mental healthhold task force- final report and recommendations€¦ · colorado mental health hold...

ColoradoMentalHealthHoldTaskForce FinalReportandRecommendations

PreparedbyTheCivicCanopy

December31,2016

ColoradoMentalHealthHoldTaskForce–FinalReportandRecommendations(12/31/2016) 4/20

TheMentalHealthHoldTaskForce

OnJuly9,2016,GovernorJohnHickenloopervetoedSenateBill16-169thatwouldhaveexpandedColorado’smentalhealthholdlaw,citingconcernsaboutthedueprocessrightsofindividualsexperiencingmentalhealthcrisis.(SeeAppendixA:GovernorHickenlooper’sSB16-169VetoLettertoColoradoSenate.) TheGovernordirectedtheDepartmentofHumanServicestocreateataskforcetoexaminetheissuesandtoproposerecommendationsthatwouldensureaccesstomentalhealthservicesforindividualsincrisis,whilepreservingtheirConstitutionalrights.Theresulting30-memberMentalHealthHoldTaskForceincludedrepresentationfromstateagencies,advocacyorganizations,providers,judiciary,lawenforcement,andothersincludingindividualswithlivedexperienceofmentalillness. Thisdocumentistheresultofthecombinedeffortsoftheindividualslistedbelowandthestakeholdersandcontentexpertswhosharedtheirinsights,knowledge,andperspectivestoadvancethegroup’swork. IreneAguilarStateSenator VincentAtchity EquitasFoundation LoriBanks ColoradoCrisisConnection EliciaBunch CentennialPeaksHospital MargaretHeil ColoradoDepartmentofPublicSafety JulieHoskins WeldCountyJudge MarkIvandick DisabilityLawColorado CheriJahn StateSenator ChrisJohnson CountySheriffsofColorado AmandaKearney-Smith ColoradoMentalWellnessNetwork MoeKeller MentalHealthColorado TracyKraft-Tharp StateRepresentative DavidKrouse FruitaPoliceDepartment LoisLandgraf StateRepresentative ElizabethLowdermilk DenverHealthandHospitalAssociation

RandyKuykendall ColoradoDepartmentofPublicHealthandEnvironment DeniseMaes ColoradoACLU BethMartinezHumenik StateSenator RichardMartinez ColoradoPsychiatricSociety FredMcKee DeltaCountySheriff PatrickMcKinstry DenverAttorney’sOffice MattMortier CODepartmentofRegulatoryAgencies/DivisionofInsurance KatherineMulready ColoradoHospitalAssociation

SharonRaggio MindSpringsHealth LenyaRobinson ColoradoDepartmentofHealthCarePolicyandFinancing SallyRyman GrandCountyRuralHealthNetwork ValerieSchlecht ColoradoCrossDisabilityCoalition CherylStorey WestPinesBehavioralHealth NancyVanDeMark ColoradoDepartmentofHumanServices/OfficeofBehavioralHealth DougWilson ColoradoPublicDefender


TaskForceMission

TheMentalHealthHoldTaskForcewaschargedwithmakingstatutory,policy,andadministrativerecommendationsto: ● Ensurepropermentalhealthtreatmentforindividualsincrisis,whilesatisfyingindividual'srightsunderthefederal

EmergencyMedicalTreatmentandLaborAct(EMTALA)anddueprocessstandards.Thisshouldincludeexploringmodelsusedinotherstates;

● Endthepracticeofconfininginjailpersonswithmentalillnesswhohavecommittednocrime; ● Whereappropriate,streamlineandalignregulatoryoversightofthementalhealthholdprocesswhileensuring

necessarypatientcarerequirementsandprotectingpatientrights; ● Understandtheneedfor,andovercomebarriersto,providinginpatientpsychiatriccaretopersonsinmentalhealthcrisis; ● Maximizeexistingstateresources,includingexaminingpotentialenhancementsthatcanbemadetothecurrent

crisisservicesandtransportationsystems; ● Developdatatrackingandprovidercommunicationsystemstobetterunderstandthescopeofthementalhealth

holdprobleminColorado.

Process

TheTaskForcemettentimesbetweenAugustandDecember2016.Allmeetingswereopentothepublic,withobserversinattendance,andincludedopportunitiesforpublicinput.TheCivicCanopy,acommunity-basednonprofit,facilitatedanddocumentedtheprocess.Overatwenty-weekperiod,theTaskForceworkedtodevelopasharedunderstandingof:thepressuresandconstraintsfeltinthecurrentsystem;bestpractice/lessonslearnedfromstatesandlocalities;andopportunitiestostrengthenandleverageexistingeffortsinColorado.Arecurringthemeindiscussionswastheextenttowhichregionaldifferencesaffectdecision-makingandoutcomes.Tosupporttheirwork,theTaskForceheardpresentationsfromtheColoradoHospitalAssociation,theTreatmentAdvocacyCenter,theColoradoDepartmentofHumanServices,theColoradoBehavioralHealthcareCouncil,andindividualswithfirst-handexperiencebeingplacedonamentalhealthhold.(SeeAppendixC:SummaryofTaskForceMeetingAgendasandPresentations.SeetheCDHSMentalHealthHoldTaskForcewebsiteformeetingagendas,minutes,andrelatedmaterials.) TheTaskForcevotedusingaFist-to-Fiveapproach,raisingtheirhandsasinvoting,withthenumberoffingersraisedindicatingtheirlevelofagreement.Thescalewasasfollows:

5fingers–Iaminfullsupportofthismotion. 4fingers–Isupportthismotion. 3fingers–I’minthemiddlesomewhere,butcanstillsupportthemotion. 2fingers–Ihavesomeconcernsbutwillgoalongwiththegroup’sdecision. 1finger–Ihavestrongreservationsbutwouldnotblockconsensus. 0fingers/fist–Iobjectandwillblockconsensus.

