Cenpatico Crisis Protocol for Yuma County

2015-2016 Cenpatico Crisis Protocol for Yuma County

Table of Contents Overview & Purpose:... 1 Definitions... 2 Crisis During Business Hours... 6 Crisis Services... 7 The NurseWise Crisis Line... 7 Crisis Mobile Teams... 8 The Recovery Opportunity Center (ROC) Living Room Model... 9 Involuntary Persons in Need of Mental Health Treatment... 9 A person in the ER... 9 A person in the community... 11 A person at an outpatient clinic during office hours... 12 When law enforcement are involved (ARS 36-525(B))... 13 A person who is detained and involuntary for treatment at the Yuma County Jail... 14 An involuntary person on the Cocopah Indian Reservation... 14 Non-Emergency Requests for Involuntary Evaluation (PAD or GD)... 14 Voluntary Crisis Services for incarcerated persons... 15 At the Yuma County Jail... 15 At a Juvenile Detention Center... 15 Revocation of the outpatient treatment of an existing COT (ARS.36-540.01 I)... 15 During Regular Business Hours... 15 Process for T19, Non-Medicare members who will be admitted to MHW-SAF... 16 Medicare members and medically compromised persons who will not be admitted to MHW-SAF.. 17 After Hours... 18 Direct Admission to a Licensed Hospital (Acute or Sub-Acute) Psychiatric Inpatient Facility... 18 By outpatient providers (voluntary only)... 18 By crisis mobile teams (voluntary only)... 18 Title 36 Transports to Mountain Health and Wellness by Law Enforcement... 19

Basic Transport... 19 Medically compromised clients... 19 Coordination of Care... 20 Coordination with the ER on Enrolled Persons... 20 Coordination with the ER on NON-enrolled persons... 20 Coordination with YRMC on medically admitted patients enrolled with an outpatient service provider... 20 Meeting Attendance... 21 The Yuma County Mental Health Crisis Systems Meeting... 21 Regular Crisis Team Meetings... 21 Problem Resolution Process... 21 Drug and or Alcohol Use - Services Available... 21 Crossroads Mission:... 22 Yuma SAF (MHW Sub-Acute Facility)... 23 Crisis Transportation for Voluntary Title 19 & 21 persons in need of a higher level of care... 23 Signature Pages... 24

Arizona Counseling & Treatment Services (ACTS) Cenpatico Integrated Care CHA Crisis Mobile Team (CMT) Cocopah Tribal Police Community Bridges Community Health Associates (CHA) Crossroads Mission Helping Associates, Inc. Horizon Health and Wellness NurseWise (NW) Providence Service Corp San Luis Police Department Somerton Police Department Wellton Police Department Yuma County Attorney s Office Yuma County Juvenile Justice Center Yuma County Sheriff s Office (YCSO) Yuma Police Department (YPD) Yuma Regional Medical Center (YRMC) Overview & Purpose: The Protocols are guidelines that describe how we will all work together to ensure that behavioral health services are delivered in Yuma County. The Purpose is to enhance the network and response capability to address behavioral health crisis in Yuma County through ongoing communication and collaborative agreements between community stakeholders and behavioral health provider agencies developing an environment where there is no wrong door. Cenpatico Behavioral Health of Arizona, LLC and Cenpatico of Arizona, Inc. dba Cenpatico Integrated Care (herein referred to as Cenpatico) and their contracted providers and identified Yuma County Community Stakeholders agree to coordinate activities to facilitate the implementation of crisis services in Yuma County. The elements of the Crisis System (including referral, assessment and service implementation processes) and the roles and responsibilities of each agency are outlined below. Cenpatico and their contracted providers and identified Yuma County Community Stakeholders agree to work in partnership on behalf of persons experiencing a behavioral health crisis to ensure they receive the appropriate services and level of care that promote resiliency and protect the community. These guidelines will be active from date of signature until modified by the involved parties. These guidelines do not create or delegate obligations or financial responsibilities. These guidelines are not a legal and binding contract or Memorandum of Understanding. These guidelines should never override the obligation to provide the most clinically appropriate intervention based on each individual situation nor should they override law or professional responsibility to members. Agencies are encouraged to have adequate clinical supervision and guidance to support such actions. 12/28/12; Revised 2/07/2013; Revised 7/31/2015 1 P age

Goals of the Crisis System To ensure persons receive the appropriate services and level of care, stabilize persons in the community whenever possible, support individuals in their recovery, promote resiliency and protect the community. Definitions Active episode of care-means they have been opened with and are receiving services at a contracted RBHA funded agency. The person may have any of the following eligibility and entitlements: o T19 (AHCCCS or SSI/MAO) o T 21 (kids) o SMI only o Medicare and T19 o Medicare and SMI Note: Cenpatico will be the health plan for persons designated with a serious mental illness (SMI) enrolled as Title XIX -- Admitting Officer Per ARS 36-501.1 Admitting officer is a psychiatrist or other physician or psychiatric and mental health nurse practitioner with experience in performing psychiatric examinations who has been designated as an admitting officer of the evaluation agency by the person in charge of the evaluation agency. Application for Emergency Admission for Evaluation Paperwork completed to initiate an emergency evaluation of a person who, based on probable cause, is believed to be, a danger to self or others and that during the time necessary to complete the prepetition screening procedures the person is likely without immediate hospitalization to suffer serious physical harm or serious illness or to inflict serious physical harm on another person Application for Involuntary Evaluation Paperwork completed to initiate a request for an evaluation of a person who is alleged to be Persistently or Acutely Disabled (PAD), or Gravely Disabled (GD), or Danger to Self (DTS) or Danger to Others (DTO), or any combination of these. This process of requesting an involuntary evaluation is for situations that are considered non-emergency requests for an evaluation. 12/28/12; Revised 2/07/2013; Revised 7/31/2015 2 P age

