Cross-Systems Crisis Planning:Preventing and Managing

Behavioral/Psychiatric IncidentsBruce E. Davis, Ph.D.

Director of Behavioral and Psychological ServicesTN Department of Intellectual and Developmental Disabilities

John Stephen Bell, Ph.D.Intensive Consultation Team Director, West TN

Jenny Matthai, Ph.D.Intensive Consultation Team Director, Middle TN

Kris Roberts, M.S.Intensive Consultation Team Director, East TN

The Problem• Tennessee's mobile crisis system receives an average

of 560 crisis calls per year for persons served by DIDD.

• 56% of these calls result in a psychiatric hospitalization.

• Hundreds more have police contacts and/or incarcerations because of Behavioral/Psychiatric incidents.

• These data remain consistent from year to year. It is important that we have a system that is prepared for these types of incidents.

What constitutes a crisis?

• In the development of Cross-Systems Crisis Plans, a crisis is defined as:

• A situation where the risk of harm to a person supported or others is increased; AND

• Immediate resources for appropriate intervention are not adequate for restoring a healthy and safe situation.

Why Develop Cross-Systems Crisis Plans (CSCP)?

• Managing a crisis often requires responses from multiple service providers and agencies.

• Our goal is to minimize harmful or traumatic outcomes (for persons supported AND staff).

• Cross-systems crisis plans are written by agency staff to provide for an effective and efficient response to an emerging crisis.

Relevant Provider Manual Requirements

• 12.7.1 Crisis Intervention Policy

• 12.7.2 Cross-Systems Crisis Plans

Constructing the CSCP Part I - FACE Sheet

• Name, DOB, etc. THIS IS PROTECTED HEALTH INFORMATION. IT IS SUBJECT TO HIPAA REGULATIONS.

• Living situation - Describe the person's home, housemates, staffing ratio, and other relevant factors.

• Diagnoses - Copied directly from psychiatrist's record. Must be updated as changes occur.

• Clinical Disorders (Psychiatric disorders including personality disorders).

• Intellectual Disability Diagnosis

• Medical/Dental Disorders - Include frequent or recurring issues

• Insurance information (Medicaid, Medicare, MCO, etc.)

Constructing the CSCP - Communication

• Mobile crisis workers and others must know:

• How the person communicates with others.

• How best to communicate with the person.

• Describe how someone could tell if the person wants something or is distressed. Include information about how well the person expresses emotions as well as how they make their wants and needs known.

• Describe the best way to ask or tell the person something. For example, avoid leading questions, draw pictures, tone of voice, vocabulary, etc.

Constructing the CSCP Strengths, Skills, and Interests• It's easy to look at the person in crisis as the problem.

• Describe the person's positive side.

1. What is he/she good at?

2. What does he/she like to do?

3. What is funny to him/her?

4. Who is important to him/her?

• Include anything that might help a mobile crisis worker develop rapport and see the person AS A PERSON.

Constructing the CSCP – Listing Circle of Support/Providers

• Include a simple directory of key people.

• Agency name

• Name of the person representing the agency.

• Email address

• Phone number

Roles/Responsibilities of Crisis Response Providers

• DIDD Provider Agency – Develop the CSCP; Utilize prevention, redirectional and physical intervention strategies in accord with their policy on behavior safety interventions; .

• Mobile Crisis – Evaluate a crisis situation determine/arrange best available options from in-home adjustments to crisis stabilization, behavioral respite, or hospitalization; participate in CSCP development.

• Law Enforcement - Additional measures of safety; Transportation.

• Behavioral Respite – Estimated length of stay 15 to 30 days out of home for clinical observation and assessment (DIDD – voluntary – not secure- may not be immediately accessible).

• Crisis Stabilization – Length of stay is 3 to 5 days for inpatient treatment (DMHSA – voluntary – not secure).

• Harold Jordan Center Stabilization Unit – Estimated length of stay 15-30 days for inpatient treatment (DIDD – voluntary – secure- may not be immediately accessible).

