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NAMI Discoveries at Psychiatric Health Facility (operated by TeleCare)

By NAMI Board Member, 2-Oct-2019

Yesterday we were warmly welcomed to a meeting with TeleCare’s local leadership overseeing the Psychiatric Health Facility (the only in-patient psychiatric hospital in El Dorado County.).  Our affiliate organized this meeting and tour.   This facility is an El Dorado County Health&Human-Services (EDC H&HS) facility built in 1941 and the services provided at what old-schoolers refer to as “the PHF.”    This in patient psychiatric hospital service is  sub-contracted to TeleCare by EDC H&HS.

Why is it that so many psychiatric hospitals are in the oldest, most unappealing buildings available within a county?  Kudos to Reno’s gorgeous brand new for profit Behavioral Health Hospital elevating the standard of care for Northern Nevada (adjacent to El Dorado County, CA).    Our NAMI Affiliate President spoke with the CEO of this Reno BH Hospital 2 years prior to their opening where he committed he would accept Medi-Cal and welcomed contracting with El Dorado County; we quickly shared this with then-Director of EDC H&HS as well as the Behavioral Health Commission.     We also advocated heavily for a renewed contract with Carson Tahoe Behavioral Health encouraging a greater focus on bi-state solutions for families in South Lake Tahoe.
If you look across most CA counties you will find those with in-patient psychiatric provide services in rather unattractive architectural dwellings.   That said, Telecare’s leaders have done well in leveraging every inch of available space.   They provide quality stabilization services and have made vast improvements under the leadership of a new director, Chandra Thomas.  Chandra previously oversaw services/supports at Crestwood in Sacramento, CA and clearly understands what quality services include.
We too have vast experience in what quality services look like having experienced quality services in other counties.  This made for positive collaboration; a meeting that welcomed excellence as a goal.
We encourage El Dorado County H&HS to at minimum provide budget for basic updating (paint, welcoming murals, warm lighting and updated interior design/furniture.).   Better yet, develop a long term strategy that includes short term and long-term solutions for the mentally ill.
Chandra has doubled capacity at this Psychiatric Health Facility in her first months on board.  Capacity was averaging about 50% at PHF for years from our NAMI observation and participation at BHCommission forums monthly.
11 different counties send their clients to El Dorado County’s TeleCare “the PHF”
TeleCare demonstrated interest in our questions and ideas on where each of us including county H&HS have the opportunity to improve in order to directly help clients and their families.
3 of our Board members along with a BHCommission leader met informally with TeleCare’s Chandra Thomas (Director); Dr Motl (Psychiatrist)  Cathi (Head of Nursing), and Maatisak (head Social Worker).   We came away feeling good about the services provided with some specific areas of opportunity.
Chandra graciously organized the team welcoming NAMI complete with very welcoming signage including one NAMI sign made by a client.  Thank you!  
Introductions were made then we were invited to ask anything.  This was a welcoming meeting where TeleCare demonstrated interest in our ideas and questions.
The objective of this informal meeting/tour was to get an understanding of Telecare’s services at this facility and how linkages with EDC H&HS and others occur.
Maatisak explained her role in leading social workers, peer support, therapists and recreation therapist (today they were making scented mini-pillows as part of recreation.). She also facilitates interaction with families and individuals.
Cathi explained her role in overseeing RN, LVN, LPT’s, Recovery specialists and clerks.
We met the Personal chef who provides nutritious meals/snacks homemade using fresh ingredients and they work with a contracted dietician on client needs and preferences.  The dietician is available monthly.
Key TakeAways:
– Telecare provides the same staffing levels on weekends and weekdays.
– Psychiatrist provides daily client check-in’s (even though per Title 22 H&HS code and contractually this is only required weekly.)

– Great focus on stabilization of clients.   Dr. Motl expressed great appreciation for Mayo Clinic’s GeneSite testing application which is now covered by Medi-Cal and used regularly within PHF.   He expressed favorable results not only for Depression/Anxiety/ADHD but also those living with Psychotic illnesses.  This test helps narrow medication options to a higher success probability (not guarantee) based on one’s DNA.    Chandra demonstrated the application on-line as a visual example.   Dr. Motl expressed appreciation for family members who provide written family genetic predisposition history and relevant traumas.

