D.19 MCM PC-14 Center for Behavioral Healthcare.pdf

Butler VA Health Care System Medical Center Memorandum PC-14 Butler, PA December 18, 2019

CENTER FOR BEHAVIORAL HEALTHCARE (50)

I. PURPOSE: To define the scope of services provided within the Center for Behavioral Healthcare (CBH) at this Butler VA Health Care System as well as provide general guidelines for the operation of the program.

II. POLICY: CBH provides outpatient Behavioral Health (BH) services to Veterans whose conditions and disorders are safely and effectively managed in this level of care.

CBH clinical staff also provides BH consultation services to staff in Butler VA programs.

The goals of CBH are recovery oriented as outlined in VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics. The goals are to reduce subjective distress and negative impact on interpersonal, social, emotional, behavioral, and vocational functioning of medical and psychiatric disorders. There is integration and coordination of care for Veterans who experience a substance use disorder and other mental health conditions, as well as collaboration for other components of health care for all Veterans.

III. RESPONSIBILITIES:

A. The Associate Chief of Staff for Behavioral Health (ACOS-BH) has overall responsibility for Behavioral Health services.

B. The CBH Nurse Manager and Psychology Supervisor are responsible for supervision of the administrative and clinical aspects of the program and report to the BH Sciences Council.

C. Clinical assessment, treatment, case management, and clinical programming within CBH are provided by the Interdisciplinary Treatment Team as outlined in PC-22, Behavioral Healthcare Interdisciplinary Treatment Planning. Other facility staff, i.e.

chaplains, Physical Medicine & Rehabilitation Services (PM&RS) therapists, and dietitians will be consulted to provide a wholistic approach to healthcare.

D. CBH policy and procedure, performance improvement activity, and program needs are reviewed by BH executive leadership for approval, concurrence, or necessary action.

IV. PROCEDURES:

A. An Outpatient Referral is a person not currently enrolled in BH Sciences services. Emergent Care is from referral source, or when patient indicates symptoms severity, or when risk of harm requires immediate assessment:

1. If patient is in the Primary Care (PC) Clinic, PC staff will complete a warm handoff to Primary Care/Mental Health Integration for same day evaluation or enter a CBH consult.

2 Medical Center Memorandum PC-14

a. Centralized Scheduling or Pre-Registration staff members will call the CBH phone (724) 679-3874 for patients who present to the HCC and request same day services.

b. All walk-in patients will be triaged by an RN and briefly assessed utilizing Measurement Based Care screens and patient self-report. The patient will then be assessed by a Licensed Independent Practitioner (LIP) staff member for identified interventions.

c. CBH LIPs will determine the need for any emergency interventions and make appropriate referrals, when indicated.

d. CBH LIPs will document their assessment with an interim plan in a progress note or CBH consult.

2. If the patient is on the telephone, facility staff will:

a. Take the patient's name and telephone number.

b. Dial 911, if indicated.

c. Inform Mental Health Treatment Coordinator (MHTC) and/or CBH managers

3. If patient verbalizes suicidal thoughts, keep patient on the line and have another staff member call 911.

B. Non-Emergent Care:

1. Establish eligibility through pre-registration staff.

2. All patients seen in the CBH are encouraged to have a PC Provider assigned.

3. The Medical Support Assistant (MSA) contacts the patient, schedules next available Initial Diagnostic Examination with clinically privileged licensed professional staff within 30 days of the consult, and then mails an appointment letter to the Veteran.

