Wisconsin Mental Health Laws Behavioral Health Training Partnership

Wisconsin Mental Health Laws Behavioral Health Training Partnership University of Wisconsin - Green Bay Revised: May 2014

AGENDA Welcome and Introductions Chapter 34 Overview Chapter 51 Related Chapters Clients Rights and Confidentiality Closing Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 2

OBJECTIVES Develop a basic understanding of Wisconsin Mental Health Law (Chapter 51) Develop a basic understanding of related statutes (Chapters 48, 938, 54, 55) Understand the criteria and process for doing an emergency detention (51. 15) Understand the criteria and process for doing a protective placement for alcohol (51. 45) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 3

OBJECTIVES (CONT’D) Become familiar with client rights and confidentiality (Chapter 94) Explore the balance between the need to protect client rights and community safety Explore the issues related to dealing with populations that don’t fit neatly into a single statutory category Practice decision-making based upon case examples of various populations in crisis Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 4

INTRODUCTIONS Please introduce yourself sharing a scenario when you were caught between two or more systems when responding to a crisis or providing linkage and follow up to a crisis situation. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 5

DHS 34, SUB (3) FRAMEWORK FOR COUNTY CRISIS WORK Promulgated in 1996 Includes expectations for; Training and supervision Risk assessment and management Knowledge of Chapter 51 and related laws Documentation including crisis planning and response planning Client rights Best practices Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 6

TRAINING AND SUPERVISION Within 90 days of hire or assignment to crisis work If staff have less than 6 months experience they need 40 hours of training specific to crisis intervention If staff have more than 6 months experience they need 20 hours of training specific to crisis intervention For every 30 hours of crisis work, 1 hour of supervision must be provided Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 7

RISK ASSESSMENT AND MANAGEMENT The most important element in crisis work Important to know the signs and symptoms that someone is at risk of harm to self or others Important to develop an intervention and/or response that manages the risk Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 8

DHS 34 RISK ASSESSMENT REVIEW Clearly identify the issue/conflict Identify and weigh the risks and liability of intervening Weigh chances of a challenge to the decision Share the risks by using colleagues, supervisors and others on the team Ensure decisions are well reasoned Document the reasons for the decision Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 9

DHS 34 LEGAL CONSIDERATIONS 51. 15 Emergency Detention 51. 45 Alcohol Hold/Protective Custody 55 Adult in Need of Protection 46. 40 Adults at Risk 48 Child/Juvenile in Need of Protection 938 Juvenile in Need of Supervision 94 Patient Rights and Grievances 51. 61 Client Rights Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 10

DHS 34 DOCUMENTATION REVIEW Crisis Plans Completed on an agency template by the consumer and treatment team and kept with either the crisis team and/or the 911 dispatcher Plan identifies whom to contact, provider staff who work with the consumer, consumer preferences related to crisis response, etc. Response Plan Completed by the crisis worker and other team members at the time of the crisis intervention Plan follows a format that includes risk assessment, diagnostic code and response plan as well as date/time/ persons involved and is signed off by the staff, consumer and licensed professional within 14 days Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 11

DHS 34 CLIENT RIGHTS Programs must comply with 51. 61 and DHS 94 on the rights of clients Consumers can use either formal or informal procedures for resolving complaints and disagreements Programs must have both informal resolution process and have an established grievance resolution system Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 12

BEST PRACTICE MOBILE CRISIS RESPONSE DHS Standard: Mobile Crisis Response is available during high utilization hours. Crisis response is available 24/7 § Access to supports and services is timely § Adequate time is spent with the individual in crisis Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 13

BEST PRACTICE DIVERSIONS DHS 34 Standard: Diversion back to the community when appropriate (least restrictive measures) Services are provided in the least restrictive manner Emergency interventions consider the context of the individual’s overall plan of services Helping the individual to regain a sense of control is a priority Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 14

WHEN TO DIVERT? Review of Door County flowchart Helpful hints: * Always try to facilitate a voluntary placement * Always find out what insurance the person has * Always make sure that the emergency detention appears to have merit Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 15

BEST PRACTICE COLLABORATION DHS Standard: There is a collaborative crisis response (plan for coordination of services) Natural supports, where available, are utilized Emergency interventions consider the context of the individual’s overall plan of services There is documented collaboration with law enforcement and/or other concerned parties There is documented collaboration with other systems including CPS, Juvenile Justice, Elderly, etc. There is a coordinated emergency MH service plan that identifies a process to plan, implement and manage crisis system issues Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 16

