The Temporary Detention Order (TDO) Process—Part II

Live event was held Tuesday, May 20, 2014, 1:30-2:45 pm Eastern Time

(Third in the Mental Health and Aging Training Initiative, Series III*)

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SERIES BACKGROUND
This third installment in the series of webinars initiated by the Geriatric Mental Health Partnership (GMHP)--an informal, voluntary group of diverse stakeholders which focuses on geriatric mental/ behavioral health care in the Commonwealth--aims to improve communication and service coordination between the mental/behavioral health and long term care systems to facilitate timely care for older adults in the most appropriate setting. Lack of adequate training regarding the complex needs of an aging population with behavioral health issues has been identified as a major barrier to successfully providing community-based care for these individuals. Six previous webinars have attracted a continuously growing audience, which attests to the unmet need for this type of training. In fact, in 2012, our webinars reached 600 senior service providers and in 2013, more than 1,300 professionals benefitted from our online training.

As the aging population continues to grow, and use of State Hospitals as the site of extended behavioral health care continues to diminish, it is essential that community based staff and providers be prepared for the rapid growth of older adults with behavioral health and dementia-related issues. This is a key issue for workforce development as the Commonwealth prepares for the future. Effective training enables staff to more quickly identify and address behavioral health-related issues before the older adult’s condition declines further or situations escalate to possibly becoming dangerous to other frail elders (or caregivers) nearby. It also helps staff distinguish between behavioral issues which can be safely addressed at the facility (or at home) versus those which constitute a true psychiatric emergency and might require inpatient treatment.

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WEBINAR OBJECTIVE

This final session will respond to questions posed during the Spring 2013 GTE webinar, “The Temporary Detention Order (TDO) Process: What Staff Need to Know.”  Case scenarios and practical suggestions to staff for responding to psychiatric emergencies involving older adults will be highlighted. The primary learning objective is to address applying the TDO process to real-life scenarios experienced in long term care facilities and the community, as well identification of alternative interventions for situations in which pursuing a TDO is not the appropriate/ recommended course of action.

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INTENDED AUDIENCE

This presentation is intended for staff from many levels, disciplines and settings (both acute care and long term care).  Attendees included, behavioral health staff, nurse practitioners, nurses, CNAs, Nursing Home Administrators, Social Workers and Case Manages from both Acute and Long term care. 

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WEBINAR ACCESS

The live event was open to all and free for all. 

Attendees were required to have a computer with access to high speed internet (to view the slide presentation) and computer speakers OR access to a telephone.  Additional information was provided through the registration form.

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WEBINAR MATERIALS

The webinar was recorded (see below). 


To download the presentation, click here.


To download the presentation, click here.

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SUPPORTERS

This event is made possible through a grant from the Virginia Center on Aging's Geriatric Training Education Initiative and supported by the Riverside Center for Excellence in Aging and Lifelong Health, the Virginia Geriatric Mental Health Partnership* and the VCU's Department of Gerontology.

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PRESENTERS

Gina O’Halloran, MS, is the Manager of Emergency Services at the Hampton Newport News Community Services Board. 

Gina has provided crisis intervention services to children and adults for over 20 years and is skilled in the diagnosis and treatment of mental illness.  She has worked in conjunction with the regional geriatric task force in an effort to provide person centered  services to older adults who are in crisis. She is knowledgeable of the Temporary Detention Order (TDO) and Emergency Custody Order (ECO) process and provides training routinely both internally and externally to law enforcement, school personnel, and other private and public agencies.  

Ms. O'Halloran holds a Master’s degree in Human Services and is a certified Prescreener. 

Rich Goddard RRT, RN, BSN, MA received his ADN from Hocking College, a BSN degree from Liberty University, and MA in Professional Counseling from Liberty University. Rich has provided assessment for clients in Emergency and Critical Care Settings across the life span for 20 years. Rich has provided Crisis Intervention for families while working as an RN in Emergency, Critical Care, Hospice and Organ Transplant situations. Rich is employed as a ES Crisis Counselor performing Pre Screens for TDO for clients across the developmental spectrum. Rich possesses certification for the Columbia Suicide Assessment tool and has received Masters Level training in Crisis Intervention. Rich has provided education for nursing students and has previously provided Community Emergency Response Training (CERT) for community members in Newport News, VA. Rich received an academic scholarship from the AACC and an award for bringing technology into the classroom while employed as a nursing instructor. Rich appreciates the challenges faced by clinicians regarding clients who have acute and chronic medical issues as well as mental health diagnosis.




