Crisis on the Continuum: Roles and Responsibilities Nena Lekwauwa, MD DMH/DD/SAS Susan Saik, MD DSOHF Art Eccleston, Psy.D DMH/DD/SAS
Overview of Practice Response System Learn about the crisis response system from the state s perspective The funding sources available for crisis treatment How do crisis services fit with the rest of the service continuum
Crisis System Philosophy: Services should be delivered in least restrictive setting possible, connected to consumers home communities whenever possible, and no more intense than needed to meet consumers needs. Reserve use of state hospitals for those most in need with most challenging conditions in need of longer lengths of stay. Increase use of alternatives to hospitalization whenever possible: Mobile Crisis, Facility Based Crisis, Social Setting Detox, Walk-In Clinics, etc. Maximize use of community inpatient beds.
Report on the Provision of Behavioral Health Crisis Services by Hospital Emergency Departments Legislatively mandated report (Session Law 2010-31, Section 10.7B.) Purpose of the report was to evaluate emergency department length of stay in community-based hospitals in NC 1915 (b)/(c) waiver entities vs. non-waiver entities Medicaid recipients vs. non-medicaid recipients North Carolina Department of Health and Human Services, 2011, Report on the Provision of Behavioral Health Crisis Services by Hospital Emergency Departments, NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services Available at: http://www.ncdhhs.gov/mhddsas/statspublications/reports/ed-admissions/edreport-3-11.pdf
Data Collection Process Community-based EDs provided data on admissions with behavioral health crises during the month of November 2010. Data collected on 8,757 behavioral health admissions 78 of 114 hospitals provided data - 68 % response rate Data was collected from hospitals but reported by LME catchment area North Carolina Department of Health and Human Services, 2011, Report on the Provision of Behavioral Health Crisis Services by Hospital Emergency Departments, NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services Available at: http://www.ncdhhs.gov/mhddsas/statspublications/reports/ed-admissions/edreport-3-11.pdf
Behavioral Health ED Admissions by Disability Group Individuals Presenting to EDs with Behavioral Health Crises by Disability Group Total: 8,757 SA 2,397 27.4% DD 31 0.4% Unknown 165 1.9% MH 6,164 70.4% North Carolina Department of Health and Human Services, 2011, Report on the Provision of Behavioral Health Crisis Services by Hospital Emergency Departments, NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services Available at: http://www.ncdhhs.gov/mhddsas/statspublications/reports/ed-admissions/edreport-3-11.pdf
Behavioral Health ED Admissions by Insurance Coverage Insurance Status of Individuals Presenting to EDs with Behavioral Health Crises Total: 8,757 Uninsured 2,828 32.3% Unknown 147 1.7% Medicaid 2,052 23.4% Other Third Party Payor 3,730 42.6% North Carolina Department of Health and Human Services, 2011, Report on the Provision of Behavioral Health Crisis Services by Hospital Emergency Departments, NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services Available at: http://www.ncdhhs.gov/mhddsas/statspublications/reports/ed-admissions/edreport-3-11.pdf
Behavioral Health ED Admissions by Disposition Disposition of Individuals Presenting to EDs with Behavioral Health Crises Transferred to other facility 172 2.0% Admitted 122 1.4% State psychiatric hospital 239 2.7% Community hospital psychiatric bed 1,904 21.7% Total = 8,757 Left against medical advice 120 1.4% Left w ithout receiving medical advice 52 0.6% Other/Unknow n 645 7.4% Home w ith existing supports 4,479 51.1% Home w ith referral to LME 365 4.2% Home w ith referral to private MH 659 7.5% North Carolina Department of Health and Human Services, 2011, Report on the Provision of Behavioral Health Crisis Services by Hospital Emergency Departments, NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services Available at: http://www.ncdhhs.gov/mhddsas/statspublications/reports/ed-admissions/edreport-3-11.pdf
ED LOS for a Behavioral Health Crisis by Disposition Overall N=8,592 9:38 Other/Unknown N=566 10:07 Left without receiving medical advice N=50 3:30 Left against medical advice N=118 5:58 Transferred to other facility N=172 8:29 Admitted N=122 22:29 State psychiatric hospital N=239 26:38:00 Community hospital psychiatric bed N=1,904 14:11 Home with referral to LME N=365 10:59 Home with referral to private MH N=659 9:25 Home with existing supports N=4,45 6:38 Average LOS in hours and minutes 0:00 4:48 9:36 14:24 19:12 0:00 4:48 North Carolina Department of Health and Human Services, 2011, Report on the Provision of Behavioral Health Crisis Services by Hospital Emergency Departments, NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services Available at: http://www.ncdhhs.gov/mhddsas/statspublications/reports/ed-admissions/edreport-3-11.pdf