MENTAL HEALTH ACT CHAPTER 51, WISCONSIN STATUTES Provides legal procedures for voluntary and involuntary admission, treatment and rehabilitation of individuals (adults and minor children) affected with mental illness, developmental disability, drug dependency or alcoholism. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 17

IMMINENT DANGER Video from JS Online Alberta Lessard http: //www. jsonline. com/news/134341463. html Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 18

VOLUNTARY SERVICES/PLACEMENT Voluntary admission is preferable in most instances because it avoids the legal system involvement Voluntary service acceptance allows for the consumer to engage at will instead of a legal coercive participation When helping a consumer navigate voluntary services/placement it is important to help them with resources, insurance, expectations etc. Linkage and follow up are the same as with nonvoluntary consumers Always give consumers the option of voluntary Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 19

51. 15 EMERGENCY DETENTION Involuntary hold Used when there is reason to believe: The subject is mentally ill, drug dependent or developmentally disabled AND Behavior constitutes a substantial probability of physical harm to self or others This is usually where the commitment process starts. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 20

CRITERIA FOR INVOLUNTARY CIVIL COMMITMENT (AFTER 51. 15) The individual has a mental illness, developmental disability, or drug/alcohol dependence The individual’s illness/disability/ dependence is treatable The individuals is dangerous to him/ herself or others due to the illness/ disability/dependence Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 21

DEFINITION OF MENTAL ILLNESS FOR INVOLUNTARY CIVIL COMMITMENT A substantial disorder of thought, mood, perception, orientation or memory which grossly impairs judgment, behavior, capacity to recognize reality, or ability to meet the demands of life, but does not include alcoholism Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 22

DEFINITION OF DEVELOPMENTAL DISABILITY FOR INVOLUNTARY CIVIL COMMITMENT A disability attributable to brain injury, cerebral palsy, epilepsy, autism, Prader-Willi syndrome, or mental retardation, which is expected to continue indefinitely, and which constitutes a substantial handicap to the afflicted individual Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 23

DEFINITION OF DRUG DEPENDENCE FOR INVOLUNTARY CIVIL COMMITMENT A disease which is characterized by the dependency of an individual who uses one or more drugs to the extent that the individual’s health is substantially impaired or his/her social or economic functioning is substantially disrupted. Other mental illness and intent to harm self or others Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 24

DEFINITION OF ALCOHOLISM FOR INVOLUNTARY CIVIL COMMITMENT A disease which is characterized by the dependency of an individual on alcohol to the extent that his/her health is substantially impaired or endangered, and his/her social or economic functioning is substantially disrupted Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 25

STANDARDS OF DANGEROUSNESS REQUIRED FOR INVOLUNTARY CIVIL COMMITMENT Recent acts, attempts or threats of suicide or serious bodily harm to self Recent acts, attempts or threats of serious bodily harm to others, or violent behavior which places others at reasonable fear of serious physical harm A pattern of recent acts or omissions which evidences impaired judgment causing the individual to be an inadvertent danger to self Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 26

STANDARDS OF DANGEROUSNESS REQUIRED FOR INVOLUNTARY CIVIL COMMITMENT (CONT’D) Mental illness causes the individual to be so gravely disabled that he/she is unable to satisfy life’s basic needs for nourishment, medical care, shelter or safety Individual’s psychiatric treatment history, coupled with his/her present mental deterioration due to incompetent decision to refuse psychotropic medication causes likelihood that the individual will lose ability to function independently in the community Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 27

STANDARDS OF DANGEROUSNESS HARM TO SELF 51. 20(1)(A)2 A Harm to Self: (Substantial probability of physical harm) Due to recent threats or Attempted suicide recently or Recent serious bodily harm Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 28

STANDARDS OF DANGEROUSNESS HARM TO OTHERS 51. 20(1)(A)2 B Harm to Others: (Reasonable fear and substantial probability of harm based on act, attempt, or threat) Recent homicidal behavior or Recent violent behavior or Others are in “reasonable fear” of violent behavior and serious physical harm Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 29

STANDARDS OF DANGEROUSNESS GRAVELY DISABLED BY IMPAIRED JUDGMENT (Recent acts or omissions indicating a substantial probability of harm to self) 51. 20(1)(a)2 c Due to impaired judgment and Appropriate alternate measures have been attempted or not available in the community Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 30

