navigating from the non-designated world to the …...1 navigating from the non-designated world to...

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Navigating from the Non-Designated World to the Designated World

Steve LiptonHooper, Lundy & Bookman, PC

Linda Garrett, JDRisk Management Services

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We think we know how your ED providersfeel on many days...

(not this )3

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W.O.R.S.E.

• Worries• Obstacles• Risks• Strategies• Execution10 things that impact (and complicate) the transition of psychiatric patients from “non-designated” to “designated” facilities, plus10 things that might make things better!

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10 Worries, Obstacles and Risks

1. Patient Variables (all are important!)a. May arrive with law enforcement, friends, family

or come to ED “self-referred” b. May or may not be on a 5150 “custodial hold”c. May or may not have a physical and/or

psychiatric “emergency medical condition” (per EMTALA)

d. May or may not have co-occurring medical (physical) health issues

e. May or may not have co-occurring substance use

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2. Legal Variables (just a sampler)– Crossing county lines – different counties have

different interpretations of the law (e.g., authorization to write a 5150, status of a hold, etc.)

– Crossing state lines – bed may be available in a neighboring state (EMTALA vs. LPS placement)

– Conflicts between EMTALA and LPS (recognition and significance of holds)

– Enforcement of a hold by a non-designated hospital

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3. Finding a Bed– Is there a current list of “designated facilities”?

– How to find a geri-psych, child or adolescent bed?

– Do you know a transferee facility’s “house rules” (e.g., age limitations, health limitations, level of dangerousness limitations, financial requirements/insurance preferences)?

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4. Understanding the differences between designated facilitiesDo you know the different licensure and clinical capabilities of each of the types of facilities you may end up contacting?– Acute psychiatric facility (APF) or acute psych

unit– Psychiatric health facility (PHF)– Crisis stabilization unit (CSU)– Psychiatric emergency services (PES)

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5. Medical clearance...is NOT standardized!!Each facility has its own admitting criteria and capability to support a patient’s health conditions, leading to different standards for “medical clearance,” e.g., have you ever had to argue about:– Methamphetamine levels? – Infectious medical condition? – MRSA? – 2nd or 3rd trimester pregnancy?

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Sound familiar?

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6. Available beds (may not be available)– Some “designated facilities” have committed

beds to other Counties, health plans or providers (so an empty bed sits empty!)

• Is this permitted?

– Some designated facilities are not covered by EMTALA, and do not have to accept patient transfers

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7. Involuntary Status vs. “Stabilized Psychiatric Condition” (per EMTALA)– If the ED physician determines that a patient’s

psychiatric condition is stabilized, can the hospital discharge the patient if he/she is “on a 5150 hold”

– Can you safely discharge and refer? – Is person on a hold an EMTALA patient which

requires an appropriate transfer to a designated facility?

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8. What is an “appropriate” transfer?– What mode of transport should (must) you

use?

– What if a patient agrees to go to a psych facility voluntarily? Can you use an ambulance without a 5150 hold in place?

– What about a voluntary patient who agrees to go in a private car? Police vehicle? “Caged” county car?

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9. Is the 72-Hour Clock Ticking?– When does the clock start in your county?

– Can you (must you?) write “serial holds” or “fresh” holds when 5150 clock has run (assuming it does)?

• Is it even legal to write serial holds?

• How will it affect the transfer?

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10.Are emergency psychiatric patients different than emergency medical patients?– Are the rules and practices for addressing

psychiatric conditions different?

– Are the rules for transfers different?

– How are you handling the collision between LPS Act and EMTALA?

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Help is on the way …

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10 Strategies and Execution Plans

(10 practical ideas to consider that will help patients’ transition to the right level of care)

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Strategies and Execution

1. We’re all in this together! – Work with designated facilities to reach

common cause!

– Meet quarterly and commit to working together to solve problems as they come up; change what needs to change based on issues that have come up in prior 3 months

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2. Engage County Behavioral Health– Discuss key issues that complicate care in your

county– Seek authority of ED physicians to write/release a

hold– Seek solutions to expedite release of patients

who do not require a hold, and transfer those who do

– Learn about substance use disorder programs in your community and make appropriate referrals

– Engage your County Board of Supervisors to work on solutions

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3. Encourage best practices– Develop protocols, county-wide or further, that

establish standardized approaches and best practices so all shifts, including nights, weekends and holidays and all staff (including “per diems” and temps) follow the same guidelines

– Develop forms or checklists that help to prompt staff to document key information and actions

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4. Identify Key Players and Resources– Create directories of key players and

resources in your County and in your region

– Include names, phone and fax numbers, hours of operation, etc., and make sure the directory is available to staff

