Alternates to the ED – 30 min - PowerPoint Presentation

Alternates to the ED – 30 min "There is no health without mental health." 1 Alt to ED Bed subcommittee 8-2017

Alternates to the ED - Overview Why are we doing this? Who are the people that will be served? What are the requirements for an Alternative Space? What are current models that exist that might serve this need? "There is no health without mental health." 2

Alternates to the ED - Why We believe: - all persons in need of psychiatric emergency care and support need access to services on an emergent basis. - Hospital Emergency Departments are only one possible avenue for meeting this need. Our goal: - Make recommendations to DMH for ways to divert people from getting “stuck” in emergency departments while waiting for inpatient hospital beds and to alleviate the strain on EDs as the “Go To Place” for after hours emotional/mental support and intervention. -Recommendations will further the practice of the State of Vermont to provide compassionate, effective and innovative person centered care. - We do not want to replicate services or put services in place that will not be accessed to the maximum capacity. "There is no health without mental health." 3

Alternates to the ED – Who will be Served All people in need of emergent psychiatric support . This may include people who are also adults, children, elders, with development challenges, acute or chronic mental health issues, homeless, who have resources, have limited resources, or with substance issues. The common factor ? VT residents with need for emergent psychiatric support. "There is no health without mental health." 4

Alternates to the ED – Requirements Must have Capabilities "There is no health without mental health." 5 Item Must have Capability Reason Why this is Needed 1 Must be able to provide meals Need to eat 2 Bathroom with shower facilities. Basic sanitary needs 3 Staffed by people that are certified in Intentional Peer Support. Unifying Vision and Evidence Based Practices 4 Psychiatric Nursing Staff Need for basic health monitoring and assessment: safety 5 Must be point of entry and able to take people referred by others Once someone gets in the “pipeline”, it’s really hard to get them out 6 Have common space with a “living room” feel Comfort w/comfortable furnishings 7 Ability to provide private spaces Privacy and safety 8 Ability for people to stay overnight Sometimes Things take time

Alternates to the ED – Requirements Must have Capabilities "There is no health without mental health." 6 Item Must have Capability Reason Why this is Needed 9 Separate adult and children’s facilities Safety, security , ability to meet differing needs 10 Parents have ability to stay with children if that is helpful Families first 11 24/7 access  People need support at all hours 12 Must not be used as a step down or for transitional housing Crisis beds and Hospital diversion programs exist for that purpose 13 Must have capacity for crisis screenings and level of care determination Mobile crisis or on site clinician or really clear criteria for when we’re in over our head

Alternates to the ED – Requirements Must have Capabilities "There is no health without mental health." 7 Item Must have Capability Reason Why this is Needed 14 Must be flexible and have easy in and out   15 Must be easily accessible to Emergency departments for safety and for EDs to refer people otherwise people won’t use it Safety, easy access if there is a higher need 16 If special populations, must be clear that the design of facility and approach meets that populations needs  

Alternates to the ED – Requirements Nice to have Capabilities "There is no health without mental health." 8 Item Nice to have Capability Reason Why this is Needed 1 Private rooms Safety, privacy 2 Multiple bathrooms Things take time; sanitary reasons 3 Access to 24/7 safe transportation if people need to go to another place Sometimes things fall apart 4 Ability to store medications safely and have people self- administer medications Maintains autonomy, 5 Outdoor space Fresh Air and reduce perception of confinement 6 Evaluate for involuntary hold and have ability to “hold” following risk assessment or to transfer the person to a hospital emergency room Treating a person in place to reduce disruption prior to hospitalization, which may also result in stabilization and alternative placement/return home

Alternates to the ED – Models Living Room The overarching goal of The Living Room is to decrease the use of emergency departments for mental health crisis and provide guests with support resources to be used long-term in order to minimize their need of further visits. The Living Room is a comfortable space that is designed and furnished to have a home-like feeling with common areas and personal rooms Staffing- Peer specialists, licensed counselor/social worker, medical (psychiatric nurse) Triage occur as necessary (medical, behavioral, psychiatric) Open 24/7 Walk-in or referred   "There is no health without mental health." 9