STANDARDS OF DANGEROUSNESS UNABLE TO SATISFY BASIC NEEDS 51. 20(1)(A)2 D (Recent acts or failure to act indicating imminent need for nourishment, medical care, or shelter) Incapable of obtaining care for self and Results in substantial probability of death, serious injury, debilitation or disease and Based on Mental Illness, and Appropriate alternate measures have been attempted or not available in the community. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 31

STANDARD OF DANGEROUSNESS INCOMPETENT TO MAKE/FOLLOW TREATMENT DECISIONS 51. 20(1)(a)2 e (Incapable of understanding, expressing or applying treatment decisions) (Rare and difficult to use) Based on evidence of treatment history and recent acts or failure to act and Person will lack services necessary if left untreated and If left untreated, person will suffer severe physical/mental harm, loss of autonomy and Based on psychiatric prediction Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 32

DEFINITIONS OF TREATMENT FOR INVOLUNTARY CIVIL COMMITMENTS Statutory: Those psychological, education, social, chemical, medical or somatic techniques designed to bring about the rehabilitation of an individual who has mental illness, developmental disabilities, drug dependency or alcoholism Jury Instructions: An individual is a proper subject for treatment if the administration of treatment techniques may control, improve or cure his/her mental illness, developmental disability, drug dependency or alcoholism Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 33

51. 45 PREVENTION AND CONTROL OF ALCOHOLISM “It is the policy of this state that alcoholics and intoxicated persons may not be subjected to criminal prosecution because of their consumption of alcohol beverages but rather should be afforded a continuum of treatment in order that they may lead normal lives as productive members of society. ” Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 34

WHAT THIS MEANS Counties must have a plan for prevention of alcoholism and treatment of alcoholics and intoxicated persons All counties in Wisconsin either provide treatment or contract with providers who provide treatment for them Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 35

DEFINITIONS OF ALCOHOL INCAPACITATION FROM A CRISIS PERSPECTIVE 51. 45(11)(b) “A person who appears incapacitated by alcohol shall be placed under protective custody by a law enforcement officer. ” Need to determine whether someone is incapacitated by alcohol This does not apply to drugs (that is covered in 51. 15) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 36

ALCOHOL INCAPACITATION Evidenced by: Gross Impairment Slurred speech Unsteady gait Incoherent, unconscious Strong odor of alcohol on breath Impaired judgment – inability to care for self Life-threatening withdrawal symptoms such as delirium tremors (seizures, shakes, elevated vitals) Intoxicated persons are at a greater risk to commit suicide Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 37

RESULTING IN Inability to care for self Dangerousness to self or others Examples Intoxicated and passed out in a snow bank Having DT’s (delirium due to withdrawal) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 38

WHEN DOES A PERSON NEED MEDICAL DETOXIFICATION? Change in mental status Hallucinations Temperature above 100. 4 Significant increases or decreases in blood pressure or pulse Seizures This is why we send clients to the ER for medical clearance. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 39

51. 45 VS. 51. 15 51. 45(11)(b) deals with incapacitation due to alcohol Mildly intoxicated not a candidate – voluntary Mild withdrawal – voluntary Mildly intoxicated and suicidal – 51. 15 or 51. 45 Drugs other than alcohol and suicidal – 51. 15 Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 40

ROLE OF CRISIS WORKER Assess for incapacitation along with law enforcement Assess for the need for detoxification Assess for the need for 51. 15 Are they in danger due to their drug use (severely psychotic, having seizures, etc. ) People under the influence are at greater risk for suicide Always re-assess after the person is sober or drug- free Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 41

51. 45(13) INVOLUNTARY COMMITMENT FOR ALCOHOLISM Very rare to get an alcohol commitment Similar process as mental health commitment Probable cause hearing within 72 hours (excluding weekends and holidays) Legal representation Commitment hearing within 14 days (excluding weekends and holidays) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 42

ALCOHOL AND DRUG COMMITMENTS Rarely done Requires established pattern of use, which causes substantial impairment of health and functioning and which causes dangerousness to self or others. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 43

INVOLUNTARY ADMISSION There are four ways a person can be admitted to a hospital against his/her will (involuntarily): Statement of Emergency Detention Treatment Director’s Hold A Three Party Petition A “Fifth Standard” Petition Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 44