Amendment of the outpatient portion of a court order- The process outlined in ARS 36-540 (E) 5. in which the medical director of the mental health treatment agency can order a person court ordered to outpatient treatment back into inpatient treatment. Business Hours-Monday through Friday from 8am to 5pm. Crisis - An acute, unanticipated, or potentially dangerous behavioral health condition, episode or behavior. Crisis Intervention Services (Mobile, Community Based) - Crisis intervention services provided by a mobile team or individual who travels to the place where the person is experiencing the crisis (e.g., person s place of residence, emergency room, jail, community setting) to: Stabilize acute psychiatric or behavioral symptoms; Evaluate treatment needs; and Develop plans to meet the needs of the persons served. Depending on the situation, the person may be transported to a more appropriate facility for further care (e.g., a crisis services center). Crisis Intervention Services (Telephone) - Crisis intervention (telephone) services provided by qualified service providers within the scope of their practice to triage, refer and provide telephonebased support to persons in crisis. This is often the first place of access to the behavioral health system. This service may also include a follow-up call to ensure the person is stabilized Danger to Self (DTS)-(a) Behavior which, as a result of a mental disorder, constitutes a danger of inflicting serious physical harm upon oneself, including attempted suicide or the serious threat thereof, if the threat is such that, when considered in the light of its context and in light of the individual's previous acts, it is substantially supportive of an expectation that the threat will be carried out. (b) Behavior which, as a result of a mental disorder, will, without hospitalization, results in serious physical harm or serious illness to the person, except that this definition shall not include behavior that establishes only the condition of gravely disabled. Danger to Others (DTO)-The judgment of a person who has a mental disorder is so impaired that he is unable to understand his need for treatment and as a result of his mental disorder his continued behavior can reasonably be expected, on the basis of competent medical opinion, to result in serious physical harm to others. Evaluation Agency- Per ARS 36-501 (13) a health care agency that is licensed by the department and that has been approved pursuant to this title, providing those services required of such agency by this chapter. There are several evaluation agencies located in Tucson including Palo Verde, Sonora 12/28/12; Revised 2/07/2013; Revised 7/31/2015 3 P age

and University of Arizona Medical Center-South Campus (UAMC-South). The preferred Evaluation Agency is the SAF in HHW. Intake and Coordination of Care Agency (ICC Agency ) - (Also referred to as Outpatient Treatment Agencies or Provider Agencies). ICC Agencies are contracted provider type requiring full execution of Intake Provider functions and requirements. ICC Agencies must accept all requests for services for eligible populations and are required to manage members care by performing the following roles: intake, assessment, service planning, clinical oversight of all services, service tracking and data reporting, enrollment and demographic submissions, education, engagement activities, psychiatric services and ensure adequate treatment service availability to all enrolled members. Local ICC Agencies in Yuma include ACTS, CIA, Community Bridges, Crossroads Mission, Horizon Health and Wellness (HHW) and Providence. ICC Agencies are further divided into High Needs Recovery Centers (HNRM) and Low to Moderate Needs Recovery Centers (LNMRC). ICC Agencies are required to screen members and refer them to either an (HNRM) or an (LMNRC). Gravely Disabled (GD)-A condition evidenced by behavior in which a person, as a result of a mental disorder, is likely to come to serious physical harm or serious illness because he/she is unable to provide for his/her basic physical needs. Guardian- A guardian is a person who has the legal authority to make personal decisions for the ward relating to living arrangements, education, social activities, and authorization or withholding of medical or other professional care, treatment, or advice. The guardian must always make decisions that are in the best interests of the ward. The guardian must always make sure that the ward is living in the least restrictive environment in which the ward can remain safe. Under 14-5312.01 (a) a guardian is able to consent to medical treatment outside a level one behavioral health facility. A mental health guardian is given under 14-5312.01 (b) for placement in a level one behavioral health facility. It is based on evidence produced from a licensed mental health expert that the ward is in need of such hospitalization due to a mental disorder as listed in 36-501. It is renewed every year with an affidavit from a mental health expert stating that it is likely that the ward will need to be placed in a level one behavioral facility. Licensed Hospital - A facility licensed per 9 A.A.C. 20 and includes a psychiatric acute hospital (including a psychiatric unit in a general hospital), a residential treatment center for persons under the age of 21, or a sub-acute facility. For the purposes of this protocol, a Licensed Hospital facility does not include Behavioral Health (BH) treatment. Natural supports- Refers collectively to support commonly identified as: 12/28/12; Revised 2/07/2013; Revised 7/31/2015 4 P age

