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Processes for Referral to a Regional Mental Health Institute

Briefing and Frequently Asked Questions about Admissions to Regional Mental Health Institutes with Available Suitable Accommodations

A change in state law (Public Chapter 531) effective July 1, 2009 allows the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) to delay admissions at state owned and operated regional mental health institutes (RMHIs) until the facility “has the medical capability, equipment and staffing to provide an appropriate level of care, treatment and physical security to a service recipient in an unoccupied and unassigned bed.” This law removes the requirement that RMHIs admit and treat service recipients without regard to whether the RMHI has sufficient resources to do so.

The change in law enabled TDMHSAS to reduce expenditures by decreasing the number of staffed (operating) beds at RMHIs from 832 to 686 by June 30, 2010 and admit only the number of service recipients who can be safely and effectively treated. Under the new law, RMHIs have the same admission standards as private hospitals and are able to maintain good standing with accrediting and regulatory entities such as the Joint Commission and the Centers for Medicare and Medicaid Services (CMS).

TDMHSAS invests in important community services to divert service recipients from inpatient hospitalization. The Behavioral Health Safety Net of Tennessee provides service recipients with serious and persistent mental illness who are poor and uninsured with key mental health services through community mental health agencies. Our current crisis system has 24/7 accessibility by telephone and/or walk in services, face-to-face crisis service capabilities including triage, intervention, evaluation/referral for additional services/treatment and follow-up services. Services are provided to anyone in Tennessee regardless of insurance coverage.

Service recipients also have access to voluntary crisis stabilization services and medically monitored detoxification crisis services. Crisis stabilization units (CSUs) are currently operated by six (6) agencies: Southeast Mental Health Center in Memphis; Pathways in Jackson; Mental Health Cooperative in Nashville; Volunteer Behavioral Health System in Cookeville and Chattanooga; Helen Ross McNabb in Knoxville; and Frontier Health in Johnson City. Five (5) agencies currently provide medically monitored detoxification crisis services: Helen Ross McNabb in Knoxville; Council for Alcohol & Drug Abuse Services (CADAS) in Chattanooga; Buffalo Valley/Meharry in Nashville, Hohenwald and Lewisburg; Pathways in Jackson; and Cocaine and Alcohol Awareness Program (CAAP) in Memphis.

Professionals should refer a service recipient needing inpatient treatment to a hospital providing psychiatric treatment in the local area before making a referral to an RMHI. Currently there are more than 2,000 inpatient psychiatric beds in hospitals other than RMHIs in Tennessee. TDMHSAS encourages referring professionals to work with local agencies, hospitals, and law enforcement to develop strategies to protect both service recipients and the community if admission to an RMHI is delayed.

Frequently Asked Questions

    1. What is the definition of available suitable accommodations at each RMHI?
    2. What is a non-secure forensic bed?
    3. What is a state-owned or operated hospital or treatment resource?
    4. If the local RMHI has no suitable bed available, what steps will the Department take to find a bed in an alternate RMHI?
    5. Which person is allowed to decline a referral to an alternate RMHI: the service recipient or the referring professional?
    6. What happens when a service recipient referred for admission has a medical condition that needs treatment prior to admission to an RMHI?
    7. What does it mean to cancel a confirmation number verifying available suitable accommodations when reasonable to do so?
    8. Will TDMHSAS contract with private psychiatric hospitals for overflow beds to use?
    9. In recent years there have been no voluntary admissions to some of the RHMIs. Is this to change?
    10. Which acute care private psychiatric hospitals take involuntary service recipients? How many beds?
    11. Which hospitals have the capacity to provide medical detoxification services?
    12. If a person is placed on a waiting list for an RMHI, who is responsible for that person until a bed becomes available?
    13. What is the community mental health agency (CMHA) provider responsibility when a service recipient needs to be admitted to an RMHI when no bed is available?
    14. What will happen when licensed mandatory pre-screening agents refuse to fulfill that function in situations where there is no appropriate disposition for the individual assessed?
    15. What if an emergency room physician refuses to perform any service other than medical diagnosis and treatment and does not address psychiatric issues due to liability for failure to secure needed hospitalization?
    16. What is the managed care organization’s (MCO) responsibility when the service recipient is on a waiting list for the RMHI but a private hospital bed is available for that member? What is the MCO responsibility when there is no bed available at either an RMHI or a private hospital?
    17. There is no authority for law enforcement to detain a service recipient after completion of a psychiatric evaluation/prescreening assessment unless legal charges permit incarceration. As a result, will a service recipient be released with documented evidence that he or she is capable of being harmful to themselves or others?
    18. Will there be an increase in situations where there is a legal duty to warn if parties are identified as potential victims of harm?
    19. What steps will the Department take to minimize travel to alternate RMHIs if no bed is available in the local RMHI?
    20. Is the written statement that is to be given to the sheriff or transportation agent a form that will be provided by TDMHSAS once bed availability has been confirmed by the RMHI?
    21. If the local RMHI has no bed and refers a service recipient to an alternate RMHI, how will the service recipient be transported to the alternate RMHI?
    22. Will it be more likely that friends, family and neighbors will transport people needing involuntary inpatient commitment?
    23. If a service recipient is sent to an alternate RMHI and is not admitted, who will provide transportation to get them back to their home county?
    24. If a service recipient is sent to an alternate RMHI and is discharged, who will provide transportation to get them back to their home county?
    25. May sheriffs refuse to transport to an alternate RMHI outside of their region, precipitating incarceration without treatment or release to the community?
    26. How long is the certificate of need (CON) valid if the service recipient is placed on an RMHI waiting list?
    27. For service recipients placed on a waiting list, where is the service recipient to be during their time on the waiting list?
    28. Individuals placed on an RMHI waiting list will frequently be difficult or impossible for crisis workers or other CMHA staff to locate when their confirmation number is available if any significant time has elapsed since the certificate of need (CON) was signed.
    29. How will waiting lists work for service recipients returned to inpatient treatment for non-compliance with mandatory outpatient treatment?
    30. What kinds of data will the Department collect about service recipients placed on waiting lists if no suitable bed is available?
    31. Based on the most recent admission and discharge data and average length of stay for each RMHI, what is the projected maximum number of individuals and approximate length of time on waiting lists following bed reductions?


