Briefing and Frequently Asked Questions about Admissions to Regional Mental Health Institutes with Available Suitable Accommodations
A change in state law (Public Chapter 531) effective July 1, 2009 allows the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) to delay admissions at state owned and operated regional mental health institutes (RMHIs) until the facility “has the medical capability, equipment and staffing to provide an appropriate level of care, treatment and physical security to a service recipient in an unoccupied and unassigned bed.” This law removes the requirement that RMHIs admit and treat service recipients without regard to whether the RMHI has sufficient resources to do so.
The change in law enabled TDMHSAS to reduce expenditures by decreasing the number of staffed (operating) beds at RMHIs from 832 to 686 by June 30, 2010 and admit only the number of service recipients who can be safely and effectively treated. Under the new law, RMHIs have the same admission standards as private hospitals and are able to maintain good standing with accrediting and regulatory entities such as the Joint Commission and the Centers for Medicare and Medicaid Services (CMS).
TDMHSAS invests in important community services to divert service recipients from inpatient hospitalization. The Behavioral Health Safety Net of Tennessee provides service recipients with serious and persistent mental illness who are poor and uninsured with key mental health services through community mental health agencies. Our current crisis system has 24/7 accessibility by telephone and/or walk in services, face-to-face crisis service capabilities including triage, intervention, evaluation/referral for additional services/treatment and follow-up services. Services are provided to anyone in Tennessee regardless of insurance coverage.
Service recipients also have access to voluntary crisis stabilization services and medically monitored detoxification crisis services. Crisis stabilization units (CSUs) are currently operated by six (6) agencies: Southeast Mental Health Center in Memphis; Pathways in Jackson; Mental Health Cooperative in Nashville; Volunteer Behavioral Health System in Cookeville and Chattanooga; Helen Ross McNabb in Knoxville; and Frontier Health in Johnson City. Five (5) agencies currently provide medically monitored detoxification crisis services: Helen Ross McNabb in Knoxville; Council for Alcohol & Drug Abuse Services (CADAS) in Chattanooga; Buffalo Valley/Meharry in Nashville, Hohenwald and Lewisburg; Pathways in Jackson; and Cocaine and Alcohol Awareness Program (CAAP) in Memphis.
Professionals should refer a service recipient needing inpatient treatment to a hospital providing psychiatric treatment in the local area before making a referral to an RMHI. Currently there are more than 2,000 inpatient psychiatric beds in hospitals other than RMHIs in Tennessee. TDMHSAS encourages referring professionals to work with local agencies, hospitals, and law enforcement to develop strategies to protect both service recipients and the community if admission to an RMHI is delayed.
Frequently Asked Questions
Answer: The determination of available suitable beds at each RMHI is based on the number of staffed (operating not licensed) beds. Beds for children are calculated separately from beds for adults. Secure forensic beds at the Forensic Services Program at Middle Tennessee Mental Health Institute are calculated separately from other beds. Beds for forensic service recipients are calculated separately from other adult beds at the facility. RMHI administrators are expected to manage the service recipient population within a hospital to accommodate new admissions regardless of acuity or gender.
Answer: Non-secure forensic beds are beds for service recipients admitted to RMHIs as the result of a court order for admission under T.C.A. Title 33, Chapter 7, Part 3 who do not require maximum security. Service recipients needing maximum security are located in the Forensic Services Program at Middle Tennessee Mental Health Institute (MTMHI), while other forensic service recipients are distributed throughout the RMHIs.
Answer: A state-owned or operated hospital is a regional mental health institute (RMHI). TDMHSAS does not currently own or operate other treatment resources.
GENERAL ADMISSION ISSUES
Answer: If the local RMHI has no available suitable accommodations, the local RMHI offers to contact an alternate RMHI and to provide contact information for an RMHI with available suitable accommodations. The referral source decides whether to accept a referral to an available bed at an alternate RMHI or place the service recipient on a waiting list at the local RMHI. If the referral source decides to place the service recipient on the waiting list, the local RMHI checks at least daily for available suitable accommodations at the local or alternate RMHIs. The local RMHI only stops checking when available suitable accommodations are identified or the service recipient is removed from the waiting list by the referral source.