Thisapproachallowedmemberstoexpresstheirlevelofsupportforanidea,andprovidedaconcretewaytotestconsensuswithinthegroup.Thisreportcapturesthreelevelsofsupport:Fullysupport(3-5fingers),supportwithreservations(1-2fingers)anddonotsupport(fist/0fingers). OnDecember21,2016,theTaskForceapprovedthefinalrecommendationsasaset.(SeeAppendixF:TaskForceVotingTallyonFinalRecommendationsfordetails.)


Contents Overview.....................................................................................................................................................................................7

ExecutiveSummary.....................................................................................................................................................................7

Recommendations......................................................................................................................................................................8

AppendixA:GovernorHickenlooper’sSB16-169VetoLettertoColoradoSenate...................................................................14

AppendixB:MentalHealthHoldSystemFramework...............................................................................................................16

AppendixC:SummaryofTaskForceMeetingAgendasandPresentations..............................................................................17

AppendixD:OverlayofCrisisStabilizationUnitandHealthcareFacilityLocationsAcrossColorado.......................................18

AppendixF:TaskForceVotingTallyonFinalRecommendations.............................................................................................19

AppendixG:Definitions............................................................................................................................................................20


Overview

Coloradohasseenmuch-neededimprovementtomentalhealthservicesinrecentyears.GovernorHickenlooper’s2012initiative“StrengtheningColorado’sMentalHealthSystem:APlantoSafeguardallColoradans”demonstratedthestate’scommitmenttoexpandingaccesstobehavioralhealthcrisisservices.In2013,SB13-266wassignedintolaw,establishingtheguidelinesforastatewidebehavioralhealthcrisisresponsesystemtoprovidecriticalservicesandsupports“whenandwhereneeded”withthegoalthattheservicesbeaccessibletoallColoradans,regardlessoftheirabilitytopay. ColoradoCrisisServices,conceivedasacontinuumofservices,launchedin2014.Thesystemincludes:1)a24-hourhotline/warmlineforcrisisassistance,staffedbytrained,professionalspecialistsandpeercounselors;2)mobilecrisisresponse;3)respitecare;4)crisiswalk-incentersandCrisisStabilizationUnits(CSUs).Sinceservicesbeganin2014,over5,000peoplehavebeenseenatwalk-incentersandCSUs,andover6,000havereceivedsupportfrommobilecrisisservices. Butmanyofthesystem’sservicesremainlargelyinaccessibleinsomeregionsofthestate,particularlyinColorado’sruralcommunities.Intheseareasfew“designatedfacilities”existthathavetheauthorityandexpertisetoprovideevaluationandtreatment.SB16-169“Concerningchangesrelatedtotheseventy-two-houremergencymentalhealthprocedure,”aroseoutofthesechallenges.Thebillhighlightedchallengesincertainregionsofthestatethatlackadequateresourcestoprovidepropercareforsomeindividualswhoareexperiencingamentalhealthcrisisorpsychiatricemergency. ExecutiveSummary

InvetoingSB16-169,“Concerningchangesrelatedtotheseventy-two-houremergencymentalhealthprocedure,”GovernorHickenloopermadeclearthatwhileitisapriorityforColoradotoensurepropermentalhealthtreatmentforindividualsincrisis,doingsowillnotbeaccomplishedattheexpenseofcivilliberties.

Broadly,theMentalHealthHoldTaskForcewascreatedtoexamineissuesofconcernaroundmentalhealthholdsinColorado.Ofprimaryconcernwastheproposaltoextendtheperiodoftimepermittedfortheemergencydetentioninjailsofindividualswithmentalillnesswhoarenotcriminallychargedandwhoawaitformalproceduresforinvoluntaryhospitalization.(ItshouldbenotedthatColoradoremainsoneofonlysixstatesthatstillpermittheuseofjailsinthesecircumstances.)

Ascurrentlyimplemented,mentalhealthholdscreateunintendedandunmanageableburdens,whilestillfailingtomeettheneedsoftheindividualincrisis. Double-BindforLawEnforcement–Currentstatelawallowsanindividualtobedetainedinajailfor24hoursonamentalhealthhold.Withinthattime,theindividualmustbetransportedtoadesignatedfacilitywhereappropriateevaluationandtreatmentcanoccur.Theproblemarisesforlawenforcementwhennobedinadesignatedfacilityisavailable/accessible.(SeeAppendixD:OverlayofCrisisStabilizationUnitandHealthcareFacilityLocationsAcrossColorado.)ThisproblemisacutelyexperiencedinColorado’sruralcommunities,wherethelawenforcementagenciestendtobesmallandthenearesthealthfacilitymaybehoursawayandmayormaynothavetheabilitytoprovideadequatementalhealthevaluationandtreatment.Inthesecases,whichoftenrequirepullingadeputyoffofpatrol,thesheriffmustchooseamongthreeoptions:

● Transporttheindividualtoadesignatedfacility(leavingthecommunitywithoutapublicsafetyofficerforanextendedperiodoftime);

● Detaintheindividualinjail(potentiallysafeguardingthecommunity,butrunningtheriskofviolatingtheindividual’srightsaswellasstatestatuteiflegalrequirementsarenotmet);or

● Releasetheindividualintothecommunity(potentiallyfailingtosafeguardthecommunityandhavingprovidednoaccesstoevaluationortreatment)

Double-BindforEmergencyDepartments–UnderthefederalEmergencyMedicalTreatmentandLaborAct(EMTALA),emergencydepartmentsareforbiddentoturnawaypatients.Atthesametime,undercurrentstatelaw,theycurrentlylacktheauthoritytoretainpatientsonmentalhealthholdsunlessdesignatedbyCDHS.(See:42U.S.Code§1395dd,C.R.S.§27-65-102,C.R.S.§27-65-105)


IndividualinCrisis–Confiningtojailapersonwhohasnotbeenchargedwithorconvictedofacrimeisamassivecurtailmentoflibertyandmayviolateaperson’scivillibertiesaffordedbytheU.S.andColoradoStateConstitutionsifappropriateproceduresarenotfollowed.Inaddition,jailshaveindicatedthattheyareill-equippedtomeettheneedsofanindividualexperiencingamentalhealthcrisis.Asaresult,individualsdonotreceivenecessarysupportandpsychiatrictreatment,andareatincreasedriskofdeterioration.Lawenforcementisinapositiontochargeindividualswithacrime,oftenforbehaviorsassociatedwiththesymptomsoftheirillness,thusfurthercontributingtothecriminalizationofmentalillness.(See:UnitedStatesConstitution,ColoradoStateConstitution.)