DEFINITIONS

1) What is the definition of available suitable accommodations at each RMHI?

Answer: The determination of available suitable beds at each RMHI is based on the number of staffed (operating not licensed) beds. Beds for children are calculated separately from beds for adults. Secure forensic beds at the Forensic Services Program at Middle Tennessee Mental Health Institute are calculated separately from other beds. Beds for forensic service recipients are calculated separately from other adult beds at the facility. RMHI administrators are expected to manage the service recipient population within a hospital to accommodate new admissions regardless of acuity or gender.

2) What is a non-secure forensic bed?

Answer: Non-secure forensic beds are beds for service recipients admitted to RMHIs as the result of a court order for admission under T.C.A. Title 33, Chapter 7, Part 3 who do not require maximum security. Service recipients needing maximum security are located in the Forensic Services Program at Middle Tennessee Mental Health Institute (MTMHI), while other forensic service recipients are distributed throughout the RMHIs.

3) What is a state-owned or operated hospital or treatment resource?

Answer: A state-owned or operated hospital is a regional mental health institute (RMHI). TDMHSAS does not currently own or operate other treatment resources.


GENERAL ADMISSION ISSUES

4) If the local RMHI has no suitable bed available, what steps will the Department take to find a bed in an alternate RMHI?

Answer: If the local RMHI has no available suitable accommodations, the local RMHI offers to contact an alternate RMHI and to provide contact information for an RMHI with available suitable accommodations. The referral source decides whether to accept a referral to an available bed at an alternate RMHI or place the service recipient on a waiting list at the local RMHI. If the referral source decides to place the service recipient on the waiting list, the local RMHI checks at least daily for available suitable accommodations at the local or alternate RMHIs. The local RMHI only stops checking when available suitable accommodations are identified or the service recipient is removed from the waiting list by the referral source.

5) Which person is allowed to decline a referral to an alternate RMHI: the service recipient or the referring professional?

Answer: When the service recipient is referred to an alternate RMHI for an involuntary commitment, the referring professional makes the decision about whether to accept the offer to place the service recipient at the alternate RMHI or to place the service recipient on a waiting list at the local RMHI. Referring professionals should take into consideration service recipients’ preferences in making this decision.

6) What happens when a service recipient referred for admission has a medical condition that needs treatment prior to admission to an RMHI?

Answer: RMHIs do not admit a service recipient if, during the evaluation for admission, it is determined that the service recipient has a physical disorder or medical condition that requires immediate medical care that the RMHI cannot appropriately provide. Service recipients are sent for treatment of the medical condition prior to being evaluated for admission to the RMHI. Any service recipient with a valid confirmation number may be transported back to the RMHI for an evaluation for admission.

7) What does it mean to cancel a confirmation number verifying available suitable accommodations when reasonable to do so?

