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Regional mental health boards forward legislative proposals to revise legal holds, bolster crisis services

Megan Messerly
Megan Messerly
Health CareLegislature
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Vitality Unlimited provides substance abuse treatment in Elko

Groups in four corners of the state have been meeting over the last year to contemplate how to better care for residents grappling with mental health issues, a population that oftentimes has no one to advocate on its behalf.

Out of those meetings, the state’s four regional behavioral health policy boards, one each in Northern Nevada, Southern Nevada, Washoe and the rural counties, have come up with four proposals they are forwarding on to lawmakers in the upcoming session. The bills, which have been prefiled with the Legislature, include proposals to revise the state’s system for placing individuals under involuntary legal holds, expand crisis mental health services and increase the ability of those in rural counties to access care over great distances.

Chuck Duarte, CEO of Community Health Alliance and chair of the Washoe Regional Behavioral Health Policy Board, said that the regional behavioral health board structure has concentrated a wide range of interests that might otherwise not have met on a regular basis.

“It’s really brought together a lot of people and increasingly we’ve seen increased attendance of community members to the meetings,” Duarte said. “I think it has been a forum for not only people to hear about these issues but possible solutions.”

The boards, which were created by AB366 during the 2017 legislative session, are required to be comprised of certain members including representatives from hospitals, community-based behavioral health providers, substance abuse treatment facilities, residential behavioral health facilities, county health officers, psychiatrists, insurance companies, law enforcement and emergency personnel, as well as someone who can advocate on behalf of patients.

Sheila Leslie, who served as the Washoe Regional Behavioral Health Board’s coordinator for the first half of the year, said the boards created a space for discussion about a group that the state hasn’t prioritized enough.

“They don’t vote. They don’t advocate well for themselves,” Leslie said. “It’s a topic that a lot of people a lot of legislators are very nervous about. They don’t understand it. They’re afraid of it. It’s not as intriguing as solar power. It’s not something a lot of people have a lot of interest in, yet if we could improve behavioral health we could increase public safety, decrease homelessness, there are so many good things that could come.”

Here’s a look at the four bills that the boards are bringing forward to the Legislature.

Northern Regional Behavioral Health Policy Board

The Northern policy board, which represents Carson City and Churchill, Douglas, Lyon, Mineral and Storey counties, undertook a review of the state’s law on involuntary mental health holds, known as Legal 2000s. The board tasked a statewide working group — which included judges, district attorneys, and public defenders from Washoe and Churchill counties, as well as representatives from Nevada Rural Hospital Partners, the Nevada Hospital Association, Renown Hospital, a couple of hospitals in Clark County and law enforcement — with examining how the legal holds function across the state.

“When the Northern Behavioral Health Policy Board decided to work on legal holds, we realized that this was a statewide issue and we really wanted to develop consensus throughout the state,” said Jessica Flood, the board’s coordinator. “It was great to get all of those perspectives because each region has their own issues they’ve identified.”

Flood said that the bill that they came up with, AB85, aims to “clarify and standardize” legal hold practices across the state.

“The vision that we were working toward is to be able to have a shared understanding across the state of how the legal hold process works and from that we can develop patient rights and education that can be handed out at every hospital in Nevada,” Flood said. “If you or a loved one were to end up on a legal hold, someone can give you a document that really describes what it is and how to advocate for yourself in that process.”

Northeastern Nevada Regional Hospital staff gather in the emergency room area in Elko on Tuesday, April 3, 2018. (Jeff Scheid/The Nevada Independent)

One primary change the bill would make is to clarify the time frame for mental health holds by specifying that the 72-hour clock for the hold begins as soon as an application for emergency admission is filed. Flood said the existing law can be confusing because it says that the 72-hour clock begins after medical clearance, but practitioners have different definitions of what constitutes medical clearance.

It also would eliminate the 24-hour window for providers to determine whether a legal hold should be placed on a person. Flood said the changes would align the law with current practice of hospitals immediately placing a hold on a person if they believe the person is likely to cause serious harm to himself or others.

The legislation also proposes changes to the timeline under which a petition for involuntary court-ordered admission to a mental health facility is ordered. Under current law, courts have five days to set a date for a hearing on the petition; the new legislation would extend that to six days to prevent courts from having to meet twice a week, Flood said.