a. "Informal Support " (support provided by those individuals who know or are related to the individual/family, but do not provide a paid service, such as a grandparent or neighbor who is connected to the individual/family) and b. "Community Support" (those supports that are part of the individuals/family's community, such as faith community, neighborhood or community organizations). Persistently and Acutely Disabled (PAD)-A severe mental disorder that meets all the following criteria: (a) If not treated has a substantial probability of causing the person to suffer or continue to suffer severe and abnormal mental, emotional or physical harm that significantly impairs judgment, reason, behavior or capacity to recognize reality. (b) Substantially impairs the person's capacity to make an informed decision regarding treatment and this impairment causes the person to be incapable of understanding and expressing an understanding of the advantages and disadvantages of accepting treatment and understanding and expressing an understanding of the alternatives to the particular treatment offered after the advantages, disadvantages and alternatives are explained to that person. Petition for court ordered Evaluation- The prescribed form used to request a petition for courtordered evaluation. This form must be reviewed and signed by the Medical Director. Revocation of the outpatient treatment portion of a court order - The process outlined in ARS 36-540-01. Section I in which the medical director of the mental health treatment agency can order a person court ordered to outpatient treatment back into inpatient treatment. Serious Mental Illness (SMI) - A condition of persons who are eighteen years of age or older and who, as a result of a mental disorder as defined in A.R.S. 36-501, exhibit emotional or behavioral functioning which is so impaired as to interfere substantially with their capacity to remain in the community without supportive treatment or services of a long -term or indefinite duration. In these persons mental disability is severe and persistent, resulting in a long-term limitation of their functional capacities for primary activities of daily living such as interpersonal relationships, homemaking, selfcare, employment and recreation. Title 36 - Arizona s state law for involuntary mental health commitment. The law is located in the Arizona Revised Statutes, Title 36 (Public Health and Safety) Chapter Five (Mental Health Services). Title 36 pre-petition screening-the review of an application (MH 100 or MH 104) requesting courtordered evaluation, including an investigation of facts alleged in such application, an interview with each applicant, and an interview, if possible, with the proposed patient. The purpose of the interview 12/28/12; Revised 2/07/2013; Revised 7/31/2015 5 P age

with the proposed patient is to assess the problem, explain the application and, when indicated, attempt to persuade the proposed patient to receive, on a voluntary basis, evaluation or other services. Note: Horizon Health and Wellness currently serves this function in Yuma and La Paz Counties. Warm Line Transfer a live transfer where the call is introduced to and accepted by the recipient before the call is transferred. WRAP Plan-Wellness Recovery Action Plan-is a self-management and recovery system developed by a group of people who had behavioral health difficulties and who were struggling to incorporate wellness tools and strategies into their lives. WRAP plans are developed by the consumer. The plan helps people to monitor uncomfortable and distressing symptoms and identify ways to help reduce, modify or eliminate those symptoms by following plan strategies. The plan includes an outline of who can help and how they can help as well as preferred management strategies and treatments. Wrap Services-Also referred to as wrap around services; these are supportive services provided to a person at home or in the community designed to provide additional support to a person in crisis or to prevent a crisis. Planned services are available 24/7/365. Wrap services include an array of professional, community, and natural (i.e., family, friends) supports and are individualized based on the needs of the person and the family. Crisis During Business Hours During regular business hours outpatient service providers will provide crisis intervention to enrolled members who are in a crisis and in the presence of their treatment provider. Crisis assessment and intervention should occur where the member is and when it is needed by the outpatient service provider that is with the member at the time of crisis. Therefore, the provider may be the assigned clinical team or another provider agency engaged in providing services to a member. Crisis intervention services include assessment, de-escalation techniques and crisis counseling as well as crisis and follow up planning by a case manager, clinical liaison, behavioral health professional, or prescriber. In some situations crisis intervention may include need for an evaluation for a medication change by a prescriber followed by close monitoring by the clinical team. Other times, the intervention may involve providing wrap around services to the person in the community such as accessing the person s support system, activating the person s WRAP plan and or advance directive, seeking respite services, or coordinating with a High Needs Recovery Center and Low/Moderate Needs Recovery Center to provide the necessary wraps. 12/28/12; Revised 2/07/2013; Revised 7/31/2015 6 P age

