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Crisis Services Advisory Workgroup September 14, 2015 Background Materials and Supporting Documents Project Framework .......................................................................................1 Project Schedule ..........................................................................................3 Sample Terms and Definitions for Discussion .............................................5 Introduction Mental Health Crisis Crisis Services Values and Guiding Principles for Crisis Services .......................................7 Notes and References ............................................................................... 11 IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH Project Framework Purpose: Document the current state of crisis services for children and youth throughout California. Develop recommendations for improving the delivery of crisis services. Identify outcomes and strategies to measure them for children, youth, family members and the communities in which they live. Goals: 1. Increase policy and decision makers understanding of the nature of mental health crises among children and youth 2. Develop a shared understanding among stakeholders of the current crisis service delivery system and its role within the continuum of care in diverse locations and communities throughout the State 3. Document challenges and constraints of the existing service delivery system and potential benefits of improved access and coordination (e.g. cost avoidance, prevention, improved individual outcomes, improved communities) 4. Increase policy and decision makers understanding of the drivers that impact the accessibility, quality and effectiveness of crisis services for California’s children and youth (e.g. State or local policies and/or procedures, funding/costs, licensing, staffing levels, etc.) 5. Develop new strategies and/or identify existing models to improve access to effective crisis services for children and youth. Tasks and Activities: Advisory Workgroup A workgroup will be formed to explore and refine the goals of this project and advise the Commission in decisions regarding project tasks, activities, work products and recommendations. The workgroup will include subject matter experts on crisis services and key stakeholders representing mental health consumers, family members, state and county leaders, service providers and others. The workgroup will be charged with defining crisis services; exploring the role of these services within a continuum of care that is prevention focused and recovery oriented; identifying challenges, barriers, opportunities and best practices; and developing recommendations to improve access, service coordination and outcomes. Advisory workgroup meetings will be open to the public and strive to incorporate a range of perspectives and experiences to support the development of shared knowledge and ensure that group recommendations address the needs and interests of diverse communities throughout California. At a minimum the Advisory Workgroup should include subject matter experts from mental health, healthcare, schools, counties, law enforcement, and consumers/family members. MHSOAC Subcommittee To ensure this project is consistent with the direction of the MHSOAC, a subcommittee of the Commission, chaired by Commissioner John Boyd, will guide all phases of the project. The Subcommittee will formulate action oriented policy recommendations and communicate these to the full Commission and stakeholder communities. During the initial phase of the project the Subcommittee will meet with the Advisory Workgroup. September 2015 1 | P age IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH Literature Review A thorough review of available written materials including academic articles, white papers and public sector reports will shape and focus the project scope, support the development of problem definitions, and identify potential service delivery models or system improvement efforts currently underway in other jurisdictions. Information gleaned from the literature review will be summarized and provided to the Subcommittee, Advisory Workgroup, and stakeholders to support a shared understanding of the problem and development of potential solutions. Site Visit(s) Commission staff will organize one or more site visits to support the development of foundational knowledge regarding crisis services, their availability and accessibility; increase understanding of how they function within the larger mental health service delivery system; and identify potential challenges or barriers to accessible and effective service delivery systems. Site visits may include crisis stabilization units, emergency departments, mobile crisis teams, or similar service locations. Panel Presentation(s) Panel presentations before the full Commission are envisioned to support the Commissioner’s understanding of the problem and identification of potential opportunities for addressing existing challenges. Panels including individuals with lived experience, subject matter experts, policy leaders, advisory workgroup members and members of the public will provide additional foundational knowledge and first person experiences supported by a discussion of existing barriers, challenges and potential opportunities for improvement. Sufficient time will be scheduled during panel presentations to allow for an in-depth discussion between presenters and the Commission. The panel presentation(s) will be designed to explore the following topics related to crisis services for children and youth: 1. How do we define a mental health crisis? 2. What services are currently in place for children and youth experiencing crisis or at risk of needing crisis services? What is the unmet demand? 3. What is working and what is not working in terms of the existing service delivery system and its relationship to needs? 