InsufficientData–NodataexistsonthefrequencyofM-1holdsinColoradojailsoremergencydepartmentsthatarenotdesignatedbecauseColoradostatuterequiringreportingappliesonlytodesignatedfacilities.Becausenoreliabledataexiststohelpunderstandthescopeandnatureoftheproblem,itisdifficulttomakethecaseforaddingresourcestoColorado’sbehavioralhealthsystem. (See:C.R.S.§27-65-102,C.R.S.§27-65-105.)

TheCivicCanopy,intheroleoffacilitator,soughttohighlightthesystemicnatureofthesechallenges,acknowledginginherentinterdependencieswithaneyetowardoptimizingsolutionsandminimizingunintendedconsequences.(SeeAppendixB:MentalHealthHoldSystemFramework.).Infulfillingitsmission,theTaskForceengagedinaniterativeprocessofdevelopingandrefiningproposedrecommendationstoresolvethedueprocessandcivilrightsconcernswhileensuringpropertreatmentforindividualsincrisis.

TheTaskForceunanimouslysupportedendingthepracticeofhousinginjailindividualswhohavebeenneitherchargednorconvictedofacrime.Theirworkovertwentyweekswastodefineandenablealternatives. Recommendations

TheMentalHealthTaskForceapprovedthefollowingeightrecommendationsonDecember21,2016.Eachoftherecommendationsexceededthenecessarytwo-thirdsvotingthresholdestablishedbytheExecutiveDirectoroftheColoradoDepartmentofHumanServices. Broadly,therecommendationsfocusonbetteruseofexistingresources,improveddatacollectionandreporting,protectionofcivilliberties,andaccesstoappropriatetreatmentforindividualsinmentalhealthcrisis. Itshouldbenotedthatinadditiontotheeightrecommendations,TaskForcemembersconsistentlyraisedoverarchingthemesfundamentaltoimprovingColorado’scontinuumofmentalhealthcareandtoensuringaccessforindividualsandfamilymembers.Theseinclude:

● Reducingstigmaandcreatingemergencyservicesoptionsthatpreservedignity. ● Encouragingpeoplewhoexperiencecompromisedmentalhealthtoseekhelpearly. ● Increasingcommunicationaroundservices,supports,anduseoftheCrisisResponseSystem. ● Advocatingforeliminationofvariationsincoverageandbarrierstopaymentforbehavioralhealthcrisisservices

regardlessofpayer.


MENTALHEALTHHOLDTASKFORCEFINALRECOMMENDATIONS Recommendation1:EndtheUseofLawEnforcementFacilitiesforM-1Holds AmendCRS27-65-105duringthe2017legislativesessiontoeliminatetheuseofjails,lock-up,orotherplaceofconfinementforpersonsplacedonM-1holdswhohavenotbeenchargedwithorconvictedofacrime. A. Weencouragelocalcommunitiestophaseinthisrecommendationevenbeforestatutorychangeshavebeenmade.* B. Inregionswhereadequatealternativesdonotyetexist,implementationofthisrecommendationshouldbephasedin

oncetheservicesandsupportsoutlinedinsubsequentrecommendationsareinplace.* C. Thepracticeofusingjails,lock-up,orotherplacesofconfinementassitesofM-1holdsforthosewhohavenotbeen

chargedorconvictedofacrimeshouldbeendednolaterthanJanuary1,2018.* RationaleandExplanation ● ThisistheprimaryobjectiveoftheTaskForceandneedstodrivetheredesignofthementalhealthholdsystem. ● Thischangewilllessenthecriminalizationassociatedwithmentalhealthholdsandshouldprovidegreaterdueprocessprotections. ● Whiledifficultinsomeruralregions,eliminatingtheuseoflawenforcementfacilitiestoholdpeoplewhohavenotbeen

chargedwithorconvictedofacrimeistherightthingtodoandwillnolongerbenecessaryoncethefollowingrecommendationshavebeenimplemented.

*VariedTaskForceSupportforRecommendation1 ● ThefirstsentenceofRecommendation1wasfullysupportedby19/22TaskForcemembers.Twomemberssupportedit

withreservations.Onememberdidnotsupportit.Sixmemberswerenotpresentforthevote.TheTaskForcememberwhodidnotsupporttherecommendationagreedinprinciple,butwantedviablealternativestobeplacebeforeendingtheuseofjailsforM-1holds.

● ItemAwasfullysupportedby22/22TaskForcemembers.Eightmemberswerenotpresentforthevote. ● ItemBwasfullysupportedby16/21TaskForcemembers.Threememberssupporteditwithreservations.Two

membersdidnotsupportitatall.Ninemembersdidnotvote.Thosewhodidnotfullysupportthiscomponentexpressedreservationsaboutthelackofspecificityof“adequatealternatives,”and/orthelackofaphase-indate.

