The Living Room Model Psychiatric Emergency Screening Services

Allison MacFadyen, MS, NCC, LPC, CPRP Bridgeway PESS Director

Rajinda Fenn, MSW, LSW Bridgeway Clinical Supervisor

Sally Andrews, MA, LCADC Bridgeway Clinical Supervisor The Living Room Model The History of De-Institutionalization

In the 1400s-1600s Individuals with mental illness were viewed as witches or of demonic possession, and most were killed or imprisoned. In the 1700s Individuals with mental illness resided in asylums, not for treatment, but for separating them from society. In the 1840s Lobbying by Dorothea Dix for better living conditions for individuals with mental illness created funding for 32 state psychiatric hospitals. Although this increased access to mental health care, eventually the hospitals were underfunded, and understaffed and poor living conditions and human rights violations were reported. In 1955 The advent of antipsychotic medications results in Phase I of Deinstitutionalization of Individuals with Mental Illness Thus began reform on “asylum-based” mental health care system and moved toward community-oriented care. In 1963 The Community Mental Health Centers Act led to state hospital closures. Strict standards were passed so only individuals who “pose and imminent danger to themselves or others” could be committed to state hospitals. (Adapted from PBS Online’s “Timeline: Treatments for Mental Illness”) The Living Room Model

Barriers Still Exist – The Impact of Psychiatric Emergency Screening Services

On May 7th, 1987 Governor Thomas H. Kean signed into a law a major revision of the statutes concerning involuntary commitment to psychiatric facilities. N.J.S.A 30:4-27.1- et seq. This “Mental Health Screening Commitment” Legislation became effective on June 7, 1989.

This legislation brought forward important change:  It required the development of mental health screening services and short-term care facilities

 It provides for the entry into the public mental health system so individuals can receive appropriate services  It offers individuals with mental illness clinically appropriate alternatives to inpatient care  When necessary, the law provides a means for involuntary commitment The Living Room Model

The 1987 Screening Law Created Psychiatric Emergency Screening Services

The Impact of the Screening Law:

 Defined Mental Illness and Dangerousness

 Created screening and short-term care to cover the whole state

 Adopted former emergency process as regular process for commitment

 Defined patient rights and gave state authority to regulate community programs

 Emphasized Diversion and sought to minimize arrests The Living Room Model

PESS – Process and Functions

A screening service is defined as the public or private ambulatory services, which provides mental health services including assessment, emergency and referral services to mentally ill persons in specified geographic area. The Goal of the screening process is to provide clinical assessment and crisis stabilization in the least restrictive clinically appropriate setting as close to the patient’s home as possible in a manner that is culturally competent and recovery oriented and assists the consumer in achieving a self-directed transition to wellness. PESS Provides:  24-hour operation of crisis phone line by a certified screener  24-hour availability for mobile outreach for clinical assessment  Assessment of the crisis and identification of stabilization, diversion and support services needed and/ or screening for involuntary commitment & crisis intervention counseling. The Living Room Model What is an involuntary level of care?

 When an adult is assessed by a Mental Health Screener at PESS, the least restrictive environment or setting is always the goal.  There are times when hospitalization is needed and that is when a person served is a danger to self, others, or property.

 A person served can be hospitalized on a voluntary, involuntary, or voluntary consensual status.

 Voluntary status-meaning the person served with a mental illness, whose mental illness causes the person served to be a danger to self, others or property, understands that hospitalization is needed, and would like to sign themselves into a psychiatric facility for inpatient treatment. Most voluntary hospitalizations can last from 2-5 days.  Voluntary Consensual means the type of admission applicable to a person who understands and agrees to be admitted to a short-term care facility (STCF)for stabilization and treatment (see N.J.A.C. 1O:37G-1 et seq) but otherwise meets the standards for commitment in that she/he is dangerous to self, others or property by reason of mental illness. The Living Room Model What is an involuntary level of care?

 A person served can be hospitalized on an involuntary status-meaning the person served is an adult with mental illness, whose mental illness causes the person to be dangerous to self, or dangerous to others or property and the person served is unwilling to accept appropriate treatment voluntarily after it has been offered. The Screener who evaluated the person served completes a Screening Document, which is a legally binding document that describes the person served current presenting presentation, mental health history, and dangerousness to self, others or property.  After the Screening Document is completed a psychiatrist has to evaluate the person served independently and, and make a disposition as to the level of care.  There are 2 ways an adult can be committed, and that’s by a Certified Mental Health Screener who completes a Screening Document and a Psychiatrist who completes a Physicians Certificate. The other way an adult can be involuntarily committed is when 2 psychiatrists (which cannot be the treating psychiatrist) completes 2 Physician Certificates.  Children cannot not be involuntarily committed by a Screener and psychiatrist. There are times when individuals under 18 can be committed, but it has to be 2 psychiatrist completing the Physicians Certificate in order to validate the commitment of a minor. The Living Room Model What is an involuntary level of care?