4. What models or examples of best practices should be explored or promoted to improve California’s mental health system as it related to children and youth in crisis or at risk of crisis? 5. What are the barriers or potential obstacles to expanding or replicating successful models across the state, and what are the opportunities or recommendations for overcoming those obstacles? Project Schedule: This project is expected to last five to six months with projected completion by February 2016. An initial half day combined Advisory Workgroup and MHSOAC Subcommittee meeting will be held in early September followed by a site visit and panel presentation to coincide with the September 24th meeting of the full Commission. An informational packet including background materials, presenters bios, summary of written material, and potential areas for additional exploration will be prepared to support that September 24th Commission meeting. It is anticipated that an additional site visit and panel presentation may be conducted during the Commission’s October meeting likely in Santa Barbara. A final report summarizing the project findings and recommendations will be developed in concert with the MHSOAC subcommittee and presented to the full Commission during their January 2016 meeting. (Refer to attached project schedule for additional details on proposed timing of tasks and activities). September 2015 2 | P age IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH Project Schedule Date* Task/Activity Participants Goals 9/14/2015  Advisory Workgroup Mtg.  MHSOAC Subcommittee  Formalize project scope and goals (e.g. how do we define  Workgroup members crisis, what does the current system look like, what are the  MHSOAC Staff challenges and barriers)  Refine schedule and activities  Finalize selection of panel members for Commission meeting  Establish foundational knowledge 9/23/2015  Site Visit—Edgewood Center  Workgroup members &  Gain increased understanding or alternate service models and Commissioners identify challenges and opportunities for improvement 9/24/2015  Panel Presentation  Full Commission  Share information with full Commission, engage key stakeholders in problem definition 10/7/2015  Advisory Workgroup Mtg.  MHSOAC Subcommittee  Document current service delivery system including  Workgroup members challenges and obstacles  MHSOAC Staff  Review alternate models and system improvement efforts  Guide selection of potential site visits and panel members 10/22/2015  Panel Presentation  Full Commission  Share information with full Commission, identify strategies for improving outcomes  Site Visit 11/9/2015  Advisory Workgroup Mtg.  MHSOAC Subcommittee  Summarize project findings and identify potential action  Workgroup members oriented policy recommendations  MHSOAC Staff Nov-Dec.  Draft Summary Report and  MHSOAC Staff  Organize, summarize and document activities and workgroup 2015 Recommendations recommendations 1/6/2016  MHSOAC Subcommittee  MHSOAC Subcommittee  Secure input and approval of summary report and Mtg.  MHSOAC Staff recommendation prior to presentation to full Commission 1/21/2016  Commission Review &  Full Commission  Commission to review, discuss and approve action oriented Approval policy recommendations for improving crisis services for children and youth *All dates are tentative at this time and subject to change. September 2015 3 | P age IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH September 2015 4 | P age IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH Sample Terms and Definitions—Discussion Items Introduction In framing a project on crisis services for children and youth, it is first important to develop a shared understanding of relevant terms and definitions. For instance, establishing a definition of what the term “mental health crisis” means for children, youth, family members, caregivers, and service providers can help guide the discussion and decision making throughout this project. Additionally, documenting definitions of common service modalities and approaches can serve as an important reference in establishing a shared understanding of the range of existing services and identifying potential gaps or areas of need. Mental Health Crisis--Sample Definitions for Discussion The California Code of Regulations, Title 9 defines an "Emergency Psychiatric Condition" as a condition in which a person, due to a mental disorder, is an imminent danger to self or others or is immediately unable to provide for or utilize food, shelter or clothing. This situation indicates an immediate need for psychiatric inpatient hospitalization or psychiatric health facility assessment. For this project however, a broader definition that more completely accounts for the child’s experience of emotional or psychological distress and addresses mental health crisis within a continuum of services and varying context may be warranted. An alternative definition offered by James and Gilliland describes crisis as “a perception or experience of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanism”i. Additionally, the Mental Health Crisis Response Institute provides the following definition “a person has a mental health crisis when they are in a state of mind in which they are unable to cope with and adjust to the recurrent stresses of everyday living in a functional, safe way.” An important distinction could also be made between the terms “emergency” and “crisis” which in turn may allow for more appropriate referrals and settings for intervention. A recent literature review conducted by the Collaborative Antwerp Psychiatric Research Institute found that overall, authors seem to agree on two aspects of an emergency: 1) it involves a danger of harm to the patient or to others, as primarily determined by the patient’s context, or it involves a context in which there exists a threat to the child’s life or development; and 2) immediate intervention is required.ii Further exploring the distinction between a crisis and an emergency, the State of Kansas Department of Social and Rehabilitative Services uses the following definitions:  A crisis occurs when the demands of a serious acute and potentially dangerous situation overwhelm an individual’s capacity to effectively resolve the situation.  