Office of Civil and Forensic Mental Health

Best Practice Guidelines for

Outpatient Competency Restoration

Exhibit A.1

Colorado Providers, In this first edition of the Best Practices Manual for Outpatient Competency Restoration, our hope is that you find this a helpful roadmap to expand and enhance your competency restoration services. The need for this manual is simple: in five short years, this program has served over 2800 of Colorado’s most vulnerable citizens giving them the chance to receive their services in their communities rather than in an inpatient facility. Given the rapid growth of the program and its reach across over 104,000 square miles, we felt it important to begin the process of memorializing standards.

We have also seen the introduction of several other community initiatives that compliment the work that you are doing, targeting this population in an effort to disentangle them from the criminal justice system. From competency dockets, to specialized Assertive Community Treatment (ACT) teams, supportive housing, day reporting and more, how we serve this population has grown tremendously!

This Best Practices Manual is meant to further support you in your work, create stronger and more meaningful programs and to help competency restoration become a common component within the array of services that you provide. As a living document, we plan to continue to review and expand this tool moving forward.

It is with a great deal of gratitude that I thank the efforts of those who participated in the planning, research and implementation of this manual. From the dozens of providers that attended our first provider roundtable, to the final draft, I thank you for your time and expertise. Specifically, I want to acknowledge the individuals below for their hard work, tenacity and dedication over several months to the project. This would never have come to fruition without you!

Best Practices Workgroup:

Jody Whitright, Program Coordinator and Project Lead - Outpatient Restoration

Ali Moaddeli - AllHealth Network Diane Pukajlo - Private Practice Clinician Dorinda Brown - North Range Behavioral Health Jacci Peterson - SummitStone Health Partners Jess Fear - SummitStone Health Partners Kim Sutherland - Centerboard Wellness

Outpatient Restoration Staff - Review and Editing:

Tara Rienow, Program Coordinator - Outpatient Restoration Candice Bernard, Program Coordinator - Outpatient Restoration Hannah Nichols OPR Intern

Respectfully, Kathryn Davis, Program Director Outpatient Restoration

Created March 2023

Table of Contents

Acronym List……………………………………………………………………………………..4

Addressing Underlying Behavioral Health Needs……………………………………………..5

Client Engagement and Managing High-Need Clients……………………………………

Crisis Situations………………………………………………………………………………...14

Culturally Humble Services……………………………………………………………………19

Gauging Client Progress Within the Restoration Curriculum………………………………22

Individualizing Services………………………………………………………………………..28

Placing a Client on a Maintenance Protocol………………………………………………….33

Treatment Team Approach…………………………………………………………………….35

Understanding and Use of Competency Evaluations…………………………………...……38

Use of Peer Support in Competency Restoration……………………………………………..42

Working with Partner Programs…………………………………………………..….……….44

Working with Individuals with Intellectual/Developmental Disabilities (IDD)…………….47

References……………………………………………………………………………………….50

Acronym List

ACT Team Assertive Community Treatment

CMHC Community Mental Health Center

IDD Intellectual Developmental Disability

IDDT Integrated Dual Diagnosis Treatment

IEP Individualized Education Plan

ITP Incompetent to Proceed

JBBS Jail Based Behavioral Health Services

MAT Medication-Assisted Treatment

MH Mental Health

MOU Memorandum of Understanding

OARS Open-ended questions, Affirmations, Reflective Listening, Summarizing

ROI Release of Information

SPMI Serious and Persistent Mental Illness

SUD Substance Use Disorder

Addressing Underlying Behavioral Health Needs

Best Practice: Providers of competency restoration should be well informed, and well connected with the appropriate services needed to address an individual's underlying behavioral health needs. Providers should be prepared and recognize that achieving restoration is not limited to engaging or completing a psycho-educational program.

All too often, many competency restoration programs merely teach, by rote learning, the psychoeducational components of court proceedings with “little regard for treatment of the underlying mental illness'' (Walker, Pann, Shapiro, Van Hasselt, 2016). Psycho-education surrounding the court proceedings is just one part of the competency process, and restoration providers should dedicate efforts towards supporting a client engaging in skill building and ancillary services to address the underlying mental illness or developmental disability.

Restoration providers should make note of and work to address deficits noted in the competency evaluation(s). Restoration providers should also be exploring and identifying needs of the client while working with them on an ongoing basis. The provider must be cognizant that achieving competency may be related to addressing underlying psychiatric needs, possibly with the use of medications.

Restoration providers should have a network of reliable resources they can utilize to make referrals to address a client’s underlying needs. Those resources should include, but not be limited to the following: mental health treatment, medication evaluation and management, crisis services, substance abuse services, traumatic brain injury services, and social support services to address needs revolving around housing, transportation, clothing, food and other basic necessities. Providers may need to be creative in their efforts to engage clients in the services they need.

