Le Lets t talk a abou out ho how w we e talk abo bout ut - - PowerPoint PPT Presentation

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ROADMAP FOR TODAY

• How Illinois Outpatient Laws Can (and Should) Break

Our Inpatient Cycles

• Incorporating

Advance Directives Into Everyday Practice

• Decriminalizing Mental Illness

WHAT’S SO IMPORTANT ABOUT COMPREHENSIVE AND COLLABORATIVE CARE?

CRISIS INPATIENT ADMISSION POOR DISCHARGE PLANNING & INCONSISTENT COMMUNITY CARE

DISCHARGE PLANNING

• When do we “start” discharge planning?
• Successful outpatient matters are not
• rchestrated the day before discharge.

What are some current “gaps” in discharge planning?

Inpatientà Outpatient: Current Gaps in IL Community Treatment

Immediate Problems & Issues:

• Housing, Housing, Housing
• Engagement by Client (With or Without Family)
• Involvement and Clear Communication With Family

By Treatment Team and Consenting Individual

• Was there a prior admission? If so, what did the

discharge plan do right and what did it get wrong?

• Medications provided at discharge? For how long?

Where is prescription being sent?

Gaps Continued: Back in the Community

• Insurance, Benefits, Affordable Medications
• Appointments and the Space Between

Appointments

• Ongoing Assessment of Level of Care

Administered

• ERs, CSUs, CIT Officers, and Living Rooms
• Community Residential Placements

OK…But How Are Our Laws Implicated/Involved? Outpatient!

• “At any time before the conclusion of the hearing and

the entry of the court's findings, a respondent may enter into an agreement to be subject to an order for admission on an outpatient basis.”405 ILCS 5/3-801.5

• The court advises the respondent of the conditions of

the proposed order in open court and is satisfied that the respondent understands and agrees to the conditions of the proposed order for admission on an

• utpatient basis. 405 ILCS 5/3-801.5(a)(2)

Ou Outpatient B By A Agreement v. v. In Involuntary y Outpatien ent

There are differences…

• What does Illinois “AOT” currently look like?
• What are the benefits of “agreed” outpatient?
• What is the “black robe effect”?
• What are some limitations (academic and practical) if outpatient is

sought involuntarily??

Ti Time out! Let’s review!

Now we’re cooki king! Let’s look k at the RE RECIPE IPE fo for a Successful Ou Outpatient Agr Agreem eemen ent:

Ingredients:

• Client
• Doctor (Provide Written Report, Certification, and about 5-10 minutes
• f testimony at any Agreed Hearing).
• Community Provider (Identify what agency or service can offer

medication refills, therapy, and the appropriate level of care: ACT, CST, etc.).

• Custodian
• Court

Pu Put it all to together:

• Involvement and “buy-in” by the: treatment team, respondent, family, and

court.

• Adequate infrastructure in the community to deliver services required

(ACT, CST, Peer Counseling, Crisis Lines, Warm Lines, etc.)

• Housing, Housing, Housing.
• Ongoing medication management between respondent and community

psychiatrist.

• An ongoing conversation with respondent about advance directives.
• Education of family/community re: services available in the area.
• By statute, renewals of AOT Orders are permitted. See 405 ILCS 5/3-

801.5(g)

No Noncomp mpliance ce W With Cou Court rt Ordered Outpatient

• Common issues post-discharge.
• An order entered under this Section shall not constitute a finding that the respondent is subject

to involuntary admission on an inpatient or outpatient basis. 405 ILCS 5/3-801.5

• An agreed order of care and custody entered may grant the custodian the authority to admit a

respondent to a hospital if the respondent fails to comply with the conditions of the agreed order. If necessary in order to obtain the hospitalization of the respondent, the custodian may apply to the court for an order authorizing an officer of the peace to take the respondent into custody and transport the respondent to the hospital specified in the agreed order. 405 ILCS 5/3-801.5 (b)

• A person admitted to a hospital pursuant to powers granted under an agreed order for care and

custody shall be treated as a voluntary recipient pursuant to Article IV of this Chapter and shall be advised immediately of his or her right to request a discharge pursuant to Section 3-403 of this Code.405 ILCS 5/3-801.5

• Notwithstanding any other provision of Illinois law, no respondent may be cited for contempt for

violating the terms and conditions of his or her agreed order of care and custody. 405 ILCS 5/3- 801.5(f)

A note about “Success”…

Advance Directives

COMPARING AND CONTRASTING: Power of Attorney for Health Care & Declaration for Mental Health Treatment But first…

Th The Purpose of Advance Directives

What are the benefits of an Advance Directive?