An emergency is defined as an often unforeseen crisis situation that requires an immediate response or intervention to prevent harm or potential harm. Crises and emergencies are typically viewed as time limited although contributing or resulting problems may last beyond the time of crisis.iii September 2015 5 | P age IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH Crisis Services—Sample Definitions for Discussion Crisis intervention or crisis services are generally described as a short term intervention focused on resolving the most immediate and pressing problems through a process of evaluation and assessment; intervention and stabilization; and follow-up planning. The Encyclopedia of Mental Disorders describes crisis intervention as “…the methods used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems.”iv Crisis intervention can alternately be described as a “brief therapeutic approach which is ameliorative rather than curative of acute psychiatric emergencies. Used in contexts such as emergency rooms of psychiatric or general hospitals, or in the home or place of crisis occurrences, this treatment approach focuses on interpersonal and intrapsychic factors and environmental modification.”v Effective crisis service systems often contain a number of key qualities. Crisis services need to be appealing, engaging, accessible, mobile, and have the ability to respond rapidly. Services should also have the capacity to respond at all levels as the crisis unfolds and resolves, promoting a successful transition through the entire process including follow-up services.vi Crisis services typically include an array of services that are designed to reach individuals in their communities and provide alternatives to hospitalization.vii Components of effective crisis service systems include: 23-Hour Crisis Beds: Provides individuals in severe distress with up to 23 consecutive hours of supervised care, including prompt assessments, stabilization, and determination of care. Short-Term Crisis Stabilization: Provides a range of community-based resources, including housing and a safe environment for recovery, to individuals experiencing acute psychiatric crises. Services are short-term. Mobile Crisis Services: Provides consumers with rapid response services in their homes, schools, communities, etc. Service providers provide immediate assessments and seek to resolve crisis situations on-site. Crisis Hotlines: Provide callers with immediate support from trained mental health providers via telephone. Staffers facilitate linkage and referral of caller to relevant services and supports. Warm Lines: Provides callers with opportunity to speak directly with trained mental health consumers who provide support for individuals in situations that are non-emergency, but have the potential for escalation. Psychiatric Advanced Directive Statements: Provide individuals the opportunity to designate their psychiatric/mental health treatment preferences should they lose the ability to make said decisions in the midst of a crisis situation. Peer Crisis Services: Provides individuals with short-term, community-based services that are administered by trained consumers of mental health services (“peers” to the individual seeking treatment). September 2015 6 | P age IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH Values and Guiding Principles for Crisis Services Essential values for appropriate and effective crisis services regardless of the nature of the crisis or the situation where assistance is offered (U.S. Department of Health and Human Services, 2009).viii Avoid Harm: An appropriate response to mental health crisis considers the risks and benefits of interventions and whenever possible employs alternative approaches. In circumstances where there is an urgent need to establish physical safety and few viable alternatives to address immediate risk of significant harm to the individual or others, an appropriate crisis response incorporates measures to minimize the duration and negative impact of interventions. Intervening in Person-Centered Ways: Appropriate interventions seek to understand the individual, his or her unique circumstances and how that individual’s personal preferences and goals can be incorporated in the crisis response. Shared Responsibility: An appropriate crisis response seeks to assist the individual in regaining control by considering the individual an active partner in—rather than a passive recipient of—services. Addressing Trauma: It is essential that once physical safety has been established, harm resulting from the crisis or crisis response is evaluated and addressed without delay by individuals qualified to diagnose and initiate needed treatment. Establishing Feelings of Personal Safety: Assisting the individual in attaining the subjective goal of personal safety requires an understanding of what is needed for that person to experience a sense of security and what interventions increase feelings of vulnerability (for instance, confinement in a room alone). Providing such assistance also requires that staff be afforded time to gain an understanding of the individual’s needs and latitude to address these needs creatively. Based on Strengths: An appropriate crisis response seeks to identify and reinforce the resources on which an individual can draw, not only to recover from the crisis event, but to also help protect against further occurrences. The Whole Person: An individual with a serious mental illness who is in crisis is a whole person, whose established psychiatric disability may be relevant but may—or may not—be immediately paramount. The Person as Credible Source: an appropriate response to an individual in mental health crisis is not dismissive of the person