STATEMENT OF EMERGENCY DETENTION (ED) Law enforcement officers or a Juvenile Intake Worker may take individual into custody, and detain that individual, based upon the officers belief from either personal observation or reliable reports of others, that the individual is mentally ill, developmentally disabled, or drug dependent and dangerous to self or others and needs treatment The form for this is in the References section Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 45

EMERGENCY DETENTION (CONT. ) The 72 hour timeline starts at the time the officer takes the individual into custody (Act 158) The Emergency Detention can be dropped prior to the 72 hours if deemed inappropriate or the person becomes voluntary Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 46

EMERGENCY DETENTIONS TO WINNEBAGO • Please complete a Certificate of Need (CON Form F -11047) Elective/Urgent Admission for all youth under age 21 being admitted to WMHI, which is an IMD (Institution for Mental Disease), regardless of the circumstances surrounding the Emergency Detention. • This is the only way to ensure inpatient Medical Assistance eligibility and payment. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 47

ALL ADMISSIONS ARE BEING REVIEWED • Without a CON completed by a team external to the IMD, the IMD can complete an internal Emergency CON if the patient meets certain criteria of risk of serious impairment or death at the time of the ED. The reviewers have a very narrow definition of dangerousness “services necessary to prevent the death or serious impairment of the health of the individual. ” Every item on the CON must be completed and legible (even signatures) The form must be dated the date of or prior to the admission. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 48

MEDICAID CLAIMS MAY BE DENIED If the Elective/Urgent CON form is absent or incomplete, Medical Assistance cannot be billed for the inpatient stay. Winnebago will re-bill counties for MA denials. See the Memo (DMHSAS Info Memo and Form HO #4) for instructions Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 49

EMERGENCY DETENTION (CONT. ) Law enforcement officers must consult with crisis or other county mental health staff County department must approve the need for detention. Medical clearance is usually required before the person can be admitted to the mental health program Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 50

TREATMENT DIRECTOR EMERGENCY DETENTION (ED) The Treatment Director of a mental health facility/unit may file statement of Emergency Detention (ED). ED must allege that the patient is mentally ill, developmentally disabled, or drug dependent and dangerous to self or others and needs treatment Treatment Director ED usually occurs when an individual is voluntarily admitted to a facility/unit and later refuses treatment and/or requests discharge Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 51

THREE PARTY PETITION FOR EXAMINATION Three adults sign a sworn petition drafted by the County Corporation Counsel At least one of the petitioners (signers) must have personal knowledge of the individual’s dangerous behavior Petition must allege that the individual is mentally ill, developmentally disabled, or drug dependent and dangerous to self or others and a proper subject for treatment Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 52

THREE PARTY – PETITION FOR EXAMINATION (CONT’D) Petitioners who have not directly observed the individual’s dangerous behavior must provide a basis for their belief that the allegations are true The County Corporation Counsel files the petition with the court. After review, the judge may order detention of the individual by law enforcement to a mental health facility or may just set the case for a probable cause hearing without detention This process may take several days or more and should not be used in emergency situations Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 53

FIFTH STANDARD A Fifth Standard Petition is similar to the Three Party Petition, but the subject must have a history of receiving treatment, and an inability to understand the benefits of treatment while suffering from mental illness. Generally there is not the requirement of a substantial probability of imminent harm A physician must be a signer of the petition The “fifth standard” is found in section 51. 20(1 )(a)2. e. (commitment standards) of the Wisconsin statutes. It was enacted in 1995 Wisconsin Act 292. It went into effect in December 1996. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 54

PROBABLE CAUSE HEARING Court hearing must be held within 72 hours of individual’s detention (excluding weekends and holidays). Witnesses testify from personal observations about the allegations of dangerousness in the petition or ED, and doctor testifies about mental illness, disability or dependence and treatment After the hearing, the judge determines if there is probable cause (reason) to believe the allegations and cause to detain and treat the individual in a mental health facility Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 55

PROBABLE CAUSE HEARING FOUR POSSIBLE OUTCOMES Case is dismissed for lack of sufficient evidence that the individual is mentally ill or dangerous Settlement Agreement is approved by the court Case is converted to temporary guardianship and protective placement or services, if the individual is not treatable (Chap 55) Probable cause is found Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 56

PROBABLE CAUSE HEARING (CONT’D) If probable cause if found Final hearing is scheduled within 14 days of detention Two doctors are appointed by the court to examine the individual and to submit written reports with their opinions and recommendations to the court Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 57