• YOUR voice, YOUR input, YOUR decisions.
• Expedite care with specificity.
• Preserve autonomy and decrease likelihood of

court involvement

PO POWE WER OF OF A ATTOR ORNE NEY Y FO FOR HE HEAL ALTH H CA CARE

• SCOPE AND LIMITATIONS
• HOW TO REVOKE
• DESIGNATE AN “AGENT”
• DURATION OF THIS DIRECTIVE?

Dec eclarati tion n for Men ental Hea Health th Trea eatm tmen ent

• SCOPE AND LIMITATIONS
• HOW TO REVOKE
• DESIGNATE AN “AGENT”
• DURATION OF THIS DIRECTIVE?

LET’S SAY THAT AGAIN:

DECLARATION FOR MENTAL HEALTH TREATMENT

• DURATION?
• SCOPE?
• REVOCATION?
• AGENT?

POWER OF ATTORNEY

• DURATION?
• SCOPE?
• REVOCATION?
• AGENT?

Le Let’s Sh Shift G Gears!

Incarceration Numbers (2016)

Local Jails: 740,700 Prisons: 1,505,400

“The United States locks up more of its citizens than any other country

• n earth. There are more people behind bars in the [U.S.] than the

incarcerated populations in India and China combined.” Greg Berman and Julian Adler, “Start Here: A road map to reducing mass incarceration”, pg. 21.

Substance Use Disorders and Incarceration

Substance Use Disorder Rate (2010):

• 65.2% in state prison.
• 65.8% in local jail.
• 54.8% in federal prison.

“Substance Abuse and America’s Prison Population 2010.” – Joseph A. Califano

Mental Health & Incarceration

INDIVIDUALS INCARCERATED WITH SYMPTOMS OF A MENTAL

ILLNESS OR RECENT HISTORY:

State Prisons: 56% Federal Prisons: 54% Local Jails: 64% Source: State and Federal prisoners in 2004 and local jail inmates in 2002, Bureau of Justice Statistics, Mental Health Problems of Prison and Jail Inmates, September, 2006, NJC 213600

90% of female inmates meet the criteria for a lifetime diagnose of serious mental illness, PTSD, or substance abuse disorder.

• Irina Alexandrovna Komarovskaya et al., “Exploring

Gender Differences in Trauma Exposure and the Emergence of Symptoms PTSD Among Incarcerated Men and Women,” Journal of Forensic Psychiatry & Psychology 22 (2011)

Pathways for Diversion

• What are some ways to mitigate against over-

incarceration of individuals with mental illness?

• Identifying points of contact w/ criminal justice

system.

• Current diversion projects.
• The “Miami Model”

The Story of George

• We’ve looked at:
• Outpatient
• Advance Directives
• Criminal Justice System

Now, let’s look at the overlap of all three categories and put it all together.

1

THE INTERSECTIONS OF LAW AND TREATMENT

Matthew R. Davison, J.D. Legal Advocacy Service Illinois Guardianship & Advocacy Commission Matthew.Davison@illinois.gov

• p. 312-520-7270

I. Introduction Mental illness does not “stay in one lane”. It affects everyone.1 Given this, it is a community problem and we need community solutions. For those in our community living with a serious mental illness, an encounter with our legal system can be life-changing (for better or for worse). Such legal entanglement is near-certain if an individual lacks reliable housing and/or has a co-occurring substance abuse affliction. What courts are the proper medium to address such issues: criminal or civil? And, what can be done to mitigate against negative legal encounters or to remedy existing gaps in community care? Shared problems call for shared answers. It is shortsighted to talk about “mental health treatment” in a vacuum – one must also consider homelessness, our criminal court system, as well as