If there are no other safe alternatives, placement in a psychiatric facility may be needed on an emergency basis. In these situations, the prescriber can facilitate a direct admission to a receiving psychiatric facility. If hospitalization is needed, the prescriber must have knowledge of and be able to attest to the need for an inpatient admission. Case managers and other direct service staff will conduct bed searches and make arrangements for admission. The prescriber will be required to complete a doc to doc phone call to the admitting agency. In these situations, there is no need to send the member out for medical clearance unless the receiving facility (or sending prescriber) has a symptom generated concern that must be evaluated medically. Outpatient providers will ensure there is sufficient staff coverage including protocols outlining the chain of command when a member is in crisis and in need of immediate intervention. In addition, contractual agreements between Cenpatico Integrated Care and intake providers require all said agencies (ACTS, Community Bridges, CHA, Crossroads Mission, Helping Associates, HHW, and Providence) to have urgent and emergency appointments available to ensure that enrolled members can be seen at the agency when an emergency arises. Crisis Services The NurseWise Crisis Line The NurseWise crisis line is available 24 hours a day, 7 days per week by calling 866-495-6735. If a crisis mobile team (CMT) is needed the request must be made to NurseWise who will triage and dispatch CMTs. NOTE: All intake provider agencies are also available to members for intensive wrap (supportive) services providing the necessary supports to avoid crisis and or out of home placement. Crisis Mobile Teams The Mobile team provider in Yuma is CHA. Crisis Mobile Team assessment and intervention services are available to any person in the County regardless of insurance or enrollment status. Intake and Care Coordination Agencies (ICC Agencies) ICC Agencies are also available to members for intensive wrap (supportive) services providing the necessary supports to avoid crisis and/or out of home placement and can conduct crisis assessment, brief intervention and treatment for members at their facility who are in crisis. High Need Recovery Centers are also available after hours as needed. The High Needs Recover Centers in Yuma County are ACTS, CHA and SEABHS. What is considered a crisis? A crisis is measured by the person experiencing it. If the situation exceeds the person s coping skills, the person is in crisis. 12/28/12; Revised 2/07/2013; Revised 7/31/2015 7 Page

Can the crisis system take calls for people diagnosed with a developmental disability, Alzheimer s or dementia? Yes. There are no medical conditions that exclude a person from receiving crisis services. The crisis line and/or crisis team can assess, intervene and make recommendations for any person in crisis. It is important to note that in order for the person to be admitted to a psychiatric facility under his or her insurance, he or she must have a treatable psychiatric condition. Crisis Mobile Team Response in the Community Services Available A Crisis Mobile Team is available to all persons in the community to assist persons in overcoming a crisis situation, assess for the need for an out-of-home placement, and coordinate safety planning. Crisis Mobile Teams are committed to responding to the community including but not limited to places such as the home, school, church, the streets, the ER, and jails. There is no need to bring a person in crisis to the Emergency Room unless there is a medical emergency. NOTE: CMTs are required to have vehicles to facilitate transportation and field interventions as well as lap tops, and cell phones for communications. Services available to private psychiatrists (in office)/persons at a local psychiatrist s office- A crisis mobile team can be requested by a local psychiatrist by calling NurseWise at 866-495-6735. The CMT will provide assessment, crisis intervention and recommendations for further treatment (if applicable). A CMT is not able to facilitate an inpatient admission for a person with private insurance under the care of a private psychiatrist. In these situations, the private psychiatrist would be responsible for facilitating an inpatient admission by coordinating with the person s insurance carrier and or facilitating a direct admission to a psychiatric facility. Response on the Reservations- See the IHS [Indian Health Services] Guide for Services from Cenpatico Integrated Care for more details. Cenpatico Integrated Care serves the entire county and is obligated to provide crisis services to any person who requests services in the county. CMTs are permitted to provide mental health and crisis services on reservation land. Police escorts can be arranged on reservations as needed. Reservation areas included in Yuma County are: Cocopah Indian Community Fort Yuma Indian Community-NurseWise is available by phone. CMTs will be dispatched within the Yuma County section of the reservation. 12/28/12; Revised 2/07/2013; Revised 7/31/2015 8 P age

Note: Neither Cenpatico Integrated Care nor its contracted agencies have the authority to remove a Native American person involuntarily from tribal land or petition a person under a Title 36 on Tribal land. The Recovery Opportunity Center (ROC) Living Room Model The ROC is a program run by CHA that offers crisis services 24 hours per day, 7 days per week, in a safe and supportive environment. The ROC accepts law enforcement referrals 24/7 and referrals from other agencies after 5:30PM Monday through Friday or anytime on Saturday, Sunday or Holidays. There are no limitations on who is served other than the person needs to be voluntary and want help for a behavioral health crisis (this includes substance use). Services are for those 18 years and older and who are voluntary. Services cannot exceed 23 hours. The number is (928) 376-0026, extension 1236. Involuntary Persons in Need of Mental Health Treatment Yuma County contracts with HHW to provide Involuntary (Title 36) pre-petition screenings and inpatient evaluations. HHW has several 24/7 phone numbers that can be called to request T36 screenings: 928-373- 6751; 6753; or 6754. There is also a dedicated fax for paperwork related to a T36 or (928-726-9799). For all enrolled persons who have received CMT services and are admitted to the HHW SAF, HHW will provide NurseWise with a disposition upon discharge including the present legal status of the person. Per ARS 36-545.06 Each county shall provide directly or by contract the services of a screening agency and an evaluation agency for the purposes of this chapter [Title 36 Chapter 5]. A person in the ED NOTE: YRMC ED staff DO NOT need to wait until the person is medically cleared before calling MHW. The only exception would be if the person is unable to communicate or is severely medically compromised. If a person is in need of mental health treatment but is not voluntary, Horizon Health & Wellness will be contacted. If NW is called, they will warm line transfer the call to HHS. The person who observed the petitionable behavior will need to fill out the Application for Emergency Admission (form MH 104). The petition paperwork will need to be faxed to Mountain Health & Wellness. The applicant will be asked by the ED staff to leave contact information with the ED so the applicant can be contacted should MHW have additional questions about the petition. Note: Witness statements should be 12/28/12; Revised 2/07/2013; Revised 7/31/2015 9 P age

