravely Disabled

: 

What is Seneca Center? www.senecacenter.org Let’s talk about values In the beginning… 2007 Crisis Intervention Program A greater need framed the evolution 2009 Crisis Stabilization Unit “Helping Children & Families Through Their Most Difficult Times

2010 In Review: 

2010 In Review

The Course: 

The Course Course Objectives To learn about a Best Practices crisis stabilization model for the evaluation and treatment of youth on an involuntary hold due to a mental disorder. To understand the legal and regulatory basis of the model. To become familiar with the establishment and daily functioning of a less-than-24 hour crisis stabilization unit for adolescents.

Slide 8: 

Post-Crisis Depression Triggering Event Escalation De-escalation Mood Baseline Rational Thought Crisis Escalation Curve Studies show that removal from situations that triggered a crisis facilitates de-escalation of youth.

Alameda County Demographics: 

Alameda County Demographics Population—1.5 million people; Approximately 10% (150,000) are teens (12-18yo); Urban (Oakland, Berkeley, Fremont) and suburban population centers; 40% Caucasian, 26% Asian, 22% Hispanic, 12% African-American;

Suicide Demographics (U.S.): 

Suicide Demographics (U.S.) 5 children/adolescents (10yo-19yo) die by suicide each day in US 3 rd leading cause of death in 15-18 yo youth Risk factors: LBGTQ, school dropouts, family disruption, juvenile detention, homeless/runaways, youth in treatment programs, mental illness, substance abuse, prior suicide attempt.

Suicide demographics, con’t.: 

Suicide demographics, con’t. 10% of suicide attempters try again within 3 months; 20% within a year; up to 50% within 3 years; Subsequent attempts are increasingly lethal. In one study, 45% of adolescents who make a suicide attempt don’t attend a single post-emergency visit therapy appointment.

Legal and Regulatory Basis: 

Legal and Regulatory Basis The CSU is the Alameda County, California Welfare and Institutions Code 5151 (5585 under 18yo) receiving center for youth on a 5150/5585 application for involuntary civil commitment. A 5150/5585 hold allows for up to a 72 hour involuntary hold for evaluation and treatment. Crisis Stabilization Services are provided at the CSU for less than 24 hours.

Legal and Regulatory Basis, con’t.: 

Legal and Regulatory Basis, con’t. The Crisis Stabilization Program has its legal and regulatory basis in California Code of Regulations Title 9, Specialty Mental Health Services Outpatient Program.

There was a need: 

There was a need Prior process for 5150 screening in Alameda County: Taken to an Emergency Department or Hospital 5150 normally accepted County was looking for a better model for adolescents in general and specifically the Medi -Cal and Uninsured clients and families Partnership Goals: Reduce unnecessary hospitalizations Increase family involvement Reduce risk of stigma Decrease costs

Agency and Community Partners: 

Agency and Community Partners Who are they Telecare Corporation Alameda County Kaiser Permanente Emergency Departments and Hospitals Emergency Medical Services (EMS) Local Group Homes Child Welfare Services Patient’s Rights and others…

Agency Relationship with Community Partners: 

Agency Relationship with Community Partners Collaborative Leadership - The Rost Approach Benefits from a commitment to Collaboration Reduce power struggles Youth and Family focused problem solving Procedure-based approach Improve care Increase staff morale Collaborative leadership Better defined roles and responsibilities

Slide 17: 

Pre-screen youth who come to us with an application for a 5150. Applications written in the community are usually not by licensed mental health professional---ie, police, Emergency Department physician, etc. Provide physical and mental health assessment, crisis stabilization, and coordinate hospital referral or outpatient follow-up.

Slide 18: 

B. What do we do? We operate a Mental Health Specialty Program serving 12-18yo’s Any teen presenting with a 5150 application (91% clients), walk-ups (9%). We serve all teens: MediCal, Kaiser-Permanente, other private insurers, and uninsured.

The CSU by the Numbers (June 2009 through September 2011): 

The CSU by the Numbers (June 2009 through September 2011) 3,610 Total Admissions 86% Unduplicated Admissions 58% Females, 41 % Males Insurance Breakdown: 35% Medi -Cal 26% Private 8% Uninsured 29% Kaiser 11.69 hours Average length of Stay Ethnicity breakdown: 28% African American 13% Mixed 25% Caucasian 6% Asian 21% Latino 5% Other 78% from Alameda County (CA) 54% Diversion Rate

Staffing: 

Staffing 24 hours a day, 7 days a week The core team per shift* One RN, one Masters-level clinician for every 4 clients, two B.A.-level counselors, and eight on-call staff available 24/7 *Shift Leader – Designated for every shift Psychiatrist A child/adolescent psychiatrist with dedicated shifts (9AM-1PM and 5PM-9PM) during the week and 24 hours on-call.

