KARE Center NIATx Beds Change Leaders: Andrea Buckley & Lauren Giannakopoulos Niatx team: Eunice Boatin, Kristin Palmer, Jeni Parkinson, & tarus Griffin

AIMS and Baseline data Reduce amount of Emergency Detentions that do not result in court orders. In 2017, approximately 36% of EDs did not result in court orders. Reduce the amount of EDs on consumers who initially present seeking voluntary hospitalization but no voluntary beds available (In 2017, 25% of all unnecessary EDs were on consumers initially seeking voluntary. This accounted for approximately 7% of all EDs) Baseline Measure: 304 total EDs in 2017, 110 of 304 did not result in court orders. 30 of the 110 were conversions, change of venues or legal drops leaving 80 EDs that were deemed unnecessary. 20 of those 80 EDs originally presented to ER seeking voluntary hospitalization but no beds were available. Total Emergency Detentions: 304 Move to More Restrictive: 29 New Orders: 163 Unknown: 2 Remaining (not placed on orders): 110 55/non-resident/legal drop: 30 Remaining: 80 Attempted Voluntary, no beds available: 20 Refused Voluntary: 32 Not Appropriate/jail: 12 Unknown: 16

Baseline Data Continued: 2018 2018 (January 1, 2018-May 31, 2018) Total Emergency Detentions: 109 Move to More Restrictive: 19 New Orders: 56 Remaining (not placed on orders): 34 Non-resident/change of venue/co. to WI/conversions to 55/legal drop: 10 Remaining: 24 Attempted Voluntary, no beds available: 4 Refused Voluntary: 7 Not appropriate/jail: 8 Unknown: 5

THE CHANGE  NIATx BEDS (June 1, 2018-June 30, 2018) Utilized two additional “emergency” NIATx beds for individuals who sought voluntary hospitalization but no beds were available and would then be at risk for being detained Implemented NIATx bed procedure and script for Adult Crisis Workers Implemented mandatory psychiatric provider visit at the KARE Center the next business day Offered crisis case management referral, and, if refused, Adult Crisis follow up Crisis NIATx Bed Procedure Resources: 2 additional KARE Center beds to utilize as an “emergency” bed effective from 06/01-06/30 Bed 1-11: “general” bed, Bed 12-13: “NIATx” bed Who Can use NIATx Beds adults who have been assessed by AC to be KC appropriate attempted to seek voluntary hospitalization but no voluntary beds were available, now risk ED Excludes individuals seeking social detox, step down, or who were otherwise diverted to KC Adult Crisis Procedure: AC received crisis call. Proceed as normal with assessment using normal diversion techniques. Consumer may agree to go voluntary. Consumer should be directed to ER if not already there. AC may then receive request from ER to do an assessment or re-assess for possible chapter for consumer who sought voluntary hospitalization but no voluntary beds were available. AC will contact on-call supervisor to staff case and get permission to utilize NIATx bed. AC responds to ER with script (see back) to present new option of using NIATx bed and to discuss other “option” of being ED. If consumer is agreeable to using NIATx bed, proceed with normal KC admission procedure but clarify that this will be an admission to the NIATx bed. If consumer is not agreeable, continue with assessment. KARE Center Procedure: Crisis staff (AC and KC) will staff consumer’s case daily at Debriefing to determine when they can be moved to general bed or go home with safety plan. Data will be recorded by Kristin Palmer. Prescribers (APNP Brenda Stallbaum and Dr. McCarthy) prioritize consumers in the NIATx beds Consumer will be referred to Crisis case management by KC staff and will be assigned by Jeni Parkinson. AC Tarus Griffin will act as back up to crisis case management as needed.

The Results NIATx Beds Utilized: 11 Emergency Detentions from NIATx consumers: 1 Average Length of stay: 3.4 days 9 of 11 saw providers next business day 5 referred to CCM, 1 already in CCS, 1 was detained, 3 refused and had AC follow up One family care referral Total Emergency Detention: 30 Move to More Restrictive: 4 New Orders: 19 Remaining: 7 Change of venue/medical drop/legal drop: 6 Remaining: 1 Attempted voluntary, no beds available: 0 Refuse Voluntary: 1 Engagement for CCM: 4 with engagement with CCM, plus CCS consumer already engaged

Next Steps: Adopt KARE Center scheduled to received funding for 16 beds. KHDS should consider implementing at least 1 permanent reserved bed as an alternative to emergency detention. Since April 2018, there were 6 instances where 5 or more consumers were unable to utilize KARE Center services due to beds being full.

Emergency Detentions Data since June 2018 July August September Total Detentions: 35 New orders: 22 1 of 22 presented seeking voluntary admission MTMR: 4 Non-residents: 2 No orders: 7 Refused voluntary: 4 Unknown: 2 Sought voluntary but not bed available: 1 Total Detentions: 29 New Orders: 11 MTMR: 8 Non Residents/Conversion to 55: 1 No Orders: 9 Refuse voluntary: 5 Unknown: 1 Sought voluntary but no bed available: 3 New Orders: 18 MTMR: 3 No Orders: 13 Refuse voluntary: 7 Sought voluntary but no bed available: 5 Total Detentions: 29 New Orders: 11 MTMR: 8 Non Residents/Conversion to 55: 1 No Orders: 9 Refuse voluntary: 5 Unknown: 1 Sought voluntary but no bed available: 3 9 unnecessary Emergency Detentions since June

Impact Costs Benefits Average cost per day at WMHI: $1,000+ Congestion Court scheduling Emergency Rooms Cost to law enforcement Transport at time of emergency detention Transport to court KHDS discharge planning for consumers not on orders Reimbursement for KARE Center clients who have MA Uphold right of consumer who initially sought voluntary by keeping them in the least restrictive environment Referred to KHDS programs and other community resources, additional revenue Can build trust in the agency and make consumers aware of services offered PER DAY INPATIENT RATE MENDOTA WINNEBAGO Adult Psychiatric Services $1,039 $1,039 Geropsychiatric 1,052 NA Child/Adolescent NA 1,100 Forensic (all security levels) 1,039 1,039 Emergency Detention Add-On First three days of service (plus intervening weekends and legal holidays) 250 250 Non-typical Services Add-On 250 250

Next steps Obtain approval for adoption of permanent reserved bed as an alternative to emergency detention Continue to provide alternatives to emergency detention/hospitalization Reviewing KHDS’ use of crisis plans as second project ***in 2019 proposed budget to go form 11 to 16!!!