gathered by HHW staff and not the CMT. If the CMT is on scene, they can provide HHW with information about other potential witnesses on scene. 1. HHW, as the screening and mental health evaluation agency will determine based on the paperwork submitted and any assessments completed, if there is probable cause to believe that the person is a danger to self or others due to mental disorder and the person is involuntary. 2. If the HHW psychiatrist agrees that the person should be admitted for involuntary evaluation, HHW will arrange placement and transportation as follows: 3. Transports will be handled individually based on the parameters outlined below: a. Persons who are medically compromised must go by ambulance b. Persons who are going out of town should be looked at on an individual basis and may be transported by ambulance or law enforcement. c. Law Enforcement should be contacted if the person is combative or there is a threat to the safety of the community. Law Enforcement will determine if they need to transport the person after arriving on scene. 4. Whoever transports the person under a COE will also need to obtain the original Application for Emergency Admission (form MH 104) and deliver it to the receiving facility. 5. Note: Applications that need to be notarized during normal business hours or after hours need to be coordinated with Mountain Health & Wellness (HHW). HHW has several 24/7 phone numbers that can be called to arrange the notary process: 928-373- 6751; 6752; 6753; or 6754. Special questions What if the person is found to be petitionable on a non-emergent basis (PAD and/or GD)? MHW will facilitate the Title 36 process on a non-emergency basis. In this situation only a judge can order a mental health pick up and the paperwork is filed with the court for this authorization. In these situations, safety plans must be put in place until the paperwork is approved. 1. What if the person does not meet criteria to be screened for a T36 and the evaluating agency s admitting officer does not agree that the person should be brought in? The CMT would need to ensure that there is a safety plan in place for the person before clearing the scene. NOTE: A screening should not be declined solely due to the person being under the influence of a substance. T36 does require evidence of a mental illness but this does not preclude the presence of a co-occurring disorder. 2. What if a bed is secured but the evaluating agency is requiring medical clearance for a person in the community? The County Attorney s office will work on getting an order from 12/28/12; Revised 2/07/2013; Revised 7/31/2015 10 P age

the Court requiring law enforcement to take the member to the hospital for medical clearance and then to the evaluating agency. If the medical director is issuing the apprehend and transport order, he or she can also edit it to state that the member first has to go to the hospital for med clearance (identify hospital and address to take patient to) and then to facility (identify facility and address). 3. Can an outpatient agency call a mobile team at any time during business hours for a crisis intervention? No, the CMT is only contacted when the outpatient provider cannot engage the person in treatment voluntarily. The outpatient clinic can complete the petition and fax it to HHW and wait for a reply, unless it is a PAD. A person in the community If a person in the community is in need of mental health treatment but not voluntary, NurseWise will be contacted and a Crisis Mobile Team (CMT) will be requested. The CIA CMT will meet with the person where they are and attempt to engage the person in treatment voluntarily. If the CMT is unable to do so, and the person is dangerous to self or others, the CMT will need to refer the person to MHW for a Title 36 screening following steps 1-7 listed below. Note: Witness statements should be gathered by MHW staff and not the CMT. If the CMT is on scene, they can provide MHW with information about other potential witnesses on scene 1. The CMT will call MHW and give a verbal summary of the presenting issues, results of the assessment, and any other pertinent information needed for a Title 36 screening and for subsequent discharge planning. The person that witnessed the petitionable behavior will need to fill out the Application for Emergency Admission (form MH 104) and will need to be available to MHW staff in case additional information is needed. 2. If possible, the petition should be faxed to Mountain Health & Wellness (MHW). If this is not possible, it can be read over the phone to the triage RN at MHW. 3. MHW, as the screening and mental health evaluation agency, will determine based on the information received if there is probable cause to believe that the person is a danger to self or others due to mental disorder and that the person is involuntary. 4. If the MHW Admitting Officer (a psychiatrist or Nurse Practitioner trained in psychiatry) agrees that the person should be admitted for involuntary evaluation, MHW will arrange placement and transportation as follows: a. Transportation from the community to the SAF: MHW prepares a pick up order which is signed by the Admitting Officer. MHW will fax the pick-up order form to the appropriate law enforcement (LE) agency dispatch and will call to verify receipt of the fax. The LE agency will pick up the person from the community and transport to MHW. 12/28/12; Revised 2/07/2013; Revised 7/31/2015 11 P age