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5. Inter-facility Cooperation– Explore exchanges of information and in-

service training between ED staff and designated facility personnel

– Explore use (expansion) of telemedicine by designated facility staff for ED patients

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More Ideas to Get Going in the Right Direction

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6. CSUs – Use them! (now in 17+ counties, and growing)– Meet and greet, and request their admission

and transfer criteria

– If there is a CSU in your County, know the rules for transferring a psychiatric patient without violating EMTALA

– Consider a transfer agreement – individual or community-wide (e.g., the Fresno model)

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7. Community Resources– Explore opportunities to develop volunteer

and mental health peer support programs

– Identify other local resources and get them involved, for example:

• Mental Health First Aid training

• NAMI

• 12-Step Programs

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8. Community Engagement– Be a catalyst for performance improvement of

emergency mental services in your county – Involve county mental health stakeholders –

hospital staff, law enforcement, ambulance and other transport providers, county mental health, patients’ rights advocates, NAMI and the public

– Seek opportunities to achieve Strategies 9 and 10

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9. Support New Paradigms– Talk to local and regional representatives

about opportunities to expand availability of mental health services and outreach; also to assure continuity of care:• Laura’s Law

• Community paramedicine

• CIT-trained law enforcement officers

• Home health nursing

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10.Reshape Old Paradigms– Work to get support for AB 1300 through

community education (County staff, mental health boards, NAMI, patients’ rights advocacy groups, provider organizations, media attention, legislators, etc.)

– Collect data so that you have more than just anecdotal evidence of problems

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Some Other Tools That Might Help...

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Risk Reduction Checklist

Find out who can write a hold in your County and create a list with contact information and availability

Find out who can “lift” a hold (create a list/contact info)

If your County “contracts” for beds, create a list with phone numbers/contact info of those “designated facilities” where patients can go for psychiatric care

Meet with County and decide who will stay with the patient (may vary depending on day/time/aggressiveness) – NO GAPS!

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Risk Reduction ChecklistFind out who is available to transport the patient (list

times/days/contact info)Ask/help County develop policies on what happens

when patient is admitted for medical care (e.g., “Mental Health will reassess when patient is ambulatory if physician sees need; hospital will contact Mental Health”)

Review your discharge procedures if the patient has no immediate transportation to his/her home

Work with County resources and social service agencies to develop plan for discharge of homeless patients

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Risk Reduction Checklist Be flexible when creating policies – things change and

unique situations present themselves!

Consider MOU with Crisis Stabilization Unit so it is clear that patient who has unstable psych emergency will get proper care if you decide to transfer patient there

Reflect transfer process in your policies!

If you haven’t secured a bed and 24 hours (H&S 1799.111), or 72 hours (5150), has passed, consider a call to County Patients’ Rights Advocate to advise them of situation (and document discussion)

Train your staff to document vital signs (as they monitor patient), phone calls on patient’s behalf and other EMTALA-required documentation

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Risk Reduction Checklist

Make sure County Mental Health staff is invited to EMTALA training so they understand “your world”

Train your staff about their EMTALA responsibilities (and CMS expectations re: screening exam, stabilization, and safe transfer plans for an unstable patient)

Have in-service meetings to discuss management of difficult cases

Try to meet with law enforcement and County Mental Health on regular basis to strengthen “community bond”

Meet, when necessary to trouble-shoot issues that come up from time to time

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Resources and Links

• CHA: EMTALA: A Guide to Patient Anti-Dumping Laws (2012) (includes EMTALA Statute and Emergency Dept.-Related Regulations, Interpretive Guidelines, sample Survey Tools, etc.)

• Link to Find Mental Health Facilitieshttp://www.dhcs.ca.gov/provgovpart/Pages/MH-Licensing.aspx

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Resources and Links• Lanterman-Petris-Short (LPS) Act Designated

Facilities– http://www.dhcs.ca.gov/provgovpart/Documents/LPS-

24hr_07162014.pdf– http://www.dhcs.ca.gov/provgovpart/Documents/LPS-

Outpatient_CSU_07162014.pdf– http://www.dhcs.ca.gov/provgovpart/Documents/LPS-

Otherfacilities_07162014.pdf• Find a Mental Health Treatment Facility

– http://www.dhcs.ca.gov/services/MH/Documents/PsychiatricHealthFacility.pdf

WARNING: No guarantees that webpages are available and up-to-date

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Questions

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Thank you

Steve LiptonHooper, Lundy & Bookman, [email protected]

Linda GarrettRisk Management [email protected]