On August 11, 2009, Governor Corzine signed P.L. 2009, ch. 112, commonly known as the Involuntary Outpatient Commitment to Treatment Law. The Law reiterates the State’s obligation to provide treatment in the least restrictive appropriate setting, even if the consumer will not consent to treatment. The intent of the Law is to provide a new option: supervision in the community for a class of consumers that the legislature agreed was not well-served without this law. This law intended to assist those who are not willing to receive treatment voluntarily and will become, in the foreseeable future, dangerous enough because of a mental illness to require supervision, but who are not so imminently dangerous that they need to be physically confined in an inpatient program. The Living Room Model

Designated Psychiatric Emergency Screening Services in New Jersey Today

Every county in the state of New Jersey has at least one Designated Screening Center funded by the Division of Mental Health and Addiction Services. The Majority of these Screening Centers are located in the Emergency Departments of Hospitals. Hospital Environments can be traumatizing, overstimulating, dehumanizing and expensive. (Clarke, D.E., Dusome, D., & Hughes, L. (2007) Mobile Outreach and Emergency Department Diversion Rates can be low in Hospital Based Screening Centers. Specifically, Somerset County Screening had an Emergency Room Diversion Rate of 3.5% for and a mobile outreach rate of 10.4% adults in 2016, which is close to the lowest in the state. In March 2017 Bridgeway Rehabilitation Services took over as the Designated Psychiatric Emergency Screening Service for Somerset County, operating outside of the hospital. By October 2017, Bridgeway opened the first walk in Living Room Model Screening Center In the state of New Jersey. The Living Room Model

Autonomy * Respect * Empowerment * Social Inclusion * Hope

One of the earlier Living Room Models (Heyland, M., Emery, C., & Shattell, M. (2013) was developed in Illinois as a community crisis respite program to provide care to people in crisis as an Emergency Room Deterrent. It was developed after the first model in Arizona in 1997. The Living Room provided services to individuals 18 or older who were experiencing a mental health crisis severe enough that they are at risk for Emergency Department visits. The setting of the Living Room is warm and inviting, with paintings on the walls, comfortable furniture and soft lighting. Staffing includes Counselors, Peer Support Counselors and a Psychiatric nurse.

The Living Room reflects many of the Recovery Model’s concepts, including autonomy, respect, empowerment, and social inclusion, and hope.

Impressive Early Outcomes in Illinois: In first year of operation the Living Room hosted 87 individuals for over 228 visits. 213 of these guests were not in need of an emergency room visit post Living Room visit giving this program an Emergency Department Diversion rate of 93% saving the state of Illinois $550,000 as high utilizers of the Living Room were uninsured or Medicaid recipients. The Living Room Model Bridgeway PESS in Somerset County, New Jersey

On October 9th, 2017, Bridgeway opened the first walk-in Living Room Model Psychiatric Emergency Screening Services Center In the state of New Jersey. Bridgeway’s PESS Living Room is in an outpatient community setting, as opposed to the hospital ER. The Living Room Model

Individuals can be assisted at all stages of Crisis, not just the acute stages of crisis The Living Room Model

 Bridgeway PESS serves adults and children  24-hour crisis line is answered by a certified psychiatric screener  24-hour availability for mobile outreach by appointment or on-demand crisis calls

 Bridgeway PESS uses security features not uniformed security personnel Features include call buttons, security cameras, alert buttons screeners wear in assessment rooms, locked exterior and waiting room doors with buzz-in entry. The Living Room Model

Walk-ins or scheduled appointments in Bridgeway’s PESS Living Room are available 7 days a week, 9:30am- 8:00pm.