The process to address underlying behavioral health needs should go as follows:

A. Discussion: Assessing for needs

a. Initial Assessment- Initial assessments gather basic need requirements without having to complete a full clinical intake. Providers will need to obtain releases of information to coordinate with community resources clients are already engaged in.

i. Initial assessments should identify barriers to accessing restoration, such as a lack of:

1. Telehealth resources vs in person

2. Transportation

3. Scheduling

4. Competencies in reading and writing

5. IDD/Brain Injury Screenings

a. OSU (Ohio State University TBI Identification Method)

6. Current Services

a. MH/SUD

b. Psychiatric- Many competency evaluations and research around competency indicate a need for clients to address medication and psychiatric needs as a barrier to restoration

c. Nursing or in home health services

d. Medical

7. Housing

8. Food security

9. Health insurance

10. Communication - email, text, phone

11. Social support

12. Benefits

13. Explore client’s motivation to be successful

b. Ongoing Assessment

i. Full Agency intake- if applicable or refer out to community if private provider

1. Identify MH/SUD needs

ii. Continued Needs assessment

1. Housing

2. Transportation

3. Communication- Email, Text, Phone

4. Food Security

5. Income

6. Benefits

7. Waiver Services

iii. Barriers to long term stability/restoration

iv. Explore client’s motivation to be successful

Providers should be assessing needs at initial meetings and throughout service episodes.

B. Discussion: Referral resources

Any barriers that have been identified that can be addressed by treatment professionals should be addressed through frequent attempts to help clients engage in these critical services.

Providers must be familiar with all resources available in their community and how to engage those resources on behalf of your client. Providers should have developed relationships with these referral resources to ensure ease of access. These services may include medication

Created March 2023 https://drive.google.com/drive/folders/1UEihf-9ENQ26zaVURlRQbNskwX3NMxcy management, mental health therapy, substance use therapy, peer support, case management, connection to services for those diagnosed with an intellectual or developmental disability and support for traumatic brain injury. These services may differ for adults and juveniles, and may have additional cultural implications that should be considered. Community systems can be difficult to navigate and, given this population, assistance is often necessary to navigate successfully. Therefore, facilitated introductions and warm-hand offs are necessary to connect clients with services.

We recommend that providers take opportunities to network with other providers to help resolve issues and identify referral resources. Examples include attending competency restoration quarterly meetings and Caffeination and Restoration sessions hosted by the OCFMH Outpatient Restoration team access through the Provider Portal. Providers should connect and form partnerships with entities already working with the population. Providers should become involved, where they can, with community resource mapping at the local level.

C. Discussion: Assessment for suicide Providers should be able to assess or have a referral resource for completing suicide risk assessments. Providers should have procedures in place for completing suicide risk assessments and/or have knowledge of local crisis resources. If providers are unsure of what steps to take when clients screen positively for suicidal ideation, they should contact local crisis resources for direction and referral. It is highly recommended that providers create a process of assessing and/or referring individuals to appropriate resources during a crisis. This process should be inclusive of the most appropriate resource within the community to address concerns effectively and timely. OCFMH Program Coordinators can assist with providing technical guidance with this planning process.

a. Resources for Assessment

i. Columbia Suicide Risk Severity Rating

ii. PHQ 2/PHQ 9 Access at PHQ9

b. Crisis Centers

c. Providers should have a referral resource to be able to complete an assessment if the provider is not trained to complete themselves.

d. Crisis resources in Colorado including hotline, warmline and walk-in center locations can be found at: Colorado Crisis Services

i. Hotlines

1. 988 Suicide and Crisis Lifeline

a. 988 Suicide & Crisis Lifeline | SAMHSA

2. Suicide Prevention Hotline: 1-800-273-TALK (8255) Spanish:

1-888-628-9454

3. Colorado Crisis Services: 1-844-493-8255 Text “Talk” to 38255

ii. Walk-in Crisis Centers

Created March 2023 https://sites.google.com/state.co.us/outpatientproviderresources/home https://drive.google.com/drive/u/0/folders/1UEihf-9ENQ26zaVURlRQbNskwX3NMxcy https://coloradocrisisservices.org/ https://www.samhsa.gov/find-help/988

1. Regions in Colorado have walk-in crisis centers

iii. Zero Suicide Website for evidence-based strategies including safety planning for individuals in a mental health crisis: Zero Suicide

D. Discussion: Medications Properly adhering to medications are often indicated as a barrier to restoration. After assessing for any current psychiatric medications, providers should work with community resources or internal agency resources to monitor medications and compliance. Clients may be resistant to taking medications, so revisiting engaging with medications in an ongoing manner may be needed. This may include involving parents or guardians for juveniles. In order to monitor medication compliance, providers should:

1. Working with jails (if applicable)

a. Does the client already have an established medication regimen? Work to ensure there are no gaps in the provision of medication between being released from jail and returning to the community.

b. This means providers should work with JBBS providers, or local jail medical providers to ensure clients are released with a fillable prescription

2. Independent providers

a. Providers should work with local CMHC’s or other community psychiatric resources to establish and monitor the client’s ongoing medication regimen.

3. Community Mental Health Centers

a. Providers should work with medication teams to identify providers, assist clients with appointments and, if necessary, attend appointments with clients.

4. Ongoing medications

a. Providers can utilize home health/in-home nursing agencies to assist with medication administration.

5. Ongoing Insurance

a. Providers must ensure clients have insurance to cover medication co-pays and psychiatric appointments.

6. Momentum- Rocky Mountain Human Services will…

a. Cover Medication co-pays, or medication not covered by insurance.

b. Cover electronic medication administration boxes.

c. Assist with getting clients into private providers if CMHCs or providers covered by other insurance are booked out.