Note: At the time of pick up, law enforcement will also obtain the original Application for Emergency Admission (form MH 104) and will deliver it to MHW 5. ALL other transports* will be handled individually based on the parameters outlined below: a. Persons who are medically compromised must go by ambulance b. Persons who are going out of town should be looked at on an individual basis and may be transported by ambulance or law enforcement. c. Law Enforcement (LE) should be contacted if the person is combative or there is a threat to the safety of the community. Law Enforcement will determine if they need to transport the person after arriving on scene. * Other Transports include those from the community to a Licensed Hospital facility outside of Yuma, transports from the ER or other facility (such as an outpatient agency) 6. Whoever transports the person under a COE will also need to obtain the original Application for Emergency Admission (form MH 104) and deliver it to the receiving facility. 7. The CMT will be available as a witness for the Title 36 petition if needed. MHW will notify the CMT member at their earliest convenience if they are to be named as a witness. A person at an outpatient clinic during office hours During regular business hours, service providers will provide crisis intervention to members enrolled in their agencies who are in a crisis and in the presence of their treatment provider. The clinical team should provide services as outlined in the section entitled Crisis During Business Hours. If the team is unable to engage the person in treatment voluntarily, and the person is danger to self or others, the team will need to refer the person to HHW for a Title 36 screening following steps 1-6 listed below. NOTE: Witness statements should be gathered by HHW staff and not the CMT or Clinical Team. If the CMT or Clinical Team is on scene, they can provide HHW with information about other potential witnesses on scene 1. The outpatient team staff member will call HHW and give: a verbal summary of the presenting issues, results of the assessment, and any other pertinent information needed for a Title 36 screening and for subsequent discharge planning. The person that witnessed the petitionable behavior will need to fill out the Application for Emergency Admission (form MH 104) and will need to be available to HHW staff in case additional information is needed. 2. The outpatient team staff member(s) will ensure that the Application for Emergency Admission (MH104) and any available recent behavioral health assessments are faxed to MHW. 3. HHW as the screening and mental health evaluation agency, will determine based in the paperwork submitted if there is probable cause to believe that the person is a danger to self or others due to mental disorder and that the person is involuntary. 4. If the HHW Admitting Officer (a psychiatrist or Nurse Practitioner trained in psychiatry) agrees that the person should be admitted for involuntary evaluation, HHW will arrange placement and transportation as follows: 12/28/12; Revised 2/07/2013; Revised 7/31/2015 12 P age

a. Transports will be handled individually based on the parameters outlined below: i. Persons who are medically compromised must go by ambulance ii. Persons who are going out of town should be looked at on an individual basis and may be transported by ambulance or law enforcement. iii. Law Enforcement (LE) should be contacted if the person is combative or there is a threat to the safety of the community. LE will determine if they need to transport after arriving on scene. 5. Whoever transports the person under a COE will also need to obtain the original Application for Emergency Admission (form MH 104) and deliver it to the receiving facility. 6. The outpatient team staff member(s) will be available as a witness for the Title 36 petition if needed. MHW will notify the staff member(s) at their earliest convenience if they are to be named as a witness. When law enforcement are involved (ARS 36-525(B)) If law enforcement encounter a person who appears to be in a psychiatric crisis and who refuses voluntary psychiatric evaluation the officer must determine whether there is probable cause to suspect this person may be suffering from a mental illness and could meet the criteria for danger to self and or others. If the peace officer determines this to be the situation, the peace officer can transport the person to HHW or to a mental health screening agency. (See section entitled Title 36 Transports to HHW by Law enforcement). The person that observed the petitionable behavior will need to fill out the paperwork to initiate an evaluation for involuntary treatment. HHW will assist law enforcement and or the applicant as needed in determining the standard by which the person will need to be petitioned as well as the proper forms to complete. NOTE: The original Application (MH 104) must be delivered to HHW or the evaluation and assessment agency along with the person being petitioned. La Paz County Sheriffs will require the transport order to be notarized. What if the person remains involuntary but does not meet DTS or DTO criteria? It is possible that this person may need to be petitioned on a non-emergency basis (PAD and/or GD). It is recommended that law enforcement call NurseWise and request a CMT. The CMT will complete an assessment, intervention, and a safety plan. If applicable, the CMT will refer the person to MHW for a non-emergency Title 36 basis. In this situation only a judge can order a mental health pick up and the paperwork is filed with the court for this authorization. In these situations, safety plans must be put in place until the paperwork is approved. What if probable cause cannot be established by law enforcement? If probable cause cannot be established and there appears to be a behavioral health crisis, law enforcement should follow internal departmental protocols. If department protocols allow AND if it is 12/28/12; Revised 2/07/2013; Revised 7/31/2015 13 P age