Answer: When the service recipient is referred to an alternate RMHI for an involuntary commitment, the referring professional makes the decision about whether to accept the offer to place the service recipient at the alternate RMHI or to place the service recipient on a waiting list at the local RMHI. Referring professionals should take into consideration service recipients’ preferences in making this decision.
Answer: RMHIs do not admit a service recipient if, during the evaluation for admission, it is determined that the service recipient has a physical disorder or medical condition that requires immediate medical care that the RMHI cannot appropriately provide. Service recipients are sent for treatment of the medical condition prior to being evaluated for admission to the RMHI. Any service recipient with a valid confirmation number may be transported back to the RMHI for an evaluation for admission.
Answer: Confirmation numbers may only be canceled in response to circumstances such as the service recipient is admitted to another facility or no longer needs inpatient hospitalization. The reason for canceling a confirmation number is to free reserved beds for other admissions. The RMHI notifies the referral source or designee if a confirmation number is going to be canceled. Confirmation numbers are not canceled when the facility is notified that a person is in route to an RMHI.
Answer: The Department does not currently contract for overflow beds and has no plans to do so. At the direction of the Tennessee General Assembly, the Department did contract with specific private psychiatric hospitals in Upper East Tennessee for the purpose of providing inpatient care to uninsured service recipients for the period June 30, 2009 to July 1, 2010.
Answer: Voluntary admissions have been and continue to be an option dependent on bed availability. Practically, voluntary admissions to RMHIs are rare.
Answer: The number of acute care private psychiatric hospitals and the number of beds for service recipients needing involuntary admission is subject to change. Service providers should contact local hospitals to determine this information.
Answer: Service providers should contact local hospitals to determine whether they have the capacity to provide medical detoxification services. To address the need for this service, TDMHSAS recently contracted with five (5) agencies to provide medically monitored crisis detoxification services: Helen Ross McNabb in Knoxville; Council for Alcohol & Drug Abuse Services (CADAS) in Chattanooga; Buffalo Valley in Nashville, Howenwald, and Lewisburg; Pathways in Jackson; and Cocaine and Alcohol Awareness Program (CAAP) in Memphis. These agencies provide twenty-four (24) hour per day services for three (3) days with transition to other treatment services.
RESPONSIBILITY OF SERVICE PROVIDERS
Answer: The Department encourages referring professionals, local agencies, hospitals, law enforcement, and treatment resources to develop community strategies to protect service recipients and the community. Referring professionals should make a decision about the best way to keep a service recipient and the community safe when there is a delay in admission to an RMHI.
Answer: When there is a delay in admission and the service recipient cannot be immediately transported to an RMHI, the Department encourages CMHA’s to handle the clinical situation just as they do currently when there is a lag-time (i.e., between signing the certificate of need (CON) and waiting for the sheriff or transportation agent to transport the service recipient). The Department encourages CMHAs to work with referring professionals, local agencies, hospitals, law enforcement and treatment resources to develop community strategies to protect service recipients and the community.
Answer: The Department will consider mandatory prescreening issues as they arise. The Department invites stakeholders to make recommendations about any issues related to available suitable accommodations and mandatory prescreening.
15) What if an emergency room physician refuses to perform any service other than medical diagnosis and treatment and does not address psychiatric issues due to liability for failure to secure needed hospitalization?
Answer: The Department cannot respond on behalf of general hospitals.
16) What is the managed care organization’s (MCO) responsibility when the service recipient is on a waiting list for the RMHI but a private hospital bed is available for that member? What is the MCO responsibility when there is no bed available at either an RMHI or a private hospital?
Answer: The Department encourages the use of private hospitals when a service recipient is on a waiting list for an RMHI. When no bed is available at an RMHI or a private hospital, then the Department encourages the referral source to contact the MCO for resources to meet the inpatient needs of the member. The MCO is responsible for access to inpatient beds within their provider network.