James M. Martinez, Jr. (Jim), MEd, has held several positions with the Virginia Department of Behavioral Health and Developmental Services (DBHDS), and has managed the Department’s mental health, substance abuse, forensic, prevention, and youth initiatives and programs.  He is currently Director of the Office of Mental Health Services, where he  supervises various administrative, policy and operational functions of Virginia’s statewide system of behavioral health services for adults.  Throughout his career, Mr. Martinez has focused on developing community services and supports for people with serious mental illness and substance use disorders and their families, and on shaping and implementing Virginia’s Vision of a person-centered, recovery-oriented behavioral health system.  In 2004, Virginia’s mental health consumers and advocates recognized Mr. Martinez with a Living the Vision of Recovery Governor’s Award for his work in this area.  Mr. Martinez served as an advisor to the Supreme Court of Virginia’s Commission on Mental Health Law Reform (2006-11), and has led DBHDS efforts to improve Virginia’s involuntary treatment statutes and strengthen the safety net of behavioral health services for all Virginians.  Mr. Martinez is a graduate of the Virginia Executive Institute, and holds a B.A from Washington and Lee University and an M.Ed. from the University of Virginia. 

MODERATOR

E. Ayn Welleford, PhD, received her BA in Management/Psychology from Averett College, M.S. in Gerontology and PhD in Developmental Psychology from Virginia Commonwealth University. She has taught extensively in the areas of Lifespan Development, and Adult Development and Aging, Geropsychology, and Aging & Human Values. As an educator, researcher, and previously as a practitioner she has worked with a broad spectrum of individuals across the caregiving and long term care continuum.

As Associate Professor and Chair of VCU’s Department of Gerontology, she currently works to “Improve Elder Care through Education” through her Teaching, Scholarship, and Community Engagement. Outside of the classroom, Dr. Welleford provides community education and serves on several boards and committees.

Dr. Welleford is former Chair of the Governor’s Commonwealth of Virginia Alzheimer’s and Related Disorders Commission, as well as a recipient of the AGHE Distinguished Teacher Award. In 2011, Dr. Welleford was honored by the Alzheimer’s Association at their annual Recognition Reception for her statewide advocacy. Dr. Welleford is the author of numerous publications and presentations given at national, state and local conferences, community engagement and continuing education forums. In 2012, Dr. Welleford was appointed to the Advisory Board for VCU’s West Grace Village project.  She is also the recipient of the 2012 Mary Creath Payne Leadership Award from Senior Connections, the Capital Area Agency on Aging.

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RECORDING


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OTHER QUESTIONS POSED DURING THE EVENT (we thank the panelists for taking the additional time to provide these answers):

Q: Wondering why "unable to care for self" was not mentioned? There are many persons in the community that present as unstable.

The criteria   “unable to care for self” was discussed in presentation # 2. The code wording has changed over the years and  “unable to care for self” is now “suffer serious harm due to his lack of capacity to protect himself from harm or to provide for his basic human needs”.

Q: Will state psychiatric facilities have acute units to accept TDOs?   

State facilities do accept TDO’s and will continue to do so.   

Q: Where would you obtain a copy of "criteria" for TDO?

In the code of Virginia § 37.2-809. Involuntary temporary detention; issuance and execution of order.

http://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+37.2-809

Q: What would you hope to see in an advance directive to help you as an ES evaluator?  And/or how does DBHDS view ADs and WRAP as impacting the TDO process?

The name and contact information of an agent who has been identified to consent to an admission to a facility and/or make health care decisions for the client as well as preferences in healthcare.

Q: What is considered alternative transportation?