Created March 2023 https://coloradocrisisservices.org/spot-the-signs/?gclid=Cj0KCQjw27mhBhC9ARIsAIFsETHnh-P69hQJa0q2zw_ob_r1mu7hXD9w8A2TtGm2waRAYRQFdSPPFRQaAoabEALw_wcB https://zerosuicide.edc.org/

Related Issues:

● Working with Partner Programs

● IDD Roadmap and other support materials are available on the Provider Portal and should be reviewed if your client has been diagnosed with an intellectual or developmental disability.

● Individualizing Services

Resources:

Provider Portal Outpatient Restoration Provider Resources | Colorado Department of Human Services

Suicide Prevention Hotline: 1-800-273-TALK (8255) Spanish: 1-888-628-9454

Colorado Crisis Services: 1-844-493-8255 Text “Talk” to 38255

988 Suicide & Crisis Lifeline | SAMHSA

Columbia Suicide Risk Severity Rating

Colorado Crisis Services

Created March 2023 https://sites.google.com/state.co.us/outpatientproviderresources/home https://sites.google.com/state.co.us/outpatientproviderresources/home https://sites.google.com/state.co.us/outpatientproviderresources/home https://www.samhsa.gov/find-help/988 https://www.samhsa.gov/resource/dbhis/columbia-suicide-severity-rating-scale-c-ssrs

Client Engagement and Managing High-Need Clients

Best Practice: It is best practice to develop a “trusting relationship between the treatment team and the individual” in order to achieve successful engagement. Success in engagement, regardless of the client's diagnosis and acuity, is defined when “an individual identifies the program as his or her service provider”.

A. Discussion: Engagement should be viewed through the lens of several areas of focus encompassing multiple strategies to achieve a high level of effectiveness.

Initial Outreach: Creating consistent strategies of prompting and outreach both prior to and after the session is key to a successful initial engagement. Strategies include:

● Timely initial outreach to clients within three business days of receiving the referral from the Program.

● Scheduling of an initial meeting (in-person is preferred) to take place within 14 days of receiving the referrals from the Program.

● Initial phone ‘intakes’ by staff prior to first meeting that discuss the program, preferred appointment times and any other client preferences. Also, providers should discuss any known barriers and connection to resources to address those barriers.

● Scripted reminder/confirmation calls made 1-2 days prior to the first session that anticipate barriers such as transportation, technology, childcare, etc. with the intent to resolve these issues before the session date.

● Initiate “contracts for services” that may include expectations of both parties. For the client, this may include items such as attendance, participation, goal setting and communication. For the provider, this includes treating the client with respect, partnering with the client and including them in treatment planning, etc. This is all done as a structured way of creating an alliance with the client.

● Utilizing partners such as Bridges Liaisons to help with engagement.

● Utilizing clients’ existing support networks.

● Utilizing all points of contact responsible for assisting clients in engaging in services.

Initial Session: Structuring the initial session to meet the needs of the client, the program and to enhance client engagement is crucial. In addition to implementing any organizational requirements, consideration should be given to the following:

● Build trust by making the unknown known. Review key principles such as confidentiality, expectations of the program, resources, and questions the client may have about what competency means.

● When possible, incorporate client preference and shared decision making with regards to restoration plans and scheduling of sessions.

● Consider all the ways that you may engage with your client for sessions (in-person, televideo, etc.) and discuss what works best for your client while being able to meet the needs of the program and restoration goals. Also, discuss their preferred method of outreach. Does your client prefer calls, text or email communication about scheduling sessions or follow up?

● If engaging in televideo services, discuss the elimination of distraction with your client with clear boundaries of the expectations that are involved with doing this type of session. Creating agreed upon rules for using televideo is key to successful sessions.

● Involve members of the client's support system if appropriate or needed, with the implementation of releases of information where appropriate.

B. Discussion: Engaging families and support systems

Essential principles include a relationship-centered approach that views the client within the context of their families and/or larger support/cultural groups. This focus should highlight that the client is the expert and that their key support system should be engaged. Provide opportunities for individuals to include family and close supporters as essential partners.

C. Discussion: Build rapport

Get to know your clients, talk about what is important to them and provide a safe space. Set parameters and boundaries related to items covered in initial intake. Learn the cultural values and expectations that guide social interaction, mental health, and salient themes within their communities. Remember with juveniles: they may feel like adults in their lives are giving up on them so they won’t expect a new relationship with a provider to be different. They may not trust easily. Additionally, they may be experiencing frequent changes in support. Define safe spaces by: (some of these could also be covered under initial sessions)

○ Encouraging clarifying questions.

○ Emphasize we are all here to learn and all have something to offer.

○ Asking the individual what pronouns they prefer. Don’t assume race/ethnicity/culture/identity/sexuality/gender, etc.Being assertive and direct if there is a concern.

○ Implementing a conflict resolution process .

D. Discussion: Staff Training and Expertise

Creating and maintaining a well-trained staff who are committed to the work has been identified as critical to client engagement. Strategies include:

● Adopting evidence-based practices and training staff to those practices.

● Creating and/or engaging in learning collaboratives that enhance staff expertise and quality.

● Bringing clinicians and administrators together regularly to brainstorm, problem solve and integrate multiple viewpoints with regards to practice.