Another significant change in the legislation, which Flood said would align Nevada with national best practices, is who qualifies for a legal hold. For instance, the bill would remove the phrase “clear and present danger” in favor of “substantial likelihood of serious harm,” as well as lengthy sections requiring providers to consider whether a person had caused or attempted self-mutilation and judge whether the person would reasonably be a danger to themselves or others in the next 30 days.

“This has always been a concern for clinicians, because they don’t have a magic wand and they can’t see into the future,” Flood said.

The legislation also would clarify that mental health providers and the courts may disclose certain information about a patient’s clinical record in order to assist health-care providers with treatment. Flood said that some providers have expressed concerns about who they can share information with and that this provision of the bill will ensure that providers are able to share necessary information to treat a patient.

It additionally includes cleanup language about what role “accredited agents of the Department” — in other words, companies or agencies that contract with the Department of Health and Human Services — play in the legal hold process. Flood said that the existing provisions applying to that group have “never really been used” but that the board wanted to preserve the portion of the law allowing accredited agents to assist in the transport of those under a legal hold as part of the state’s efforts to create better options for behavioral health transportation in the state.

The bill also removes a provision that requires at least one person of the same gender or a close relative be present in order to transport someone to a mental health facility, something that Flood said “creates an unnecessary barrier” and can be addressed through training. The legislation would also require hospitals to report 72 hour holds to the state in order to better track the use of involuntary holds, something that Flood said the hospitals have expressed support for even though it is an added burden for mandated reporting.

Flood said that the working group plans to continue to meet and that the bill is the first portion of a two-step process that includes stakeholder and community education about how legal holds function across the state.

“We are trying to talk about how it enhances patient rights, standardizes practices and really clarifies practices,” Flood said.

Washoe Regional Behavioral Health Policy Board

The Washoe policy board, which unlike the other policy boards only covers a single county, is putting forward legislation to address crisis mental health care after the county’s only crisis triage center abruptly shut its doors earlier this year. Duarte, the chair of the policy board, said WestCare’s closure brought the need for additional crisis mental health services in the county into sharp focus.

“That was an abrupt slap in the face that caught everybody off guard without notification, and it created its own minor crisis,” Duarte said. “As a policy board, it obviously was top of mind for the board members and the folks that were presenting information.”

Men's dorms at WestCare nonprofit addiction treatment center in downtown Las Vegas on Thursday, May 10, 2018. (Jeff Scheid/The Nevada Independent)

Clark County also struggled with its WestCare-operated crisis triage center this year when the company threatened to shut its doors if it didn’t receive additional funding from the local governments, hospitals and state. County officials grudgingly agreed to continue funding the center while they contemplated alternatives, including looking at other companies that could provide community triage center services.

Duarte said that the board brought in a number of speakers — from Canton, Ohio to Maricopa County, Arizona — to better understand effective crisis stabilization models across the county. He said that under the state’s existing crisis triage center model, the goal is to assess and refer patients out within 23 hours, whereas crisis stabilization programs in Canton and Maricopa County allow for multi-day stabilization and respite care before recommending patients out for intensive outpatient treatment.

“People are coming in crisis. They don’t need to be in isolation in an inpatient ward. They don’t need to be in an emergency room, but in a friendlier environment that doesn’t isolate them, as much as possible,” Duarte said. “It provides this bridge between triage, 23-hour observation care, and inpatient hospital or outpatient services. It’s part of a continuum of care that’s completely lacking in Washoe County.”

If approved, the bill, AB66, would require the state to establish centers to provide crisis stabilization services in Clark and Washoe Counties. The legislation would allow the state to enter into contracts with behavioral health-care providers to offer crisis stabilization services with the goal of de-escalating or stabilizing mental health crises and avoiding admitting patients to inpatient mental health facilities or hospitals.

Each facility would be required to operate 24 hours a day, seven days a week, with eight beds for patients to stay in no longer than 14 days. Duarte said that the centers would be “agnostic to payer source,” meaning that they would serve all patients equally whether they are covered by private insurance or Medicaid or are uninsured.