• ther factors. What follows herein are some hypothetical scenarios and how existing laws can be

utilized to augment the community response to mental illness in a positive manner. For each fact pattern, note the various “Intersection Points” of how the law may fundamentally alter the course of an individual’s mental health treatment and wellness. II. The Story of “George” George is approached at a convenience store by local law enforcement due to erratic behavior and raising his voice at other customers and clerks. George appears unwilling to leave and one clerk indicates to the officers that George was making verbal threats and shaking his fist at pedestrians

• utside a few minutes prior. The officers are concerned about George’s health and safety (as well as

the safety of others) and they quickly approach him.

• Intersection Point 1 and Questions to Consider-
• Do the officers have Crisis Intervention Team (CIT) training? If so, is there a better way

to approach the situation and attempt to de-escalate?

• Where will George be taken? Consider each venue and how it will affect the outcome of

George’s treatment. For each venue, consider also the economic implications:

• Jail?

1 In 2014, one in five adults experienced a mental health issue. One in 10 young people experienced a period of

major depression. One in 25 Americans lived with a serious mental illness such as schizophrenia, bipolar disorder, or major depression. Source: https://www.mentalhealth.gov/basics/mental-health-myths-facts .

2

• An Emergency Room?
• A Crisis Stabilization Unit (“CSU”)?
• A mental health facility?

Ultimately, the officers arrest George for trespassing and he is transported to the local jail. George is now part of the criminal court system.

• Intersection Point 2 and Questions to Consider-
• George’s appointed attorney reviews the case file to quickly determine if George is eligible for

bond or even for a quick plea in exchange for his release back into the community, but what if George is presenting with significant symptoms due to not taking previously prescribed medications? What can his attorney do if George is unable or unwilling to speak and is instead presenting with delusions and aggression?

• Are there any existing mechanisms to alert the Court that this matter likely originated from a

mental health crisis and not “criminal activity” so that George may be immediately diverted

• ut of the criminal system and into a civil setting?
• What happens if George’s criminal charge is more serious or significant (a felony) and,

consequently, he is likely remain in jail for a prolonged period of time? What services are available to George inside the jail to assist with his mental health treatment? What if George refuses this treatment?

• Does a criminal plea or imprisonment ultimately remedy the underlying facts that caused this

intersection? ### George’s lawyer was unable to communicate with George and has significant concern for George’s wellbeing. Counsel for George asks that the Court order an exam to determine whether George is competent to stand trial and able to mount a defense in his case. The exam indicates George is unfit and requires medical care before any criminal case can be resolved. Accordingly, George is then transported to a state facility for mental health treatment (while his charges remain pending) and he is provided care until he is deemed “fit” to engage in his defense. George refuses treatment and his treatment team engages in a civil court process to involuntarily medicate George (with a Judge’s approval). After receiving forced medication for about six weeks, George begins voluntarily taking his medication. Months have now passed, and George is transported back to the criminal system where he pleads “guilty” to the original minor offense of trespassing. He is given “time served” and released from custody. It is now December and George must find a safe place to stay where he can get his medication and stay warm. He is denied a bed at various locations due to his recent criminal background.

• Intersection Point 3 and Questions to Consider-
• What resources exist in the community for George to remain active in his mental health

treatment?

3

• What housing resources are available that offer access to WRAP services?
• Does George have insurance? Has he ever applied for Medicaid?
• What about disability income? Has George ever applied for disability? What agencies offer

assistance with these applications?

