36C24419R0074-035.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

Erie, Pennsylvania

Medical Center Memorandum No. 116-18 May 29, 2019

BEHAVIORAL HEALTH EMERGENCY GUIDELINES FOR CBOCS

I. PURPOSE: To delineate policy, responsibility, guidelines, and procedures related to addressing the emergent assessment of behavioral health patients who are in crisis, express suicidal or homicidal ideations, or are experiencing an acute exacerbation of psychiatric symptoms in a Community Based Outpatient Clinic (CBOC).

II. POLICY: It is the policy of the Erie VA Behavioral Health Clinic (BHC) to offer on-site or Telemental Health (TMH) services, where applicable, to individuals who live in closer proximity to the CBOCs. Patients, who are at an imminent risk of self harm, harm to others, or who are experiencing an acute exacerbation of symptoms that places themselves or others at risk will be sent to the Behavioral Health Inpatient Unit at the

University Drive Division of the VA Pittsburgh Healthcare System (UD) or a local facility for inpatient mental health care.

III. RESPONSIBILITY:

A. The Chief, Behavioral Health, Assistant Chief, Behavioral Health, and Medical

Director, Behavioral Health, are responsible for the implementation of this policy.

B. The staff at the CBOC is responsible for providing 1:1 observation of suicidal patients.

C. Behavioral Health staff is responsible for assessing the Veteran and arranging for transportation to the appropriate facility for medical clearance and/or inpatient admission.

IV. PROCEDURES:

A. Dangerousness: Veterans who are flagged for disruptive behavior or who are otherwise deemed to have potential for disruptive behavior and/or violence may be considered inappropriate for care at the CBOCs. Local police should be called if a Veteran becomes threatening in a CBOC.

B. TeleMental Health (TMH) in the event that a Behavioral Health (BH) clinician identifies a patient who is at imminent danger to self or others during a telemental visit, the treating clinician will call the CBOC staff to alert them to this matter using the emergency telephone number if necessary. Procedures will be followed

MCM 116-18 Behavioral Health Emergency Guidelines for CBOCs as outlined in the Behavioral Health Emergency Guidelines for Telemental Health

Visits policy.

C. Voluntary Hospitalization

1. During the pursuit of a voluntary commitment, the individual shall be placed on one-on-one observation if suicidal/homicidal. Every effort will be made to remove any item in close proximity to the patient that could be used as a weapon or potentially harmful.

2. Primary Care staff completing the Transfer Summary and associated forms will document in the CPRS record the mode of transportation that the Veteran will use and a clinical justification as to the selection of the mode of transportation, as appropriate.

a. For Veterans who require transportation from Emergycare:

Behavioral Health staff will page #565 and work with the

Transportation Coordinator to arrange for transportation to the appropriate psychiatric inpatient facility.

b. Veterans who are voluntary may be transported by other means

(e.g., family transport, drive themselves, etc.) depending on the clinical needs of the Veteran.

3. Depending on the circumstances, the Veteran will be transported to a local community Emergency Room, the Erie VAMC Urgent Care Center, or

UD. Decisions to transfer and initiate admission are made by the BH clinician who assessed the Veteran. The SPCs will ensure that a verbal report is given to the receiving ER or UCC. If a provider to provider transfer is necessary, SPCS will ensure that a CBOC provider provides the report (see Attachment A).

4. Additional assistance may be required of the Erie BHC’s Suicide

Prevention Coordinators, psychiatric nurses, as well as BH staff who may be on-site at the CBOC. Coordination of care will occur via telephone between the Behavioral Health staff and CBOC staff. To reach an appropriate BH staff member in Erie immediately, CBOC staff may call the designated crisis line by dialing X6999 or X6996 (see Attachment B).

D. Involuntary Hospitalization: During the pursuit of an involuntary commitment, the individual shall be placed on one-on-one observation while awaiting the arrival of the local crisis department and/or the local police department. Refer to

MCM 116-10, BH Admissions, Voluntary and Involuntary, for additional guidance. Coordination of care will occur via telephone between the BH staff and

CBOC staff.

E. Acute Symptoms/Other Mental Health Crisis: If a Veteran presents to a CBOC in crisis, available Behavioral Health staff in the CBOC will first be asked to assess the Veteran for treatment recommendations. If a CBOC Behavioral Health employee is not available, the Veteran can be assessed by a Behavioral Health clinician in Erie using TMH or by a BH clinician via telephone. This can be arranged by coordinating with the Erie Behavioral Health Medical Support

Assistants (MSAs) or the Assistant Chief, Behavioral Health.

V. REFERENCES:

A. MCM 116-05, Suicide Identification and Prevention

B. MCM 116-10, BH Admissions, Voluntary and Involuntary

C. Nursing Policy and Procedure 1-1 Observation

D. VHA Telehealth Services, TeleMental Health Operations Manual Supplement, VHA TeleHealth Documents and Forms

E. Erie VAMC Behavioral Health SOP, Emergency Guidelines for TeleMental

Health Visits

F. Acute Mental Health Unit and Non-Mental Health Unit One-To-One Observation for Suicide Risk. Memorandum dated May 10, 2019.

