The Temporary Detention Order (TDO) Process: What Staff Need to Know

Live webinar held May 29, 2013

INTENDED AUDIENCE

This presentation was intended for staff from many levels, disciplines and settings ( both acute care and long term care). Attendees included, behavioral health staff, nurse practitioners, nurses, CNAs, Nursing Home Administrators, Social Workers and Case Manages from both Acute and Long term care.

EXPECTED OUTCOMES

At the end of this one-hour presentation, participants will learn:

  1. What are the current regulations governing when and how this may occur;
  2. How to initiate the process, e.g., who should petition and what to do; and
  3. What are practical considerations to keep in mind, e.g. transportation, timing, helpful documentation, readmission to facility after treatment and stabilization, etc.

WEBINAR ACCESS

The live event was open to all and free for all.

Attendees were required to have a computer with access to high speed internet (to view the slide presentation) and computer speakers OR access to a telephone. Additional information was provided through the registration form.

PANEL

Sarah W. Bisconer, PhD

Sarah W. Bisconer, PhD

Panelists

Sarah W. Bisconer, PhD,is the Emergency Services Coordinator at Colonial Behavioral Health, an Adjunct Associate Professor of Psychology at The College of William and Mary, a Virginia Licensed Applied Psychologist, and a Virginia Resident in Counseling.

Beth was the Director of Social Work for Centra for over 20 years before becoming the Program Manager for the county satellite out-pt. clinics at Horizon Behavioral Health.   Her experience has a combined focus in Social Work Discharge Planning and Case Management  as well as Clinical Social Work for Seriously Mentally Ill adults  and geriatrics.

James M. Martinez, Jr. (Jim), MEd

James M. Martinez, Jr. (Jim), MEd

Panelists

James M. Martinez, Jr. (Jim), MEd,has held several positions with the Virginia Department of Behavioral Health and Developmental Services (DBHDS), and has managed the Department’s mental health, substance abuse, forensic, prevention, and youth initiatives and programs.

He is currently Director of the Office of Mental Health Services, where he supervises various administrative, policy and operational functions of Virginia’s statewide system of behavioral health services for adults. Throughout his career, Mr. Martinez has focused on developing community services and supports for people with serious mental illness and substance use disorders and their families, and on shaping and implementing Virginia’s Vision of a person-centered, recovery-oriented behavioral health system. In 2004, Virginia’s mental health consumers and advocates recognized Mr. Martinez with a Living the Vision of Recovery Governor’s Award for his work in this area. Mr. Martinez served as an advisor to the Supreme Court of Virginia’s Commission on Mental Health Law Reform (2006-11), and has led DBHDS efforts to improve Virginia’s involuntary treatment statutes and strengthen the safety net of behavioral health services for all Virginians.

Mr. Martinez is a graduate of the Virginia Executive Institute, and holds a B.A from Washington and Lee University and an M.Ed. from the University of Virginia.

E. Ayn Welleford, MS, PhD, AGHEF

E. Ayn Welleford, MS, PhD, AGHEF

Moderator

E. Ayn Welleford, MS, PhD, AGHEF,received her BA in Management/Psychology from Averett College, MS in Gerontology and PhD in Developmental Psychology from Virginia Commonwealth University. She has taught extensively in the areas of Lifespan Development, and Adult Development and Aging, Geropsychology, and Aging & Human Values.

As an educator, researcher, and previously as a practitioner she has worked with a broad spectrum of individuals across the caregiving and long term care continuum. As Associate Professor and Chair of VCU’s Department of Gerontology, she currently works to “Improve Elder Care through Education” through her Teaching, scholarship, and Community Engagement. Outside of the classroom, Dr. Welleford provides community education and serves on several boards and committees. She is the Immediate Past Chair of the Governor’s Commonwealth of Virginia Alzheimer’s and Related Disorders Commission.

Dr. Welleford is the proud recipient of the 2008 AGHE Distinguished Teacher Award.

SLIDES AND EVENT RECORDING

QUESTIONS and ANSWERS:

The following answers were generously provided by the two presenters post event:
Q: While a individual is in the Mental Hospital, is the family or individual still required to pay a bed hold for the bed? How is that handled best?

A: The facility administrator and insurance company are the entities best able to address this question in each case.