• Are there any proactive measures George can take to ensure his health care decisions are

honored should he ever lose the capacity to make his own decisions? What is a declaration for mental heath treatment? Are there organizations that can help George with this paperwork? ### With the help of a local organization, George applies for disability but is told it can take a very long time to receive a response, and an appeal of any denial would take even longer. Meanwhile, George is threatened at the shelter he is staying at and feels unsafe. His insurance does not cover the cost of the injection he was receiving once a month while in custody, and the day-to-day oral medication is difficult for him to manage and to remember to take. Besides, George is beginning to “feel better” and reasons that “maybe he doesn’t need this medication forever.” George leaves the shelter due to feeling unsafe and the constant competition for a bed each

• night. He does not take his supply of medication with him. He is now on the streets again and without
• medication. He quickly decompensates and is found at a local train station shouting at various vendors

and automated machines. Responding to auditory hallucinations, he begins harming himself with glass from a broken bottle. Officers arrive and help transport George to a local emergency room. At the ER, the staff identify George as in need of mental health treatment and file a petition to have George examined for possible inpatient commitment.

• Intersection Point 4 and Questions to Consider-
• What does it mean to be involuntarily committed? What is required to file for such a

proceeding and who is able to file a petition? What expert support is needed to give merit to such a petition?

• How long can someone be committed for? Is it a permanent solution? What is the “least

restrictive setting” for someone to engage in treatment?

• What are the deadlines involved for committing George against his wishes? How soon must

the facility act?

• Where will George reside in the interim?
• What is the criteria for an inpatient commitment?
• Consider your local hospitals and psychiatric units; how many beds are available and what type
• f funding is accepted at each location?

###

4 George is transported to a local state psychiatric facility where a petition has been filed with the Court to have George committed to the facility. He remains there involuntarily, and he refuses to take any medications. The staff also files a petition to medicate George. Both petitions (commitment and medication) are pending with the local court. George is appointed an attorney to contest the

• proceedings. The attorney notices that the commitment petition was improperly completed and files

a motion to dismiss. Before the motion to dismiss is heard, George begins taking the offered medications. With George’s permission, a social worker attempts to call his mother to determine whether she is able to provide shelter for George but is quickly interrupted when George’s father grabs the phone and states that medication is for “weak people” and George “doesn’t needs meds.” Next, the facility is pleased that George is beginning to get better, but it is under pressure to free up George’s bed. They discharge George and provide him a bus pass with a 10-day supply of

• medication. Both court cases are dismissed.

George is again in the community but only has a limited supply of medication and no access to community care. He is unsure of where to get refills or whether any psychiatrists in the community are able to provide services. The previous shelter refuses to take George back as he left on bad terms and due to conflict. George finds a dry area under a bridge and tries residing there. Shortly thereafter, George again experiences auditory hallucinations. He is out of medication and begins self-medicating with drugs and alcohol. One night, George enters a local gas station. He has not showered in several weeks and appears to be laughing to himself. He takes a few random items off of the store shelf and walks

• utside with them. He is alleged to be shoplifting and law enforcement arrive to assess what has

happened. The officers are local CIT officers and they recognize George from prior encounters. One customer demands that the police “lock George up” as they consider him a menace. The officers instead speak with the store owner and calmly talk with George about taking a trip to a local doctor to see if he needs any care or a warm shower. They express their concern and desire to help George get assessed and examined to see if he needs any psychiatric care. George denies needing any care but agrees to go speak to a psychiatrist to show them that he’s fine. The officers transport George to a Crisis Stabilization Unit. Once at the CSU, George accepts limited care. The team is concerned George needs additional care or that he will continue to deteriorate so they petition the Court to have George committed to a local state hospital where he will be held while that petition is pending. The team at the local hospital remembers George from his prior visit. They are still low on beds and are eager to return George to the community. This time, though, they don’t stabilize and immediately move for his discharge. Instead, the team approaches George about Outpatient Treatment and working with a Community Provider to ensure he stays on his medications and receives care upon his discharge.

5 George agrees to the Outpatient plan, but the treatment team wants the plan memorialized with a Judge so that it has a “black robe effect” of ensuring George keeps his promise to remain compliant with treatment. The team files for “Assisted Outpatient Treatment” (“AOT”) and asks that a civil Judge oversee George’s promise for 6 months. George is appointed an attorney to negotiate an Outpatient Agreement.

• Intersection Point 5 and Questions to Consider-
• What is outpatient commitment in Illinois? What is required for such a proceeding?
• Who are the interested parties in an outpatient proceeding?
• What does it mean when outpatient is “agreed to” as opposed to when outpatient is

“contested”? What are the differences?