FINAL HEARING (TRIAL) Court hearing held within 14 days of the individuals detention, or 30 days if there is no detention after probable cause hearing Witnesses testify from personal observations about the dangerous behavior, and court appointed examiners (psychologists and/or psychiatrists) testify about mental illness, disability or dependence and treatment After the hearing the judge determines if there is clear and convincing evidence to commit the individual either inpatient or outpatient initially, and whether the individual is competent to refuse psychotropic medications Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 58

FINAL HEARING FOUR POSSIBLE OUTCOMES Case is dismissed for lack of clear and convincing evidence Settlement Agreement is approved by court Conversion to guardianship and protective placement/services if untreatable condition (Chap 55) Order of involuntary Civil Commitment for treatment Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 59

SETTLEMENT AGREEMENT A negotiated contract for treatment between the individual his/her attorney and the County Corporation Counsel and approved by the court Waives the court hearings for a specified period of time – up to 90 days Cannot be extended at end of time period, if individual is compliant with treatment. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 60

SETTLEMENT AGREEMENT (CONT’D) Includes a list of treatment conditions the individual must comply with including the maximum time (number of days) of inpatient treatment Failure to comply with the treatment conditions may result in return to a mental health facility and continuation of court proceedings Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 61

ORDER OF INVOLUNTARY CIVIL COMMITMENT FOR TREATMENT If there is clear and convincing evidence that the individual is mentally ill, developmentally disabled, or drug dependent and dangerous to self or others, and a proper subject for treatment, and individual may be committed by court order to the care and custody of the county department of community programs for inpatient and/or outpatient treatment for up to 6 months Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 62

OUTPATIENT TREATMENT CONDITIONS Committed individuals are given this document upon discharge to outpatient treatment, informing them to comply with the listed conditions deemed necessary to ensure treatment and safety in the community The individual’s failure to comply with the conditions may result in his/her return to a mental health facility by law enforcement Psychotropic medications may not be administered involuntarily (forcibly) as an outpatient treatment condition Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 63

ORDER TO TREAT The court may order that medication may be administered to an individual regardless of his/her consent (involuntarily and/or forcibly). After a finding of probable cause, effective only until the final hearing After an order of commitment is granted, effective for the duration of the commitment Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 64

ORDER TO TREAT (CONT’D) The court must find sufficient evidence to believe that the individual is not competent to refuse due to illness/disability/dependence, because he/she is: Incapable of expressing and understanding of the risks, benefits, and alternatives of medications, OR Incapable of applying an understanding of the medication to his/her own condition to make and informed choice to accept or refuse Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 65

EXTENSION OF COMMITMENT (RECOMMITMENT) Prior to expiration of a commitment, the county department, to which an individual is committed, may file a recommendation to extend the commitment County Corporation Counsel files petition for recommitment alleging the individual continues to need treatment, is dangerous without treatment, and is unlikely to comply without court ordered treatment Order of Extension of Commitment can be up to 12 months if the court finds that there is a “substantial likelihood that the individual should become a proper subject for commitment if treatment was withdrawn” Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 66

MONITORING SETTLEMENT AGREEMENT/ TREATMENT CONDITIONS OF COMMITMENT Noncompliance does not automatically result in returning the individual to a more restrictive environment (re-detention to a mental health facility) Need for re-detention is based on level of noncompliance, dangerous behavior, and/or potential for dangerousness If individual is unstable and in need of inpatient treatment and willing to comply, he/she can be voluntarily admitted without court involvement Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 67

CHAPTER 51 COURT HEARINGS: RIGHTS OF MINORS Minors have the right to Be represented by adversary counsel at public expense Have a closed hearing Request an open hearing Remain silent Present and cross-examine witnesses Have a jury trial Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 68

CHAPTER 51 COURT HEARINGS: RIGHTS OF PARENTS/LEGAL GUARDIANS Parents/Legal Guardians have the right to: Participate in the court hearings Be represented by counsel (at their own expense) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 69

WHY ARE MINOR CHILDREN ED’D? Effective 8/1/06, Wisconsin law permits parents/legal guardians to sign their minor child into a psychiatric hospital for treatment without the child’s consent However, if the child is physically combative and/or unwilling to accept treatment, voluntary admission may be inappropriate and unavailable Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 70

