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Current statutes and procedures governing when and how the Temporary Detention and involuntary admission process

may occur

How to initiate the Preadmission Screening and Temporary Detention process

Practical considerations to keep in mind when initiating the Temporary Detention and involuntary admission process (e.g., helpful documentation, timing, medical clearance, transportation, readmission to facility after treatment and stabilization)

Case studies will also be presented.

Abbreviation Detail ALF Assisted Living Facility BHA Behavioral Health Authority CSB Community Services Board

DBHDS Department of Behavioral Health and Developmental Services


DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders (replaced by DSM-V in May 2013)

ECO Emergency Custody Order

ISP Individualized Service Plan


MOT Mandatory Outpatient Treatment TDO Temporary Detention Order

This presentation includes material about Virginias involuntary treatment process for people with mental illness, which is based on Virginia law. Individual states all have their own involuntary treatment laws. State laws in this area are often similar, but rarely identical, and some individual states laws are very different from those in other states. The situations discussed here are relevant anywhere, so its important to know the laws of your state.

Involuntary admission is the court process by which a petition is filed to initiate involuntary psychiatric treatment for a person who needs care but who is unwilling, or incapable of volunteering for treatment (Code of Virginia, 37.2-808, et. seq)

The petition is adjudicated by a judge or special justice at a formal court hearing.


Due process protections are important, but balancing rights of individuals with community interests and public safety can be difficult. Treatment resources are limited and controversies abound.

Emergency Custody (ECO) CSB Crisis Contact Temporary Detention (TDO)

Release or Dismissal Mandatory Outpatient Treatment Voluntary Inpatient Treatment

Petition Filed

Court Hearing (on petition)

* Operational procedures vary considerably from locality to locality

Involuntary Inpatient Treatment

Emergency custody and temporary detention are not required for every involuntary admission (i.e., ECO is not required for temporary detention, TDO is not required for commitment). But, both procedures are needed for due process and practical reasons, for example: Emergency custody allows an in-person examination, to confirm the need for temporary detention.

Temporary detention allows time to organize a fair involuntary admission court hearing.

issued by a magistrate on a petition or his/her own motion,

An ECO may be:

or

initiated by a law enforcement officer on his/her own observations or the reports of others (officer-initiated or paperless ECO).

PROBABLE CAUSE is the evidentiary standard for emergency custody to be used.

Under an ECO, the person is taken into custody and brought to a convenient location, if needed, so that CSB can complete the in-person evaluation required for temporary detention. TDO may result.

TEMPORARY DETENTION IS A BRIEF PERIOD OF CONFINEMENT ORDERED BY A MAGISTRATE (TDO) PRIOR TO THE COURT HEARING.

Temporary Detention

May be ordered if the in-person CSB evaluation (i.e., the ECO evaluation) has occurred,* criteria are met and TDO is needed. Occurs in a safe clinical setting, (usually a hospital) where treatment can be started.

During temporary detention, the hearing is scheduled, participants are organized and relevant information is gathered.

* There are some exceptions to the requirement for prior in-person evaluation.

. person (i) has a mental illness and . 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.

* Other specific findings and determinations are associated with each procedure.

A preadmission screening report is required to be presented, by the appropriate CSB, at the involuntary admission court hearing. The requirements for preadmission screening report are different from ECO/TDO evaluation requirements, but In almost all instances, when a CSB performs an exam for a TDO, that evaluation also serves as the CSBs preadmission screening report for the subsequent court hearing.

Only qualified CSB employees or designees may perform ECO evaluations for TDO, and preadmission screening for commitment hearings. Requirements are:

Masters degree in a clinical field recognized by the Virginia

Department of Health Professions (e.g., Counseling, Psychology, Social Work, Rehabilitation Counseling).
Licensed Registered Nurse with 36 months professional

work experience with a psychiatric population.


Completed DBHDS Preadmission Screening on-line

Certification Training (a series of modules)


CSB supervisory approval

Documentation of above (i.e., educational credentials, supervisory approval and completion of on-line curriculum) is maintained in CSB personnel files.

See http://www.dbhds.virginia.gov/OMH-MHReform.htm.