● Committing to providing regular supervision that focuses on staff support, training needs, and honest assessment of client engagement issues. This is a chance for administrators to identify opportunities for efficiencies, adjust productivity targets as needed and enlist the help of other staff to assist with additional client needs. (Example: facilitate Motivational Interviewing training for restoration providers.)

E. Discussion: Be Creative

When considering client engagement, it is important to explore the barriers and challenges not only from the perspective of the treating professional, but from the perspective of the client. The client should be included in addressing their own engagement in an effort to create a collaborative relationship.

Be creative about how you might engage different individuals. Some examples are:

● Use of peer support specialists,

● Use of ACT teams, where appropriate,

● Inviting someone from another team,like a therapist to meet with you and the client during a session so you can introduce them

● Be knowledgeable about the resources available within your community to address barriers, keeping in mind that these services can/should be long-term wherever possible.

● Addressing social factors that impede quality of life such as health conditions, housing, etc.

● Use of motivational interviewing and incentives where appropriate

● Emphasizing the importance of continued engagement in services necessary to facilitate continued success in the individuals future post-competency process.

Leverage individual education plans (IEPs) for juveniles as they provide insight into present level of performance, strengths, and needs.

Best Practices for teaching (with the goal of keeping people engaged in sessions and consistent in their attendance) include:

● Active learning (games, board games, videos, etc.) in lieu of passively listening to lectures)

● Concept mapping (Bubbl.us is an example)

● Resources in the Provider Portal

Created March 2023 https://bubbl.us https://sites.google.com/state.co.us/outpatientproviderresources/home

Addressing Underlying Behavioral Health Needs

Culturally Humble Services

Individualizing Services

Treatment Team Approach

Working with Partner Programs

Resources:

National Center on Substance Abuse and Child Welfare

Best Practices in Learning and Teaching

The Change Process in Clients with High Needs

How to Engage and Motivate Clients in Therapy

Created March 2023 https://ncsacw.acf.hhs.gov/ https://www.oswego.edu/celt/best-practices-learning-and-teaching https://files.eric.ed.gov/fulltext/EJ728821.pdf https://positivepsychology.com/engage-clients/

Crisis Situations

Best Practice: Restoration services must have their own crisis protocol that goes beyond simply contacting 911. This may include developed relationships with local crisis management teams and comprehensive safety planning resources. If your organization does not currently have a crisis management response, it is strongly encouraged you create one.

It is not a matter of if a crisis situation will occur, but when it will occur. Therefore, having a plan and protocol in place is necessary. Once the crisis has been addressed and deescalated, providers should review the critical incident report policy and determine if the situation warrants making a report.

Discussion: While your organization should have their own crisis protocol, there are existing resources that may enhance your existing policy or aid in creating one. Encourage individuals to be participants in their own intervention. An example of this may include encouraging an individual to make their own phone call to a crisis line with support from provider(s) or be participants in creating their own safety plan. If you are unsure about when it would be appropriate to utilize these intervention techniques, always default to the higher level of intervention and assistance.

Questions one can ask to assess severity and immediacy of a crisis:

1. Do you feel the individual is in immediate danger to themselves, others or property?

2. Can you handle the situation yourself or do you need help?

a. Do you need emergency assistance? (assistance can come from mobile crisis teams, not just 911)

3. If you need help - what type of help do you need and from who?

4. Do you have time to start with a phone call for guidance and support from a mental health professional?

A 7-step crisis intervention model is considered best practice and is outlined below:

1.) Assess

- Assess lethality or imminent danger

- Conduct a biopsychosocial assessment

- Do not interrogate, use a motivational interviewing style to elicit information 2.) Establish rapport 3.) Identify major problems

- Prioritize the problems that need to be addressed

- Working with the client to identify how the situation escalated to become a crisis can lead to understanding the client's coping styles.

Created March 2023 https://docs.google.com/forms/d/14NPKDFjOapYRSf9xPQlQaq7Fm-FR_f9ToW6_g8qJ1i4/viewform?edit_requested=true

4.) Deal with emotions and feelings

- This could involve reframing the client's situation and providing information that may help overcome negative thought patterns 5.) Offer and explore alternatives

- Give options 6.) Implement a plan of action

- Negotiate safety 7.) Follow-up

- Ensure you check in with the client in the days after a crisis situation.

More information about the 7-step crisis intervention model can be found in this article from The Recovery Village Ridgefield.

Additional best-practices during a crisis situation include:

- A no-wrong-door, integrated crisis system. This means:

- crisis services are available for anyone, anywhere, anytime.

- Crisis services include:

- 1) crisis lines accepting calls 24/7 and assessing needs/dispatching services based on individual caller;

- 2) mobile crisis teams dispatched in the community (not just to hospital emergency departments);

- 3) crisis receiving and stabilization facilities

- Becoming familiar with de-escalation strategies

- De-escalation Strategies for Care Providers Working with Individuals with Mental Health Symptoms

- Participating in training opportunities for continued education for organizations and/or providers

- Community Resources for Wellness and Resilience Review the Navigating a Mental Health Crisis resource from NAMI.