● ItemChadthefullsupportof15/21TaskForcemembers.Sixmembersdidnotsupportitatall.Ninememberswerenotpresentforthevote.Memberswhodidnotfullysupportthiscomponentexpressedreservationsaboutthedate:somemembersfeltthatoneyearwastoolongtowaittoendthepracticeofusingjails;othersfeltthatoneyearprovidedinsufficienttimetoimplementviablealternatives.

Recommendation2:StreamlineRegulationsandEstablishaStrongerSystemofAccountability. StreamlinethevariousregulatorypowersdelegatedtotheColoradoDepartmentofPublicHealthandEnvironment(CDPHE),theColoradoDepartmentofHumanServices(CDHS),andtheDepartmentofHealthCarePolicyandFinancing(HCPF)andestablishaMentalHealthCareOmbudsmanOfficetoensureaccountabilitybetweenallstateagencies.Thisbodyshouldensurethatindividualsplacedonmentalhealthholdsreceivepropercare,thatprovidersandregulatorsplaytheirproperroles,andthatgrievancesareimpartiallyreviewedandresolved. ● Thisofficeshouldbelocatedwhereitcanhaveproperautonomytocarryoutimpartialreviews—perhapsinthejudicial

branchinamannersimilartotheOfficeofColorado’sChildProtectionOmbudsman—andshouldnotduplicatetheeffortsofanyotherbodies.

● Theofficewouldhandleappealsandgrievancesfromindividualswithdue-processconcernsthatwerenotaddressedatlowerlevelsofreviewandfromproviderswithpaymentorregulatoryconcerns.

● TheOmbudsmanshouldbeengagedtopreventback-to-backholdsandcapturedataonprevalenceoftheiruse. RationaleandExplanation ● ThecurrentsystemofM-1holdshastoomanyoverlappingroles,responsibilities,regulatoryframeworks,andpotential

orperceivedconflictsofinterestmakingitdifficulttoidentifywhoisultimatelyaccountabletomakesurethesystemworksasintendedandthatindividualdignityandrightsarepreserved.

● Thisrecommendationwouldstreamlinethoseoverlappingframeworksandprovideawaytoresolvegrievanceswhentheyarise.


Recommendation3:EstablishaTieredSystemforCarryingOutM-1Holds Establishathree-tieredsystemforcarryingoutM-1holdsthatensuresprotectionofindividualrightsthroughouttheM-1holdprocessandacknowledgesthedifferentlevelsoflicensedcarethatprovidersareequippedandexpectedtoprovide.OversightforthevarioustierswouldbesharedbytheColoradoDepartmentofPublicHealthandEnvironment(CDPHE)andtheColoradoDepartmentofHumanServices(CDHS)tobestalignwithexistingregulatoryframeworksatthestateandfederallevels.ConsistentdatawouldbecapturedbyanyfacilitywhereanM-1holdisplaced.Thetierswouldconsistof:

Tier1:Currentdesignatedfacilities(short-andlong-termfacilities) Tier2:Hospitalw/mentalhealthpartnership(facilityplacementagreement) Tier3:Generalemergencydepartmentwithoutpsychiatricspecialtyservices

● Allcrisisservices/hospitalstaffwillreceiveupdatedtrainingsonthespecificsofM-1holdprocessesandwhatisrequired. ● Thissystemwouldsetminimumstandardsofcareforallfacilitiesinvolvedinmentalhealthholds,andwouldallowfora

broaderuseoffacilityplacementandotheragreementswithsurroundingfacilitieswhereneeded. ● TheOfficeofBehavioralHealth(OBH)wouldshiftsomeoversighttoCDPHEwhereappropriate,retaininganannual

reviewtoensureaccountability. ● Definewheretheresponsibilityliesforensuringdueprocessprotections. ● Establishdatareportingrequirementsforeachtierfacility. RationaleandExplanation ● Thecurrentsystemofdesignationdoesnottakeintoaccountthedifferentcapacitiesofdifferentfacilitiesandleaves

hospitals,lawenforcementagencies,andpeopleexperiencingmentalhealthcriseswithoutthesupportstheyneed. ● Atieredsystemwouldallowbettercoordinationofcarewhilestillensuringtheprotectionofpatients’dueprocessrights. Recommendation4:EnsureNetworkAdequacy Ensurethateachregionofthestatehasanadequatenetworkofproviders—includingtheCrisisResponseSystemworkforceaswellasMedicaidandprivateproviders—toensuretheavailabilityandcoordinationofacontinuumofproperpsychiatriccare.TheOfficeofBehavioralHealth(OBH)andtheBehavioralHealthTransformationCouncil(BHTC)shouldconveneasubcommitteetoconductaneedsandcapacityassessmentoftheCrisisResponseSystemtoensureitismeetingdemandandtoidentifyneededenhancementssuchas:

o assessingwhethertheinitialfourmodalitiesofservicesarestillrelevant, o assessingworkforcecapacityineachregion, o assessingcrisisservicecapacityofMedicaidandOBHfundedprograms, o aligningdistanceadequacystandardsacrossregionsandpayers(e.g.definetheminimumdistancefromplaceinthe

regiontoacrisisfacility), o establishingbestpracticeresponsestandards(e.g.having2respondersavailableforcallsthatincludestheuseofpeers), o ensuringtheCrisisResponseSystemisaccessiblestatewide,and o reviewingmandatedservicesanddatacollectionrequirements.

● TheCrisisResponseSystemshouldprovidethefirstpointofcontactineachregionforlawenforcementandemergencydepartmentstohelpcoordinatethebestresponsetocrisesandtohelpdeterminethebestlocationforassessingsomeoneonanM-1hold.Sinceduplicationofservicesincrisiscentersandemergencydepartmentshasalargeimpactoncostandpayment,carecoordinationisessentialtoachievenetworkadequacy

● Eachregionneedstofindwaystocoordinateitsdeliveryofcarebetweenlowerlevelandhighacuitybedstomakesurethatpeopledealingwithandrecoveringfromcrisisepisodescanbeplacedintheproperfacility.Crisisregionsshoulddefinehowtomeetnetworkadequacyguidelinesintheirregion.