Answer: Confirmation numbers may only be canceled in response to circumstances such as the service recipient is admitted to another facility or no longer needs inpatient hospitalization. The reason for canceling a confirmation number is to free reserved beds for other admissions. The RMHI notifies the referral source or designee if a confirmation number is going to be canceled. Confirmation numbers are not canceled when the facility is notified that a person is in route to an RMHI.

8) Will TDMHSAS contract with private psychiatric hospitals for overflow beds to use?

Answer: The Department does not currently contract for overflow beds and has no plans to do so. At the direction of the Tennessee General Assembly, the Department did contract with specific private psychiatric hospitals in Upper East Tennessee for the purpose of providing inpatient care to uninsured service recipients for the period June 30, 2009 to July 1, 2010.

9) In recent years there have been no voluntary admissions to some of the RHMIs. Is this to change?

Answer: Voluntary admissions have been and continue to be an option dependent on bed availability. Practically, voluntary admissions to RMHIs are rare.

10) Which acute care private psychiatric hospitals take involuntary service recipients? How many beds?

Answer: The number of acute care private psychiatric hospitals and the number of beds for service recipients needing involuntary admission is subject to change. Service providers should contact local hospitals to determine this information.

11) Which hospitals have the capacity to provide medical detoxification services?

Answer: Service providers should contact local hospitals to determine whether they have the capacity to provide medical detoxification services. To address the need for this service, TDMHSAS recently contracted with five (5) agencies to provide medically monitored crisis detoxification services: Helen Ross McNabb in Knoxville; Council for Alcohol & Drug Abuse Services (CADAS) in Chattanooga; Buffalo Valley in Nashville, Howenwald, and Lewisburg; Pathways in Jackson; and Cocaine and Alcohol Awareness Program (CAAP) in Memphis. These agencies provide twenty-four (24) hour per day services for three (3) days with transition to other treatment services.


RESPONSIBILITY OF SERVICE PROVIDERS

12) If a person is placed on a waiting list for an RMHI, who is responsible for that person until a bed becomes available?

Answer: The Department encourages referring professionals, local agencies, hospitals, law enforcement, and treatment resources to develop community strategies to protect service recipients and the community. Referring professionals should make a decision about the best way to keep a service recipient and the community safe when there is a delay in admission to an RMHI.

13) What is the community mental health agency (CMHA) provider responsibility when a service recipient needs to be admitted to an RMHI when no bed is available?

Answer: When there is a delay in admission and the service recipient cannot be immediately transported to an RMHI, the Department encourages CMHA’s to handle the clinical situation just as they do currently when there is a lag-time (i.e., between signing the certificate of need (CON) and waiting for the sheriff or transportation agent to transport the service recipient). The Department encourages CMHAs to work with referring professionals, local agencies, hospitals, law enforcement and treatment resources to develop community strategies to protect service recipients and the community.

14) What will happen when licensed mandatory pre-screening agents refuse to fulfill that function in situations where there is no appropriate disposition for the individual assessed?

Answer: The Department will consider mandatory prescreening issues as they arise. The Department invites stakeholders to make recommendations about any issues related to available suitable accommodations and mandatory prescreening.

15) What if an emergency room physician refuses to perform any service other than medical diagnosis and treatment and does not address psychiatric issues due to liability for failure to secure needed hospitalization?

Answer: The Department cannot respond on behalf of general hospitals.

16) What is the managed care organization’s (MCO) responsibility when the service recipient is on a waiting list for the RMHI but a private hospital bed is available for that member? What is the MCO responsibility when there is no bed available at either an RMHI or a private hospital?

Answer: The Department encourages the use of private hospitals when a service recipient is on a waiting list for an RMHI. When no bed is available at an RMHI or a private hospital, then the Department encourages the referral source to contact the MCO for resources to meet the inpatient needs of the member. The MCO is responsible for access to inpatient beds within their provider network.

17) There is no authority for law enforcement to detain a service recipient after completion of a psychiatric evaluation/prescreening assessment unless legal charges permit incarceration. As a result, will a service recipient be released with documented evidence that he or she is capable of being harmful to themselves or others?

Answer: The Department encourages referring professionals, local agencies, hospitals, law enforcement and treatment resources to develop community strategies to protect service recipients and the community. Referring professionals must make decisions about the best way to keep the community and a service recipient safe if there is a delay in admission to an RMHI.

18) Will there be an increase in situations where there is a legal duty to warn if parties are identified as potential victims of harm?