Discussion: Assessment for suicide Providers should be able to assess or have a referral resource for completing suicide risk assessments and/or have knowledge of local crisis resources. If providers are unsure of what steps to take when clients screen positively for suicidal ideation, they should contact local crisis resources for direction and referral. It is highly recommended that providers create a process of assessing and/or referring individuals to appropriate resources during a crisis. This process should be inclusive of the most appropriate resource within the community to address concerns effectively and timely. Program Coordinators can assist with providing technical guidance with this process.

- Assessment

- Columbia Suicide Risk Severity Rating

Created March 2023 https://www.ridgefieldrecovery.com/intervention-guide/crisis-intervention/ https://www.ridgefieldrecovery.com/intervention-guide/crisis-intervention/ https://www.dshs.wa.gov/sites/default/files/ALTSA/hcs/documents/ND/Jessica%20Shook-%20De-escalation.pdf https://www.dshs.wa.gov/sites/default/files/ALTSA/hcs/documents/ND/Jessica%20Shook-%20De-escalation.pdf https://denvergov.org/Government/Agencies-Departments-Offices/Agencies-Departments-Offices-Directory/Public-Health-Environment/Community-Behavioral-Health/Behavioral-Health-Strategies/Denver-Strong https://www.nami.org/Support-Education/Publications-Reports/Guides/Navigating-a-Mental-Health-Crisis/Navigating-A-Mental-Health-Crisis?utm_source=website&utm_medium=cta&utm_campaign=crisisguide

- PHQ 2/PHQ 9 Access at PHQ9

- Crisis Centers 1-844-493-8255

- Referral resource to be able to complete if provider is not skilled, trained to complete themselves.

- 988 Suicide and Crisis Lifeline

- 988 Suicide & Crisis Lifeline | SAMHSA

- Suicide Prevention Hotline: 1-800-273-TALK (8255) Spanish:

1-888-628-9454

- Colorado Crisis Services: 1-844-493-8255 Text “Talk” to 38255

- Walk in Crisis Centers

- Regions in Colorado have walk in crisis centers

- ALL of colorado has access to the Colorado Crisis Services line

- Crisis resources in Colorado including hotline, warmline and walk-in center locations can be found at: Colorado Crisis Services

- Zero Suicide Website for evidence-based strategies including safety planning for individuals in a mental health crisis: Zero Suicide

Techniques that may help de-escalate a crisis:

✔ Keep your voice calm ✔ Avoid overreacting ✔ Listen to the person ✔ Express support and concern ✔ Avoid continuous eye contact ✔ Ask how you can help ✔ Keep stimulation level low ✔Move slowly ✔ Offer options instead of trying to take control ✔ Avoid touching the person unless you ask permission ✔ Be patient ✔ Gently announce actions before initiating them ✔ Give them space, don’t make them feel trapped ✘ Don’t make judgmental comments ✘ Don’t argue or try to reason with the person

Safety planning has been shown to reduce suicide risk and days in inpatient care (Drapeau, 2019).

When creating a collaborative multidisciplinary safety plan, consider:

- Identifying access to medications that could be helpful or weapons that could be harmful..

- Preparing phone numbers of support systems/crisis resources you can contact if needed

Created March 2023 https://drive.google.com/drive/u/0/folders/1UEihf-9ENQ26zaVURlRQbNskwX3NMxcy https://www.samhsa.gov/find-help/988 https://zerosuicide.edc.org/

- Inviting individuals to be active participants in the creation of their own safety plan

- Using a strength-based approach

- Develop a dynamic continuous process so this is not a one-off event.

- Practice using the safety plan before a crisis occurs

Guidelines for creating safety plans:

- General mental health Safety Planning Guide

- Basic Safety Planning Template

Veteran Safety Plan Quick Guide

- Suicide Prevention Stanley-Brown Safety Planning Intervention and Training

Related Issues:

Consider individuals with a substance use disorder and the comorbidity between a primary mental health diagnosis and SUD.Crisis intervention may look different for someone with these co-occurring mental health concerns. Read the following resources for more information:

- NIMH » Substance Use and Co-Occurring Mental Disorders

- Mental Health and Substance Use Disorders | SAMHSA

1. Current crisis intervention policies may include calling 911 as part of the plan or may use calling 911 as a last resort. Repeated studies have shown that 911 call centers lack the resources to effectively respond to a mental health crisis (911 Call Centers Lack Resources to Handle Behavioral Health Crises)

- Some call centers have limited specialized resources available to dispatch to behavioral health crises and law enforcement is often the only option.Mobile crisis teams (MCT) should be standard practice to assess alternatives to arrest Mobile Crisis Dispatch - Rocky Mountain Crisis Partners

Resources Information around M1 holds

- Emergency Mental Health Holds (17-38) | Colorado General Assembly

- Mental Health Holds - NAMI Arapahoe/Douglas Counties

STAR Program

- Support Team Assisted Response (STAR) Program - City and County of Denver

Crisis Services

- About | Colorado Crisis Services

- Crisis program | Behavioral Health Administration

Map of walk-in crisis centers by area code

- 2-1-1 Colorado

Toolkit

- Crisis Response Toolkit: Responding to Children, Youth and Families | Behavioral Health