• What ancillary services can be drafted into the AOT Agreement?

George and the treatment team enter into an Agreed Care and Custody Order for Outpatient

• Treatment. The facility is comfortable discharging George now because he has formally gone before

a civil court and promised to take certain medications and attend certain appointments in the

• community. As part of the Agreement, the Judge also appoints a “Custodian” to be the Court’s “eyes

and ears” during the 6-month agreement to ensure George is taking his medication and attending

• appointments. George has no family in the area but the Court is able to appoint a local mental health

agency as a willing Custodian. Further, George is connected with a community provider under his AOT Agreement so he will have access to a psychiatrist and transportation to his various appointments. The provider under George’s Agreement provides Assertive Community Treatment (“ACT”) services, so they are able to see and provide care to George on an almost daily basis. George’s ACT team follows up about his disability application and confirms that he is to receive a small amount of assistance every month. They connect George with a Single Room Occupancy (“SRO”) that accepts part of his disability income as rent. Once a month, George travels to Court with his ACT team and they inform the Judge and the attorneys how well George is doing and whether there have been any lapses in care or missed

• medications. The Judge reminds George that if he does not comply with the Agreement, then the

appointed Custodian may take George to a hospital against his will for an evaluation. During the six months of George’s outpatient treatment, he remains at the SRO and is consistent with his medication. At the end of his outpatient agreement, the team and George decide whether to renew his agreement for another six months. During this time, George executes advance directives with a pro bono legal aid clinic that directs a medical team how to administer mental health treatment to George should he ever lose capacity. SOME LESSONS FROM GEORGE

• Treatment in jail is not ideal and focused diversion from criminal courts for those with mental

illness must be a priority.

• Diversion, diversion, diversion.

6

• Housing, housing, housing…but with the caveat that the State must closely monitor

unlicensed providers that offer “beds” for “disability money” and abuse/neglect such residents.

• Remember that inpatient commitment, in most cases, is not the “destination” but instead a

“detour”. Many facilities are overworked, understaffed, and short on beds.

• Outpatient community commitment “AOT” is available but community infrastructure must

be in place to offer: health services, housing services, and reliable/consistent care.

• These illnesses are deemed “chronic” for a reason. These are life-long struggles. Investing a

large amount of money and resources into “quick” fixes or jails/prisons will only cost taxpayers more money in the long-term. The sooner we identify and diagnose a problem, the more cost- effective our plan can be and the higher chances of our success. A significant change must

• ccur in the minds of doctors, judges, and providers so that community treatment can be

prioritized over incarceration and inpatient commitment.

• Investing in community care can reduce:
• unfunded ER visits,
• criminal cases, and
• inpatient admissions.

*It is not possible for a single agency or a sole individual to “fix” this. It is a mosaic and requires

• pen communication and partnerships among: civil courts, criminal courts, community providers,

jail staff, treatment teams, inpatient facilities, crisis stabilization units, homeless shelters, substance abuse centers, and community partners. Further Reading: Insane: America's Criminal Treatment of Mental Illness by Alisa Roth The New Jim Crow: Mass Incarceration in the Age of Colorblindness by Michelle Alexander “A ‘Bright Light,’ Dimmed in the Shadows of Homelessness”, Benjamin Wheeler, March 3, 2018, New York Times found at: https://nyti.ms/2CUUW7A

ASSISTED OUTPATIENT TREATMENT

Frequently Asked Questions

By: Matthew R. Davison Matthew.Davison@illinois.gov 312-520-7270 1. Is the treater expected to come and testify, even if the Individual is agreeing to the outpatient

• rder? Generally, yes. For a Judge to enter an agreed care and custody order, the Judge must be

comfortable with what has been presented and make certain findings such as this agreed order will be in the best interest of not only the Respondent but the public as well. The treater’s availability will greatly aid a Judge’s understanding and comfort level prior to entering an Agreed Order. Moreover, the treater’s attendance is a show of support to the individual patient. Note, an agreed care and custody “hearing” is drastically shorter than a full-length trial and a psychiatrist’s attendance is usually limited to 10-15 minutes. 2. How does the hospital get their case on the Court’s “radar” so that an agreed order can eventually be entered? Currently, the easiest method for securing court involvement is to petition for involuntary outpatient commitment with 2 certificates by faxing this paperwork to the Clerk as