Answer: In the case of a delayed admission to an RMHI, referring professionals should continue to comply with their responsibilities under T.C.A. § 33-3-206. If referring professionals have questions about their responsibility under the law, they should discuss their questions with their attorney.


TRANSPORTATION

19) What steps will the Department take to minimize travel to alternate RMHIs if no bed is available in the local RMHI?

Answer: Each RMHI follows a protocol to identify an available bed in those RMHIs closest to the local RMHI.

20) Is the written statement that is to be given to the sheriff or transportation agent a form that will be provided by TDMHSAS once bed availability has been confirmed by the RMHI?

Answer: RMHIs use a specific form to confirm bed availability. In most cases, the RMHI faxes this written statement with a confirmation number to the certifying professional. We understand that mobile crisis teams do not always have fax machines or other means of printing the RMHI form readily available in the community. In such circumstances, the RMHI with bed availability may provide the confirmation number verbally and the referral source or designee may generate the written statement. The referral source or designee is responsible for providing a written statement with a confirmation number to the transportation agent.

21) If the local RMHI has no bed and refers a service recipient to an alternate RMHI, how will the service recipient be transported to the alternate RMHI?

Answer: The responsibility for transporting a service recipient to an RMHI for involuntary emergency mental health inpatient treatment has not changed. The sheriff or designated transportation agent is responsible for transporting service recipients referred for involuntary admission to an RMHI regardless of the location of the RMHI with an available bed. The sheriff or transportation agent will not transport a service recipient without being provided a written statement with a confirmation number.

22) Will it be more likely that friends, family and neighbors will transport people needing involuntary inpatient commitment?

Answer: We recognize that friends, family or neighbors may transport service recipients needing involuntary inpatient treatment if the referral source determines the service recipient does not require physical restraint or vehicle security.

23) If a service recipient is sent to an alternate RMHI and is not admitted, who will provide transportation to get them back to their home county?

Answer: If a decision to “not admit” the service recipient is made within the timeframe (defined by statute) the sheriff or designated transportation agent is required to wait, the sheriff or designated transportation agent is responsible for returning the service recipient to the county from which the service recipient was transported. If a decision to “not admit” the service recipient is made after the timeframe (defined by statute) during which the sheriff or designated transportation is required to wait and they have left, the RMHI is responsible for returning the service recipient.

24) If a service recipient is sent to an alternate RMHI and is discharged, who will provide transportation to get them back to their home county?

Answer: When a service recipient is discharged after having been admitted to an RMHI, the RMHI is responsible for arranging or providing transportation.

25) May sheriffs refuse to transport to an alternate RMHI outside of their region, precipitating incarceration without treatment or release to the community?

Answer: The law requires sheriffs to transport the service recipient to an RMHI if a service recipient is properly referred for admission and the referral source provides the sheriff with a written statement with a confirmation number verifying that suitable accommodations are available at an RMHI.


WAITING LIST

26) How long is the certificate of need (CON) valid if the service recipient is placed on an RMHI waiting list?

Answer: There is no statutory expiration of a CON.

27) For service recipients placed on a waiting list, where is the service recipient to be during their time on the waiting list?

Answer: When there is a delay in admission and the service recipient cannot be immediately transported to an RMHI, we encourage certifying professionals and agencies to handle the clinical situation just as they do currently when there is a lag-time (i.e., between signing the certificate of need (CON) and waiting for the sheriff or transportation agent to transport the service recipient).

28) Individuals placed on an RMHI waiting list will frequently be difficult or impossible for crisis workers or other CMHA staff to locate when their confirmation number is available if any significant time has elapsed since the certificate of need (CON) was signed.

Answer: If the CON has been completed but admission is delayed, referring professionals, local agencies, hospitals, law enforcement and/or treatment resources should identify the location where the service recipient will be waiting for admission.

29) How will waiting lists work for service recipients returned to inpatient treatment for non-compliance with mandatory outpatient treatment?

Answer: If RMHIs do not have available suitable accommodations, service recipients referred for re-commitment due to non-compliance with mandatory outpatient treatment are admitted and placed on a waiting list until a suitable bed becomes available.

30) What kinds of data will the Department collect about service recipients placed on waiting lists if no suitable bed is available?

Answer: The Department collects and maintains data required for making quarterly reports to the Legislature and to facilitate future management decisions. The information includes at least the number of delayed admissions and the length of any delayed admissions.

31) Based on the most recent admission and discharge data and average length of stay for each RMHI, what is the projected maximum number of individuals and approximate length of time on waiting lists following bed reductions?

Answer: The Department posts the most recent quarterly report on its website.

RMHI Referral Processes Links