Staffing, con’t.: 

Staffing, con’t. Administrator-On-Call 24 hours a day Program Director, Assistant Program Director, Clinical Supervisor, Nursing Supervisor Administrative Support (Team Assist) Program Assistants Case Assistants (handle medical records requests, billing, and quality assurance)

An Overview of CSU Process: 

An Overview of CSU Process Mode of Arrival/Referral Triage Stabilization Discharge or Transfer

The Intake Process: 

The Intake Process Referrals from Emergency Departments and Hospitals Arrival via Ambulance: The ambulance calls to announce the ETA The nurse and clinician meet the ambulance If client appears to be medically stable client is brought into Triage on the gurney Triage: Physical Assessment Mental Health Assessment – 5150/5585 application is accepted or not accepted

The Intake Process: 

The Intake Process Triage (continued) If the 5150/5585 application is accepted the transfer process to an inpatient psychiatric hospital begins, and assessment and stabilization continue If the 5150/5585 application is not accepted, stabilization continues, while staff work with the client and family toward discharge in less than 24 hours

CSU Stabilization Process: 

CSU Stabilization Process CSU Mental Health Interventions Assessment Collateral Therapy/Counseling* Psycho-Education Medication Management Linkage * Motivational Interviewing is a model used throughout the process.

Slide 39: 

Post-Crisis Depression Escalation De-escalation Mood Baseline Rational Thought Triggering Event CRISIS Willow Rock Center Safety Plan Client’s name: ____________________________ Date of Plan:_____________ CSU Staff: ______________ What is my goal? ___________________________________________________________________________ What events, feelings or situations trigger a crisis for me? _______________________________________________________ ____________________________________________________ ________________________________________________ What are my coping skills? Distraction: ______________________ ________________________________ ________________________________ Self Care: ______________________________________ _______________________________________________ _______________________________________________ Communication: _______________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Who is in my support system that I can ask for help?_____ _____________________________________________ Have I tried my coping skills? Used my supports? Dial 9-1-1 in an emergency. Alameda County 24Hour Crisis Hotine : 1-800-309-2131

CSU Stabilization Process: 

CSU Stabilization Process Team discussion Identify Strengths and Resources Identify Problems to be addressed Psychiatric Assessment *Single-Session Family meeting (caregiver, treatment team, etc) Assess home environment and current resources Discharge to the Community/Transfer of Care Ready and available to meet the current specific needs of the youth * Single-session therapy is used throughout the process.

What makes the Seneca CSU unique: 

What makes the Seneca CSU unique Centralized Receiving Center for County Homelike Secure Environment Early and Intensive Collateral Services Single-session Family Meetings Interdisciplinary team Continued Assessment and Stabilization for Transfer clients Staffing Ratio, Trainings, Supervisions Positioning of Youth (No Milieu)

What makes the Seneca CSU unique: 

What makes the Seneca CSU unique One to One Counseling Minimize Distractions Youth-driven Safety Plans Assessment by Psychiatrist for Youth to be Discharged Individualized Care Plans Co-located with Telecare Psychiatric Health Facility Short-term outpatient care Mobile Response Team

What makes Seneca’s CSU unique: 

What makes Seneca’s CSU unique Clinical Standards Committee Root Cause Analysis (The Joint Commission) Medication Formulary Continue medications the client is already on Don’t initiate medications with formulary Emergency medications Ahimsa – Do No Harm

Initial Growing Pains: 

Initial Growing Pains Capacity Ambulance clearance times Crisis-line counseling Leaving the client on 5150/5585 for further evaluation on the CSU Explored restraint gurney Medications Anxiety about becoming a CSU

Challenges of Crisis Work: 

Challenges of Crisis Work Few comprehensive models of a CSU in literature Attempting to stabilize youth who were routinely hospitalized, often for 1-2 days Working with caregivers in the midst of a crisis Rapid and accurate assessment of situation and resources No evidence-based models for suicide prevention for adolescents Formation of an interdisciplinary team

Vignettes: 

Vignettes Group exercise Gather in small groups Select a reader; read the vignette to the group Discuss possible issues, further information you’d like to have, your anticipated disposition of the client Select a reporter who will briefly report to the large group Large group discussion