“We see some Medicaid [managed care organizations] contracting with these private networks to provide some of these services and that’s great and we can use more of that, but these things are for anybody,” Duarte said. “We don’t want to do a wallet biopsy or look at your Medicaid card. The goal is to treat the crisis and get you stable.”

The bill would allow the Division of Public and Behavioral Health to accept gifts, grants or donations to establish the crisis stabilization centers. Under the crisis triage center model, facilities bill Medicaid or whatever private insurance the patient has and funding from local governments, hospitals and the state is supposed to foot the remainder of the bill.

Duarte said that he and others in Washoe County have continued to stress the need for crisis triage services, but that the crisis stabilization centers would fill a gap in the county’s crisis mental health services.

“We hope we can build upon that and further enhance it with these types of programs that are really proving not only effective in providing quality care to these people but, even more importantly, drastically reducing health-care costs in terms of hospitalization and ER use and helping the state avoid problems with inappropriate institutionalization that we’re experiencing today in emergency rooms and sometimes in emergency hospitals,” Duarte said.

Though the bill as written would only apply to Clark and Washoe Counties, Rural Regional Behavioral Health Board coordinator Joelle Gutman said she would like to see the rural counties included in the bill to allow for regional crisis stabilization services.

“I’m hoping that will change during session because I think if we don’t address the gaps in services in the rurals it is still going to affect our urban regions, our urban counties. About 10 percent of all psychiatric admits are from the rurals,” Gutman said. “So it’s important that we are addressing capacity issues and gaps in our region.”

Rural Regional Behavioral Health Policy Board

The rural policy board, which covers Elko, Eureka, Humboldt, Lander, Lincoln, Pershing and White Pine counties, is proposing legislation to address the unique problem rural communities face in providing crisis mental health care. In rural Nevada, the burden of crisis mental health care often calls on sheriffs and their deputies, some who have acknowledged that the back of a police car or a jail cell is not the best place for a person in crisis but have grasped for alternatives.

The legislation, AB47, proposes to create a pilot program that would provide for an initial in-person response to a person undergoing a mental health crisis and seek to develop a new transportation model to transfer those individuals to a facility better suited to help them. Oftentimes the burden of transportation falls on law enforcement, meaning a person in crisis has to spend several hours in the back of a police car in order to get help — and the transporting officer is off the streets for twice the amount of time due to the round trip.

A sunset view of the Ruby Mountain as seen from Elko on Tuesday, Feb. 6, 2018. (Jeff Scheid/The Nevada Independent)

Specifically, the bill would require the state to develop a pilot program to provide for the transportation of people struggling with mental health issues by someone other than law enforcement “within a reasonable amount of time and in a manner that is safe and dignified” and appropriate a lump sum of $75,000 for that purpose. Gutman, the board’s coordinator, said state law currently only allows patients in crisis to be transported by law enforcement, taxi or ambulance.

“We’re confined to these three mechanisms of travel: taxi, which we don’t even have and is totally inappropriate; ambulance, which in my region sometimes our counties only have one or two ambulances and can’t afford to take them out of the county for a mental health emergency because they need it for a physical emergency like a car accident,” Gutman said. “And it places a huge burden on our sheriff’s offices.”

She noted that in some of the state’s smallest counties, like Eureka, a mental health transport could mean taking the only deputy on duty out of the county for 12 hours, and that being transported in the back of a police car can be a stigmatizing and traumatizing experience for the individual in crisis. She said that the board is hoping that the pilot program, if approved, will allow the state to explore what companies might be interested in providing this kind of service and ensure that there is a reimbursement model in place for them.

The bill would also require an emergency medical attendant or law enforcement officer who has gone through crisis intervention team (CIT) training to provide an initial in-person response to a mental health crisis in conjunction with a mental health provider, either in person or via telehealth. The legislation asks for $150,000 to conduct additional CIT training and another $150,000 to hire a mental health provider to coordinate the training and provide the crisis response; Gutman said that of all the bill’s monetary asks, the $150,000 for CIT training would be her top pick.

“With the money, I think we could train about 60 first responders. Then we could potentially have a certain percentage of CIT trained officers on duty at all times. It’s going to take years and years to get there with no funding help,” Gutman said. “But if each county has had somebody trained in CIT, that’s a success.”