4. Clinically privileged licensed professional staff conduct Diagnostic Examinations and determine a plan of care. Based on a review of available records, review of the patient self-report via Measurement Based Care screens and a clinical interview, the report of the Initial Diagnostic Examination will include the following data:

Current pattern of emotional/behavioral functioning; history of emotional and behavioral problems; suicide risk assessment; history of addictive behaviors, including use of alcohol or other drugs, gambling, internet use; prior use of community resources to deal with emotional and/or behavioral problems; family history of mental health and/or addictive behavior problems; brief childhood history; level of education; military history;

vocational history and current employment status; religious and/or spiritual orientation;

3 Medical Center Memorandum PC-14 current financial circumstances; legal history; marital history; sexual history; leisure interests; usual social and peer group settings; current environmental and living situation. The Initial Diagnostic Examination will conclude with a brief interim treatment plan outlining any recommendations for additional assessment, psychiatric evaluation, referral for group and/or individual therapy, and the need for family participation.

5. Clinically privileged licensed professional staff will enter an internal consult to the treatment team identified based on diagnosis and interim plan of care. Clinically privileged BH staff will enter orders for scheduling with a Psychiatrist. CBH LIPs will enter consults for treatment teams.

6. The MHTC is the Principal Mental Health Provider:

a. Must be identified in the medical record using PC Management Module (PCMM) and the Mental Health Treatment plan and provider made clear to the patient.

b. Ensures regular contact is maintained with the patient as clinically indicated as long as ongoing care is required.

c. Coordinates and develops the patient’s treatment plan in accordance with MCM PC-22, Interdisciplinary Care Planning, incorporating input from the patient, family (when appropriate and with consent when the patient possesses adequate decision-making capacity or with the patient’s surrogate decision-maker’s consent when decision making capacity is inadequate). The treatment plan will utilize evidence-based interventions and measure outcomes utilizing measurement-based care screens.

Gender-specific care for gender specific issues are provided based on the Veteran’s preference.

d. Implementation of the treatment plan is monitored and documented, which includes tracking progress in the care delivered, outcomes achieved utilizing measurement-based care screens and attainment of goals.

e. Communicates with the patient and/or family or significant other about the treatment plan and for addressing any of the patient’s problems or concerns about their care.

f. For patients who are at high risk of losing decision-making capacity, such as patients with a diagnosis of schizophrenia or schizoaffective disorder, such communications need to include discussions regarding future mental health care treatment outlined in VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives.

g. Ensures that treatment plan reflects the patient’s goals and preferences for care and Veteran’s verbal consent to the treatment plan in accordance with VHA Handbook 1004.01, Informed Consent for Clinical Treatments and Procedures.

h. If the patient’s decision-making capacity is suspect, then the provider must

4 Medical Center Memorandum PC-14 ensure formal assessment and documentation of such. For patients who are determined to lack capacity, the provider must identify the authorized surrogate and document the surrogate’s verbal consent to the treatment plan.

i. Collaborate with the Suicide Prevention Coordinator (SPC) to support the identification of those who have survived suicide attempts and others at high risk to ensure they are provided with increased monitoring and enhanced care.

8. In circumstances where there is a conflict between the treatment provided in CBH and services provided to a patient by community agencies, the MHTC will attempt to clarify the conflict via phone or written contact with the community agencies. Details are discussed at the regular CBH interdisciplinary team meetings in order to reach a consensus as to the optimal resolution of the conflict in the best interests of the patient.

Appropriate documentation regarding the conflict and its resolution are entered in the medical record. Conflicts that arise regarding the treatment of patients within various programs or departments at Butler VA are resolved in the same fashion.

9. The MHTC will make a referral for Vocational Assessment under any of the following circumstances when working with patients who express a desire to continue/return to work: Clear pattern of repeated, extended periods of unemployment;

change in psychiatric status that would have a negative impact on a patient’s ability to return to/continue in current job; mutual agreement that sustained mental health is jeopardized by continuing in/returning to a current/former job.

10. Reassessment of patients:

a. Patients are to be reassessed at each appointment in CBH.

Reassessment will track target symptoms, response to medications, response to psychotherapy, commitment to sobriety, etc. Psychiatrists will participate in reassessment through treatment team meetings.

b. Patients who have not been seen in the clinic for 24 months or more are formally reassessed by clinically privileged licensed professional staff at the time the patient presents to the clinic to re-open treatment.

c. Patients are formally reassessed by the MHTC in cases where there has been a relapse to active substance abuse, psychiatric hospitalization, and/or suicidal gesture/ideation.

