Emergency rooms and inpatient psychiatric care

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Many individuals living with a serious mental illness (SMI) do not adhere to outpatient treatment, often resulting in increased rates of suicide and self-harm, violent behavior, insecure housing, high utilization of ERs, and frequent contact with law enforcement. These behaviors and vulnerabilities lead to high rates of inpatient psychiatric hospitalization and incarceration.

Assisted outpatient treatment (AOT) is a legal mechanism for providing outpatient treatment to individuals living with SMI whose non-adherence places them at risk for negative outcomes. AOT works by compelling the recipient to receive specific treatment that will prevent their condition from worsening and by committing the mental health system to provide treatment. AOT orders allow concerned parties (such as families and treatment providers) to intervene on behalf of an individual living with an SMI without having to wait until that individual reaches a crisis, increasing the individual's ability to function in the community.

Emergency rooms

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Why does AOT matter to emergency rooms?

Emergency departments (ERs) have seen significant increases in admissions for patients presenting with mental health concerns. In Michigan, psychiatric emergencies were the most common reason for ER visits from 2017-2020. Patients admitted for mental health concerns stay disproportionately longer than other patients, often because of factors outside of the ER (such as limited inpatient beds). This results in an enormous financial burden to hospitals and limits capacity to provide other emergency services. In many cases, these increases can be attributed to frequent admissions of a small portion of patients with SMI in need of more sustained intervention.

People living with SMI often experience an inability to recognize their illness or symptoms which make them suspicious of treatment, making it challenging for them to adhere to outpatient treatment. This can lead to further decompensation and high utilization of ERs for healthcare. Many of these individuals are more familiar to ER staff than community mental health professionals, creating a unique opportunity for ER staff to directly address the problem of high utilization by starting the process for AOT. Research has found that individuals on an AOT order have less frequent ER visits, reduced suicidal and violent behavior, and reduced substance misuse.

AOT is designed to address the issue of non-compliance among people living with SMI, particularly those that cannot recognize that they are ill. Under Michigan law, the AOT process can be easily initiated  by completing the same form used for involuntary hospitalization (PCM 201 "Petition for Mental Health Treatment"). It can be submitted to the Probate Court for those being discharged home or sent along with the standard documentation for those being transferred to an inpatient psychiatric facility.

What are emergency rooms responsible for? 

• Contact CMH if someone with an AOT presents at the ED – if unsure, check probate court website or directly with CMH.
• Coordinate care with CMH and other providers.

Action steps for emergency rooms:

• Educate staff on patients eligible for AOT.
• Adopt a process based on existing evidence to screen patients eligible for AOT.
• Work with county Probate Court(s) to create a system to easily file petitions.
• Identify a contact person within the community mental health authority(s) to assist in the tracking and monitoring of the AOT process.

Inpatient psychiatric facilites

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Why does AOT matter to inpatient psychiatric facilities?

AOT is designed to address the issue of lack of adherence among individuals living with SMI, particularly those that cannot recognize that they are ill. Under the current mental health code, individuals are eligible for AOT if their lack of recognition that they need treatment results in non-compliance and the likelihood that their condition will worsen, increasing the risk of harm (physical or mental) to themselves or others.

Lack of adherence can lead to decreased capacity to manage illness, worsening of symptoms, failure to connect to outpatient treatment, and thus frequent utilization of inpatient psychiatric care. Individuals can become dependent on costly care for their SMI needs, particularly those on Medicare who do not have contact with their community mental health until they have exhausted their benefits. Thus, inpatient psychiatric facilities are often the only mental health contacts many individuals have and the best opportunity for AOT to be initiated.

Research has found that individuals with an AOT order have less frequent hospital visits, reduced suicidal and violent behavior, and reduced substance misuse. Accordingly, using AOT as a tool to intervene with the individuals seen most frequently offers potential benefits to the inpatient facility and staff, including reduced readmission rates, increased patient safety, and improved employee retention.

The role of inpatient facilities in deferrals

The deferral conference is a critical component for connecting individuals to treatment in the community who have been hospitalized pending a court hearing. These individuals have been certified by two doctors to require hospitalization. About 60% of all mental health petitions are resolved at the deferral stage. The Mental Health Code requires that the hospital where the person is hospitalized schedule the deferral conference and notify:

• legal counsel.
• a treatment team member assigned by the hospital director.
• a person assigned by the executive director of the community mental health services program.
• if possible, a person designated by the individual.

The purpose of the deferral conference is to inform the individual of the proposed plan of treatment in the community which may include a period of hospitalization as well as assisted outpatient treatment. If the individual agrees to a plan of treatment that includes assisted outpatient treatment, and requests deferral, the hospital director is required to release the individual from the hospital to the outpatient treatment provider.
 
At the deferral conference, the individual may agree to sign a stipulation to agree to voluntary treatment and waive a court appearance. It is important that the waiver and stipulation identify the specifics of the treatment plan.
 
The importance of connection to treatment in the community in the event of a deferral is the ability to convene a hearing during the period of the deferral to secure compliance with treatment. 

What are inpatient psychiatric facilities responsible for?

• Coordinate with CMH in discharge planning.
• Notify the court within 5 days of discharge of an individual who is on an AOT.
• Screen patients for appropriateness of AOT if they are not already on one.
• Schedule and host deferral conference when appropriate.

Action steps for inpatient psychiatric facilities:

• Educate staff on AOT, including identifying patients eligible for AOT.
• Develop internal process for screening clients to identify who could benefit from AOT.
• Identify community providers (such as CCBHCs and CRSPs) who offer common AOT services and establish liaison role.
• Work with county Probate Court(s) to create a system to easily file petitions.
• Identify a contact person within the community mental health authority(s) to assist in the AOT process.