Understanding the community mental health system CHILDREN, YOUTH, and FAMILIES August 25, 2010 Julie de Losada, Angela Fraser, & Pat Morris Adapted from Children’s Mental Health Services, by Judy Gosney, 2003.

North Sound Mental Health Administration Centers for Medicare & Medicaid Services Federal Government Mix of State Mental Health and Federal $$ DSHS MAA CA ADSA DDD JRA other other Pearl Street McGraw CSTC Tamarack DBHR ESH WSH CLIP North Sound Mental Health Administration RSN Catholic Community Services NW Whatcom, Skagit, Snohomish Compass Health Skagit, Snohomish, San Juan SeaMar Behavioral Health Skagit, Snohomish, Whatcom Whatcom Counseling & Psychiatric Clinic CMHA Region 3 NSMHA From Washington to Washington…

39 Counties Grouped into 13 RSNs

Role of VOA 24/7/Phone Crisis Intervention (800-584-3578) 24/7/ Triage Clinician Line (800-747-8654) Linkage to Regional (Five-County) Integrated Crisis Response System Regional Lifeline call center (1-800-273-8255) ACCESS to Outpatient counseling (888-693-7200) Inpatient Certification & Authorization (800-707 4656 Offers ASIST and safeTALK community trainings

Volunteers of America (VOA) Access to Care 4 Ways to Enter the Community Mental Health System Crisis Services Outpatient Services Inpatient Services* CLIP* Volunteers of America (VOA) *Neither NSMHA nor our Providers deliver inpatient or CLIP services. NSMHA may authorize for these levels of care.

Accessing Crisis Services 24/7 Phone Crisis Intervention Services @ 800-584-3578 100,000 Annual Total Calls Serving Five North Sound Counties Self-Defined Crisis Mental Health Professional Staff Consultation with Crisis Intervention Access to Consumer Info Database Crisis Appointments Crisis Planning Crisis Respite Dispatch for voluntary Outreach Dispatch for Involuntary Evaluations

Accessing Outpatient Services MUST meet Medicaid Financial Eligibility Established by Community Service Office (CSO) MUST have a covered “Access to Care” diagnosis MUST meet “medical necessity” MUST call ACCESS to Mental Health Services @ 888-693 7200

Access to Care “B” Diagnosis

RSN/ CMHA Service Outpatient services offered by NSMHA contracted Community Mental Health Agencies Catholic Community Services NW Compass Health SeaMar Whatcom Counseling and Psychiatric Services

ALL Providers Offer… Assessment/ Evaluation Individual Therapy Group Therapy Family Therapy Medication Management Case Management Coordination with formal systems Coordination with natural supports

SOME Providers Offer… CHAP – Children’s Hospitalization Alternative Program Co-Funded by Children’s Administration for 16 yrs. Individualized/ intensive care In-home & out-of-home Respite 24/7 Crisis Response Compass Health: Snohomish/ Island Catholic Community Services: Whatcom

SOME Providers Offer… Wraparound Family-driven/ Youth-Guided Team Based Natural Supports Community Based Culturally Competent Strengths Based Collaboration Persistent Outcomes Based Compass Health: Snohomish/ Island Catholic Community Services: Whatcom/ Skagit

Individual and Tailored Care Each person has a unique combination of strengths and needs. Services should be designed to: utilize strengths meet needs In the least restrictive manner.

Plans Should… Include a mix of formal services and informal supports. Include age appropriate normal activities. Be provided in a natural environment.

Family Voice and Participation Assessments based on family strengths and needs. Families should be included in the entire planning and treatment process.

Considerations for Adolescents Youth who are thirteen and older can request mental health services without the consent of their parents. RCW 71.34.500 Youth who are thirteen or older and who are a danger to themselves or others, and refuse treatment may be involuntarily detained and hospitalized. RCW 71.34.710

Accessing Inpatient Services Two ways to access inpatient services Voluntary Involuntary RCW 71.34.600 : Parent may request determination whether minor has mental disorder requiring inpatient treatment — Minor consent not required (1) A parent may bring, or authorize the bringing of, his or her minor child to an evaluation and treatment facility or an inpatient facility licensed under chapter 70.41, 71.12, or 72.23 RCW and request that the professional person examine the minor to determine whether the minor has a mental disorder and is in need of inpatient treatment.