In the waiting room, individuals are asked to fill out demographic information and then escorted to one of two Living Rooms. The Living Room Model Bridgeway PESS Adult Living Room

In the Living Room, individuals are offered hot and cold beverages, a basket full of snacks, and magazines, in a calm atmosphere of soft lighting, comfortable seating, a faux fireplace, and a television equipped for Netflix. The Living Room Model Bridgeway PESS Children’s Living Room

In the Children’s Living Room, individuals are offered hot and cold beverages, a basket full of snacks, and children’s books, in a calm atmosphere of soft lighting, comfortable seating, a television equipped for Netflix, along with toys, games, and a chalkboard paint area. The Living Room Model Time To Decompress

Within 5-10 minutes after entering the PESS Living Room, a screener will bring the individual, and perhaps accompanying family members, into a private neutral space to begin an evaluation. If the individual is a child, the legal guardian is escorted to a private neutral space and the child will be evaluated after the screener meets with the legal guardian. During the evaluation, the Certified Screener gathers information from the individual and family members to link to the least restrictive treatment option. Linkage can include linkage to community services, voluntary inpatient hospitalization, or involuntary hospitalization As a result of Bridgeway PESS being in the community, Direct Inpatient Admissions are available for children and voluntary adults allowing rapid access to inpatient care without emergency room visit. When individuals are linked to community resources, a follow up face to face visit or phone call is scheduled to ensure successful linkage and satisfaction. If linkage is not available immediately, PESS can provide up to 4 sessions of brief therapy from our fully licensed staff and medication evaluations from our on-site psychiatrists. The Living Room Model

Who is being referred to the living room?

 Children or Adults experiencing suicidal or homicidal thoughts, with or without plan

 Children who have been expressing suicidal/ homicidal thoughts or plan via social media

 Children or adults engaging in self-harm behavior

 Children or adults experiencing an increase in mental health symptoms in need of immediate intervention or linkage to a higher level of care  Children or Adults running out of medication with a long wait or no linkage to psychiatric provider The Living Room Model

Who is referring to the living room?

EMS Squad Police Sheriff’s Department/ Jails Local Emergency Departments Family Members Primary Care Physicians Schools Outpatient Providers Board of Social Services Community Mental Health Clinic Local professionals Spiritual Leaders The Living Room Model Mobile Outreach or the Living Room

Despite having the on-site PESS Living Room, Bridgeway remains dedicated to providing Mobile Outreach.

Mobile outreach or the living room, it is up to the person receiving PESS service where evaluation takes place. The Living Room Model Who is not coming to the Living Room?

 Individuals who prefer to be seen in their homes or do not have transportation to PESS

 Individuals who are actively assaultive

 Individuals who are under arrest or in custody

 Individuals who are already in the local hospital Emergency Department or who are admitted to a medical or voluntary unit

 Individuals who need immediate evaluations and are not safe to leave their current location

Individuals transported to Emergency Department by EMS or Police:

 Individuals who are intoxicated

 Individuals who need medical attention prior to Evaluation FY 2019 Data July 1, 2018-February 28, 2019

 158-266 Individuals are seen per month by PESS

 21-95 Children are seen per month

 95-183 Adults seen per month

 67%-83% are served by mobile outreach

 51%- 69% of individuals were diverted from Emergency Department

 On average 55% of children hospitalized are a direct admission The Living Room Model

Hospital Based Somerset County 2016 data vs Bridgeway PESS 2018 data Division of Mental Health and Addiction’s Service System Review Committee Data for Fiscal Year 2018 Showed that Bridgeway’s Living Room Model had the highest Adult Emergency Room Diversion Rate in the State The Living Room Model Case #1

A Homicidal wife and mother was brought in by her husband. John Smith walked into Living Room with his wife Jane. Jane reported to him that she was depressed and was having thoughts of killing their children as well as herself. Jane and John met with screener. Jane was tearful and afraid but was not willing to sign herself into the hospital. After consulting with a supervisor, the screener determined the most appropriate recommended disposition would be involuntary commitment. The screener sat down with Jane and John and explained the clinical rationale behind the disposition and the next steps in the process. The screener explained that the police have to transport her to the emergency room, so she can be medically cleared and then a psychiatrist will evaluate her. The screener explained that typically the police will ask her to empty her pockets or check her pocket book. The screener asked if she wanted to have the police hold her possessions or if she wanted to give them to her husband. Jane expressed that she wanted her husband to follow her to the Emergency Department behind the police car and wanted him to hold onto her possessions. It was explained that once at the Emergency Room our psychiatrist will evaluate her and he or she will tell her if she is involuntarily committed. PESS will locate a bed if involuntary commitment is recommended and then she will be transported to receiving facility by ambulance. The police arrived, and Jane calmly stood up and went with the police officer. The Living Room Model Case #2