safe to do so, a CMT can be requested by calling NurseWise. The CMT will assess and intervene in the crisis. A person who is detained and involuntary for treatment at the Yuma County Jail If the inmate is refusing all treatment offered and is dangerous to self or others, persistently and acutely disabled or gravely disabled, the jail may call HHW and advise them that an inmate in the jail is in need of an involuntary Title 36 screening. If the jail calls NurseWise, the call will be warm-lined to HHW. The jail staff shall give a verbal summary of the presenting issues to MHW including the results of any recent assessments and any other pertinent information needed for a Title 36 assessment and for subsequent discharge planning. The person that observed the petitionable behavior will need to fill out the paperwork to initiate an evaluation for involuntary treatment. MHW will assist the jail staff in determining the standard by person will need to be petitioned as well as the proper forms to complete. The jail staff may also need to be available as a witness for the Title 36 petition and MHW should notify any potential witnesses at their earliest convenience if they are to be named as a witness. An involuntary person on the Cocopah Indian Reservation Note: Neither Cenpatico Integrated Care nor its contracted agencies have the authority to remove an American Indian person involuntarily from tribal land or petition an American Indian person under a Title 36 on Tribal land. If there is a crisis and a need for involuntary treatment of a person on the reservation, NurseWise and the CMT will work with Tribal Police to ensure the safety of the member. Non-Emergency Requests for Involuntary Evaluation (PAD or GD) All non-emergency petitions should be coordinated with Mountain Health & Wellness (MHW). MHW has several 24/7 phone numbers that can be called to request T36 screenings: 928-373-6751; 6752; 6753; or 6754. There is also a dedicated fax for paperwork related to a T36 (928-344-8950) or (928-726-9799). In these situations, safety plans must be put in place until the paperwork is approved. Note: If a person is enrolled in an active episode of care with a local agency, that agency should facilitate the non-emergency petition and work with MHW to get the screening completed and petition filed. 12/28/12; Revised 2/07/2013; Revised 7/31/2015 14 P age

Voluntary Crisis Services for incarcerated persons At the Yuma County Jail If an inmate in the jail is in a psychiatric crisis the jail can call NurseWise and request a Crisis Mobile Team (CMT). The CMT can provide crisis assessment and short term crisis intervention as well as recommendations to detention staff. The CMT can only make recommendations to the jail and cannot remove a person from the jail to facilitate further treatment. At a Juvenile Detention Center If a juvenile in detention is in a psychiatric crisis the detention center can call NurseWise and request a Crisis Mobile Team (CMT). The CMT can provide crisis assessment and short term crisis intervention as well as recommendations to detention staff. The CMT can only make recommendations to the detention center and cannot remove a person from the center to facilitate further treatment. If the CMT does recommend a higher level of care for a juvenile in detention, the detention center will follow internal protocols to ensure placement in an appropriate treatment setting. The NW/outpatient clinical team can assist with locating an appropriate treatment setting. The Detention Center has internal protocols to address a juvenile in detention who is not voluntary for treatment. NOTE: Contractual agreements between Cenpatico Integrated Care and local intake and care coordination agencies (ACTS, CIA, HHS, CBI, CRM. Helping Associates, Providence and MHW) require all said agencies to coordinate care of enrolled members with the jail system. Coordination of care can be achieved by visiting the inmate and or participating in treatment and release planning for enrolled members Revocation of the outpatient treatment of an existing COT (RCOT) (ARS.36-540.01 I) If all attempts at outreach and engagement and crisis planning have failed to re-engage a member under court ordered treatment, a revocation of outpatient treatment may be necessary. This revocation would result in re-hospitalization of the member. NOTE: The need for medical clearance will be determined on a case by case basis. The mobile team should coordinate with the admitting officer of the evaluation agency to identify the need for such clearance If medical clearance is requested by the receiving facility, the clinical team/cmt must find out the reason for the request and document this in the clinical record. In some cases, unnecessary medical clearance may be avoided if recent health assessment documentation can be provided to the receiving facility or a doc to doc can help rule out medical concerns. 12/28/12; Revised 2/07/2013; Revised 7/31/2015 15 P age

During Regular Business Hours Revocations are the responsibility of the assigned outpatient agency s clinical team, led by their Medical Director. MHW will provide technical assistance as needed to provider agencies during the revocation process. Each agency will ensure the proper paperwork is filled out and filed with the court. The agency will also be responsible for arranging for transportation of the member to a Licensed Hospital facility. The member s clinical team will be responsible for locating a bed. Process for T19, Non-Medicare members who will be admitted to HHW-SAF 1. The Medical Director/Designee of the outpatient treatment agency will complete a Re-Admit under T-36 and the rescission of Order form. 2. The Medical Director/Designee of the treatment agency is required to provide an original signature on both forms. The team will make 4 copies of each form for filing. 3. The treatment team will call the SAF triage RN and give information regarding presenting concerns so the HHW triage paperwork can be completed. 4. The SAF RN will: a. Run a Medifax and confirm AHCCCS coverage. b. Contact the SAF Medical Director/Designee to discuss the case and receive admitting orders if applicable. c. Contact the referring treatment agency to inform them of the admission status. 5. The outpatient treatment agency will fax a Pick-Up Order signed by their Medical Director/Designee to the appropriate law enforcement agency. Note: If the person is at a local outpatient agency, other transportation arrangements may need to be made. 6. The referring outpatient treatment agency will deliver the original Re-Admit Under T-36 and Rescission of Order form to the Yuma County Clerk of the Superior Court. One copy is given to the County Attorney s office, one is given to the judge (at the information desk), one is given to the SAF and one is placed in the client record. 7. These forms must be filed with Yuma County Superior Court within 24 hours of the admission of the person on COT (excluding weekends and holidays). 8. When the member is ready for discharge, the following documents need to be filed by the outpatient clinical team with the Yuma County Clerk of Superior Court within 24 hours of discharge: Medical Directors Order for Conditional Outpatient Treatment and Outpatient Treatment Plan. These forms must have an original signature of the Medical Director of the Outpatient Treatment agency. The agency will make two copies of the documents to be filed as follows: a. One original packet to be filed with the Yuma County Clerk of Superior Court. Note: The documents will be stamped by the Yuma County Clerk of Superior Court. 12/28/12; Revised 2/07/2013; Revised 7/31/2015 16 P age