Administration Hotlines

Created March 2023 https://www.sprc.org/sites/default/files/SafetyPlanningGuide%20Quick%20Guide%20for%20Clinicians.pdf https://docs.google.com/document/d/1r1Rtx4QG_0mCHJVZtIWJ1TV8w96ZGDoI/edit?usp=share_link&ouid=113857683595623229389&rtpof=true&sd=true https://www.mentalhealth.va.gov/docs/vasafetyplancolor.pdf https://talksuicide.ca/wp-content/uploads/2022/05/Stanley-Brown-Safety-Plan-8-6-21.pdf https://www.youtube.com/watch?v=2g6PCKJ4m9o https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health https://www.samhsa.gov/find-help/disorders https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/10/new-research-suggests-911-call-centers-lack-resources-to-handle-behavioral-health-crises https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/10/new-research-suggests-911-call-centers-lack-resources-to-handle-behavioral-health-crises https://rmcrisispartners.org/home/services/mobiledispatch/ https://leg.colorado.gov/publications/emergency-mental-health-holds-17-38 https://www.namiadco.org/nami-blog/mental-health-holds/ https://www.denvergov.org/Government/Agencies-Departments-Offices/Agencies-Departments-Offices-Directory/Public-Health-Environment/Community-Behavioral-Health/Behavioral-Health-Strategies/Support-Team-Assisted-Response-STAR-Program https://coloradocrisisservices.org/about/#:~:text=CRISIS%20LINE%3A,substance%20use%20or%20emotional%20crisis https://bha.colorado.gov/behavioral-health/crisis https://search.211colorado.org/search?terms=mental%20health%20crisis%20lines&page=1&location=colorado&service_area=colorado https://bha.colorado.gov/cyf-crisis-toolkit https://bha.colorado.gov/cyf-crisis-toolkit

- 1-844-493-TALK (8255) is a 24/7/365 support line for anyone affected by a mental health, substance use or emotional crisis. All calls are connected to a mental health professional, who will provide immediate support and connections to further resources.

- 988 in Colorado | Behavioral Health Administration - 988 is the new, easy-to-remember three-digit number for calls (multiple languages), text, or chat (English only) that connects people to the existing National Suicide Prevention Lifeline, where compassionate, accessible care and support is available for anyone experiencing mental health–related distress.

- The chat feature will be available through the Lifeline’s website.

- How to Use 988 to Respond to Behavioral Health Crisis Calls

No-Wrong-Door Policy

- National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit Executive

Summary | SAMHSA Mental health crisis resources for LGBT populations

- Mental Health Crisis — Umbrella Collective BIPOC community mental health toolkit

- About - Mental Health Partners

- Call Blackline 1 (800) 604-5841

- Call BlackLine® provides a space for peer support, counseling, reporting of mistreatment, witnessing and affirming the lived experiences for individuals who are most impacted by systematic oppression with an LGBTQ+ Black Femme Lens QTBIPOC (Queer, Trans, Black, Indigenous People of Color) resources (crisis lines and mental health organizations). *The QTBIPOC population is prioritized.

- QTBIPOC Mental Health and Well-Being - Human Rights Campaign Resources for Older Adults | SAMHSA Indigenous and Native Resources

- Native Crisis Text Line - We R Native

- text the word “NATIVE” to 741741

- 40 Resources To Support Native and Indigenous Mental Health & Addiction

Recovery | Live Another Day

Created March 2023 https://bha.colorado.gov/behavioral-health/988 https://suicidepreventionlifeline.org/chat https://bja.ojp.gov/doc/how-to-use-988-to-respond-to-behavioral-health-crisis-calls.pdf https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-services-executive-summary-02242020.pdf https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-services-executive-summary-02242020.pdf https://www.umbrellacollective.org/mental-health-crisis https://www.mhpcolorado.org/bipoc-stress-and-trauma-toolkit/ https://www.callblackline.com/ https://www.hrc.org/resources/qtbipoc-mental-health-and-well-being https://www.samhsa.gov/resources-serving-older-adults#:~:text=Call%20or%20text%20988%20or,Treatment%20Locator%20to%20get%20help https://www.wernative.org/articles/native-crisis-text-line https://liveanotherday.org/bipoc/indigenous/ https://liveanotherday.org/bipoc/indigenous/

Culturally Humble Services

Best Practice: Providers should be cognizant of the impact the disproportionate distribution of marginalized groups throughout the criminal justice system has had on the client, provider, and systems perspectives and approach. Providers should be cognizant of the historical exclusionary and traumatic practices and stigma mental and behavioral health treatment and social services have placed on marginalized groups and how this can impact perceptions for both client and provider of interactions, strengths, needs, progress, and relationships. Restoration services should strive to be constantly culturally humble to mitigate unconscious biases that can negatively impact our daily interactions that can contribute to care disparities. To be culturally humble, one must be willing and able to overcome the tendency to view one’s own beliefs, values, and worldview as superior, and instead be open to the beliefs, values, and worldview of the their client (Hook, Davis, Owen, Worthington, and Utsey, 2013). Cultural humility is not a destination, rather it is a lifelong journey which requires an active, and open mindset to help one develop skills to work collaboratively with anyone.

Providers must ensure they’re providing equitable, understandable, respectful, and quality services that are responsive to diverse populations.

Discussion: Don’t Assume To be culturally humble, restoration providers should not assume competence for working with clients solely due to previous experiences or even expertise.

All work with clientele should be viewed as a collaborative approach, characterized by respect for all and without an attitude of superiority.