CRISIS REFERRALS OF CHILDREN/YOUTH Things to think about when considering referral of children to inpatient. Can the child return home safely as part of the crisis response plan? Is there a family member that the child can safely stay with as part of the crisis response plan? Can a community crisis bed be utilized? Can you work with the 48 System to find an appropriate placement if the child cannot stay with family? Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 71

WHAT CAN FAMILIES EXPECT FROM THE TREATMENT FACILITY? Consultation with social workers and/or treating psychiatrist Information about assessment of the child and treatment recommendations Parental consent must be obtained prior to administering any medications Family phone calls and visits allowed as appropriate Social worker will coordinate discharge plan with family and community providers Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 72

WHAT CAN FAMILIES EXPECT AFTER DISCHARGE TO OUTPATIENT TREATMENT? If case is dismissed, there is no further court involvement unless a new involuntary civil commitment case is initiated If individual is discharged under settlement agreement or treatment conditions of commitment, county of residence will provide services and monitoring, and will determine if/when individual needs to return to inpatient treatment Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 73

LAWS GOVERNING CHILDREN/YOUTH Chapter 48—Child Protective Services Chapter 938—Juvenile Justice Services There may be child welfare issues along with mental health issues Could lead to confusion about which system would best serve the youth Important to collaborate with social workers in the child welfare system Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 74

CHAPTER 48 § Investigation of reports of abuse (physical, emotional and sexual) and neglect § Regulates child protection, foster care and other out of home placements Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 75

CPS ROLE Report is filed (mandatory reporting for crisis workers) Agency makes a decision about whether an investigation is needed Agency makes an assessment and takes necessary action to keep the child safe either In the home with a safety plan OR Placed out of the home Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 76

CHAPTER 938 Juveniles may be supervised for delinquency (breaking the law) if they are age 10 or over OR Need protection or services because of running away, truancy, or committing a delinquent act but under the age of 10 OR Not responsible due to mental disease or defect Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 77

ROLE OF JUVENILE JUSTICE Report comes into the agency Agency evaluates the report and makes a decision about whether the child requires services If behavior is a risk to public safety, the juvenile may be placed at shelter care, secure juvenile detention or even a county jail (dependent upon risk to community safety) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 78

FACILITIES FOR MENTAL HEALTH REFERRAL Exception to placement in foster care, juvenile shelter care or detention for those in need of mental health care May go to an inpatient psychiatric facility Also may go to a designated crisis bed in a licensed foster home or group home if crisis certified for up to 5 days voluntarily Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 79

UNBORN CHILDREN OF MOM’S WHO ARE USING 48 also provides jurisdiction over unborn children in need of protection or services when their mothers habitually lack self-control in the use of alcohol/controlled substances, which places the unborn child at substantial risk Rarely used Best to try to get women to voluntarily seek help, but if they refuse, it needs to be reported to CPS Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 80

PARENTAL AUTHORITY OVER MINORS IN NEED OF SUBSTANCE ABUSE OR OTHER TREATMENT Legislative changes were made in regard to parental authority over minors in need of substance abuse treatment Under the revisions to Sec. 51. 13 Wisconsin Statutes the following can now execute a petition for voluntary admission for inpatient treatment, depending on the type of treatment to be provided Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 81

PARENTAL AUTHORITY OVER MINORS IN NEED OF INPATIENT TREATMENT Voluntary admission for treatment of: Minors Age Authority needed from: Substance Abuse <18 Parent only Mental illness, Developmental Disability Under 14 Parent (or minor with court permission) Mental illness, developmental disability or substance abuse 14 or older Parent and minor (parent can admit if minor refuses) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 82

PARENTAL AUTHORITY OVER MINORS IN NEED OF TREATMENT A minor 14 years or older (or someone acting on the minor’s behalf) can apply for voluntary admission for inpatient treatment where the parent or guardian cannot be found or is unreasonably withholding consent for the admission The court must approve the admission if it finds that the admission is proper and the parent/guardian cannot be found or is unreasonably withholding consent (Section 51. 13(c)1) If a minor under 14 applies for inpatient treatment and the parent or guardian cannot be found or is unreasonably withholding consent for the admission, the court can approve the admission after holding a hearing on the matter (Section 51. 13(1)(c)2 Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 83

REQUEST FOR DISCHARGE FROM A VOLUNTARY ADMISSION Discharge from Treatment for: Minor’s Age Request needed from: Substance abuse <18 Parent only Mental illness, developmental disability 14 or older Minor and parent Mental illness, developmental disability Under 14 Parent only Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 84