Slide 47: 

Chloe’s Individualized Care Plan Summary: Chloe has used our services frequently, often in the context of an argument for fight with her mother. Chloe has a history of cutting, substance abuse, running away, sexual promiscuity, and multiple psychiatric hospitalizations. Reason for ICP: History of escalating and fighting with other teens in the CSU. Refuses to give up her bra, often with cigarettes and a lighter in it. Displays escalating behaviors including targeting staff leading to need for hospitalization. Hurts self if needs are not met. Elopement risk. Makes allegations against staff. Use of drugs prior to arrival. Mother often refuses to come to WRC to get Chloe. Action Plan: Her mother should be contacted immediately upon our awareness that Chloe is coming to the CSU and should be encouraged/helped (taxi voucher) to come to WRC promptly for engagement and resolution with Chloe. If she appears intoxicated upon arrival at the CSU or gives a history of recent drug use or being out of parental supervision for 24 hours or more, send her for medical screening. Separate Chloe from other teens. Put on suicide watch if any concern for contraband. Be cautious when she is making threats. Minimize her access to outdoors Never have only one staff with her; always have “eyes on”. Additional helpful information: Chloe does not usually act upon her threats to staff. She does well with constant engagement Chloe can develop a positive relationship with staff. Although Chloe looks older, communicate with her according to her chronological age. Staff should focus on her behaviors and the plan for keeping her safe. She has tolerated Seroquel for calming when she is escalated. Resources: Her mother MRT Psychiatric evaluation vs. consultation: Reviewed 11/18/10

Slide 48: 

Christopher's Individualized Care Plan Due to Christopher’s potential to engage in high risk behaviors and chronic medical conditions, Christopher should be sent out for medical clearance if he presents to WRC from the community; staff should notify the PHF to see if they have a bed available AOC should be notified immediately if Christopher presents to WRC Kaiser Call Center should be notified immediately if Christopher presents to WRC There should be an available Kaiser bed at the PHF when Christopher is en route to WRC. If no bed is available at the PHF, he should not be cleared for admission to the CSU. The Kaiser Call Center should find an inpatient bed for direct transfer. Christopher needs 1 to 1 staffing and separation from other clients. If Christopher escalates, staff should not restrain him. Staff should use evasive maneuvers and exit the room. Christopher is no longer at Fred Finch What Works: Provide Christopher with verbal behavioral expectations. Provide positive reinforcement. He has tolerated and responded to Zyprexa Zydis. Reviewed 11/18/10

Slide 49: 

John’s Individualized Care Plan Summary: John has complicated medical issues and has been admitted to Willow Rock on several occasions due to DTS and DTO. Reason for ICP: Due to John’s medical issues (liver transplant, diabetes), staff should be aware of unusual medical labs and consult with current providers. Due to the severity of his medical needs and the risks involved if he does not take the necessary medication, client has access and means to seriously harm or kill himself. Action Plan: John should be medically cleared at Children’s Hospital Oakland (CHO is his current health care provider); if this is not possible, or if JV is being medically cleared at another hospital, encourage the ER doctor to consult with CHO doctor Follow “Diabetics, Insulin-Dependent” Policy and Procedure regarding his dietary needs. ER doctor and/or CHO doctor should contact Dr. Dana Futuron directly at PHF to discuss whether or not client would be able to be admitted at PHF if he meets criteria. John has some strong connections to staff at the PHF. If appropriate, CSU staff can utilize PHF staff to talk with client. If John presents to WRC and meets criteria for a 5150 hold, the Seneca psychiatrist should consult with the PHF psychiatrist due to his complicated medical conditions. Other helpful information: Resources: Mom is open to working with staff to support John Social worker and therapist through Children’s Hospital Oakland Psychiatric evaluation vs. consultation:

Conclusion: 

Conclusion Is it a significant improvement over the prior system? Is it accepted by the clients and families? Is the county pleased? Are our other partners? Is it overused - ie, by having such a fully functional facility and staff, do we create a need?

Appendix: 

Appendix Demographic table of the CSU population Medication reconciliation form Policy/procedure/guideline training format

References: 

References Rosenbaum, Robert and Talmon, Moshe “The Challenge of Single Session Therapies: Creating Pivotal Moments in Wells and Giannetti (eds.) Handbook of the Brief Psychotherapies Plenum, 1990. Rost paper Motivational Interviewing reference