Q: How do we get the contact information for the Virginia Beach area to request a pre-admission screening?

A: Virginia Beach Crisis can be reached at 757-385-0888. Other CSB contact information can be found on the Virginia Association of CSBs web site at http://www.vacsb.org/directory.html and on DBHDS’s website at http://www.dbhds.virginia.gov/SVC-CSBs.asp

Q: What do you do when your CSB doesn't respond in a timely manner?

A: Call and speak to the Emergency Services Coordinator, their supervisor, or the CSB executive director.

Q: So the process starts with contacting CSB? How and where do you contact them?

A: CSB contact information can be found on the Virginia Association of Community Services Boards’ web site at http://www.vacsb.org/directory.html and on DBHDS’s website at http://www.dbhds.virginia.gov/SVC-CSBs.asp

Q: Have you ever had a situation where a Facility Administrator does not want to accept a resident back into the facility and if so, what happens at that time?

A: The individual likely will be returned to the facility. The CSB Preadmission Screener often cannot secure a bed with the psychiatric hospital if the individual does not have a confirmed discharge setting. The Preadmission Screener is not responsible for securing another placement for the individual.

Q: What happens to the individual when the facility will not issue the guarantee to re-admit the individual? There is no less a need for treatment for someone who may be identified as a "troublemaker"?

A: The CSB Preadmission Screener often cannot secure a bed with the psychiatric hospital if the individual does not have a confirmed discharge setting. Let’s also emphasize that hospitals generally provide short-term interventions, and these behaviors and symptoms are usually best managed by an outpatient physician and by implementing behavioral interventions in the residential setting. Nevertheless, some individuals require different levels of care by different providers at different times on an ongoing basis as their needs wax and wane. The involved providers should understand that it will take all of them working together, with each meeting specific needs at different times, to be successful in the long run.

Q: It looked like the Virginia regulations require the individual to have a mental illness. How does the ECO and TDO process work with someone who has dementia (not a mental illness) but is a risk to themselves or others?

A: Inpatient psychiatric hospitalization is appropriate for elders with dementia if there is reason to believe that the acute psychiatric symptoms will improve with treatment. Acute psychiatric hospitalization to start or adjust psychiatric medications is considered appropriate and best practice.

Q: What happens if an administrator refuses to sign letter accepting individual back to a community? Where do you go from there?

A: The individual likely will be returned to the facility. The CSB Preadmission Screener often cannot secure a bed with the psychiatric hospital if the individual does not have a confirmed discharge setting. The Preadmission Screener is not responsible for securing another placement for the individual.

Q: What are the steps to take if CSB is not willing to evaluate when it is clear that a individual is in need?

A: Call and speak to the Emergency Services Coordinator, their supervisor, or the CSB executive director. Also, listen to the explanation. Many individuals are not appropriate for acute psychiatric hospitalization and other interventions will need to be considered.

Q: When is a individual with Dementia/Alzheimer's with psychosis considered for a screening?

A: Inpatient psychiatric hospitalization is appropriate for elders with dementia if there is reason to believe that the acute psychiatric symptoms will improve with treatment. Acute psychiatric hospitalization to start or adjust psychiatric medications is considered appropriate and best practice.

Q: If a individual is found to need inpatient hospitalization for an extended period of time and there is no bed, what happens?

A: This should not happen very often. The Preadmission Screener will continue looking for a bed until a bed is secured.

Q: In a SNF/LTC is the attending psychiatrist allowed to initiate the detention process or should CSB always be called?

A: A physician, or any other “responsible person”, may initiate the temporary detention process by filing a petition with a magistrate, but the temporary detention order cannot be issued until the CSB has completed its examination of the individual. The physician could also call the CSB to start this process, but again, the temporary detention order would not be issued until the CSB had completed its examination of the individual. The CSB determines also the facility of temporary detention prior to the issuance of the TDO. These processes can vary from CSB to CSB, so It is helpful to talk to your local CSB and understand how this process works in your community.

Q: Given staffing of CSBs and the volume of calls, what occurs if the wait time for a response extends over 8 hours?