Gutman said that the region held its first-ever CIT training in May and is planning its second for Winnemucca next week with funding pieced together from a number of different community coalitions.

The bill also asks for $200,000 to support four case managers who would be required to provide follow up responses to those who have gone through a mental health crisis specifically focused on addressing the person’s ongoing need for care.

Gutman said that all of the pieces of the legislation will hopefully add up to offer a so-called sequential intercept model of crisis intervention, from ensuring that first responders are adequately prepared to respond to a crisis to providing the case manager follow up post-crisis.

“We know how bills don’t look the same at the end as they did at the beginning,” Gutman said. “But I’m really hoping some of these pieces stay so we can demonstrate that case management and crisis intervention, the sequential intercept model, can work in a rural region as well.”

Southern Regional Behavioral Health Policy Board

The Southern policy board, which covers Clark, Nye and Esmeralda counties, put forward a bill that builds on and refines the legislation passed in 2017 that created the four policy boards. Assemblyman Steve Yeager, who chaired the Southern board, said the aim of the bill, AB76, is to expand the ability of the boards to collect and analyze behavioral health data as they are putting forward solutions.

“It was pretty difficult meeting even monthly for us to really wrap our arms around everything that was going on in this region and in this space,” Yeager said. “One of the things we were tasked with originally in the legislation was to take a look at data and analyze it and talk about it, and you can just imagine all the data that’s out there between various commissions and reports. It seems like every couple years there was one of those coming out.”

That’s why he said the board is recommending the state hire four full-time coordinators housed within the Commission on Behavioral Health whose sole responsibility it will be to assist the boards with data analytics and crafting policy solutions. Under the existing structure, four grant-funded coordinators assist the board but also carry out various responsibilities as liaisons between their communities and the state.

Yeager acknowledged that his board may have felt the crush of its responsibilities more acutely than other the boards because it comprises not only the state’s largest county, Clark, but two rural counties as well. Washoe County, which is one-fifth the size of Clark, had its own board, while the smaller counties were clustered into the northern and rural boards.

“One of the hard things in Southern Nevada, in Clark, is just to say what do we have going on because there are so many moving pieces,” Yeager said. “I don’t know that anyone has made a bona fide effort to say, ‘Let’s really look at what we have whether it’s state resources and nonprofit resources, what do we have going on there.’”

Freedom Behavioral Health clients gather in the court yard at Freedom Behavioral Health apartments in Las Vegas on Monday, Oct. 30, 2017. (Jeff Scheid/The Nevada Independent)

He said that the original intent of the policy boards — as they evolved out the Southern Nevada Forum, a group of lawmakers, business leaders and stakeholders who develop legislative priorities ahead of the session — was to also have separate money boards that would be responsible for allocating behavioral health funding within regions. Yeager said that if the money boards are created in the future, it would help to have additional information so the policy boards can make informed recommendations.

“Right now if they were to say, ‘Hey Southern Nevada here’s all of your money,’ I don’t think we are equipped to do that,” Yeager said. “I don’t think we have a complete picture of where the gaps are, who’s doing what.”

Yeager said a full-time coordinator dedicated only to the board would be able to conduct surveys, compile reports and talk to community members in order provide information that would enable the board to have more focused discussions at its meetings. The bill proposes to spend about $640,000 on the four positions over the biennium.

“The folks we have now did a fantastic job, but this is only a small fraction of their duties and it was hard to expend a massive amount of time preparing things for the board,” Yeager said.

The bill also asks the four boards to establish websites to track and compile data relating to the number of people admitted to mental health facilities, their outcomes, and what happens to them once they complete treatment. Yeager said that through its inquiries, the board discovered that there is no one place people can go to if they’re looking for behavioral health resources in Southern Nevada.

“We want to make it easy as possible for people to get information and not this, ‘Man, I’ve got to do 100 searches,’” Yeager said.

The bill also proposes to make other changes including adding Lincoln County to the southern board, though Yeager said he’s no longer sure that the county actually wants to join the board. It also would make accommodations for the people required to be appointed to the boards in the event that no such person is available, an issue that arose with the rural board because there is no psychiatrist in any of the board’s seven counties.

The legislation additionally would allow the boards to notify the state about any redundant, conflicting or obsolete federal, state or local laws that relate to behavioral health.

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