● Withincreasedcapacityintheregions,thestateshouldexploretheneedtoaddorfreeupbedsatFt.Loganforindividualswhoaredifficulttoplace,suchasthosewithTraumaticBrainInjury,intellectualordevelopmentaldisabilities,orindividualswithdementiaandaggressivebehaviors.

RationaleandExplanation ● InordertoeliminatetheuseoflawenforcementfacilitiesduringtheM-1holdprocess,eachregionofthestatemust

haveadequatenetworksofmentalhealthcareandsupportthatincludefacilitiesthatarepreparedandwillingtoaccepthigh-acuitypatientsandtheabilityofproviderstoworkwithpeoplewithmultipledisabilities.

● Moreservicesatlowerlevelsofinterventionwillkeeppeopleoutofhospitalsandhigh-acuityfacilities,reducecosts,andreduceescalationofcrises.

● Toachievethefullcontinuumofcare,theCrisisResponseSystemshouldhelpcoordinateamongthevariousproviders. ● Servicelocationsmightneedtobeaddedinunderservedregionsofthestatetoensurethatservicesareaccessible.


Recommendation5:ExpandandExtendtheBehavioralHealthWorkforce Developashort-andlong-termbehavioralhealthworkforceexpansionandextensionplantoensureadequatebehavioralhealthstaffingthroughoutthestatethatincludesincreaseduseofpeersupport,telehealth,integratedmodelsofcare,hub-and-spokestrategies,andcrisistrainingforrelevantstaff.ReviseCRS27-65toallowAdvancePracticeNurseswithminimumtwoyears’behavioralhealtheducationtoreleasementalhealthholds.Aswarranted,reviewlevelsoflicensureneededtoplaceandreleasementalhealthholds,ensuringthatallrelevantprofessionaldisciplinesareincludedintheconversation.Removebarriersthatlimitcurrentworkforcefromoperatingwithinthefullestextentoftheirlicensure.Ensurethatstaffingmodelsaddressregional(notaggregate)needs. ● ClarifyreportingauthorityoftheBehavioralHealthTransformationCouncil(BHTC). ● EngagetheBHTCworkforcesubcommitteetoconveneagenciestoexaminethefollowing:

o RelyonDepartmentofRegulatoryAgencies(DORA)forworkforcedata. o LinktolargerstateworkforcedevelopmentworkinStateInnovationModel(SIM)workforceworkgroup;Officeof

EconomicDevelopmentandInternationalTrade(OEDIT);DepartmentofLabor(DOL)–forstatistics. o Ensuretelehealthisaviable,immediateworkforceextensionplan. o Develop(re-establish)collaborativeagreementsbetweenthehighereducationsystemandstateandlocalmental

healthdepartmentswithgoalofencouraginghealthprofessionalsincludingpsychiatriststopursuecareersincommunityandpublicmentalhealth.

o Establishinitiativestoencouragehighschool/collegestudentstochooseeducationalprogramswithbehavioralhealthcareerpaths.

o ExpandColorado’sloanrepaymentassistanceprogramtoincludepart-timeandinpatientbehavioralhealthprofessionals.

o Offerpaidinternshipsincentivizinggraduatestudentstoshadowmentalhealthprofessionals o Supportandacknowledgethepeersupportprovidercertificationprocess–ensuringadequatetraining,supervision

andclearlydefinedjobdescriptions. o Developstandardsfortelehealthandleveragegrantfundedopportunitiestoexpandtheusestatewide. o Reviewandalignrulesandregulationsacrossstatedepartmentstoensurethatallprofessionalcategoriesareable

tooperatefullywithintheircompetencebasedontraining,education,andscopeofdiscipline. o Evaluatetheworkforceneedsrelatedtomobileresponse. o Consideraffordingparamedicsadistinctcustodialstatusforthepurposesoftransport.

● Shareexamplesofexistingbestpracticeamonghospitals,crisisresponsesystemcontractors,andotherrelevantstakeholders.

RationaleandExplanation ● Withoutadequatestaffing,regionsaroundthestatewillnotsucceedineliminatinguseoflawenforcementfacilitiesin

theM-1holdprocess. ● Aworkforcethatincludesmorebehavioralhealthexperts,includingpeers,duringcriseswillhelpde-escalateepisodes

andrequirefewerlawenforcementresources. ● Tobuildthatworkforce,amorecomprehensivereviewmustbeconductedforhowtoextendthereachofcurrentstaff

intheshortterm(e.g.telehealth,peersupport)andexpandfuturerecruitmentefforts.


Recommendation6:CreateaSustainableandReliableDataMonitoringSystem DevelopacomprehensivebutsustainabledatatrackingsystemformentalhealthholdsacrossColoradothatincludesallsiteswhereholdsareconductedaswellasappropriateextrapolationmethodswhereactualdataisdifficulttocapture.Datashouldbegatheredinwaysthatprotectindividualprivacyandincludebutnotbelimitedto: ● MandatetheOfficeofBehavioralHealth(OBH)toreportannuallytoensureoverallmonitoringofmentalhealthhold

systemandrequireallfacilitiesinvolvedwithM-1holds—includinglawenforcementfacilitiesandemergencydepartments—toabidebythefollowingproposedstatutorychange:

(a)ONORBEFOREDEC.31,2017,ANDEACHJULY1THEREAFTER,EACHFACILITYTHATRECEIVESANINDIVIDUALONAMENTALHEALTHHOLDWHICHHASTAKENCUSTODYOFAPERSONORTREATEDAPERSONPURSUANTTOTHISSECTIONSHALLPROVIDEANANNUALREPORTTOTHEDEPARTMENTTHATINCLUDESONLYAGGREGATEANDNONIDENTIFYINGINFORMATIONCONCERNINGPERSONSWHOWERETAKENINTOCUSTODYORTREATEDATTHEFACILITYTHATRECEIVESANINDIVIDUALONAMENTALHEALTHHOLDPURSUANTTOTHISSECTION.LAWENFORCEMENTFACILITIESMAYCONTACTCRISISCENTERSFORASSISTANCEINFULFILLINGTHEREQUIREMENTSOFTHISSUBSECTION(4.5). THEREPORTMUSTCONTAINTHEFOLLOWING: (I)THENAMESANDCOUNTIESOFTHEFACILITIES; (II)THETOTALNUMBEROFPERSONSTAKENINTOCUSTODYORTREATEDPURSUANTTOTHISSECTION,INCLUDINGASUMMARYOFDEMOGRAPHICINFORMATION; (III)ASUMMARYREGARDINGTHEDIFFERENTREASONSFORWHICHPERSONSWERETAKENINTOCUSTODYORTREATEDPURSUANTTOTHISSECTION;AND (IV)ASUMMARYOFTHEDISPOSITIONOFPERSONSWHETHERRELEASEDFROMCUSTODYORTRANSFERREDTOADESIGNATEDFACILITY.

RationaleandExplanation ● ToproperlymonitorthenumberofM-1holdsandtheirproperusage,aconsistentandreliabledatatrackingandreview

processmustbeimplementedacrossthestate. ● Thedatacollectedmustbelimitedtoonlythemostsalientitemstoreducetheburdenonproviders,shouldutilize

existingdatasystems,andmustbereviewedannuallytoensurethesystemisworkingasitshould.

Recommendation7:EnsureProperPaymentforTreatmentofIndividualsonMentalHealthHolds Thepresenceofasubstanceuseconditionorotherdiagnosisshouldnotpreventorimpedeaperson’sabilitytoaccesscoverageforamentalhealthcrisis.Towardthisend, ● Crisiscareshouldbereimbursedbytherelevantpayer. ● TheTaskForcerecommendsexpandingfundingforMedicaidtocoversubstanceabuseandotherdualdiagnoses. Inaddition,appropriatelyenforcethebenefitsthatcurrentlyexist,identifyingandremovingbarrierstoreimbursementforservicesdeliveredduringmentalhealthholds. ● Ensurethatbothclientsandprovidershavetheabilitytoaccessafairappealprocessby:

o WorkingwiththeDepartmentofHealthCarePolicyandFinancing(HCPF)tostrengthentheaccountabilitymechanismscurrentlyinplacetoensurepaymentforservicescurrentlycoveredbyMedicaid(includingboththeBehavioralHealthOrganization(BHO)systemandthefutureRAE(RegionalAccountableEntity)system).

o WorkingwiththeDivisionofInsurance(DOI)tostrengthentheaccountabilitymechanismscurrentlyinplaceforprivateinsuranceplans.

RationaleandExplanation ● Inthecurrentsystem,asignificantpercentageofclaimsformentalhealthservicesprovidedduringmentalhealthholds,

especiallythehighestacuitycases,aredeniedbecausethediagnosisinvolvessubstanceuseandhospitalizationisnotcoveredbytheMedicaidcapitationprogram.AllowingclaimsformentalhealthdiagnosesforwhichsubstanceusedisordersorotherdiagnosesthatarenotcoveredbytheMedicaidprogramarepresentwouldremovethisbarrier.

● IfprovidersknewtheywouldbereimbursedforthecostsofM-1holds,morebedswouldbeavailableinthesystem,increasingnetworkadequacyandreducingtheneedforlawenforcementfacilitiesduringtheM-1process.

● Currentlackofaccesstohigh-acuitypsychiatriccareisdue,inpart,totherebeingnoappealprocessforprovidersofhighestacuitypsychiatriccarewhentheyaredeniedpayment.


Recommendation 8: Identify and Pilot Client Transportation Solutions that Reduce the Costs, Stigma, and TraumaAssociatedwithM-1Transport Inventoryandidentifymethods/systemsofnon-emergencytransportationforpeopleonM-1holdsthatensurementalandphysicalhealthparity,altertheuseofEmergencyMedicalServices(EMS)andlawenforcementresourceswhilereducingrequirementsforpeopleonmedicalholdstobeseeninemergencydepartmentswhennotmedicallynecessaryandexpandoptionsforprovidingsafetransportwithminimalstigmaattached.Thesetransportationsystemsmustaccountforbothruralandurbanneedsandresources. ● TheOfficeofBehavioralHealth(OBH),theColoradoDepartmentofPublicHealthandEnvironment(CDPHE),andthe

BehavioralHealthTransformationCouncil(BHTC)shouldconveneacommitteetoidentifymethods/systemsofnon-emergencytransportationforpeopleonM-1holds.Thecommitteeshould: o ReviewstatutesandrulespertainingtothetransportofindividualsonM-1holds. o WorkwiththeColoradoNetworkofHealthAlliances,EMSproviders,DepartmentofHealthCarePolicyand

Financing(HCPF)andotherstoinventoryexistingtransportationmodels o Establishcleartransportbestpracticerecommendationsforregionstofollow(e.g.involvingpeersintransport

solutions). o Expand/developtheuseofnon-emergencymedical,orotherappropriatetransportationsystemswheretheyexist

andidentifymethodstoexpandthosesystemsintoareaswheretheycurrentlydonotoperate. o Pilotprograms,designedtointroducemoresuitableformsoftransportinbothurbanandruralregions.Thesepilot

programscouldtestoutmechanismstoreducecosts,improveefficiencyandde-escalatecrises. o ProvidetrainingandeducationtolawenforcementandEMSpersonneltoimprovetheirabilitytoassessand

effectivelyinteractwithclientstominimizestigmaandtrauma. o Workwithlocalemergencymedicalservicesagenciesandtheirphysicianmedicaldirectorstodevelopprotocols

thatsupportthetransportationofclientstonon-acutecaremedicalfacilitieswhenappropriateanddevelopcostsupportsaccordingly.