Diagnostic Categories with 3 or More ED Readmissions in the Past 30 Days Top Five Diagnostic Categories With 3 or More ED Readmissions in the Past 30 Days N=177 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Alcohol Abuse Anxiety Disorders Paranoia/Delusional Disorders Schizophrenia Depressive Disorders Series1 19.77% 18.64% 12.43% 11.30% 9.04% North Carolina Department of Health and Human Services, 2011, Report on the Provision of Behavioral Health Crisis Services by Hospital Emergency Departments, NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services Available at: http://www.ncdhhs.gov/mhddsas/statspublications/reports/ed-admissions/edreport-3-11.pdf
Reducing Recidivism Detox in ED and discharge without linkage to treatment services perpetuates cycle of returning to ED. Can we link patients to treatment earlier (from ED or from medical detox)? Outreach by ADATCs to EDs and Medical Detox to engage consumers earlier is a promising new approach.
Considering Alternative Settings of Care Almost 2/3 of individuals seen were discharged home with relatively short stays Is it possible that many of these individuals could have their needs met or better met in an alternative setting? If so, what would that setting look like? Would at least some of the individuals that were admitted also be able to be served in an alternative environment and possibly avoid hospitalization?
ED Workgroup The North Carolina Department of Health and Human Services instructed the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services in partnership with various stakeholder groups to consider and advise on actions that would address the following issues:
ED Workgroup continued 1. Reducing the number of people entering the Emergency Department with mental illness by promoting early intervention systems and strategies. 2. Reducing the length of stay for individuals with mental illness admitted to hospital emergency departments. 3. Linking consumers to housing, services, and supports to prevent future Emergency Department admissions.
ED Workgroup continued To effectively address these issues, the Division of MH/DD/SAS in collaboration with its stakeholders, is working on developing an Action Plan. The plan will describe goals and action steps that will continue to strengthen and improve North Carolina s crisis service system. The Action Plan is intended to serve three major functions:
ED Workgroup continued 1. To serve as a roadmap to guide our immediate priorities, as well as priorities over the next several years, with flexibility to respond to unanticipated opportunities and challenges.
ED Workgroup continued 2. To act as a communication tool to share our plans with consumers, partners and the public, and engage wider support in achieving these goals.
ED Workgroup continued 3. To provide a list of priority solutions showing how additional funding could improve the system of care to individuals with mental illness.
Goals There are four primary goals and associated action steps that comprise the framework of this plan: Pre-Crisis Pre-Emergency Department Emergency Department Post-Emergency
Pre-Crisis GOAL: To promote early intervention systems and to prevent crisis events through a collaborative effort. Recommendations: 1. Develop and provide crisis/prevention/de-escalation training. 2. Require an enhanced crisis reduction plan for high risk, high volume consumers. 3. Increase provider accountability for consumer outcomes. 4. Convene internal critical care conferences for individuals who have high utilization of crisis services. 5. Develop funding and planning to provide transportation.
Pre-Emergency Department GOAL: To reduce the number of people entering the Emergency Department with Behavioral Health issues. Recommendations: 1. Enhance the effectiveness and efficiency of Mobile Crisis Management Services. 2. Augment the role of Facility Based Crisis Centers (FBC) and 24 hour Walk-In Clinics. 3. Work with Law Enforcement. 4. Enhance accountability in First Responders. 5. Develop consistent Screening, Triage, and Referral (STR) procedures. 6. Use non-emergency department resources for medical clearance evals. 7. Work with Magistrates. 8. Provide care coordination. 9. Diversify and strengthen workforce.