Discussion: Participation in on-going training and educational opportunities To be culturally humble, restoration providers should strive to develop cultural sensitivity skills that seek out, perceive and interpret cultural information from clients.

Restoration providers should be afforded and seek out opportunities to explore their own biases, recognize their privilege and learn about social injustices that individuals undergo due to power imbalances. Restoration providers should be aware of their own cultural beliefs and values, and how they may differ from others. Restoration providers should challenge themselves when only viewing their values as the norm.

Restoration providers should be afforded and seek out opportunities to participate in educational training and workshops, including historical awareness, to further develop their skills and knowledge.

Discussion: Use of Alternative Terminology Providers should be considerate of the need to use alternative terminology during sessions. The following resources have suggestions for alternative terminology.

Gauging Client Progress Within the Restoration Curriculum Terminology section Client Engagement and Managing High-Need Clients Build Rapport section

Discussion: Use of interpreter services As needed, providers should be considerate of the need for interpreter services in working with clientele. In some instances, the use of an interpreter is required by court order.

When an interpreter is needed for someone who has limited English proficiency, and/or other communication needs, the restoration provider should offer language assistance to facilitate all services. These services can be accessed from the interpreter list on the Provider Portal.

Related Issues:

Individualizing Services

Gauging Client Progress Within the Restoration Curriculum

NOTES:

We have chosen to use “cultural humility” rather than “cultural competency” in this context because "cultural competence is more aptly viewed as a process; a journey, not a destination.

And cultural humility is the mindset that fuels the journey" (Sacred Heart University, MSW Program, 2023).

Definition: “Cultural humility is the process of self-reflection and discovery in order to build honest and trustworthy relationships” (Yeager & Bauer-Wu, 2013).

Individuals who are culturally humble will develop a set of skills to approach any individual from any culture at any time. This approach encourages lifelong learning and reflection and attempts to diminish the power dynamics between individuals. Learn more about cultural humility at https://www.chea.upenn.edu/cultural-humility/

Cultural humility is not limited to race or ethnicity but can extend to family roles, acculturation levels, cultural beliefs and values, spirituality, religion, gender, language, and more.

Steps towards achieving cultural humility from CHEA:

Be cognizant that we all often make assumptions about others based on their culture and background Ask open questions and practice reflective listening

Created March 2023 https://sites.google.com/state.co.us/outpatientproviderresources/home https://www.chea.upenn.edu/cultural-humility/ https://www.chea.upenn.edu/cultural-humility/

Treat others as experts on their own lives Practice humility with every interaction, not just with clients providers should provide services that are respectful of and responsive to individual differences, preferences, needs, and values and ensure that clients' values guide all decisions. Providers should provide equitable services that do not vary in quality with respect to personal characteristics, ethnicity, geographic location, or socioeconomic status.

Three things to know about cultural humility:

1. We move between several different cultures - often without even thinking about it.

2. Cultural humility is distinct from cultural competency and reflexivity.

3. Cultural humility requires historical awareness and personal accountability.

Humble individuals, on an interpersonal level, have an accurate view of self. Humble individuals on an interpersonal level are able to maintain an interpersonal stance that is other-oriented rather than self-focused, characterized by respect for others and a lack of superiority (Hook, Davis, Owen, Worthington, and Utsey, 2013).

Resources:

● 3 Things to Know: Cultural Humility

● GAINS Webinar: Culturally Adapted Evidence-Based Treatments

● National Standards for Culturally and Linguistically Appropriate Services (CLAS) in

Health and Health Care

● U.S. Department of Health and Human Services Office of Minority Health has a plethora of resources, including free E-Learning Programs designed to build knowledge, skills and awareness.

● NCCC | Self-Assessments - National Center for Cultural Competence

● Teaching & Learning for Inclusive Teaching & Learning - Colorado Rises - CDHS

Learning and Teaching EDI Toolkit

Disability Etiquette

● Guidelines for setting up accessible meetings and events The 4 I’s of Oppression

● Inclusion Starts with I

● 4 Steps for Busting Unconscious Bias

Created March 2023 https://hogg.utexas.edu/3-things-to-know-cultural-humility https://www.youtube.com/watch?v=fZG7F7UlGQ4 https://drive.google.com/file/d/1h1WKQmXz5NSOlk83Vw-inXDSdOR8070z/view?usp=sharing https://drive.google.com/file/d/1h1WKQmXz5NSOlk83Vw-inXDSdOR8070z/view?usp=sharing https://www.minorityhealth.hhs.gov/ https://nccc.georgetown.edu/assessments/ http://masterplan.highered.colorado.gov/equitytoolkit/teaching-learning/ https://dpa.colorado.gov/sites/dpa/files/documents/Disability-Etiquette-One-Pager.pdf https://dpa.colorado.gov/sites/dpa/files/documents/how-to-set-up-accessible-meetings.pdf https://www.youtube.com/watch?v=3WWyVRo4Uas https://www.youtube.com/watch?v=2g88Ju6nkcg https://www.youtube.com/watch?v=K-n7el87Dmo

Gauging Client Progress Within the Restoration Curriculum

● Best Practice: Providers should evaluate the progress of a client as objectively as possible with good articulation in monthly reporting and progress notes. Progress can be viewed from multiple perspectives, including: Meeting standards of the provider contract for service provision including minimum engagement standards of two sessions per week. Documenting demonstration of understanding of the curriculum.

