Council on Homelessness May 16, 2008 Discharge Planning for Residents of State Mental Health Treatment Facilities Council on Homelessness May 16, 2008

State Mental Health Treatment Facilities Facility Type Bed Capacity Forensic Step Down Beds Baker Act Beds Florida State Hospital, Chattahoochee Civil Forensic 490 528 290 200 Northeast Florida State Hospital, Macclenny 613 152 461 North Florida Evaluation and Treatment Center, Gainesville 216 West Florida Community Care Center, Milton 80 Treasure Coast Forensic Treatment Center, Indiantown 175 South Florida State Hospital, Pembroke Pines 335 55 280 South Florida Evaluation and Treatment Center, Florida City 213 South Florida Evaluation and Treatment Center Annex, Miami 100 Forensic facilities serve residents committed under chapter 916, F.S. These residents are all charged with felonies and have been determined incompetent to proceed to trial or not guilty by reason of insanity. Forensic facilities are secure facilities. Civil facilities serve both forensic and civil residents. That is they serve people committed under Chapter 394, the civil statute, and Chapter 916, the forensic statute. Forensic people served in civil facilities have been determined that they are appropriate for a less secure setting than provided by the secure forensic facilities. Baker Act beds are for people committed under the civil statute. They’ve been determined to have a mental illness and are a danger to themselves or others. Total Beds = 2,750; Total Forensic Beds = 1,729; Total Baker Act Beds = 1021

Who do we serve? People with a severe and persistent mental illness committed to a state mental health treatment facility pursuant to Chapter 394, Florida Statutes, or Chapter 916, Florida Statutes Criteria for placement under Chapter 394, F.S., (Baker Act): Due to a major mental illness, the person is either A danger to themselves or others, or Likely to suffer from neglect or refuse to care for themselves May be voluntary or involuntary. Voluntary must be competent and able to give express and informed consent. Less restrictive placement in the community is not available Must be 18 years of age or older The majority of people committed under the Baker Act are committed as involuntary. Express and informed consent means consent voluntarily given in writing by a competent person, after sufficient explanation and disclosure of the subject matter involved to enable the person to make a knowing and willful decision without any element of force, coercion, duress, or fraud.

Who we serve (continued) Criteria for commitment under Chapter 916, F.S. (forensic): Person is charged with a felony offense and is either Incompetent to Proceed (ITP) or Not Guilty by Reason of Insanity (NGI) Person is mentally ill and because of the mental illness Incapable of surviving alone or with the willing help of others Likely to suffer from neglect, or refuse to care for themselves, and Likely to inflict serious bodily harm to self or others Less restrictive alternatives are judged inappropriate Must be 18 years of age or older or a juvenile adjudicated as an adult

Admission to a Civil State Mental Health Treatment Facility Needs more intensive services and supports than those provided in the community Evaluated by a receiving facility and determined appropriate for state hospital admission – all other community alternatives deemed inappropriate or unavailable Petition court for placement if seeking involuntary commitment (majority of commitments) Referral to the state mental health treatment facility in their catchment area Admission is scheduled in order of receipt of a complete referral packet and available bed Why and how is a person admitted to a SMHTF? The majority of people in a mental health crisis who go to a receiving facility or community mental health center are evaluated, treated, stabilized and returned to the community. However, for a smaller number of people who need more intensive services and supports and who meet the criteria for commitment, an order to commit the person to a state treatment facility is sought. If the person is competent and is willing to go to a state treatment facility voluntarily, an order from the court is not required. This determination is made by the clinician in the community conducting the evaluation. If the person appears to meet the criteria and is not willing to be committed voluntarily or is not competent, than an order for involuntary placement is sought. The order is good for 6 months. Catchment areas – People who need to be admitted to a state treatment facility are referred to the facility that is within their catchment area, and is usually the closest in proximity. Each facility serves specific counties within Florida that make up the judicial circuits. The circuits are grouped into catchment areas for each facility. The next slide shows you how the catchment areas are defined.

Civil Facility Catchment Areas West Florida Community Care Center 1 Florida State Hospital 1,2,6,13,14, Taylor, Madison Northeast Florida State Hospital 3,4,5,7,8,9,10,18 South Florida State Hospital 11,12,15,16, 17,19,20

Admission to a Forensic State Mental Health Treatment Facility Adjudicated NGI or ITP Evaluations conducted – recommend needed services Court ordered for placement at a state mental health treatment facility (all are involuntary) Diversion to the community considered inappropriate Referral packet sent to the Mental Health Program Office Admission scheduled for next available bed statewide

Discharge Planning Authority Chapter 394, F.S. Chapter 916, F.S. 65E-5, Florida Administrative Code, Mental Health Act Regulation 65E-15, F.A.C., Continuity of Care Case Management Department operating procedures

Responsibilities State Mental Health Treatment Facility Recovery Teams Community Case Manager or Forensic Case Manager Circuits Necessary for all parties indicated to work collaboratively in order for the person to be successful after discharge. Facilities will: stabilize the person, provide treatment, rehabilitation and enrichment services to prepare the person for a successful discharge to the community Notify the resident’s circuit when the resident is actively seeking community placement Recovery Teams: Conduct initial observations, assessments and develop the recovery plan with the resident. Develop a plan of expected services and supports needed upon discharge Update and revise the discharge plan as necessary Responsibiliities completed in collaboration with the case manager Case Managers or Forensic Case Managers Participate in the development of the discharge plan and identify services and supports needed for discharge Research resources for needs identified by the Recovery Team Participate in discharge planning meeting Secure community placement and services in cooperation with SMHTF social worker or discharge planner Ensure recommended services are received after discharge Circuits Track or follow residents in SMHTF to ensure continuity of care. Develop needed services/supports not readily available Monitor the provision of services through designated case management providers (circuits manage the contracts for the provision of case management services and local providers).