CONSENT TO TREAT UNDER 51. 61(6) Consent for treatment of: Minor’s age Consent needed from: Substance abuse <18 Parent only Mental illness, developmental disability 14 or older Parent and minor Mental illness, developmental disability Under 14 Parent only Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 85

ADDITIONAL INFORMATION Under Section 51. 47 minors 12 or over may receive limited treatment for substance abuse (assessment, counseling and detoxification for less than 72 hours) without the parent or guardians consent only if the parent or guardian cannot be found. The parent/guardian must be notified of these services “ as soon as practicable” (Sec. 51. 47(3)) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 86

GUARDIANSHIP Guardianship definitions vary by statutory chapter Primary chapters: WI Chapters 48 and 54 Children’s Court has exclusive jurisdiction over minor guardianships (48. 14(2)(b)) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 87

GUARDIANSHIP UNDER 54. 01 “Guardian” means a person appointed by a court to manage the income and assets and provide for essential requirements for health and safety and the personal needs of a minor, and individual found incompetent or a spendthrift. (54. 01(10)) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 88

GUARDIANSHIP UNDER WISCONSIN CHAPTER 48 Child must be found to be in need of protection or services The child will remain outside of the parents home and the person nominated is willing to care for the child until age 18 It is not in child’s best interest to terminate parental rights. Placement may become a kinship guardianship or a subsidized guardianship Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 89

PRIVATE GUARDIANSHIP UNDER CHAP. 54 May be appropriate where the county does not or cannot step in For example, parents are deceased and someone steps forward to take custody of the children Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 90

ADULT PROTECTIVE SERVICES AND RELATED STATUTES 46. 90 – Refers to elder Adults at Risk (60+) Chapter 54 – Refers to Rules of Guardianship Chapter 55 – Refers to Protective Placement of Adults (some of which may be elder adults) at risk due to: Severe and persistent mental illness Degenerative brain disorder Developmental disabilities Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 91

CHAPTER 55 ADULTS IN NEED OF PROTECTION Elderly or disabled adult in need of protective services Unable to care for basic needs, or Being abused or exploited Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 92

CHAPTER 55 SCOPE OF ACTIVITIES Set up major mechanisms by which protective services and placement may be provided – Investigation of, or other response to, reports that an elderly adult/adult at risk has been abused, exploited or neglected Voluntary services to an elder adult/adult at risk at the request of the person or person’s guardian Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 93

SCOPE OF ACTIVITIES CHAPTER 55 (CONT’D) Emergency protective placement Court ordered protective placement for a mentally incompetent person, who has a disability that is likely to be permanent and presents a substantial risk of serious harm to self or others due to an inability to provide for their own care and custody Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 94

DIFFERENCES 51 VS. 55 Adults at risk due to severe and persistent mental illness, degenerative brain disorder, developmental disability (55) 51. 15 states “due to an apparent mental disorder” The presumption in 51 is that the person is treatable and will improve Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 95

MENTAL ILLNESS AS DEFINED Mental illness as defined in 51. 01(13) and 55. 01 (4 m) The definitions are not the same (Chapter 55 includes a need for custody as part of its definition. Chapter 51 has a separate definition for mental illness that is a basis for commitment) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 96

CHAPTER 51 AND CHAPTER 55 Chapter 51 Governs admission to services and facilities for treatment of mental illness Delineates separate procedures for different processes Chapter 55 Governs services (including placement) for protection from abuse and neglect by self or others Somewhat different rules apply if placement is sought in specific facilities or the subject is developmentally disabled Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 97

CHAPTER 51 AND CHAPTER 55 Chapter 51 (cont’d) Chapter 55 (cont’d) Presumption of incompetency Standards based on treatable illness and dangerousness to self or others Standards based on incompetency and need for protection of individual from abuse neglect or exploitation Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 98

ELDERLY ADULTS/ADULTS AT RISK AND 51. 15 As a rule, an emergency detention of someone with dementia or developmental disabilities should be avoided Not best practice Recent court case that bears this out Exception might be the elderly person with a mental illness or substance use disorder as the main feature of the crisis Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 99