b. One copy to be delivered to the Yuma County Attorney s Office (located in the basement of the Superior Courthouse). c. One copy to be filed in the member s medical record. Medicare members and medically compromised persons who will not be admitted to HHW SAF 1. The Medical Director/Designee of the outpatient treatment agency will complete a Re-Admit under T-36 and the rescission of Order form. 2. The Medical Director/Designee of the treatment agency is required to provide an original signature on both forms. The team will make 4 copies of each form for filing. 3. A thorough Medicare bed search must be conducted by the outpatient treatment agency. The team will contact inpatient psychiatric facilities appropriate for the member (e.g. Medicare providers or hospitals that can take a medically compromised person) and fax referral packets so the member can be put on the waiting list for admission. Continued communication with the hospitals is imperative. Note: If after a thorough Medicare bed search, no bed can be found for a Medicare funded member, the MHW SAF could admit the person to their facility. In this case, follow steps outlined in the section above entitled Process for T19, Non-Medicare members who will be admitted to HHW-SAF ). 4. The outpatient treatment agency must facilitate transportation of the person to the accepting psychiatric facility. If the member being amended is combative or threatening, local law enforcement can be called for assistance. Upon arriving on scene, Law Enforcement will determine if they will transport the person. If the person is medically compromised, an ambulance can be arranged. 5. The referring outpatient treatment agency will deliver the original Re-Admit under T-36 and rescission of Order form to the Yuma County Clerk of the Superior Court. One copy is given to the Deputy County Attorney s office, one is given to the judge (at the information desk), one is given to the SAF and one is placed in the client record. 6. These forms must be filed with Yuma County Superior Court within 24 hours (excluding weekends and holidays) of the admission of the person on COT. 7. When the member is ready for discharge, the following documents need to be filed by the outpatient team with the Yuma County Clerk of Superior Court within 24 hours of discharge: Medical Directors Order for Conditional Outpatient Treatment and Outpatient Treatment Plan. These forms must have an original signature of the Medical Director of the Outpatient Treatment agency. The agency will make three copies of the documents to be filed as follows: One original packet to be filed with the Yuma County Clerk of Superior Court. NOTE: The documents will be stamped by the Yuma County Clerk of Superior Court. One copy to be delivered to the Yuma County Attorney s Office (located in the basement of the Superior Courthouse). One copy to be filed in the member s medical record. 12/28/12; Revised 2/07/2013; Revised 7/31/2015 17 P age

After Hours The CMT can be called to intervene in a crisis and will take necessary steps to assure the safety of the person and the community. If the Medical Director/Designee of the treatment agency cannot be located and the person remains involuntary HHW SAF about getting the person admitted under a COE. (See section entitled Involuntary Persons in Need of Mental Health Treatment). Note: In this case, the assigned outpatient treatment agency would be contacted during the first regular business hour of the week so they can complete a COT revocation and the new court order would be dropped. They would follow the process outlined above and omit the bed search and transportation steps. Direct Admission to a Behavioral Health (Acute or Sub-Acute) Inpatient Facility Note: A direct admission can occur without medical clearance barring any symptom driven reasons for a medical screening. If the person has a guardian, the guardian must consent to the treatment and sign for admission. For all enrolled persons who have received CMT services and are admitted to MHW Sub-Acute facility (SAF), HHW will provide NurseWise with a disposition upon discharge including the present legal status of the person. By outpatient providers (voluntary only) Outpatient providers serving enrolled Cenpatico members are able to seek direct admissions to Licensed Hospital facilities for their enrolled voluntary members if they determine that an emergency admission is needed during regular business hours. In these situations, there is no requirement for pre-authorization or a Certification of Need (CON) (per Provider Manual section 3.14). (See the section entitled Crisis During Business Hours for more details. By crisis mobile teams (voluntary only) CMTs can refer persons in a mental health crisis who are voluntary for treatment to a Licensed Hospital facility for direct admission. NurseWise will conduct bed searches and facilitate placement in these situations. In these situations there is no reason to take the person to the ED prior to admission. The admitting psychiatrist may request, based on symptom driven concerns that the person be medically screened for prior to admission. If medical clearance is requested, NurseWise and/or the CMT will gather information about the specific medical symptoms or concerns that require medical clearance and will ensure this is documented. This information will also be clearly relayed to YRMC case management (in the day-time) or the charge nurse (after hours). Once accepted to a facility, NW will arrange transportation or the CMT can transport the member if the transport does not interfere with crisis call response. NOTE: In La Paz and Yuma Counties all T19 persons who are 12/28/12; Revised 2/07/2013; Revised 7/31/2015 18 P age