17) There is no authority for law enforcement to detain a service recipient after completion of a psychiatric evaluation/prescreening assessment unless legal charges permit incarceration. As a result, will a service recipient be released with documented evidence that he or she is capable of being harmful to themselves or others?
Answer: The Department encourages referring professionals, local agencies, hospitals, law enforcement and treatment resources to develop community strategies to protect service recipients and the community. Referring professionals must make decisions about the best way to keep the community and a service recipient safe if there is a delay in admission to an RMHI.
Answer: In the case of a delayed admission to an RMHI, referring professionals should continue to comply with their responsibilities under T.C.A. § 33-3-206. If referring professionals have questions about their responsibility under the law, they should discuss their questions with their attorney.
Answer: Each RMHI follows a protocol to identify an available bed in those RMHIs closest to the local RMHI.
Answer: RMHIs use a specific form to confirm bed availability. In most cases, the RMHI faxes this written statement with a confirmation number to the certifying professional. We understand that mobile crisis teams do not always have fax machines or other means of printing the RMHI form readily available in the community. In such circumstances, the RMHI with bed availability may provide the confirmation number verbally and the referral source or designee may generate the written statement. The referral source or designee is responsible for providing a written statement with a confirmation number to the transportation agent.
Answer: The responsibility for transporting a service recipient to an RMHI for involuntary emergency mental health inpatient treatment has not changed. The sheriff or designated transportation agent is responsible for transporting service recipients referred for involuntary admission to an RMHI regardless of the location of the RMHI with an available bed. The sheriff or transportation agent will not transport a service recipient without being provided a written statement with a confirmation number.
Answer: We recognize that friends, family or neighbors may transport service recipients needing involuntary inpatient treatment if the referral source determines the service recipient does not require physical restraint or vehicle security.
Answer: If a decision to “not admit” the service recipient is made within the timeframe (defined by statute) the sheriff or designated transportation agent is required to wait, the sheriff or designated transportation agent is responsible for returning the service recipient to the county from which the service recipient was transported. If a decision to “not admit” the service recipient is made after the timeframe (defined by statute) during which the sheriff or designated transportation is required to wait and they have left, the RMHI is responsible for returning the service recipient.
Answer: When a service recipient is discharged after having been admitted to an RMHI, the RMHI is responsible for arranging or providing transportation.
Answer: The law requires sheriffs to transport the service recipient to an RMHI if a service recipient is properly referred for admission and the referral source provides the sheriff with a written statement with a confirmation number verifying that suitable accommodations are available at an RMHI.
Answer: There is no statutory expiration of a CON.
Answer: When there is a delay in admission and the service recipient cannot be immediately transported to an RMHI, we encourage certifying professionals and agencies to handle the clinical situation just as they do currently when there is a lag-time (i.e., between signing the certificate of need (CON) and waiting for the sheriff or transportation agent to transport the service recipient).
28) Individuals placed on an RMHI waiting list will frequently be difficult or impossible for crisis workers or other CMHA staff to locate when their confirmation number is available if any significant time has elapsed since the certificate of need (CON) was signed.
Answer: If the CON has been completed but admission is delayed, referring professionals, local agencies, hospitals, law enforcement and/or treatment resources should identify the location where the service recipient will be waiting for admission.
Answer: If RMHIs do not have available suitable accommodations, service recipients referred for re-commitment due to non-compliance with mandatory outpatient treatment are admitted and placed on a waiting list until a suitable bed becomes available.
Answer: The Department collects and maintains data required for making quarterly reports to the Legislature and to facilitate future management decisions. The information includes at least the number of delayed admissions and the length of any delayed admissions.
31) Based on the most recent admission and discharge data and average length of stay for each RMHI, what is the projected maximum number of individuals and approximate length of time on waiting lists following bed reductions?
Answer: The Department posts the most recent quarterly report on its website.