Conduct face-toface assessments of persons in crisis for acute mental health and substance use disorders; Implement Virginias involuntary admission statutes, including attendance at court hearings. Collate information from individuals being served, family members, other providers, medical and other records and any other source;

TYPICAL CSB EVALUATOR RESPONSIBILITIES

Document assessment findings and determinations in the Virginia Preadmission Screening Report form.

Provide crisis counseling, outpatient and inpatient referrals. Serve as primary gatekeepers to community hospitals, state hospitals, & training centers, including locating and accessing inpatient beds for temporary detention.

COURT HEARINGS

Court hearings must be held within 48 hours of TDO, or on the next business day if 48-hour period ends on Saturday, Sunday or holiday.

Persons receives explanation of rights, counsel, etc.


Independent examination required. CSB preadmission screening report required.

Hearing attended by judge (usually special justice), individual and attorney, petitioner, as well as independent evaluator,* CSB screener* (both may participate by telecom), treating MD* or hospital representative, family or friends. *may participate and/or report by electronic means.

Dismissal of the petition, and release from court jurisdiction;

POSSIBLE HEARING OUTCOMES

Voluntary inpatient admission for a minimum 72hour period, then 48-hour notice if leaving;

Involuntary inpatient admission (up to 30 days on initial order, 180 for renewal or recommitment);

Mandatory Outpatient Treatment (MOT).

The involuntary admission process can be painful and traumatizing.

Voluntary alternative dispositions, at any stage, should always be encouraged, such as:

Release to care of self, or with family or friend support;

Voluntary admission to a regional crisis stabilization unit; or

Voluntary admission to a psychiatric hospital.

Many other important issues are covered in involuntary admission statutes, such as: Permitted disclosures; Transportation, including use of alternative transportation; Mandatory outpatient treatment; Impact on right to purchase firearms, etc.

Also, be mindful of Advance Directives (54.1-2981, Health Care Decisions Act)

Law permits agent appointed in an advance directive or a guardian to admit an incapacitated person to a psychiatric facility for up to 10 days if:

Physician from admitting facility examines person and finds in writing that: CSB pre-admission screening is required for state hospital admission. Hospitalization may be continued beyond 10 days via other provisions of law (i.e., involuntary admission).

The person has mental illness, is incapable of making an informed decision, and needs inpatient treatment;

Proposed facility is willing to admit ; and

The persons AD authorizes admission by agent, or the guardianship order authorizes admission by guardian.

Virginia involuntary admission and related statutes leave room for local variations in practice. It takes all partners working together to make emergency services work well.
Collaboration and commitment to customers first is

essential.

Too much variation can complicate the process, and reduce timely access to care for some.

Appearance (neat, clean, disheveled, unkempt, bizarre)


Behavior/Motor Disturbance (agitation, aggression) Orientation (person, place, time, situation)

Speech (rapid, pressured, slowed, slurred)

A Mental Status Assessment is a systematic evaluation of a persons level of functioning and helps staff monitor changes from baseline level of functioning.

Mood/Emotions/Impulse Control Range of Affect (labile, flat, blunted, full range) Thought Processes (disorganized, flight of ideas, tangential) Thought Content (religious delusions, paranoid thoughts) Sensory Perceptions (auditory, visual, tactile, olfactory gustatory) Memory (immediate, recent, remote) Appetite/Sleep Insight and Judgment Risk Assessment (suicide or homicide ideation, intention, plan, means)

DELIRIUM
A person becomes disorganized, confused, and disoriented in a matter of hours or days.

COMMAND
HALLUCINATIONS

A person experiences command hallucinations or voices telling him to harm self or others.

SUICIDE
A person voices suicidal or homicidal thoughts with intent to harm self or others.

MANIA
A person develops manic or depressed mood symptoms.

PSYCHOSIS
A person develops psychotic symptoms including delusional thoughts or hallucinations.

What are delusional thoughts?

Paranoid (Believes CIA or FBI is monitoring him) Religious (Believes Jesus talks to with him) Somatic (Believes electronic devise is implanted in his brain) Grandiose (Believes he is president of the U.S.)

A person becomes psychotic.


Auditory (Hearing voices) Visual (Seeing things) Olfactory (Smelling things) Gustatory (Tasting things) Tactile (Feeling things on skin)

What are hallucinations?

What is a fixed delusion? Who develops a fixed delusion?