Emergency Department GOAL: To reduce emergency department length of stay for individuals who present with behavioral health crises. Recommendations: 1. Implement a computerized psychiatry bed registry. 2. Develop protocols and practice guidelines to standardize/utilize best practices for mobile crisis management teams in the emergency department. 3. Clarify and support the role of LMEs with regard to emergency department behavioral health crisis admissions. 4. Reduce legal obstacles. 5. Enhance disposition options for individuals with behavioral health crises in the emergency department. 6. Engage individuals with substance use disorders earlier and link to treatment services
Post-Emergency Department GOAL: To link consumers to housing, services, and supports to prevent future Emergency Department admissions. Recommendations: 1. Ensure available housing and essential benefits are available in order to help the person remain successfully in the community and out of emergency departments. 2. Development of a Uniform System of Care Coordination. 3. Implementing Assertive Engagement statewide. 4. Prior to discharge, appointments scheduled with-in 48 hours. 5. Establish local relationships among all stakeholders to facilitate seamless coordination of care.
Crisis Services Resources Individual/family/supp orts LME-STR/crisis lines First responders Mobile Crisis Management Walk-In Crisis Telepsychiatry NC START Crisis respite Facility Based Crisis Detox 3-way contract beds Other private inpatient beds State Psychiatric hospitals State ADATCs
Crisis Services: SFY11 Funding MCM: $5.7 million state allocation Medicaid = $4.22 M IPRS = $5.03 M Total claims paid = $9.25 M Total persons served = 18,564 Walk-In Crisis: $4.46 million state allocation
Crisis Services: SFY11 Funding NC START: $3.2 million state funding Facility Based Crisis Medicaid = $2.15 M IPRS = $7.33 M Total claims paid = $9.48 M Total persons served = 6,892
Services in Less Restrictive Settings Services must be robust, accessible, and predictably meet the needs of the consumer.
Comprehensive Crisis Center recognizable location - simplified decision tree sharing of unique resources facility and personnel Immediate/convenient access to stepped up or stepped down services Efficiencies gained allow for strengthening of collective crisis services.
DURHAM CENTER ACCESS: GOALS Reduce state hospital utilization Support community-based treatment Coordinate with outpatient providers to maximize consumer benefit and continuity of care during crisis events Stabilize the consumer and reintegrate into the community Assist individuals who are not engaged with accessing care
DCA CRISIS FACILITY: SERVICES 24-hour crisis facility for individuals in crisis 16 facility-based crisis and detox beds for short-term stabilization for adults as alternative to inpatient hospitalization 11 23-hour crisis evaluation observation rooms (one for juveniles) for short-term intensive intervention to stabilize acute or crisis situations Telephone and face-to-face screening, triage and referral to community providers
DCA CRISIS FACILITY: SERVICES Crisis risk assessment Mental health and substance abuse assessment Psychiatric and petition evaluations Non-hospital medical detoxification service
TARGET POPULATION: Durham County citizens PROVIDER: DCA CRISIS FACILITY Freedom House Recovery Center TIMELINE: July 2004: Facility opens July 2006: Freedom House contracted August 2008: DCA moves to new facility on Crutchfield Street near Durham Regional Hospital
DCA MOBILE CRISIS Community-wide team response for individuals in crisis Teams have capacity to intervene quickly, day or night, when the crisis is occurring LME Alliance: The Durham Center, OPC and Alamance-Caswell TARGET POPULATION: Durham County citizens PROVIDER: Freedom House Recovery Center START DATE: November 2008
DCA MOBILE CRISIS: GOALS Stabilize individuals in crisis as quickly as possible and assist their return to pre-crisis level of functioning Avoid unnecessary hospitalizations Make referrals and link to needed services and supports Enable individuals in crisis or distress to access a range of crisis services in a timely and effective manner in their environment or other appropriate setting
DCA MOBILE CRISIS: GOALS Provide a consistent, integrated response to crises in the community 24/7/365 Make every effort to restore the individual to the previous level of functioning
DCA MOBILE CRISIS: LIMITATIONS Life-threatening emergencies or violent situations, such as a person with a weapon or one attempting to hurt self or others Domestic violence disturbances Requests for transportation in non-crisis situations Requests for step-down services from in-patient hospitalization Requests to serve individuals from other counties and states