RationaleandExplanation ● ThecurrentsystemsfortransportingpeopleonM-1holdsreliesheavilyonEMSandlawenforcement,further

traumatizingpeopleintimesofcrisisandtaxingpublicsafetyresources.However,CRS27-65-105embedstheroleoflawenforcementandthecourtsregardingtheM-1holdprocessandlendstotheroutineuseofEMSandlawenforcementtransportationresources.

● Anysavingsidentifiedduringthepilotcouldhelpcoverthecostsofexpandingtheprogramtootherregionsinthestate.


AppendixA:GovernorHickenlooper’sSB16-169VetoLettertoColoradoSenate


AppendixB:MentalHealthHoldSystemFramework

TaskForceconversationswereorganizedaroundasystemframeworkcomprisingsixprimaryelementstiedtoareasofconcernexpressedbyGovernorHickenlooper.


AppendixC:SummaryofTaskForceMeetingAgendasandPresentations

Meetings TaskForceMeetingObjectives PresentationstoTaskForce Mtg.18/4/16

● ClarifythechargeoftheTaskForce ● Establishsharedunderstandingofeffectivegroupworkingconditions ● ReviewprocessdesignandtimelineforTaskForcework

BillFulton,TheCivicCanopyWorkingEffectivelyasaTaskForce

Mtg.2 8/23/16

● ReviewworkingagreementsoftheTaskForce ● Applyasystems-thinkinglenstothequestionofmentalhealthholds ● ReviewinsightsfromMeeting1tobuildahigh-levelconsensusonthedesignofabettersystem

● BuildsharedunderstandingofEMTALAdueprocessconsiderations

KatherineMulready,CHA EMTALAOverview

Mtg.3 9/7/16

● ReviewMHHSystemFrameworkfromMeeting2toensuresharedunderstanding

● Applyaperson-centeredapproachtotheMHHprocesstoestablishaPathwayDesign

● IdentifycriticaljuncturesandopportunitiesinPathwayDesign ● UpdateMHHSystemFrameworkwithpreviousworkandinsightsfromthisdiscussion

● Setanagendaforupcomingmeetings

AmandaKearney-Smith,CMWN AFrameworkforChange LaceyBerumen,ERNurse ChrissieHodges,self-identifiesashaving“PureO”&hasexperiencedamentalhealthhold CharlesSteinbach,self-identifiesashavingchronic,paranoidschizophrenia&hasexperiencedamentalhealthhold

Mtg.4 9/21/16

● DevelopsharedunderstandingofcurrentdraftofCOMHHSystemmap ● LearnaboutandapplylessonsfromnationalexamplestothedesignofColorado’ssystem

● Refinepreviousdiscussionpointsintopotentialrecommendations

FrankieBerger,TAC MentalHealthHolds:ANationalPerspective

Mtg.5 10/6/16

● Developasharedunderstandingofhowtoframediscussioninnon-polarizedterms

● ReviewandreviseaflowchartoftheMHHprocess ● ReviewandupdatecurrentproposalstoimproveMHHSysteminCO ● Refinepreviousdiscussionpointsintopotentialrecommendations

ToddMerendino,CDHS-OBH Overviewof27-65-105,C.R.SEmergencyProceduresandDesignatedFacilityRule

Mtg.6 10/18/16

● DevelopsharedunderstandingofCO’sCrisisResponseSystemandhowitrelatestotaskofdevelopingabettersystemMHHmanagement

● ReviewandreviseanupdatedflowchartoftheMHHprocess ● ReviewandupdatecurrentproposalstoimproveCOMHHSystem ● Reachagreementonrecommendationsreadyforaction

NancyVanDeMark,CDHS-OBHFrankCornelia,CBHC ColoradoCrisisResponseSystem:OverviewandFutureDirection

Mtg.7 11/2/16

● RefineupdatedrecommendationstoimproveCOMHHSystem ● Reachagreementonrecommendationsreadyforaction ● Definenextstepsandanyadditionalinfoneededtoreachagreement

None

Mtg.8 11/16/16

● RefineupdatedrecommendationstoimproveCOMHHSystem ● Reachagreementonrecommendationsreadyforaction ● Definenextstepsandanyadditionalinfoneededtoreachagreement

DougWilson ColoradoPublicDefender CCJJ’sProposedChangestoTitle27-65

Mtg.9 12/7/16

● Reviewprocesstoreachfinalagreementonrecommendationsandproducereport

● RefineupdatedrecommendationsforimprovingtheMHHsysteminCO ● Reachconsensus/agreementonrecommendationsreadyforaction ● Definenextstepsandanyadditionalinfoneededtoreachagreement

None

Mtg.10 12/21/16

● Reviewremainingsmallgroupproposalsaroundtiereddesignationandownershipforrecommendations

● Testthesetofrecommendationsagainstreal-worldchallenges ● Reachconsensus/agreementonrecommendationsreadyforaction ● Evaluatetheprocessandgatherclosingreflections

None


AppendixD:OverlayofCrisisStabilizationUnitandHealthcareFacilityLocationsAcrossColorado


AppendixF:TaskForceVotingTallyonFinalRecommendations

TheTaskForcevotedusingaFist-to-Fiveapproach,raisingtheirhandsasinvoting,withthenumberoffingersraisedindicatingeachmember’slevelofagreement. 5fingers–Iaminfullsupportofthismotion. 4fingers–Isupportthismotion. 3fingers–I’minthemiddlesomewhere,butcanstillsupportthemotion. 2fingers–Ihavesomeconcernsbutwillgoalongwiththegroup’sdecision. 1finger–Ihavestrongreservationsbutwouldnotblockconsensus. 0fingers/fist–Iobjectandwillblockconsensus. OnDecember21,2016,theTaskForcevotedtoapprovethefullsetofrecommendations,thetablebelowshowsthelevelsofagreementforeachrecommendation.