• ne would with any other petition (call the Clerk ahead of time, as usual). Once that is done, a case

number will be generated and the case will be put on the Court’s regular status call. Once that is done, the parties can resolve the pending petition by agreed order pursuant to statute. 3. Other than petitions and certificates, what else should be completed prior to the hearing date with the Court? Before the Court date, the Judge and the Parties should be provided a written report. This is outlined in statute, where our law states that “the facility director or such other person as the court may direct shall prepare a written report including information on the appropriateness and availability of alternative treatment settings, a social investigation of the respondent, a preliminary treatment plan, and any other information which the court may order. The treatment plan shall describe the respondent's problems and needs, the treatment goals, the proposed treatment methods, and a projected timetable for their attainment.” In practice, this written report is generally 1-2 pages in length. 4. How can the treatment team feel comfortable that the client will follow through with

• utpatient and take any agreed on medications? First, the Court will ensure that whomever is

going to be the patient’s Custodian understands his or her role in the process and that there are expectations not just for the client but for the Custodian as well. This is done at the Court as

• hearing. If the individual is substantially non-compliant, the Court Order allows the Custodian to

have the respondent admitted back to a mental health center as a “voluntary.” If the Custodian is concerned about transporting the Respondent back to a facility due to non-compliance, they may apply to the Court to have a Peace Officer assist in the transfer. Additionally, the Court that entered the Agreed Order will have ongoing subsequent status dates where it asks counsel whether any issues or problems have developed with the patient, the custodian, or the overall process, so the discharged patient is not “off the radar” at any point during the 6-month period. The 6-month Order may be extended in certain situations, pursuant to statute. 5. Is Outpatient only for individuals that are voluntary and are agreeing to enter into care and custody orders described here? No, outpatient law contemplates a wide variety of scenarios where the individual may not be in agreement with the proposed plan and if that is the case, then a full trial will be held to determine whether the person should be subject to the requested relief.

The Legal “Recipe” for an Outpatient Case

What’s expected for a successful Agreed Outpatient Case? 1. The People

• Client (Most patients described below are interested and willing to agree to Outpatient

Order)

• Doctor (Provide Written Report, Certification, and about 5-10 minutes of testimony at any

Agreed Hearing).

• Community Provider (Identify what agency or service can offer medication refills, therapy,

and the appropriate level of care: ACT, CST, etc.).

• Custodian (This individual or agency will be identified in the Court Order and expected to

assure the Court they will be the Court’s “eyes and ears” once the Client enters the community to ensure compliance and oversee Client’s readmission in the event of non- compliance).

• Court (A petition for involuntary commitment is filed to initiate these proceedings with 2

certificates, the Case is handled by an ASA for the Petitioner and a GAC-Attorney for the Respondent — if it is expected the matter will be resolved by agreement, these parties will draft the Agreed Care and Custody Order).

• Housing and Ancillary Services. Housing is absolutely critical for long-term success with

respondents in mental health matters. Similarly, some clients require substance abuse counseling and the appropriate level of care that integrates substance abuse counseling into the treatment plan and discharge planning. 2. The Paperwork

• Petition for Outpatient Commitment
• Two Certificates
• Written Report explaining SMI and need for outpatient.
• Custodian Information (address, phone number)
• Any agreed on medications and dosages and testings.

3. Common Clients That Benefit and Are Interested in Outpatient by Agreement: Outpatient Commitment can be customized to fit and address a variety of populations:

• Clients with multiple hospitalizations, strong family support but regularly go off medications

“when they’re feeling better.” An Agreed Care and Custody Order is a firm blueprint to hold the Client accountable and report in to a Judge about compliance.

• Homeless and Voluntary; individuals interested in the wrap services that may accompany

being connected with a community provider and custodian as well as reliable housing.

• Patients that are post-medication hearing and responding well to court-ordered medications.