Family members are very key in helping Dr. Motl and PHF staff do their best in helping the client.  The family history going back to childhood is very important. Dr. Motl recently received a 20 page family history and leveraged this in his work process.
– There is an opportunity for EDC H&HS BH and Public Guardian to improve leverage of their websites to communicate/guide individuals and families.  For example, how would families know when county initiates guardianship vs when family can initiate this.   What are the pros/cons?  Why is this not posted anywhere especially when this can be a lifesaving element of stabilization and post-discharge-release and even core to obtaining past medical history to further help in the stabilization process?
– Team meetings occur weekly facilitated by Telecare: Fridays with Public Defender, Nicole from EDC H&HS BH – to discuss individual cases.
– Team meetings occur weekly facilitated by Telecare – Tuesdays with Public Guardian.
RISKS:
– There are no services in El Dorado County for the seriously mentally ill in terms of quality post-hospital step-down or longer term locked facilities or readily-available-quality Board & Care.  Discharging to homelessness is common and a county decision (not a TeleCare policy).   NAMI and TeleCare observe quality services are being provided by Shingle Springs Health & Wellness with in-patient psychiatrist appointment wait-times of about 1 week.    Seeing an outpatient psychiatrist post discharge to outpatient services is highly recommended.
– EDC performs a “contractual utilization review process” of PHF clients.  They do this without ever meeting the client; this process is done electronically by EDC H&HS BH reading case documentation notes written by PHF Psychiatrist and staff in order to make a decision as to release.  An average of 3 clients per month are released too soon without seeing the benefit of linkages to next level of care due to this flawed process.    Chandra took a class in documentation from SFCounty recently and will soon be cross-training the entire staff to help improve their documentation process.   Angelina Larragin from EDC H&HS BH oversees this process utilization on-line review and NAMI urges improved governance.   We are hearing cases where a next step longer-term treatment bed is reserved for a patient at the PHF but they are released prematurely through this utilization review process.  This is sad for families, the individual, and the TeleCare treatment team.
– Today EDC H&HS BH is the sole entity performing 5150 probable cause assessment.  The problem we observe is that EDC H&HS BH is not merely assessing “probable cause” but making determinations about whether someone is gravely disabled (or danger to self/others which is a more straight forward measure.)  Going from probable cause to 72-hour hold which would of course then allow skilled psychiatrist and licensed emergency mental health workers such as those at the PHF saves lives.
– El Dorado Community Health Centers (Placerville, Diamond Springs and Cameron Park) 530-621-7700 https://www.edcchc.org stopped providing long acting injectables!   LAI’s are the gold standard for those living with psychotic disorders such as Schizophrenia, BP1, etc.  It is wildly concerning this has stopped rather than being expanded!   NAMI will be investigating this further.   They have told TeleCare leaders that there is no psychiatrist to provide the injection.  NAMI and TeleCare were quick to point out that providing a LAI (Long Acting Injectable) does not require a psychiatrist to perform the injection.  Any med tech can perform this (some Safeway specialty pharmacies provide this; med techs, etc.).
– EDC H&HS do call to remind patients about their transition from discharge appointments.   However, particularly with the homeless population that have not indicated family support, this is an area where we lose people and the cycle begins all over again.   The transition out of TeleCare into EDC H&HS BH needs improvement, policy, governance, measures.  That said, this county needs to invest in long-term care solutions.
About 85% (best guesstimate by TeleCare) are getting connected to EDC H&HS BH for follow-up when the client is already in the EDC H&HS BH system.  Some of course are already in the Shingle Springs Health & Wellness system so they are transitioned to that system of care.  Kaiser is another example of next step post-PHF-release system of care.    Ensuring loved ones get into a system of care is crucial as we all must anticipate relapse and openly dialogue about systems of care.
Drug testing:   Improved drug testing to begin in mid-October through Millennium Health.   They test upwards of 100 different types of drugs (the things that are common but not typically tested for such as Spice, Kradom, etc.  Typical hospital drug screens are for opiates, THC, etc.) It takes 2-3 days to get results from Millennium to PHF.  The results become part of client’s medical file.   Medical files are available for 7 years.  Release of Information forms are available at TeleCare and are typically for a duration of 1 year.   NAMI advises supportive family members to be  included on a ROI (Release of Information) and recognizes medical files are available for 7 years per TeleCare.
Linkages to EDC H&HS Computer System known as AVATAR: Telecare key staff have access to El Dorado county’s AVATAR system where EDC H&HS BH note diagnosis and observations/history/and medications/treatments.    Telecare can directly update discharge diagnosis into AVATAR but cannot update more detailed information screens.     Telecare has access to “some” but not all of AVATAR going back about 5 years (Telecare guesstimate)
Dr. Motl, Psychiatrist is provided client account history for review in daily treatment team meetings.
Telecare guesstimates that about 65% of their clients are homeless; about 35% have family members and a far lesser percentage have family members providing proactive support and family history.   We observed great concern by Telecare’s leadership about releasing clients to “homelessness.”   El Dorado County like many counties lack services within their own community.   This means El Dorado County H&HS must pay other counties for their short term or long term services when local options are not available.   .This does not always occur.   Homelessness is common but release to homelessness can even occur when loving family support is available.   It requires a high level of skill supporting those living with anosognosia (lack of insight.).   We urge EDC H&HS to leverage longer-term treatment options by quality secure facilities available outside of the county.
In 2017 we heard from EDC H&HS Assistant Director that they are not allowed to send clients to Nevada hospitals because judges won’t honor CA law and they have witnessed a client being released to homelessness during a CA 5150 hold which gets transitioned to Legal 2000 hold in NV.  We investigated further to find EDC H&HS in fact routinely uses NV in-patient hospital, West Hills, to the tune of about 18-24 patients per year.  We have urged EDC H&HS to develop bi-state solutions – these are absolutely essential for people who live and work across state lines which is commonplace for those in the South Lake Tahoe part of the county.    EDC used to have a contract with Carson Tahoe Behavioral Health in-patient psychiatric.     Telecare (like our NAMI affiliate) acknowledges greater challenges in county services in South Lake Tahoe than on the Western Slope (Placerville / El Dorado Hills.)
Telecare provides a written after care plan that includes documentation about date/time of linkages to next step services.  This discharge planning order and aftercare form includes medication orders and diagnosis codes, diet, and prognosis, etc.   It is exceptionally helpful to include family in discharge planning process which Telecare attempts to do where family is available/helpful-to-aftercare.
We obtained the Q1 2019 report provided to BHCommission late summer 2019 outlining all spend on county subcontractors for EDC H&HS.  This is evidence of $ received from from other counties using EDC H&HS  TeleCare “the PHF” as well as $ expended outside of this county when Telecare is full or a higher level of care is needed.     We encourage EDC H&HS to post such reports transparently on their websites (this report for example could be a part of the monthly reporting link provided to the BHCommission.)
Where is the county’s strategic plan for the mentally ill?   Where will El Dorado County be in 3 years; 5 years; 10 years in terms of treatment, services, supports, clearly communicated guidance, policies/procedures and self-auditing which hunts for operational improvements?
“Make no little plans; they have no magic to stir men’s blood… Make big plans, aim high in hope and work.” Daniel H. Burnham (1846 – 1912)

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