A fixed false belief that is resistant to reason or actual fact. People with schizophrenia and other psychotic disorders. Not necessarily!
Person believes she has 4000 babies and is pregnant again. Person believes he was abducted by the CIA as a baby. Person believes he is transmitting his thoughts via radar.

Is a fixed delusion an acute psychiatric emergency?

Examples:

WHAT IS MANIA?

A person becomes manic.

Inflated self esteem or grandiosity Decreased need for sleep More talkative than usual Flight of ideas or racing thoughts Easily distracted Increased activity or psychomotor agitation Excessive involvement in pleasurable activities

WHAT IS DEPRESSION?

A person becomes depressed.

Sad, empty, tearful Diminished interest or pleasure in activities Sleeping too little or too much Psychomotor agitation or retardation Fatigue or loss of energy Feels worthless or excessive or inappropriate guilt Poor attention and concentration Recurrent thoughts of death or suicide

WHAT ARE RISK FACTORS FOR SUICIDE?


Active psychosis (hallucinations, delusions) Self injurious, reckless, or impulsive behavior Current alcohol or drug abuse Presently clinically depressed (hopelessness, anxiety) Chronic debilitating medical illness with poor pain management Suffered recent major loss (death, divorce, home) Isolated from others socially Thoughts or fantasies about suicide Unexpectedly giving gifts or giving away personal items Unexpectedly writing a will or making funeral arrangements

A person wants to kill themselves.

WHAT ARE RISK FACTORS FOR HOMICIDE?


Active psychosis (hallucinations, delusions) Acute manic mood symptoms Paranoid beliefs that others want to hurt him/her Overt anger and hostility toward others Verbal threats to hurt or kill others Recent physical aggression toward others Thoughts or fantasies about killing someone History physical aggression toward others

A person wants to kill another person.

What are command hallucinations?

Auditory hallucinations or voices telling you to do something. Acting on the command can be life threatening. Sometimes voices tell you to kill yourself or kill someone else. Sometimes voices tell you to jump off a building because you can fly. Sometime voices tell you to do something more neutral (e.g., brush your hair). All command hallucinations should be taken seriously.

A person experiences command hallucinations.

Who might experience command hallucinations?

Persons with schizophrenia or schizoaffective disorder. Persons with bipolar disorder during manic or depressed mood phases. Persons with dementia. Persons with acute delirium.

Disorganized speech Change in the way a person communicates

Odd or incoherent sentences Forgetting words or names or making up words Changing topics repeatedly and rapidly

A person becomes disorganized, confused, disoriented in a matter of hours or days.

Disorganized behavior Change in normal behavior patterns

Naked in public settings Wearing costumes or many layers of clothing Incontinent or voiding in inappropriate places Taking things that do not belong to them Wandering into other persons rooms

Confusion and disorientation person

Does not recognize well-known staff or family Cannot find his bedroom or the dining room Does not know the time, day, month, year, season Does not know the name of the facility Does not know the town, state, country where he resides Cannot share his life history

Delirium is Always an Acute Medical Emergency.

Delirium is an acute, transient (comes and goes), reversible state of confusion characterized by disorganized thoughts and behavior, confusion, disorientation, poor attention and concentration, sleep disturbance, agitation, hallucinations and other psychotic symptoms.

Likelihood of developing delirium increases exponentially with age.

Delirium can be caused by the following factors:


Alcohol or drug use or abuse Over-the-counter drugs (laxatives, sleeping aids, antacids, pain relievers) Polypharmacy adverse interactions Acute physical illness (blood sugar, blood pressure, thyroid, kidney) Brain injury, lesions, stroke Vitamin B12 and folate deficiencies Sodium and potassium imbalances HIV/AIDS Surgical procedures and anesthesia

Psychosocial stressors (family death, social isolation)


Sleep deprivation Urinary tract infection / dehydration Lack of sensory stimulation and immobilization

Drugs commonly associated with delirium

Anticholinergics

Artane, Benadryl, Cogentin, Symmetrel

Anti-Parkinsons Anxiolytics sedatives hypnotics Histamine-2 receptor blockers

Levodopa, Carbidopa

Ativan, Klonopin, Ambien

Tagament, Zantac

Narcotic analgesics

Demerol, Dilaudid, Fentanyl, OxyContin, Percocet, Vicodin

Following is the DSM-IV-TR Diagnosis:

The development of multiple cognitive deficits manifested by:


one (or more) of the following COGNITIVE DISTURBANCES: Aphasia (language disturbance) Apraxia (impaired motor functions) Agnosia (failure to recognize or identify objects) Disturbance in executive functioning (planning, organizing, sequencing, abstracting)

MEMORY IMPAIRMENT (impaired ability to learn new information or to recall previously learned information)

DEMENTIA

Learning Problems Memory Problems Dysarthria or Involuntary Movement Hypo-activity

Associated Features

Hyper-activity Psychosis Depressive Mood Sexual Dysfunction Sexually Deviant Behavior Odd or Eccentric or Suspicious Personality Anxious or Fearful or Dependent Personality Dramatic or Erratic or Antisocial Personality

Medical screening and assessment is an important part of screening for hospitalization. psychiatric hospitals today justifiably emphasize the importance of careful medical screening and assessment prior to admission of any person, and most hospitals will not admit a person unless such screening has been completed. To bring more consistency to practice, Virginia developed Medical Screening and Assessment Guidance Materials in 2007 (see http://www.dbhds.virginia.gov/documents/omh-reformMedicalScreenGuide.pdf These materials are in the process of revision and will likely be completed Summer 2013.

CAUSE
A first logical step in an acute psychiatric emergency is to rule out a medical cause for changes in mental status and behavior.

PHYSICAL
Physical exam, blood and urine lab work, and other medical tests are conducted to rule out a medical problem. Mental status and behavior often stabilizes with medical treatment.

PSYCHIATRIC CLEARANCE Once a medical


cause is ruled out a psychiatric bed can be obtained. Medical clearance is almost always required by a psychiatric hospital before accepting a person for admission specifically to rule out medical causes for change in mental status and behavior.

Elders with a dementia diagnosis can benefit from inpatient psychiatric treatment if they have:

Acute symptoms of psychosis Acute symptoms of depression or mania Acute symptoms of anxiety and agitation Current Alcohol or substance abuse

Medical Record should reflect systematic changes in mental status and behavior. Good documentation helps the Preadmission Screener with decision to hospitalize or not.

Inpatient psychiatric hospitalization is appropriate if there is reason to believe that the acute psychiatric symptoms will IMPROVE with treatment. Chronic behaviors and symptoms should be managed by an outpatient physician and by implementing behavioral interventions in the residential setting.

Acute symptoms are not dangerous to self or others and can be treated and monitored by an outpatient physician.

Elders with a dementia diagnosis likely will not be accepted for inpatient psychiatric treatment if:

Symptoms or behaviors are not expected to improve with psychiatric medication.

Symptoms or behaviors are chronic and persistent and have not responded to psychiatric medication trials in the past.

Condition for admission to any hospital:


Facility Administrator often must state in writing that the

person can return to the facility when the accepting hospital determines the person is ready for discharge.
Without a letter many hospitals will not admit the person. Average length of stay 3 to 14 days.

Any person

Other care provider Anyone can request an evaluation or a Preadmission Screening Assessment:

Family or friend of person

Hospital

Police

CSB office

Crisis center
Assessment is completed in a safe setting approved by the Crisis Counselor

Hospital Assisted living setting Jail or police department Home or private location (per CSB policy)

If person is an acute danger, severely disorganized, uncooperative, assessment is done under police supervision in a secure setting
Magistrate issued ECO Officer initiated ECO

If person is cooperative and not dangerous, assessment is done without police supervision at a location determined by the Crisis Counselor.

The following case studies illustrate concretely different kinds of acute psychiatric emergencies. The scenarios are designed to help integrate the information provided in the previous slides. The scenarios show the many layers of intervention and care associated with any crisis and the importance of collaboration and communication between all the partners. For each case scenario the interventions are presented followed by outcomes.

CASE SUMMARY
She is a 72 year old female residing in an assisted living facility for the past five years. She has received treatment for bipolar disorder since her early 20s. When stable, she is kind, sociable, a friend to many persons. Staff notices she has started wearing flamboyant jewelry, bright and provocative dresses, bright eye shadow and blush. She is making sexually explicit comments to male persons, even inviting them to her room. When approached by staff she is verbally hostile, insulting, loud, disruptive, and angry. She even attempts to hit staff when approached for daily care. She tells you that You have AIDS and Tuberculosis, you get away from me.