Hillsborough Police dropped off Frank who was engaging in self-harm behavior (hitting himself) and was making suicidal statements. Frank resides in a group home and has been involuntarily committed in the past due to self- harm and suicidal ideation. Frank has a diagnosis of Bipolar as well as Autism Spectrum Disorder but has effective communication skills. Frank was escorted into the living room and offered a beverage. He requested a “decaf iced coffee with milk and two sugars”. When asked if he wanted to watch anything on TV, he responded “Family Guy Season 3 episode 6”. Frank ceased hitting himself once sitting on the couch and engaged in a self-soothing rocking motion. Due to his comfort level in the Living Room and no other individuals present, the screener met with him in the Living Room. After completing assessment and consulting with supervisor the recommendation for disposition was voluntary admission. Unfortunately, due to some complex medical issues, a direct admission could not be arranged. The screener met with Frank and explained the process of voluntary admission and the need to go through the emergency room first. He requested to finish his coffee before going. Bridgeway PESS staff gave him the option of ambulance transport or PESS staff transporting him. He chose to be transported by Bridgeway staff. Frank was hospitalized voluntarily. The Living Room Model Case #3

Barbara called PESS worried about her adult daughter Ashley, who has a diagnosis of PTSD and Agoraphobia. She was discharged from an inpatient hospital stay with 30 days of medication 24 days ago. Today was her scheduled intake for her psychiatric prescriber and she had a panic attack when trying to get into the car. PESS scheduled an outreach with Barbara and Ashley in their home with a screener and PESS psychiatrist. PESS psychiatrist refilled her medication for 4 weeks and adjusted her anxiety medication in hopes that this would help her manage leaving her home. PESS referred Ashley to outpatient services and scheduled 2 follow-up visits to ensure medication was effective and no side effects were seen. The day of intake for outpatient services Ashley had another panic attack when trying to leave her home. Barbara called PESS and a mobile outreach in the home was provided by both the screener and the Psychiatrist. Recommended disposition for linkage to outpatient services changed to in home services with a Psychiatric provider. A doctor to doctor communication occurred, with the assistance of the (county mental health administrator) with a local non-profit mental health clinic who agreed to work with Ashley in home with intensive CBT and Medication Management to work up to outpatient services. Another two weeks of medication was prescribed by PESS psychiatrist and follow up phone call confirmed successful linkage. The Living Room Model Case #4

Ken brought his 15-year-old son James to the Living Room with his younger sister Kelly, age 10. James reported to his school counselor that he was depressed and experiencing suicidal ideation, and the school counselor referred the family to PESS. The screener met with Dad first and then with James. James was open and honest with the screener expressing feeling overwhelmed at school, depressed at home, and experiencing consistent thoughts of suicide with momentary thoughts of different plans. He had one inpatient hospitalization 1 year ago for same symptoms. After consulting with the supervisor, the screener came to the disposition that James needed inpatient hospitalization. James and Dad agreed with the screener’s recommendation. A direct admission was arranged with a adolescent psychiatric unit and Dad expressed feeling comfortable driving James to the hospital. PESS called to confirm arrival at receiving hospital and faxed over clinical assessment. The following day Ken came back to Living Room with his daughter who had been crying on and off since her brother was hospitalized. A screener met with Kelly and linked her with outpatient services, and a follow up phone call was completed to ensure linkage and satisfaction with services.

A week later Ken came back to Living Room by himself to ask for linkage to services. He was given resources for support groups and linked to an outpatient provider. The Living Room Model Psychiatric Emergency Screening Services

Questions? References

Bryson, S., Gauvin, E., Jamieson, A., Rathgeber, M., Faulkner-Gibson, L., Bell, S., Davidson, J., Russel, J., Burker, S., (2017). What are effective strategies for implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings? A realistic systematic review. International Journal of Mental Healht Systems, 11 (36). 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 20 January 2019, from (http://www.gjcpp.org/). Adapted from PBS Online’s “Timeline: Treatments for Mental Illness”. Retrieved 19 March 2019. Raja, Sheela; Hasnain, Memoona; Hoersch, Michelle; Gove-Yin, Stephanie; Rajagopalan, Chelsea. (2015). Trauma Informed Care in Medicine. Family & Community Health, 38 (3), 216-226 Shattell, M., & Andes, M. (2011). Treatment of persons with mental illness and substance use disorders in medical emergency departments in the United States. Issues in Mental Health Nursing, 32(2), 140-141.

N.J.S.A 30:4-27.1- et seq. “Mental Health Screening Commitment” (1989).

N.J.S.A. Involuntary Outpatient Commitment to Treatment Law (2009).