A. Discussion: Competency restoration pertains to three distinct areas that must be equally addressed in order to ensure success. Only providing psycho-education is not sufficient to achieve the program’s goals. However, this best practice document is specific only to the psycho-educational portion of competency restoration. Educationally, the goal is to help the client understand the factual and rational areas of the curriculum, demonstrate understanding of these areas and have the ability to apply that knowledge to their own case. This should be measured as objectively as possible through the use of measurement tools such as rating systems, assessments and direct client quotes.

Providers may consider using the following skills during sessions:

● Providers can utilize a simple rating scale where each client rates their own understanding of each concept. Ratings can range from 1-4 with the following ratings:

1. “I don’t get this topic, I need help.”

2. “I think I get it, but let’s keep reviewing the topic.”

3. “I understand the topic.”

4. “I could teach this topic to the judge.”

● Providers can utilize the pre- and post-test assessments provided in the restoration manuals available on the Provider Portal; however, they should not be the sole items relied upon to gauge progress and/or retention of the material.

● Providers can observe throughout the session while documenting progress, like “the client correctly answered the educator’s questions throughout the session, showing understanding of the vocabulary words and concepts in the module.”

● Providers should be considerate of the client’s learning style. For example, do they prefer that you read the questions to them or do they prefer to read the questions themselves?

● The provider should assess understanding of the material by having the client complete true and false or open-ended quizzes, reciting responses, asking to recap definitions, asking them to respond to hypothetical questions and/or noting direct quotes from the client’s response. With regards to quizzes or other scorable activities, providers can utilize a percentage or fraction of the

Created March 2023 successful responses to provide insight into a client’s understanding.

Providers should not rely on passing scores on the pre- and post-test as sole qualifiers for demonstration of understanding the concepts.

● Other tools may include games such as crossword puzzles and matching games. How well the client completes the activity may give an indication to the level of understanding that a client has with regards to various concepts.

Tools such as videos are a great option for clients with literacy difficulties.

Providers can use a client's interests or hobbies to relate certain concepts. For example, if a client likes sports, the provider can relate working with a coach and assistant coach to the concept of working with their attorney or provider.

● Use of stories and vignettes can help provide context to the concepts. Follow up questions may help the provider gauge how well a client can verbalize understanding of concepts, and how they can apply them to various situations.

B. Discussion: Terminology Providers will need to be mindful of the need to use a variety of terminology that may resonate with the client.

For example:

Lawyer versus attorney Defense Counsel versus public defender, alternate defense counsel Prosecutor versus district attorney versus DA Clerk versus Judicial Assistant Use ‘lesson’ instead of ‘module’, A few questions’ instead of ‘pre-test or post-test’

C. Discussion: Documentation of Understanding Providers should actively complete informal and formal assessments of a client’s progress within the curriculum materials and modules in formative and summative ways.

Providers should provide consistent documentation that gives insight into the progress, or lack thereof, with the restoration curriculum. Documentation should provide insight into what material is covered within each session, and notations on progress, or lack thereof, with that material. Documentation should also provide insight into how that material was presented, what methods were successful and which were not. Providers should not provide documentation as to an individuals’ progress towards competency or make opinions on whether or not a person is restored or restorable.

Providers should use direct quotes from clients when asking questions to check for understanding and document them on the monthly reports and session notes.

Providers should be specific in the language used to describe a client’s understanding of concepts such as breaking down the concept into parts. For example, the concept of relating to your attorney may include knowing the name and role of their attorney with respect to other courtroom participants, understanding the collaborative nature of the relationship between the client and their attorney, understanding client/attorney privilege and understanding the best ways to communicate with their attorney.

Providers should not be overly reliant upon pre- and post-test scores as a means of determining understanding.

Note that guides, examples and training of reporting is located on the Provider Portal.

The provider should be evaluating clients on these concepts:

1. Constitutional Amendment Rights: Does the client have an understanding of their legal rights? Does the client have an understanding of basic protections afforded under the United States Constitution?

● Assessment: is the client familiar with their amendment rights (4th, 5th, 6th, 8th)? Is the client able to correctly identify what rights are afforded by which amendment? Is the client able to identify what a warrant is, and the purpose?

Is the client able to identify and have an understanding of the concept of search and seizure? Does the client understand what it means to remain silent, and to not self-incriminate? Does the client understand what due process and procedural fairness are and what those mean for them? Does the client have an understanding of the Miranda Warning? Does the client understand they have a right to an attorney? Does the client understand what a jury trial is? Does the client understand that defendants are presumed to be innocent until proven guilty? Does the client understand what a speedy trial is and what that means to them? Does the client understand what an appeal is and what that might mean for their case? Does the client understand what a witness is and their rights with confronting and calling witnesses? Does the client understand what bail is, what excessive bail is, what a fine is, what an excessive fine is, and what cruel and unusual punishment means?

2. Roles of Courtroom participants:

● Assessment: does the client understand the parties who participate in the court process and where they sit in the courtroom? Does the client understand what an attorney is? Can the client identify, and do they understand the role of a defense counsel, of a prosecutor, and, if applicable, a guardian ad litem?