INTERVENTIONS
Staff recognized and started documenting changes in mental status and behavior. Staff monitored closely for medication compliance and she was put on close observation status. Physician ordered a urinalysis, basic blood work, and a Lithium or Depakote level. She refused to cooperate with the physicians orders. Staff called the CSB for guidance. Staff was instructed how to obtain an ECO from the local Magistrate. The ECO was obtained and she was taken by police to the emergency department for medical clearance and preadmission screening. She was medically cleared. The preadmission screener met police at the emergency department, interviewed the person, started preparing the preadmission screening report, and started looking for a TDO bed. The preadmission screening report was faxed along with the medical results to a psychiatric hospital. She was accepted for admission under the condition that the facility administrator would state in writing that she could come back to the facility once the hospital determined she was ready for discharge. The facility administrator wrote the letter and the letter was faxed to the hospital admissions department. She was accepted for admission. The TDO was issued. The police transported her to the accepting hospital.

OUTCOME
While under TDO, she refused to take her medications. She was evaluated by the psychiatrist and an independent evaluator in preparation for court. She met with the attorney assigned to represent her in the court hearing. A CSB representative attended the court hearing as required by law. The psychiatrist and independent evaluator recommended involuntary hospitalization for up to 30 days. The psychiatrist also requested judicial authorization to start client on a mood stabilizer and an antipsychotic medication. Both orders were issued by the special justice. She was hospitalized for 15 days. During hospitalization her mood, thoughts, and behavior stabilized. She gained insight about her decompensation and agreed that she needed to stay on her medications in order to stay stable. She returned to the facility where she was happy to see her friends and resume her life.

CASE SUMMARY He is a 77 year old man with dementia. He has several medical problems including hypertension and type II diabetes mellitus. He is treated for depression with an antidepressant and mild antianxiety medication. Generally he is cooperative with care. He has family who visits often. Sometimes he does not recognize them or calls them by the wrong name, but otherwise he enjoys their company. One morning he is uncooperative with ADL care.

INTERVENTIONS Staff immediately reported the specific changes in mental status to the supervisor. The supervisor contacted his physician. The physician instructed staff to arrange immediate transport to the emergency department. Staff called 911 and he was transported to the emergency department. The supervisor contacted the emergency department and gave report to the charge nurse. Report included medical history, current medications, description of baseline mental status, and a description of specific changes noted in the past 24 hours. Family was informed as appropriate and the incident was documented in detail in his medical record.

OUTCOME He was transported to the emergency department via rescue squad for assessment and treatment. He had a urinary tract infection and he was dehydrated. His blood sugars and blood pressure both were high. He was admitted to the hospital and over a two-day period his medical problems stabilized and his mental status returned to baseline. Family were helpful to hospital staff in reporting baseline functioning. He was discharged back to the facility much to the relief of his children and grand children.

He is agitated, strikes out at his care provider, is talking loudly but you cannot understand what he is saying.
He is incontinent of bowel and bladder. This is a rapid and striking change to his normal behavior.

CASE SUMMARY
He is a 57 year old male with schizophrenia since his mid-20s.

INTERVENTIONS
Prior to the incident of self-harm, staff recognized and started documenting his voiced complaints and concerns, and changes in sleep and appetite patterns. His psychiatrist was contacted. A PRN sleep aid was ordered. No additional safety or support measures were implemented at that time. When staff found him in bed with self-inflicted injuries, staff called 911 and he was transported to the ED for medical evaluation, treatment, and preadmission screening by the CSB. The supervisor contacted the emergency department charge nurse and then the CSB emergency services preadmission screener and gave report. The report included his psychiatric and medical history, current medications, description of incident, description of specific changes observed in the past two weeks, and a description of his baseline mental status and level of functioning. Family was informed as appropriate. The incident was documented in detail in his medical record. The preadmission screener was informed by the emergency department physician that he was medically cleared and ready for assessment. The preadmission screener found that he was severely depressed and psychotic and was considered a danger to himself and in need of acute psychiatric treatment; he was not considered competent to consent to voluntary admission. The preadmission screening report was faxed along with the medical results to a psychiatric hospital. He was accepted for admission under the condition that the facility administrator would state in writing that he could come back to the facility once the hospital determined he was ready for discharge. The facility administrator wrote the letter and faxed it to the hospital admissions dept. He was accepted for admission. The preadmission screener requested a TDO from the local Magistrate. The TDO was issued. Police transported him to the accepting hospital.