DCA PSYCHIATRIC WALK-IN CLINICS Office-based outpatient services for adults, children and adolescents Immediate screening/assessment and brief, intensive interventions to resolve crisis and prevent admission to more restrictive level of care Service provided face-to-face at DCA and via telepsychiatry at 4 satellite locations Start date: February 2009 LME Alliance: The Durham Center, OPC and Alamance-Caswell
DCA PSYCHIATRIC WALK-IN CLINICS TARGET POPULATIONS AND ELIGIBILITY CRITERIA Children and adults from the identified catchment areas in need of psychiatric services AND: Discharged from State hospitals, private psychiatric hospitals, and community hospitals and are unable to secure a timely appointment in the community; OR Currently NOT served by the Provider Network and need immediate psychiatric assessment and care, medication evaluation and aftercare planning; OR Actively served by a provider, and presenting with needs exceeding provider capacity
DCA PSYCHIATRIC WALK-IN CLINICS OUTCOMES/GOALS Improved accessibility of urgent care services for individuals experiencing psychiatric and substance abuse difficulties Reduced need for consumers to go to EDs Reduced need for admissions to hospitals for consumers who can be served in the community Better structure for coordination of care Alternative to EDs for law enforcement interacting with consumers in distress or on petition
DCA ASSESSMENT TEAM A group of experienced MH and SA professionals housed at DCA to provide the Durham community with an independent assessment service Available to adults without insurance to determine clinical needs and connect them with appropriate treatment and assistance in the community 1 Supervisor, 3 Assessors, 2 QPs, 1 Admin Assistant, 1 part-time Peer Specialist Operates Monday-Friday, 8:30am-5:00pm
DCA ASSESSMENT TEAM: SERVICES Coordinated and planned approach to assessing and connecting individuals in need to the right services and supports available in the community A plan for continued treatment supported by the consumer, family and referring party Support and education Contact with consumer until connection is made with services, including for waitlisted consumers Renewed hope and confidence
DCA ASSESSMENT TEAM: RATIONALE Centralization of assessments provides standardization of the assessment process Assessments ensure a consistently intensive, comprehensive evaluation and better integration of services for co-occurring disorders Access to medication or on-site crisis services, SA services or other immediate placement
DCA ASSESSMENT TEAM: RATIONALE Providers are unable to accommodate waitlists resulting from reductions in service capacity necessitated by recent budget cuts Care Coordination/Behavioral Health Support Services when clinically appropriate
DCA PRIMARY CARE CLINIC OUTCOMES/GOALS Routine and/or non-emergent primary care, physical health screening and/or assessment Connection and/or re-connection to Lincoln Primary Care services Reduce the need for individuals served to go to emergency departments TARGET POPULATION: Durham County citizens participating in any other program at DCA PROVIDER: Lincoln Community Health Center
DCA PRIMARY CARE CLINIC LINCOLN COMMUNITY HEALTH CENTER: A leader in providing accessible, affordable, high-quality outpatient health care services to the medically-underserved in Durham County Collaborates with other community partners with a goal of 100% Access and 0 Health Disparities A JCAHO-accredited facility
DCA PRIMARY CARE CLINIC: SERVICES All individuals admitted to crisis services provided the opportunity for services Individuals in need of emergent medical care go to Emergency Department Individuals well-connected to primary care provider don t use Lincoln Laboratory services for medical (not BH) issues Operates Monday-Friday, 8:00am-Noon Six patients per day on average
The Durham Center and Durham Center Access are key partners in Durham System of Care Network of Care is a comprehensive online source of information about services available to individuals and families and agencies working with them Visit Network of Care at durhamnetworkofcare.org or System of Care at durhamsystemofcare.org
KEY COMMUNITY PARTNERS CJRC, The Durham Center, Lincoln Community Health Center, Freedom House Recovery Center Magistrates Office, Durham Police Department, Durham County Sheriffs Office, CIT Program Durham Provider Network First Responders Emergency Departments at Duke, Durham Regional Hospital, VA Medical Center