RECOMMENDATIONNUMBER FullySupport Supportwith

Reservations DoNotSupport

5 4 3 2 1 0 Recommendation1(FirstSentenceonly) AmendCRS27-65-105duringthe2017legislativesessiontoeliminatetheuseofjails,lock-up,orotherplaceofconfinementforpersonswhohavenotbeenchargedwithorconvictedofacrime.

18 0 1 1 1 1

Recommendation1(ComponentAonly) Weencouragecommunitiestophasethisrecommendationevenbeforestatutorychangeshavebeenfinalized.

20 2 0 0 0 0

Recommendation1(ComponentBonly) Inregionswhereadequatealternativesdonotyetexist,implementationofthisrecommendationshouldbephasedinoncetheservicesandsupportsoutlinedinsubsequentrecommendationsareinplace

10 3 3 3 0 2

Recommendation1(ComponentConly) Newstand-alonebulletendingthepracticeofuseofjailsnolaterthanJanuary1,2018:

13 0 2 0 0 6

Recommendation2(aswritten) 12 11 1 0 0 0 Recommendation3(aswritten) 23 1 0 0 0 0 Recommendation4(aswritten) 23 1 0 0 0 0 Recommendation5(aswritten) 16 5 3 0 0 0 Recommendation6(aswritten) 21 3 0 0 0 0 Recommendation7(aswritten) 16 3 2 0 0 0 Recommendation8(aswritten) 20 2 0 0 0 0 ALLRECOMMENDATIONS,ASASETIncludesrecommendations2-8andthefirstsentenceonlyofrecommendation#1.

9 12 0 0 0 0


AppendixG:Definitions

AnAcuteTreatmentUnit(ATU)isafacilityoradistinctpartofafacilityforshort-termpsychiatriccare,whichmayincludesubstanceabusetreatment,thatprovidesatotal,twenty-four-hour,therapeuticallyplannedandprofessionallystaffedenvironmentforpersonswhodonotrequireinpatienthospitalizationbutneedmoreintenseandindividualservicesthanareavailableonanoutpatientbasis,suchascrisismanagementandstabilizationservices.(C.R.S.§27-65-102) ABehavioralHealthOrganization(BHO)isanentitycontractingwiththestatedepartmenttoprovideonlybehavioralhealthservices.(C.R.S.§27-5-403) TheColoradoDepartmentofPublicHealthandEnvironmenthasstatutoryauthoritytolicensehealthfacilitiesinColorado. TheCrisisHotline/WarmlineisacomponentoftheCrisisResponseSystem.Theserviceisavailable24/7/365toanyoneaffectedbyamentalhealth,substanceuse,oremotionalcrisis.Theserviceincludesapeersupport“warm-line,”texting,andchatfeatures. Colorado’sCrisisResponseSystemwassignedintolawinMay2013toprovidecriticallyneededservicesandsupports“whenandwhereneeded”withthegoalthattheservicesbeaccessibletoallColoradans,regardlessoftheirabilitytopay.Thesystemincludes:1)a24-hourhotline/warmlineforcrisisassistance,staffedbytrained,professionalspecialistsandpeercounselors;2)mobilecrisisresponse;3)respitecare;4)crisiswalk-incentersandCrisisStabilizationUnits(CSUs). ACrisisStabilizationUnit(CSU)providesshort-term,crisis-focusedinterventionandtreatmenttopeoplewhoareinpsychiatriccrisis.Treatmentisprovided24hoursaday,7daysaweekandisavailabletoanyone,regardlessoftheirabilitytopay. TheDepartmentofHealthCarePolicyandFinancing(HCPF)isthestateagencythatmanagestheadministrationofabroad-basedmedicalcareprogramforlow-incomefamiliesinColorado. ADesignatedFacilityisanagencythathasappliedforandbeenapprovedbytheColoradoDepartmentofHumanServicestoprovidementalhealthservices.(2CCR502-1) An“M-1Hold”isamentalhealthholdthatmaybeinvokedwhenaqualifiedmentalhealthprofessionaldeterminesthatanindividual“appearstobeanimminentdangertoothersortohimselforherselforappearstobegravelydisabled.Inthiscircumstance,theindividualcanbetakenintocustodyandplacedinafacilitydesignatedorapprovedbytheColoradoDepartmentofHumanServicesforfurtherevaluationandtreatmentforupto72hours.(C.R.S.27-65-105)“M-1”referstothelegaldocumentthatinitiatesthe72-hourhold. MobileCrisisisacomponentoftheCrisisResponseSystem.Theserviceisavailable24/7/365,andmeetsindividualsattheirhomes,otherlocations,orothercommunitylocations. NetworkAdequacyisunderstoodasensuringthateachregionofthestatemusthaveadequatenetworksofmentalhealthcareandsupportthatincludefacilitiesthatarepreparedandwillingtoaccepthigh-acuitypatientsandtheabilityofproviderstoworkwithpeoplewithmultipledisabilities.Networkadequacyisessentialtosupportingemergencydepartmentsandjails,andtoeliminatingtheuseoflawenforcementfacilitiesduringtheM-1holdprocess. TheOfficeofBehavioralHealthisthestateagencyresponsibleforgranting“designation”statustohealthcarefacilitiesinColorado.Designationiscurrentlyoptionalforemergencydepartments. PeerServicesareacomponentoftheCrisisResponseSystem.Peerservicesprovideopportunitiesforindividualstoconnectwithotherswhohaveexperiencedmentalhealthchallenges.

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