C. Consultative Services:

1. Community Living Center (CLC) consults are assigned to clinical staff (Psychiatry, Psychology), who function as consultants and team members to the CLC staff.

2. CBH LIPs provide mental health support to DRRTP via consults for psychiatric medication management while patient is engaged in residential treatment

5 Medical Center Memorandum PC-14 program.

3. HBPC consult support.

E. Clinical Procedures: Various clinical procedures may be performed by CBH staff within the limits of scopes of practice and clinical privileges accorded to them including, but not limited to: psychosocial evaluation, psychiatric diagnostic examination, psychometric evaluations, collection of vital signs, dispensing of medication by injection, various individual and group psychotherapies, crisis intervention, case management, and referral within and outside the facility.

F. Evaluation:

1. The Interdisciplinary Treatment Team will hold interdisciplinary care planning meetings at intervals of not less than once each week.

2. The ACOS BH, CBH managers, and Social Work supervisors will review quality, workload, and performance improvement activities.

G. Assessment and transfer of Veterans for Inpatient Mental Health/Detox Care:

Veterans requiring detox from alcohol.

1. Veterans who walk in or have a PC appointment and are determined to be in need of alcohol detox are assessed by a clinically privileged licensed professional staff in PC.

2. For Veterans who walk in or are at the facility and are determined to be in need of acute psychiatric inpatient admission:

a. PC staff will contact the co-located PCMHI staff to assess Veteran and discuss the admission process. Walk in patients will be assessed via activation of the

CBH phone (724) 679-3874. Other CBH clinically privileged licensed professional staff may be contacted to assist as needed.

b. A suicide assessment is completed and if positive, a risk assessment and a safety plan is initiated.

c. RN, APN or PA will order required lab work, including a blood alcohol level and Electrocardiogram (EKG).

d. Once all information has been obtained, the APN will contact the PC

Provider to examine Veteran for medical clearance.

6 Medical Center Memorandum PC-14

e. The MSA contacts bed management service at VA facility or a community facility if there are no VA beds available.

f. A staff member is assigned to stay with the Patient until transferred to an acute care facility. Patients will be placed on a 1:1 observation if they verbalize suicidal ideation.

g. If the Veteran is in need of acute care and is not willing to be admitted voluntarily, a 302 commitment is sought (refer to MCM PC-09, Behavioral Health

Commitment).

V. OPERATING POLICIES:

A. Admission criteria: Patients are admitted to care in the CBH based on the following guidelines:

1. A medical, psychiatric, or psychosocial problem or disorder exists and its symptoms impact on functioning and are amenable to behavioral healthcare clinical intervention.

2. The severity of symptoms and their impact on subjective distress and impairment of functioning does not require more intensive care such as partial hospitalization or inpatient care to safely and effectively provide care.

3. The housing, interpersonal, and social environment in which the patient lives is supportive of their level of care and will not likely preclude benefit from treatment.

4. The Veteran accepts the need for care and is willing to work collaboratively with staff to develop and implement a care plan.

B. Discharge Criteria:

1. If the Veteran fails to keep three consecutive appointments or fails to respond to telephone and mailed treatment status requests, the treatment team will suspend care until further contact.

2. If the Veteran responds but fails to keep a future appointment, the team will suspend care until the Veteran and treatment team meet and develop a new care plan.

3. When the patient requests discharge and when reasonable follow-up plans have been made, patient is discharged, or

4. When the patient's psychiatric or psychosocial problem or disorder has improved and treatment is no longer indicated, patient is discharged.

C. Clinic cancellation:

7 Medical Center Memorandum PC-14

1. Veterans who call to cancel a scheduled appointment are rescheduled at the time of their cancellation call. The MSA will negotiate a date with the Veteran to determine a day and time that would be convenient for the Veteran.