OUTCOME
While under TDO he was fully cooperative with medication and treatment. He demonstrated insight about his depression and self-injurious behavior. He was evaluated by the psychiatrist and an independent evaluator in preparation for court. He met with the attorney assigned to represent him in the court hearing. A CSB representative attended the court hearing as required by law. During the court hearing the special justice asked him if he wanted to sign in on a voluntary treatment order. He stated that he did. The special justice asked the independent evaluator and hospital representative if the individual had the capacity to consent to voluntary admission and both said he did. The CSB representative agreed. He was allowed to sign in voluntarily and informed by the special justice that he should work closely with the treatment team on his treatment and discharge plan. He was told that if he decides that he wants to leave early he must state so in writing and allow the hospital 48 hours to prepare for his discharge. He stated he understood. He was hospitalized for 9 days during which his mood, thoughts, and behavior stabilized. He participated in groups and activities. He returned to the facility and resumed his life.

He was hospitalized at Western State Hospital for two years and then discharged to an ALF due to his fragile medical condition.
He has a loving and supportive family who visits often. He has been active in day treatment programs. He accepts his medication injection every two weeks. He becomes increasingly depressed over a two-week period. He complains that he cannot sleep. His appetite is poor. He complains of voices and noises outside his bedroom keeping him awake at night. He becomes increasingly anxious, distraught, and frightened.

He is found one morning in his bedroom with non-life-threatening cuts on his wrists and neck.

CASE SUMMARY
She is an 82 year old female with dementia. She does not have a history of psychiatric problems. She was admitted to an ALF six weeks ago because she could no longer live independently. She has had a difficult time adjusting to this new setting. She does not seem to recognize staff day to day and she becomes confused, agitated, restless, and frightened. She is often tearful. She resists care and can be physically aggressive toward staff. She believes that other persons are stealing her belongings and she has taken to yelling and striking out at other persons.

INTERVENTIONS
Staff called the CSB for guidance. It was determined that she was willing to go to the emergency department for medical evaluation. Staff arranged transfer via medical transport. The supervisor contacted the emergency department charge nurse and gave report. The report included her medical history, current medications, description of behaviors since admission to the facility, and description of her baseline mental status and level of functioning. Family was informed as appropriate. The incident was documented in detail in his medical record. The preadmission screener was informed by the emergency department physician that she was medically cleared and ready for assessment. The preadmission screener found that she is confused, agitated, and psychotic. She would benefit from short-term evaluation and treatment in a psychiatric hospital. She was not considered competent for voluntary admission. A TDO bed was pursued. The preadmission screening report was faxed along with the medical results to a psychiatric hospital. She was accepted for admission under the condition that the facility administrator would state in writing that she could come back to the facility once the hospital determined she was ready for discharge. The facility administrator wrote the letter and the letter was faxed to the hospital admissions department. She was accepted for admission. The preadmission screener requested a TDO from the local Magistrate. Alternative transportation via medical transport also was requested. The TDO and alternative transportation order was issued.

OUTCOME
While under TDO she was started on medication to help stabilize her psychiatric symptoms. She was evaluated by the psychiatrist and an independent evaluator in preparation for court. She met with the attorney assigned to represent hher in the court hearing. A CSB representative attended the court hearing as required by law. She was involuntarily committed to the hospital for up to 30 days. She spent 25 days at the hospital and upon discharge returned to the facility. Family visited often and provided valuable feedback to the staff about her baseline level of functioning. Upon discharge, once again she had to adjust to a new setting, new people, and new routines. Her family visited several times a week to help with her transition and adjustment.

First and foremost you should always feel free to call Emergency Services to consult about a case.

Finally, and most importantly, develop and nurture relationships with your community partners and work with them to provide best practice care for people experiencing a psychiatric or behavioral crisis.

Watch for, recognize, and document early symptoms and early changes in mental status and behavior.

SUMMARY

If you are a facility, consider implementing an evidence based behavior and environmental management program for persons with challenging behaviors.

Rule out medical causes for changes in mental status and behavior.