Forsyth Behavioral Health Emergency Department Crisis Care Model Todd M. Clark, PhD, LPC, LCAS NCCCP Annual Conference December 6, 2012
AGENDA Data Operations Clinical Partnerships Future
Data
6000 Annual BH Patient Volume FM C ED 1995-2011 2008 - JUH closed adult 2010 - Community units. Support Services 5000 4000 2000 - Charter 2002 - FMC opened BH 3-bay area in ED 2004 - CPHS became LME. Target populations implemented. 3898 2005 - HopeRidge - CRH opened w/ decreased Behavioral Health capacity. - IPRS defunded closed for Res SA Tx w/ 4104 4172 4257 Mcare/caid 4404 defunded. 4726 4793 5000 Hospital, WS closed 3184 3000 2521 2735 2822 2000 1830 1449 1164 1000 884 505 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Average Daily Census 26 Patients: reduced 50% Average Length of Stay 38 Hours: reduced 33%
Operations
Remarkable Environment for the BH Patient Safety (Patients and Staff) 10-bed secured area in ED / 25-bed ED Holding area Private rooms Video assisted monitoring Staff rounding Staffing (In the E.D.) Nursing Team RNs and Psyc Techs (CNA) Dedicated BH Mid-levels (NP & PA) Access Team LPC, LCSW, LCAS Rec Therapy TelePsyc Services
Clinical
Decompensation Increases Length of Stay Evaluations Pharmacy Tech Reconcile meds Access Team Quick glance Assess & disposition Recreation Therapy Spending time Support system Community resources Coping strategies Relaxation strategies BH Mid-level Evaluation Re-assessments Medical acuity
Decompensation Increases Length of Stay Programming Recreation Therapy Reversing decompensation Safer and productive E.D. mileau Re-assessment opportunities Staffing cost reduction Alternative to sitters Telepsyc Services Immediate Psyc consult for ED provider Validate OP discharge plans Assist with fence sitter dispositions
Partnerships
Building Relationships LME Care Coordinators = gateway to resources Homeless Liaison Regular operational-focused meetings Administrators: remove systemic or oganizational barriers / provide resources Provider Agencies: CABHA, ACT Teams, Support Services Community Resources Homeless Shelters Long Term Care Facilities Medical/Medication Clinics Mobile Crisis Response Team BH Referral Development Rep 1. Invite them in. 2. Visit their shop. 3. Create the easy button.
Future Current Model: Temporary solution to mitigate the current tsunami of volume occurring in past 2 years. Failure: Behavioral consumer come to medical E.D. seeking care. Ideal: A robust continuum of community services that proactively meets the needs of consumers, where they are.
Questions?
Director Todd M. Clark PhD LPC 336-718-2518 O 336-277-9538 F 336-726-3206 P My # 1 job responsibility is to deliver the most remarkable patient experience, in every dimension, every time. tclark@novanthealth.org
First Responder
First Responder Requirements What is it? Applies to CABHAs Defines how we respond to clients in crisis Outlines responsibilities Implementation Update # 86 April 6, 2011
Critical Decision Points ED Crisis Plan Support Magistrate FBC EMS LEO Self Family Clinical Home WIC LME/STR MCM
First Responder: When and to whom does it apply? Applies to consumers receiving any services through a CABHA Applies to Crisis situations High level of mental or emotional distress, or an episode, which without immediate intervention will foreseeably result in the person s condition worsening, environmental instability or could result in harm to self or others. Is 24/7/365
First Responder: What are the requirements? Be able to respond directly and also collaborate/guide treatment when others involved Written policies and procedures for consumers needing assistance in a crisis Information for the consumer to call the CABHA first before other responders (such as EDs and MCM) Phone number that reaches a live person 24/7/365
First Responder: What are the requirements? Response may be telephonic but there must be an attempt to provide face to face services before referring consumer to alternative crisis responders. If a referral occurs to another crisis responder, the CABHA must communicate and facilitate coordination of care.
Reasonable Attempt Policy and procedure outlining how you respond to crises Patient ed. about the policy/procedure Assessment - may be telephonic but must follow accepted standards of care. (CC, History incl. how past crises were handled, symptoms, risk/dangerousness, support systems, etc) Conclusions and determination of needed level of care should be supported by facts contained in the assessment and a rationale. First Responder that is built into service definition must be responded to by the appropriate team.