2. The MSA will send a reminder letter to the Veteran of the new appointment date and time.

3. Telephone follow-up is not necessary for Veterans who cancel appointments for specific causes.

4. If the Veteran has a Patient Record Flag (PRF) designating them as high-risk for suicide, they are referred to the SPC.

5. Providers who cancel a clinic need to see all scheduled Veterans prior to the date of cancellation unless the Veteran chooses to be seen at a later date.

D. No-shows:

1. Veterans who have a PRF designating them as high-risk for suicide are referred to the SPC. The SPC will attempt to make direct contact with the Veteran at the time of the missed appointment. If unable to contact the Veteran, the SPC will call other contacts given by Veteran in order to ascertain Veteran’s safety. If contact is unsuccessful, local law enforcement is contacted.

2. Veterans who miss scheduled mental health or substance use disorder appointments must be contacted three times via a combination of phone calls and letters with documentation in the electronic medical record. Follow-up can be completed by any staff member, unless the patient has a high risk flag. High risk patients must be contacted by a qualified mental health provider. At least three attempts must be made and documented to reach high risk Veterans.

3. If contact is unsuccessful for high risk patients after three attempts, the SPC will collaborate with the treatment provider(s) to determine the next appropriate step utilizing clinical judgment and the pre-developed Safety Plan. Community based Crisis Services will be contacted if there is sufficient concern regarding the patient’s safety.

VI. APPOINTMENT SCHEDULING

A. Veterans requesting or who are referred for mental health and/or substance abuse treatment will receive an initial evaluation within 24 hours. The goals of the initial evaluation are:

1. Determine the urgency of need for care.

2. Identify the appropriate setting for subsequent evaluations and treatment and to arrange for treatment.

8 Medical Center Memorandum PC-14

3. Provide Veterans with the name and contact information for a mental health professional that they can contact even before they begin treatment if they have questions or concerns as well as instructions about accessing emergency services as needed.

4. Respond to the patient’s questions or concerns and facilitate engagement in care.

5. Process:

a. This requirement will apply to Community Based Outpatient Clinics (CBOCs) as well as to VA Healthcare facilities.

b. This evaluation is conducted by a mental health provider or, when appropriate, a PC provider on a face-to-face basis, by clinical video telehealth, or by telephone.

c. Follow-up will occur within a maximum of 14 days to allow a full diagnostic and treatment-planning evaluation and the initiation of appropriate care, unless they request to be seen on a desired date beyond the 14 days.

B. Veterans who are requesting follow-up care are seen within 30 days of the desired date of appointment.

C. If Veteran’s presentation when requesting or when being referred for mental health treatment indicates the possibility of an emergent mental health problem and assessment of emergent needs are conducted immediately and appropriate intervention initiated.

D. Follow-up must be completed on all patients in mental health and substance abuse treatment who miss appointments, including newly presenting patients. Goals of this follow-up are to:

1. Conduct evaluations to identify Veterans whose mental health conditions present a danger to themselves or others.

2. Answer questions or concerns about the Veteran’s mental health condition and the treatment provided and reinforce the importance of continued care.

E. Post-Hospitalization: Patients who are admitted for hospitalization are to be reevaluated 7-10 days after discharge.

VII. REFERENCES:

Joint Commission Behavioral Health Standards.

MCM PC-15, Management of Suicidal Veterans MCM PC-27, Emergency Medical and Behavioral Care

9 Medical Center Memorandum PC-14

VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics.

VHA Directive 2008-036, Use of Patient Record Flags to Identify Patients at High Risk for Suicide.

VIII. RESCISSIONS: Medical Center Memorandum PC-14, dated April 16, 2015.

SHARON COYLE, MSN, RN, MBA

Interim Director

(Automatic Review Date: December 18, 2022)