DEMENTIA PATIENTS AND INVOLUNTARY COMMITMENT State Court of Appeals ruled that patients who have a diagnosis of only dementia cannot be involuntarily committed for treatment under 51. They need to be served through the 55 rules. Patient does not suffer from a qualifying mental condition and is not a proper subject for treatment There are no techniques that can be employed to bring about rehabilitation from dementia Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 100

CLIENT RIGHTS Applies to anyone who is receiving services for mental illness, a developmental disability, or substance abuse in the state of Wisconsin In 1972 a Supreme Court decision, entitled Lessard v. Schmidt, set forth the rights of mental health patients Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 101

CLIENT RIGHTS (CONT’D) These rights were adopted into state law with the creation of Wisc. Stats. 51 in 1976 Administrative rules to implement patient rights and confidentiality were adopted as Wisconsin Administrative Codes; DHS 94 Patient Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 102

PERSONAL RIGHTS You must be treated with dignity and respect You have the right to have staff make fair and reasonable decisions about your treatment and care You may not be treated unfairly because of your race, national origin, sex, age, religion, disability or sexual orientation You may make your own decisions about things like getting married, voting and writing a will, if you are over 18 are have not been found legally incompetent You may use your own money as you choose You may not be filmed, taped or photographed without consent Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 103

TREATMENT RIGHTS Receive prompt and adequate treatment Participate in their treatment planning Be informed of their treatment and care No treatment or medications without consent (except in an emergency or guardianship) Refuse treatment and medications (unless court-ordered) Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 104

TREATMENT RIGHTS (CONT. ) May not be given unnecessary or excessive medications May not be subject of ECT without informed consent You must be informed in writing of any costs of care You must be treated in the least restrictive manner and setting necessary to achieve the purposes of admission to the program, within the limits of available funding Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 105

RECORD PRIVACY AND ACCESS Staff must keep patient information confidential Records cannot be released without patient consent (with some exceptions) Patients may see their records They can always see records of their medications and health treatments During treatment, access may be limited if the risks outweigh benefits Patients may challenge the accuracy, completeness, timeliness or relevance of entries in their records Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 106

OTHER RIGHTS There additional rights that affect both outpatient and inpatient care: Communication Rights Have reasonable access to a telephone* See (or refuse to see) visitors daily* Send or receive mail Contact public officials, lawyers or patient advocates * These rights may be limited or denied for certain reasons. See Clients Rights Limitation or Denial for further information Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 107

OTHER RIGHTS (CONT’D) Privacy Rights Have privacy in toileting and bathing* Have a reasonable amount of secure storage space for his or her possessions* Not be filmed or taped without his/her consent * These rights may be limited or denied for certain reasons. See Clients Rights Limitation or Denial for further information Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 108

GRIEVANCE PROCEDURE AND RIGHT OF ACCESS TO COURTS Before treatment is begun, the service provider must inform clients of their rights and how to use the grievance process. If the client feels his/her rights have been violated, he/she may file a grievance They may not be threatened or penalized in any way for presenting their concerns formally or informally They may also take the matter to court and sue if they feel their rights have been violated Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 109

GRIEVANCE RESOLUTION STAGES Informal Discussion (Optional) Grievance Investigation – Formal Inquiry Program Manager’s Decision County Level Review State Grievance Examiner Final State Review Note: There are time frames for many of these stages – county grievance procedures given to consumers should be clear Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 110

SUMMARY OF KEY POINTS Develop a basic understanding of Wisconsin Mental Health Law (Chapter 51) Develop a basic understanding of related statutes (Chapters 48, 938, 54, 55) Understand the criteria and process for doing an emergency detention (51. 15) Understand the criteria and process for doing a protective placement for alcohol (51. 45) Become familiar with client rights and confidentiality Explore the balance between the need to protect client rights and community safety Explore the issues related to dealing with populations that don’t fit neatly into a single statutory category Practice decision-making based upon case examples of various populations in crisis Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 111

HOMEWORK Familiarize yourself with protocols related to CPS, APS, Juvenile Justice—whom to contact. Familiarize yourself with the grievance procedure at your agency. Familiarize yourself with the commitment and settlement agreement processes and protocols for monitoring those on commitments/agreements. Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 112

CLOSING Takeaway Discuss, briefly the participant’s responses to the following questions. What was most helpful to you in the training? What will you be taking away? Evaluation Please complete the training evaluation Behavioral Health Training Partnership University of Wisconsin – Green Bay WI Mental Health Laws May 2014 May be reproduced with permission for training purposes 113