Alternates to the ED – Models Living Room The Living Room model has been used in at least six states to provide alternatives to ED (citation: Peer Services in a Crisis Setting; The Living Room, Lori Ashcroft, META Services Inc, March 2006). (http://www.recoveryinnovations.org/pdf/LivingRoom.pdf) The original Living Room located in Illinois, in its first year, had 228 visits from 87 unique individuals, most of them diverted from the ED, which saved the State of Illinois approximately $550,000 (citation: Heyland , M., Emery, C., & Shattell , M. (2013). The Living Room, a Community Crisis Respite Program: Offering People in Crisis an Alternative to Emergency Departments. Global Journal of Community Psychology Practice, 4(3), 1-8. Retrieved 8/8/17, from (http://www.gjcpp.org/).   "There is no health without mental health." 10

Alternates to the ED – Models Living Room – What People Want A study of focus groups by Recovery Innovations (formerly META) with people who had either used one of their crisis programs (including Living Room), or had been hospitalized for psychiatric care found that people expressed needing: • A place that looks and feels more like a home than like a clinic or hospital. • A place that feels natural and has a friendly, accepting and supportive environment. • A place where I will be treated with respect and dignity that is non-judgmental about my condition or situation. A place where I feel safe and valued. • A normal mode of transportation not involving law enforcement, which makes us feel like we’ve broken the law by being ill. If you would come and pick us up, we’ll go voluntarily. • Policy of not using restraints or seclusion. We also don’t want chemical restraint. These approaches set back our recovery process.• A place with lots of peer staff on board who can give us hope and remind us who we really are. "There is no health without mental health." 11

Alternates to the ED – Models Living Room – What People Want What people want from a Living Room Model (Continued) • A place where we can be in contact with our friends, families and children; where they can come and be with us during our hard times. • A place where we can access food and snacks. We’d like to make a sandwich, or get someone else a cup of coffee. • A place with outside space so we can be outdoors if we feel like it. • A place that provides interesting things to do, activities that will promote our recovery process.• A place that offers medication education and choices.• A place that offers lots of help with recovery – recovery planning, recovery options, and good solid plan for recovery when we leave. • A place we can come back to if we start to slip, and not worry about being locked up. "There is no health without mental health." 12

Alternates to the ED – Models Immediate Access Bed Immediate Access beds would be beds located on Inpatient Psychiatric units. These beds would function similar to Intensive care beds in a general hospital. These would be at hospitals that agree to provide this level of care. These beds would either be new or existing beds whose sole purpose is to house, assess and treat persons in need of immediate Emergency Psychiatric treatment. Immediate access beds would get a reimbursement from the state, operate as a grant, or be able to bill (needs a deeper dive) Once the emergent need for intensive care is past or a person is stabilized sufficiently, the person is either admitted to a unit voluntarily or involuntarily, discharged to a lower level of care such as crisis bed, living room, or home with supports or home without intensive supports, depending on the persons needs at the time. When it's over, it's over and the bed is made available for the next person in need of immediate intensive psychiatric care. "There is no health without mental health." 13

Alternates to the ED – Models Immediate Access Bed Pros: Incentivizes hospitals to provide immediate care and rapid disposition, rather than it being somebody else’s responsibility.Allows patients to be in an environment of care designed to meet specialized needs, with specialized staff and environments. Less reliance on mini milieus in EDs Speeds up access to hospitalization on parity with medical access.   Cons: Hospitals must agree to time limited beds and to potential for having empty beds if there are no people in need of immediate access. How many beds would we need? Cost? Now the EDs carry the cost. "There is no health without mental health." 14

Alternates to the ED – Related Data Requirements in Word Format "There is no health without mental health." 15

"There is no health without mental health." 16