Discharge Planning for Civil Residents Begins at admission Supports and services wanted/needed in the community Resident involvement Making informed choices Requires participation of resident, recovery team, case manager These are the standards or requirements for the discharge process at the facilities. Discharge planning begins at admission. As soon as a person is admitted, the process of planning for discharge begins. The facilities mission is to return the person to the community as soon as the person is ready. Supports and services the person will need after discharge are identified after admission and is revised as the person’s needs change. Resident involvement in the discharge process is key. The facilities all utilize recovery based approaches where the person drives their own recovery process. In order for the person to be successful after discharge, it is necessary that he/she “owns” their plan and was a major player in its development. The resident will be involved in identifying placement options, visiting potential placements and identifying needed/wanted services. This will also help the resident make informed choices about life after discharge. A successful discharge will have the involvement of all parties: resident, recovery team and case manager.

Discharge Planning Process Recovery Plan developed within 30 days of admission to a state mental health treatment facility addresses discharge barriers, discharge criteria and recommended placement needs. Recovery Plan is reviewed/updated every 30 days Recovery Team includes residents, clinical professionals, family, case manager, etc. The Recovery plan: identifies the resident’s clinical, rehabilitative and quality of life/enrichment service or recovery needs, (based on assessments) the strategy for meeting those needs, Contains recovery goals and objectives, and progress in meeting specified goals and objectives.

Types of Civil Commitments Impact Discharge Process Involuntary – discharged when resident no longer meets commitment criteria (harm to self or others) under Chapter 394, F.S. Voluntary – Resident may request discharge or revoke consent to admission. Must be discharged within 24 hours, unless commitment status is changed to involuntary. Can be extended to three working days to allow for adequate discharge planning. Involuntary – an involuntary commitment order under Chapter 394, F.S., lasts up to six months. After 6 months, the SMHTF must petition the court if the person continues to meet Baker Act criteria (danger to self or others). The facility will request that the order is continued and present evidence to judge showing that the person is a danger to self or others. If the judge agrees, the order is continued for 6 more months. If the judge does not continue the order, the person should be discharged immediately. Many times, if the facility does not think the person meets Baker Act criteria, they will let the order expire and work on discharging the person prior to expiration. Voluntary – the person should be discharged when he/she no longer meets Baker Act criteria. The person may also request to be discharge or refuse services and must be discharged within 24 hours, which can be extended to 3 working days. If a voluntary person requests to be discharged and the facility determines that the person is not competent to provide express and informed consent and the person meets Baker Act criteria, the facility may petition the court for an involuntary placement order.

Prior to Discharge Apply for benefits Research and identify placement and services Secure placement, services, and supports Develop conditional release plan for forensic residents only Seek a conditional release order from the court for forensic residents Coordinate final discharge meeting Copy of discharge plan given to case manager Schedule discharge date and aftercare appointments

Discharge Plan Financial Resources Employment and Education Physical and Mental Health Living Environment Self Care Capabilities Relationships (family/guardian, other) Legal Status Special Needs Transportation Aftercare and Support Services Leisure Activities

Post Discharge Aftercare services provided by some facilities through the transition period Case management services provided by case manager Medication provided from treatment facility until aftercare appointment is held (with psychiatrist) Court notified of civil discharge Medication is usually provided for 30 days, unless the appointment with a psychiatrist is sooner.

Forensic Discharges Majority discharged back to jail, with eventual return to the community Some conditional released into community Conditional release requires court approval of discharge, including community placement and services Usually not a concern regarding homelessness due to conditional release requirement

Data on Discharging into Homelessness Facility Type Discharges FY 05-06 FY 06-07 2 Year Total Civil Total 875 808 1,683 Homeless 7 Forensic 1,250 1,309 2,559 Over the last 2 years, .4%, less than 1% of the civil discharges were to homeless and 0 of the forensic discharges were to homelessness. Most of the people discharged to homelessness would have been taken to a homeless shelter. Last year, no there were 0 discharges to homelessness. *Data retrieved from the Substance Abuse and Mental Health data system

Facility Best Practices Living Environments Alternative Preferences (LEAP) Monthly and Quarterly Provider and Catchment Area Meetings Aftercare Follow Up Services Community Needs Assessment (in development) LEAP – electronic system that contains information and pictures of potential community placements and environments. People can research on line places that they might like to live. It is not always possible to visit places in person, especially if you are returning to a community that is far from the facility you are in. Right now this is only at FSH. CNA - An electronic database and process between the state mental health treatment facilities, circuits and case managers which will allow for ongoing, electronic communication regarding continuity of care and required services, supports and treatment individuals will need for successful discharges. This tool will provide constant communication between facilities, districts, and providers, so that communities are informed of the services, supports and treatment individuals will need in order to live successfully in the community upon discharge.

Difficulties Legal vs. Ethical Issues Voluntary residents request discharge, three days to discharge Baker Act Commitment not continued unexpectedly Resident is not a United States Citizen and does not have benefits

Closing thoughts Discharging people into a homelessness situation is a rare occurrence May happen due to legal constraints and issues related to individual rights The facilities and case managers work closely together with the resident to develop a viable plan for community living prior to discharge Facilities are meeting discharge guidelines in s.420.626