• Psychiatric Hospital – Estimated length of stay is 0 – 15 days for intensive treatment and medication adjustments (DMHSA – voluntary or involuntary - secure).

• Intensive Behavior Residential Service – Estimated length of stay is 6 to 12 months for intensive psychological/psychiatric treatment. Not an emergency service. (DIDD –voluntary – not secure).

Process - COS Involvement in CSCP Development

• All appropriate members of COS may/should have input for the plan.

• A central team member from the primary provider agency will draft the plan and share it with others.

• Mobile crisis personnel and even police should also have input if consent to share information is obtained from the person or his/her legal representative.

Crisis Classification by Topography/Intensity of Behavior

Constructing the CSCP Part II - General Guidelines

• Describe general patterns of behavior (i.e., baseline).

• What does a typical (good) day look like?

• What kinds of typical difficulties/frustrations does the person experience that are NOT part of a crisis?

• This information is important because it defines the person’s baseline.

• The need for crisis services is based on behavioral health symptoms that are different from baseline.

Part II - General Guidelines (Continued)

• What factors are might bring about a crisis (i.e., increase stress)?

• Anniversaries

• Holidays

• Noise

• Change in routine

• Anticipation of a planned event

• Fatigue

• Difficulty communicating the experience of pain

• Particular types of interactions

• Re-experience of traumatic events

• Lack of control over personal decisions

• Impulsive decision making

• Social rejection

Part II - General Guidelines (Continued)

• Describe specific ways for family/staff to prevent the need for out-of-home placement and KEEP a “good day” going. Examples of general prevention strategies are:

• Follow BSP strategies for ______.

• Reduce sources of excess stimulation.

• Implement daily schedule

• Community outings

• Avoid confrontational or loud requests

• Ensure proper medical care for specific conditions

• Ensure personal preferences/non-negotiables are provided.

• Provide information specific to the person in this section. You may refer to the ISP, BSP, or other document as needed, but also provide a brief description here.

• Include only the most critical strategies here. Make it a brief list of no more than 5 or 6 items.

Constructing the CSCP Part III - Disposition Recommendations

• What out-of-home placements are most likely to work well for the person?

• Behavioral Respite

• Crisis Stabilization Unit

• Psychiatric Hospital

• Other state facility

• Be specific about the most appropriate facilities to provide assistance. To the extent possible, coordinate with them in advance.

Constructing the CSCP Part IV - Back-Up Protocol

• As the crisis develops family/caregivers must know the following:

1. What may happen?

2. Who to call.

3. What to do.

4. Phone number.

• Make the description and plan of action as brief as possible.

• Include redirectional strategies to de-escalate the crisis.

• Include circumstances under which physical intervention is used. Agencies should provide this training to Direct Support Professionals, if needed, to keep the person or others safe.

• Agency policy on the use of behavioral safety interventions may be referenced. This policy should outline the agency protocol in the event of a behavioral health crisis.

• Include criteria for when to call others for help.

Consent to Release Information

• If the CSCP is to be shared in advance of an actual crisis, consent to release the information is required.

• Example: CSCP is developed and primary provider agency wants to share it with the local mobile crisis unit. Consent REQUIRED.

• During a crisis, consent to release is not required.

• It is best if information can be shared in advance.

Complex Situations• Regional Office ICT teams may be able to provide additional support and

consultation for cases that are extremely complex.

• Some criteria to consider in making a referral:

• Two or more crises in six months (police or mobile crisis calls, behavioral respite, psychiatric hospitalization, incarceration).

• Significant risk to self or others.

• Barriers to cross-systems collaboration.

• Volume of requests is often heavy. Requests for Regional Office/Resource Center assistance are subject to prioritization of needs.

• West: Dr. John Stephen Bell (901) 745-7442

• Middle: Dr. Jenny Matthai (615) 231-5110

• East: Ms. Kris Roberts (423) 787-6731