MCM in the Continuum MCT embedded within CABHA Provider with array of services (also housing FBC, WIC, etc) Ability to assess needs and link to appropriate services/level of care Use of licensed staff for initial assessments Inclusion of psychiatrists in workflow QA Care Coordination utilizing applications that track the consumer from crisis through resolution
The Role Of The LME Christina Carter, MSW Chief Operating Officer Smoky Mountain Center 73
LME Responsibilities Care Coordination: LME clinicians & QPs monitor inpatient admission rates Rapid readmits of consumers who are not engaged in services Provider & Stakeholder meetings: LME staff call meetings with providers, hospitals and law enforcement to review long ED wait times and high risk cases Concurrent reviews: Inpatient facilities Facility based crisis and detox admissions Discharge planning for high risk and complex cases 74
LME Responsibilities Post discharge tracking to ensure engagement Gap analysis and trouble shooting for high risk consumers with unmet needs System management Stable funding with realistic billing and Medicaid expectations Monitor outcomes including average length of stay, wait times, rapid readmission rates, consumer satisfaction and engagement in services 75
Integrating Mobile Crisis With The Service System Doug Trantham
The Smoky Mountain Center and Appalachian Community Services Crisis System
History Emergency services developed by SMC The Balsam Center crisis unit opened in 2004 First exam pilot initiated in March 2004 Opened Behavioral Health Unit at HRMC 2009 Converted to a full mobile crisis management model in 2010 Operation assumed by ACS July 1, 2010
Service Area
Key Features Of The SMC/ACS Model
Emergency Dispatch Call center staffed 24/7/365 Receives all requests for service and information directly Tracks urgent/emergent referrals across region using custom web based tracking software Triages calls and assigns to available clinicians Reporting, quality assurance, faxing, support
Reliance on awake rather than on call staff Reliance on licensed clinicians for initial response Regular use of psychiatric backup MCM clinicians complete many IVC first exams - approximately 500-600 per year (loss of LCAS in program restricts IVC capability) Provide emergency services under contract as well as billable MCM services Credentialed staff respond to local emergency departments Integrated with comprehensive CABHA including facility based crisis, walk-in centers, outpatient, psychiatric and enhanced services
MCM staff are specialists, but crisis response is a priority for all ACS staff Daily ED report sent To LME Official notification to LME of any client in ED beyond 72 hours, or any client expected to wait longer than 72 hours Team meetings scheduled with LME/providers/stakeholders for clients waiting in ED longer than 72 hours or cases of concern Very extensive marketing with community stakeholders.
Use of QPs for follow up and engagement Expansion of service upstream to avert crisis prior to involuntary petition or ED, and downstream to ensure engagement and stabilization following the crisis. Shifting from ED to community response Diversion from ED and IVC Promotion of CIT with law enforcement
Benefits One number to access services Avoid multiple levels of triage Calls are tracked until disposition, often for days or weeks, while maintaining continuity Many consumers are diverted to outpatient, crisis unit or local inpatient services Much greater penetration rate in rural communities
Community Response 2010 2011 Community 30% 38% ED 70% 62%
Daily ED Report To LME Date/Time: 4/14/11 6:00 4/14/2011 6:00 Totals: SR N/C R SMC Number in EDs: 4 0 4 Number in ED Awaiting Transfer: 0 0 0 Facility: Murphy MC Haywood RMC Cherokee IH Harris RH Angel MC Highlands H Swain MC Response?: Yes Yes Number in ED: 2 2 Number Awaiting Txfr: Southern Region Patient # Primary Disability Facility Location Funding County Referral Source Age xxxx Adult MH Murphy MC ED Medicaid Cherokee Self-Referred (W xxxx Adult MH Haywood RMC ED Other Insuranc Haywood IVC xxxx Adult MH Murphy MC ED Indigent Cherokee Self-Referred (W xxxx Geriatric MH Haywood RMC ED 'Care/'Caid Haywood Self-Referred (W Elapsed time in hours Currently Violent? Gender Detox Admit Date Admit Time Disposition 04/13/11 23:30 6.5 Undetermined No Female No 04/13/11 23:20 6.7 Undetermined No Male No 04/13/11 23:00 7.0 Undetermined No Male No 04/13/11 17:00 13.0 Undetermined No Male No 3 Way Bed? SMC use Only