as a credible source of information—factual or emotional—that is important to understanding the person’s strengths and needs. Recovery, Resilience and Natural Supports: An appropriate crisis response contributes to the individual’s larger journey toward recovery and resilience and incorporates these values. Accordingly, interventions should preserve dignity, foster a sense of hope, and promote engagement with formal systems and informal resources. Prevention: an adequate crisis response requires measures that address the person’s unmet needs, both through individualized planning and by promoting systemic improvements. September 2015 7 | P age IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH Key principles to ensuring that crisis services embody the essential values outlined above (U.S. Department of Health and Human Services, 2009). Access to supports and services is timely: Ready access to assistance is important not only because it holds the promise of reducing the intensity and duration of the individual’s distress, but also because as a crisis escalates, options for interventions may narrow. Timely access presupposes 24-hour/7-days-a- week availability and a capacity for outreach when an individual is unable or unwilling to come to a traditional service site. Services are Provided in the Least Restrictive Manner Possible: Least-restrictive emergency interventions not only avoid the use of coercion, but also preserve the individual’s connectedness with his or her world. Individuals should not be unnecessarily isolated from their routine networks of formal and natural supports and should be encouraged to make contact with outside professionals, family and friends who can provide assistance through the crisis event and beyond. Peer Support is Available: Services should afford opportunities for contact with others whose personal experiences with mental illness and past mental health crises allow them to convey a sense of hopefulness first-hand. In addition, peers can offer opportunities for the individual to connect with a supportive circle of people who have shared experiences—an option that may have particular relevance given feelings of isolation and fear that may accompany a mental health crisis. Adequate Time is Spent with the Individual in Crisis: In settings such as hospital emergency departments, there may be intense pressure to move patients through quickly. People who provide assistance must have an adequate understanding of the crisis situation, not only objectively, but also as it is being experienced by the individual who is in crisis. Settings that cannot accommodate the individual in this way may not be appropriate venues for psychiatric crisis intervention. Plans are Strengths-Based. A strengths-based plan helps to affirm the individual’s role as an active partner in the resolution of the crisis by marshalling his or her capabilities. A strengths-based approach also furthers the goals of building resilience and a capability for self-managing future crises. Emergency Interventions Consider the Context of the Individual’s Overall Plan of Services: Appropriate crisis services consider whether the crisis is, wholly or partly attributable to gaps or other problems in the individual’s current plan of care and provide crisis measures in ways that are consistent with services the individual receives (or should receive) in the community. In addition, appropriate crisis services place value on earlier efforts by the individual and his or her service providers to be prepared for emergencies. Appropriate crisis interventions also include post-event reviews that may produce information that is helpful to the individual and his or her customary service providers in refining ongoing services and crisis plans. Crisis Services are Provided by Individuals with Appropriate Training and Demonstrable Competence to Evaluate and Effectively Intervene with the Problems Being Presented: Crisis intervention may be considered a high-end service, that is high-risk and demanding a high level of skill. Within the course of a psychiatric emergency, various types of crisis interventions may occur—some by healthcare professionals, some by peers and some by personnel (such as police) who are outside of healthcare. Throughout, the individual experiencing a mental health crisis should be assured that all interveners have an appropriate level of training and competence. Individuals in a Self-Defined Crisis are not Turned Away. People who seek crisis services but do not meet the service criteria of an organization should receive meaningful guidance and assistance in September 2015 8 | P age IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH accessing alternative resources. This is particularly applicable in organizations or programs that carry out a screening or gatekeeping function. Interveners have a Comprehensive Understanding of the Crisis: Meaningful crisis response requires a thorough understanding of the issues at play. Yet, for people with serious mental illnesses, interventions are commonly based on a superficial set of facts: behaviors are seen to present a safety issue, the individual has reportedly failed to take medications as prescribed, or an encounter with the police has occurred. An appropriate understanding of the emergency situation not only includes an appreciation for what is happening at the moment, but also why it is happening and how an individual fares when he or she is not in crisis. Mobile outreach services, which have the capacity to evaluate and intervene within the individual’s natural environment, have inherent advantages over facility-based crisis intervention, especially when an individual who has personal experience with mental illness and mental health crises is a part of the intervention team. Such mobile outreach capacity is even more meaningful when it is not restricted to a special crisis team, but rather when staff and peers familiar with the individual have the ability to literally