A: A CSB preadmission screening evaluator is expected to be available to respond to an emergency call within 15 minutes, and to be available for face-to-face evaluation within one hour (in an urban CSB) or two hours (in a rural CSB). All CSBs are expected to have these capabilities. If there are excessive delays and your CSB is not meeting these standards, you should call and speak to the Emergency Services Coordinator, their supervisor, or the CSB executive director.

Q: Why does the facility have to write a letter to take them back?

A: Historically, facilities have sometimes refused to accept a resident back following psychiatric hospitalization. The resident then becomes the responsibility of the psychiatric hospital. This is contrary to the individual’s interests and rights, compromises the hospital’s mission (i.e., having a resident that no longer needs hospital treatment) and takes valuable hospital bed space out of circulation.

Q: We are an ALF and had a neighbor who was 92 years old with terminal illness. He requested admission but we didn't have an opening. His family insisted that he go to another ALF. Once there he insisted to be taken home and his daughter checked him out. When he returned home he voiced that he would rather die than go back to the other nursing home. Several days later he committed suicide. Prior to this, we had voiced our concern to the social worker assigned to his case regarding his suicidal thoughts. The social worker commented that she didn't believe it was a concern because it was common for people to say that in this situation. What could we do in the future to help prevent this?

A: Please take all suicide statements very seriously. Suicide is not uncommon (there were 1,067 suicides in Virginia in 2011) and for every suicide there are an estimated 12 suicide attempts. Know the risks factors for suicide. Call and request that a suicide risk assessment to be performed by a trained and knowledgeable clinician. There are also many training programs and resources that can help your facility be better prepared to recognize and respond to suicide risks.

Q: I assume that the costs for TDO or ECO are borne by the state. Is this a correct assumption? Will this change with implementation of the Affordable Care Act?

A: The Department of Medical Assistance pays the costs of temporary detention if there is no other payer source (such as Medicaid or other insurance). This is not expected to change with implementation of the Affordable Care Act.

Q: In all four cases, the original facility wrote the letter they would accept the patient back. Do they have to write this letter? What happens if they do not write the letter?

A: If they do not write the letter the client likely will be returned to the facility. The Preadmission Screener often cannot secure a bed with the psychiatric hospital if the client does not have a confirmed discharge setting. The Preadmission Screener is not responsible for securing another placement for the client.

Q: Where can we find these decision algorithms at DBHDS? Can anyone access the local CSB?

A: We do not have these decision algorithms. But please refer to the slides for the processes described. Yes, anyone can access the local CSB.

Q: Is it appropriate for a case manager or support service worker to file a petition on a individual in an ALF if they have witnessed an issue?

A: Yes, absolutely. Any individual who has witnessed behavior can petition for a TDO. However, the temporary detention order cannot be issued until the CSB has completed its examination of the individual. An ECO may be ordered if needed to enable this exam to occur.

Q: What happens if facility Administrator will not write a letter stating they can return to facility? Could be setting themselves up for legal trouble if readmitting the resident?

A: If they do not write the letter the individual likely will be returned to the facility. The legal issues should be discussed with social services and the facility’s attorney.

Q: Does the law enforcement community in Virginia have any training in mental health awareness or mental illness?

A: Yes. Virginia is actively training law enforcement and correctional officers in Crisis Intervention Team training (CIT).

Q: What are "evidence based behavior and environmental management programs for individuals with challenging behaviors" that you indicate facilities should implement? Can you provide some references or examples?

A: The first webinar in this series addressed this topic. A link to this webinar is provided here.

Q: One of the biggest challenges facing us as Virginians is the lack of treatment facilities for individuals with dementia so that they can be stabilized and sent to a less restrictive environment. Will anyone address that issue?

A: As the older adult population grows, we can expect our health care system to be continually challenged, but in fact, psychiatric beds for elders has increased in Virginia and these facilities recognize the need for acute treatment of elders with dementia with psychiatric symptoms that would benefit from acute hospitalization. In the Tidewater region of Virginia we send elders with dementia to Williamsburg Place – The Pavilion, Virginia Commonwealth University/Medical College of Virginia, Rappahannock General Hospital – Bridges Program, Virginia Beach Psychiatric Center, and Sentara Norfolk. Call the CSB in your region to identify the hospitals equipped to treat this population.


*THE GERIATRIC MENTAL HEALTH PARTNERSHIP (GMHP)