When is Inpatient Appropriate? Needs crisis stabilization in order to avoid a higher level of care. Potential danger to self, others, or property. Caregiver or youth are unable to ensure safety. Needs constant supervision and adult intervention to assure safe environment Inability to think clearly or distinguish reality. AND other less restrictive services have been tried which were not successful or were unable to ensure the youth's safety

What to expect… Time limited crisis stabilization (5-10 days) Limited psychiatric evaluation/assessment Possible medication assessments/ adjustments Coordination with outpatient provider (if there is one) Coordination with other systems (if indicated) Discharge Planning

More about Inpatient Services No child/youth psychiatric inpatient facilities in our region. ALL child/youth psychiatric inpatient facilities in WA are private. Fairfax (6-17) Seattle Children’s (6-17) Two-Rivers Landing (11-17) Kitsap Youth Inpatient Unit (8-17)

When is Inpatient Inappropriate? When less restrictive interventions have not been attempted. Solely for “medication adjustments” or “medication vacations”. In lieu of “placement”. When another system can better or more appropriately serve the child/youth (detention, Children’s Administration, primary care, etc. When the crisis and youth’s primary diagnosis are not directly related to mental health diagnosis.

What is CLIP? CLIP stands for Children’s Long-Term Inpatient Program. The highest, most restrictive, most intensive level of mental health treatment in Washington State. Provides inpatient treatment for youth who have severe psychiatric impairment. Services are available to both Medicaid and non-Medicaid youth. There are 3 ways to access CLIP: Voluntary application, Involuntary commitment and RCW 10.77 competency / restoration. A CLIP admission is not available as a crisis service, nor are children admitted to a CLIP Program solely because they need a safe place to live. Medicaid / non-Medicaid youth - All youth served in CLIP are eligible for Medicaid funding while in residence. If the youth has private insurance that covers psychiatric inpatient care, those benefits are also applied to the cost of the stay.

CLIP Facilities There are 91 beds total divided among 4 CLIP facilities that serve the entire state: McGraw Center in Seattle has 19 beds Pearl Street Center in Tacoma has 12 beds Child Study & Treatment Center (CSTC) in Lakewood has 47 beds divided in 3 cottages: Camano Cottage youth 7 to 11 Ketron Cottage youth 12 to 14 Orcas Cottage youth 15 to 17 Tamarack Center in Spokane has 13 beds All facilities admit both male and female youth. Region 3 youth are not typically admitted to Tamarack Center.

Core CLIP Services Core CLIP Services that are generally offered by each of the 4 facilities. These may vary depending on the facility: Individualized evaluations, assessments and care plans 24 hour psychiatric & nursing care Medication, as needed Safe, structured environment Crisis stabilization Behavior management Family, group and individual therapy Full educational program on site

Core CLIP Services Continued… Social work/case management Recreational, expressive, and leisure therapy Social skills development Dietary assessments & monitoring Occupational Therapy Parent support & advocacy Chemical dependency assessments & treatment

Minimum Admission Criteria Must be under 18 yrs. prior to admission to CLIP. Must be legal residents of WA state or in the custody of a guardian who is a legal resident. Applicants must have a severe psychiatric impairment. Less restrictive treatment setting should be attempted prior to application. Applicants will not be excluded from consideration due to intellectual functioning, physical or medical disabilities. Applicants 13 yrs and younger vs. applicants 13 yrs. and older. (ITA). Severe Psychiatric Impairment - Applicants must have a severe psychiatric impairment with severe emotional disturbance, corroborated by a clear psychiatric diagnosis which warrants the intensity of CLIP Less Restrictive Opitons - Before applicants are considered for CLIP, a less restrictive treatment setting should be attempted, if appropriate and available, prior to application. Excluded - However, the applicant must meet the minimum admission criteria and demonstrate an ability to benefit from the treatment being provided in the CLIP program. Age - under the age of 13, the legal guardian must agree to the treatment. If the applicant is 13 years old or older, the client must agree to voluntary treatment. CLIP does not have the right to hold a youth against their will unless they have been court ordered to treatment via the Involuntary Treatment Act (ITA).