meet the individual where he or she is. Helping the Individual to Regain a Sense of Control is a Priority. Regaining a sense of control over thoughts, feelings and events that seem to be spinning out of control may be paramount for an individual in mental health crisis. Staff interventions that occur without opportunities for the individual to understand what is happening and to make choices among options (including the choice to defer to staff) may reinforce feelings that control is being further wrested away. Incorporating personal choice in a crisis response requires not only appropriate training, but also a setting with the flexibility to allow the exercise of options. Services are Congruent with the Culture, Gender, Race, Age, Sexual Orientation, Health Literacy and Communication Needs of the Individual Being Served. Given the importance of understanding how an individual is experiencing a crisis and engaging that individual in the resolution process, being able to effectively connect with the individual is crucial. A host of variables reflecting the person’s identity and means of communicating can impede meaningful engagement at a time when there may be some urgency. Establishing congruence requires more than linguistic proficiency or staff training in cultural sensitivity; it may require that to the extent feasible, an individual be afforded a choice among staff providing crisis services. Rights are Respected: An individual who is in crisis is also in a state of heightened vulnerability. It is imperative that those responding to the crisis be versed in the individual’s rights, among them: the right to confidentiality, the right to legal counsel, the right to be free from unwarranted seclusion or restraint, the right to leave, the right for a minor to receive services without parental notification, the right to have one’s advance directive considered, the right to speak with an ombudsman and the right to make informed decisions about medication. It is critical that appropriately trained advocates be available to provide needed assistance. Services are Trauma-Informed: Children and youth with serious mental or emotional problems often have histories of victimization, abuse and neglect, or significant traumatic experiences. It is essential that crisis responses evaluate an individual’s trauma history and the person’s status with respect to recovery from those experiences. Similarly, it is critical to understand how the individual’s response within the current crisis may reflect past traumatic reactions and what interventions may pose particular risks to that individual based on that history. It also requires establishing a safe atmosphere for the individual to discuss potential traumatic events and to explore their possible relationship to the current crisis. September 2015 9 | P age IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH Recurring Crises Signal Problems in Assessment or Care: Many organizations providing crisis services—including emergency departments, psychiatric hospitals and police—are familiar with certain individuals who experience recurrent crises. While staff sometimes assume that these scenarios reflect a patient’s lack of understanding or willful failure to comply with treatment, recurrent crises are more appropriately regarded as a failure in the partnership to achieve the desired outcomes of care. And rather than reverting to expedient clinical evaluations and treatment planning that will likely repeat the failed outcomes of the past, recurrent crises should signal a need for a fresh and careful reappraisal of approaches, including engagement with the individual and his or her support network. Meaningful Measures are Taken to Reduce the Likelihood of Future Emergencies: Considering the deleterious impact of recurrent crises on the individual, interventions must focus on lowering the risk of future episodes. Crisis intervention must be more than another installment in an ongoing traumatic cycle. Performance-improvement activities that are confined to activities within the walls of a single facility or a specific program are sharply limited if they do not also identify external gaps in services and supports that caused an individual to come into crisis. Although addressing certain unmet needs may be beyond the purview of one facility or program, capturing and transmitting information about unmet needs to entities that have responsibility and authority (e.g., state mental health programs, housing authorities, foster care and school systems) is an essential component of crisis services. September 2015 10 | P age IMPROVING CRISIS SERVICES FOR CALIFORNIA’S CHILDREN AND YOUTH Notes and References i James, K.J. & Gilliland B. E., Crisis Intervention Strategies. (Pacific Grove, PA: Brook/Cole, 2001) ii Collaborative Antwerp Psychiatric Research Institute, Emergency psychiatric care for children and adolescents: a literature review, Pediatric Emergency Care (2013) iii Hodge, M. & Curtis, L. (2000). Best practices crisis and emergency services – a synopsis, in Hodge & Curtis, Psychiatric Crisis Services and Early Intervention: A critical Analysis of system performance in the State of Kansas, monograph (Topeka, KS: Kansas State Department of Social and rehabilitation Services, Health Care Policy, Mental Health/Substance Abuse Treatment and Recovery, 2000) pp. 88-96. iv “Crisis Intervention” http://www.minddisorders.com/Br-Del/Crisis-intervention.html#ixzz3kh7y10DD, accessed September 2, 2015 v Thesaurus of Psychological Index Terms, 7th ed. (APA, 2007) vi Mark Ragins, MD, Recovery Based Crisis Services, (Training, July 29, 2015) vii Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies, (SAMHSA, 2014) viii Values and guiding principles of crisis services contained in this document were adapted from “Practice Guidelines: Core Elements for Responding to Mental Health Crisis.” HHS Pub. No. SMA-09-4427. (Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2009) September 2015 11 | P age