Alternative transportation can be transportation provided by family, friends, CSB, medical transport. Essentially the CSB wants to make sure that a reliable person/s will safely transport and individual to the accepting facility. This is used when a client is not at risk of harm to self/others during transport and not at risk of fleeing.   

Q: is there language that prevents private hospitals from taking patients that meet criteria for inpatient care but may not be uninsured?

This may be better answered by the private hospitals. Most facilities follow EMTALA guidelines. It may be helpful to review these guidelines. 

Q: If an older adult, who is living at home, exhibits agitated behavior, what is the best immediate action for a family member to take?  There are signs of early dementia, plus history of a stroke that affected cognitive functions.  Most of the time trying to talk softly & giving the person space helps, but what if it doesn't?

Every situation is different and your solution (talk softly…personal space) is most often helpful. If it isn’t, try to determine the trigger for the agitation, there is always a trigger. Music and aromatherapy have been shown to be helpful. If you are aware of a person’s favorite music, try that. On the same note, decrease unnecessary background noise (a TV that is not being watched). If there is no risk of physical harm to self/others, allow him to vent. Often, a trigger can be identified when one is venting. If the agitation continues, a visit to the doctor may reveal a physical source.

Q: I was told here in VA  ALF administrator can no longer do ECO. The police will need to see the client acting up.   This was changed 1/1/2014 .

There are 2 different types of ECO.

One is a paperless ECO that the police can initiate. The code for this type states “A law-enforcement officer who, based upon his observation or the reliable reports of others, has probable cause to believe that a person meets the criteria for emergency custody as stated in this section may take that person into custody and transport that person to an appropriate location to assess the need for hospitalization or treatment without prior authorization”.

The other is a “papered”,  magistrate issued ECO. The code for this type states “Any magistrate shall issue, upon the sworn petition of any responsible person, treating physician, or upon his own motion, an emergency custody order when he has probable cause to believe that any person (i) has a mental illness and that there exists a substantial likelihood that, as a result of mental illness, the person will, in the near future, (a) cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting, or threatening harm and other relevant information, if any, or (b) suffer serious harm due to his lack of capacity to protect himself from harm or to provide for his basic human needs, (ii) is in need of hospitalization or treatment, and (iii) is unwilling to volunteer or incapable of volunteering for hospitalization or treatment.”

I am not aware of any code change effective 1/1/2014.  

Q: Do you know of a contact at VA DMAS that we can get in touch with regarding billing and payment of services under TDO? 

The “helpline” at DMAS is 1-800-552-8627.  

Q: do you ever go to the LTC or ALF to do the evaluation or is the screening always done at the CSB?

Some CSB’s are “mobile” meaning they will provide an assessment in the community at a person’s residence. Some CSB’s conduct assessments in their office or in an emergency room. I would recommend consulting with your local CSB to see how they respond.

Q: Depression underdiagnosed especially among older adults living alone and not reporting symptoms clearly? Also dosage of antidepressants - should be different than younger adults?

Yes, depression is often under- diagnosed in older adults. What medication and what dose should be individualized and that decision should be made by a physician who knows the individual well.   

Q: In cases where law enforcement is already involved in crisis situation, at what point is MH evaluation done (when law enforcement may not be aware of prior MH diagnosis)?

At the time law enforcement (if they are initiating the ECO) determines ECO criteria is met, they will take the individual into custody for the purpose of an evaluation.  For law enforcement, often it is solely presenting behavior that initiates their ECO. During the ECO evaluation, there is more time for the CSB to gather history and find if there is a prior mental health diagnosis. A prior mental health diagnosis is not necessary to request an ECO.  

Q: Please comment on how your approach would change (or not) for dually diagnosed individuals (i.e. MH and ID/DD).

The TDO assessment process includes gathering collateral information as well as face to face mental status exams. The TDO criteria remains the same for all individuals who present with a mental health crisis despite additional diagnoses. The challenge for clients with IDD/DD many times is determining baseline status and what behaviors are a result of the IDD/DD vs mental health diagnosis.  Collateral information from case managers as well as other caregivers can assist clinicians in determining the most positive outcome for clients.  Clinicians should conduct assessments based on an individual’s abilities.