VI. FOLLOW UP RESPONSIBILITY: Medical Director, Behavioral Health, Chief, Behavioral Health, and Assistant Chief, Behavioral Health

VII. REPORTING REQUIREMENTS: None

VIII. RESCISSION: MCM 116-18 Behavioral Health Emergency Guidelines for CBOCs, dated April 16, 2018.

(Original signed 5/29/19)

John A. Gennaro

Medical Center Director

Attachments: A. Admission Process for CBOC Patient: Guide for BH Clinicians

B. What to do with Suicidal/Homicidal Patients in the CBOC: Guide for BH

Clinicians http://vaww.infoshare.va.gov/sites/telehealth/docs/Forms/ops.aspx

ATTACHMENT A

ADMISSION PROCESS FOR CBOC PATIENTS:

GUIDE FOR BH CLINICIANS

In the event a Veteran is in need of inpatient admission in the CBOC area, please adhere to the following:

FOR A VOLUNTARY ADMISSION:

• BH staff must coordinate with CBOC staff to ensure that the Veteran is placed on 1:1 observation at all times while he/she is in the clinic. Staff providing 1:1 will constantly observe the patient and will have no other responsibilities during the assignment to 1:1 observation. While under 1:1 observation, any restroom visit requires an escort who can visually monitor the patient for suicidal behavior.

• BH staff will call the University Drive Division of the VA Pittsburgh Healthcare

System (UD) to see if they have beds and determine if the Veteran is appropriate for

UD admission.

• If UD has beds available and the Veteran has had a recent physical, the

CBOC PCP can be consulted to see if they are willing to clear the Veteran based on current vital signs and recent bloodwork. If this can be accomplished and UD accepts, Page #565 to arrange transportation from the CBOC to UD.

o Staff will provide the Veteran with an Explanation of Voluntary

Commitment Rights and have them sign a Consent for Voluntary

Commitment Rights (see MCM 116-10 BH Admissions, Voluntary and Involuntary). If necessary, a Suicide Prevention Coordinator or other BH staff person will explain the documents by telephone and

CBOC staff can ensure that the documents are signed and accompany the Veteran at time of transfer.

o If medical clearance at the CBOC is not possible and UD has beds, the

Veteran must be transferred to the Erie VAMC Urgent Care Center (UCC) for medical clearance. Page #565 to arrange transportation from the

CBOC to the VA UCC.

• If the Veteran is unable to be transferred to UD, a local admission will be sought.

Page #565 to arrange transportation from the CBOC to a local Emergency Room.

• In the event that Emergycare is unable to provide transportation in an acceptable manner, the local ambulance service will be called by the Transportation Coordinator and the Veteran will be transferred to the nearest local inpatient psychiatric facility.

Authorization for admission will be given for one night and the Veteran will be transferred to UD the following day or when a bed becomes available.

• A CBOC provider must complete the transfer summary and document how the patient was transported to a local ER, the UCC, or the admitting hospital and justification for that mode of transport must be provided. The receiving facility (ER, UCC, or UD) must be given an oral report of the transfer. In the event that a provider to provider transfer is necessary, the CBOC Primary Care Provider will provide the report.

IN THE EVENT OF AN INVOLUNTARY ADMISSION:

• BH staff must coordinate with CBOC staff to ensure that the Veteran is placed on 1:1 observation at all times while he/she is in the clinic. Efforts should be made to encourage the Veteran to remain in the clinic, although there is no authority to detain.

If the Veteran chooses to leave the facility, the local crisis unit should be called and advised of such.

• The local crisis number/police should be immediately called in order to initiate the county's involuntary admission process:

o Ashtabula (police): 440-998-2221 o Crawford: 1-800-315-5721 o McKean: 1-800-459-6568 o Venango: 814-432-9100 o Warren: 814-723-2800

• Transportation to the local ER will be in compliance with the county's laws and regulations.

ATTACHMENT B

WHAT TO DO WITH SUICIDAL/HOMICIDAL PATIENTS IN THE CBOC:

GUIDE FOR CBOC STAFF

• A staff person must remain with a Veteran at all times while he/she is in the clinic.

• Please notify BH immediately (extension 6999 or 6996) if BH is not already involved and ask to speak with a Suicide Prevention Coordinator or BH nurse.

• BH will make transportation arrangements and work as quickly as possible to get the

Veteran to the appropriate facility.

• If at any time you need assistance because the Veteran has become threatening toward self/others, please call 911 immediately to summon local authorities

• In some circumstances, the PCP may be asked to provide a medical clearance report to University Drive. This will only be asked of the provider if there is recent lab work, the Veteran's vitals are within normal limits, and the PCP feels comfortable providing the clearance. BH will provide assistance with this process, when applicable.