Voluntary Application Two Tiered Process: A comprehensive application must be submitted to RSN CLIP Coordinator. Next, a screening date is set for youth’s legal guardian and other team members to present to the RSN CLIP committee. The RSN CLIP committee refers youth to the CLIP Administration . The CLIP Administration Process & Decision. Again, youth 13 yrs and older must agree to the voluntary treatment. Application - A comprehensive application must be submitted to RSN CLIP Coordinator. and reviewed for completeness, to start the process at the local level. Completeness - Once completeness is established, a screening date is set for youth’s legal guardian and other team members to present the application to the RSN CLIP committee. Refer to CLIP Administration - The RSN CLIP committee refers youth to the CLIP Administration only after consideration and approval of the application at the local level. The CLIP Administration Process & Decision. then compiles a written summary that is submitted to the CLIP Certification Team for review. Based on the materials provided, the Certification Team makes the final determination whether an applicant meets Medicaid medical necessity criteria. If the Certification Team approves the application, the child's name is placed on the statewide waiting list until a bed becomes available at the most appropriate CLIP Program.

Involuntary Application Involuntary Commitment (ITA) 180-day Restrictive Orders for Inpatient Treatment: Under RCW 71.34, adolescents aged 13-17 may be committed for up to 180 days of involuntary inpatient psychiatric treatment. Under this 180-day restrictive court order, the adolescent becomes eligible for admission to a CLIP Program. The adolescent's name is placed on the statewide waiting list as of the date of the 180-day Restrictive ITA order. RSN CLIP committee consults with CLIP Administration

RCW 10.77 Competency / Restoration Competency / Restoration is the least common way to CLIP: RCW 10.77 allows for children to be court-ordered, through the criminal justice system for psychiatric evaluation at CSTC and/or to regain competency to stand trial. RCW 71.34 also permits the transfer of an adjudicated youth from a Juvenile Rehabilitation Administration (JRA) facility to CSTC for up to 14 days of psychiatric evaluation and treatment. 10.77 RCW - allows for children to be court-ordered, through the criminal justice system for psychiatric evaluation at CSTC and/or to regain competency to stand trial. If the responsible RSN determines that the child should remain in treatment beyond the term of the 10.77 order (up to 90 days), a voluntary application must be submitted to the CLIP Administration according to voluntary application procedures. RCW 71.34 - also permits the transfer of an adjudicated youth from a Juvenile Rehabilitation Administration (JRA) facility to CSTC for up to 14 days of psychiatric evaluation and treatment. After the 14 days, the youth may only remain if placed on an involuntary order, or if approved for voluntary admission by the CLIP Administration.

Other notes on CLIP Length of stay can be from 6-12 months. Most youth average about 9 months. RSN CLIP Coordinator will follow the youth’s treatment throughout their stay. Youth are returned to their home community as soon as possible. Community partners, including family, DSHS caseworkers, therapists, schools, RSN, etc., are expected to collaborate with the CLIP Program to assure appropriate discharge resources are in place prior to discharge. Youth can be admitted to CLIP more than once as long as admission criteria has been met and there is expected benefit. If an application is not recommended by RSN, treatment recommendations will be made by the local committee.

Questions? For more information, contact: Contacts NSMHA www.nsmha.org 360.416.7013 Julie de Losada, M.S. julie_de_losada@nsmha.org Angela Fraser, M.A. angela_fraser@nsmha.org Pat Morris, M.Ed pmorris@voaww.org Contacts