Western Highlands Network

Friday E-Mail Newsletter

Number 66
08/25/2006

The Friday E-Mail is a weekly update for providers by the Services Management Department of Western Highlands Network. Please distribute to all your staff.

A Follow-up On Outpatient Commitments: the Good, the Bad, and the Required

Hope everyone is having a pleasant Friday. One of the most stress producing activities for a service provider can be providing appropriate follow-up treatment to high risk consumers who are on outpatient commitment (OPC). While this can at times seem like a daunting task, OPCs can be a valuable tool in keeping the consumer safe and engaging the consumer in necessary follow-up services.  The information below is intended to be used as a resource document to help this process.

Procedure:

Consumers placed on Outpatient Commitment (OPC) are likely to be high-risk individuals about whom there is also a concern about treatment compliance. The goal is to assure that a strong effort is made to provide appropriate follow-up for consumers on OPC. The following procedure applies to follow-up by designated providers for consumers who are on outpatient commitment to Western Highlands Area Authority (some text has been paraphrased from the NC States Laws):

1. Outpatient Commitment (OPC) to Western Highlands Area Authority will be coordinated through the Access Unit. One worker in the Access Unit (the OPC Access Worker) will be designated to maintain a spreadsheet on all consumers on outpatient commitment. This team member will receive the original outpatient commitment order sent to Western Highlands, gather needed identification information, authorized needed services, log the information and then mail the order to the designated provider. The OPC Access Worker will conduct random event checks of consumer attendance while the OPC is in effect. Retrospective review of consumer records will be done to assure provider compliance.
2. In general, we strongly discourage referral of consumers on outpatient commitment to providers who have a small practice where aggressive case management and follow-up is not readily available for non-compliant consumers. When a consumer on OPC is assigned to a provider who is unable to provide aggressive follow-up for non-compliance, that provider must notify the OPC Access Worker promptly of this non-compliance by mail and e-mail. This notification must include the client's last known address and phone number and any information related to the consumer’s location. The OPC Access Worker will then authorize an outreach provider to follow-up with the client. The outreach provider will take the follow-up measures described below.
3. If the consumer tells his or her current provider that the consumer is moving to another county in the Western Highlands area and wants to receive services from a new provider, the original provider should request that the consumer contact the LME to arrange a case responsible transfer located within the new county with the new provider. If the consumer is moving to a new county but staying with the same provider organization then the consumer's new contact should be arranged by the current provider (i.e., A New Vistas/Mountain Laurel consumer is moving from Madison County to Rutherford County and continues to receive services from New Vistas/Mountain Laurel). As outlined in Paragraph 5.g. below, the law requires any move from one county or another must be done through the court and a hearing should be requested.
4. Many consumers are placed on outpatient commitment by a judge at a hearing when they are discharged from inpatient care. Outpatient commitment can also be initiated during the involuntary commitment process by a MD on the first evaluation after the initial petition. In the latter case, the evaluating MD can check the Outpatient Commitment box in Section 111-Recommendation for Disposition, on the Examination and Recommendation to Determine Necessity for Involuntary Commitment form .The MD must complete the name and address of the proposed outpatient treatment center or physician. The initial evaluating MD must also give the client an appointment time and date for the follow up visit with the outpatient provider. The Initial Petition and the first evaluation must be returned to the Clerk of Court prior to the follow-up appointment with the proposed provider.
   
   If the consumer does not show up for the follow-up appointment the proposed provider must attempt follow-up and, if that fails, may have the client picked up for evaluation using the Request for Transportation Order and Order.
   
   The proposed provider' MD must complete another examination to determine if the consumer continues to meet the criteria for outpatient commitment. If the consumer is still in need of an outpatient commitment the proposed provider/clinician will need to attend the hearing where the judge decides whether or not to continue the outpatient commitment. The MD for the proposed provider may also need to attend the outpatient commitment hearing for face-to-face testimony. This outpatient commitment hearing is held within ten days of the initial evaluation.
   
   Of course, if the consumer shows up for the follow up appointments and no longer meets the criteria for outpatient commitment, the MD can sign the Change of Commitment form and follow the mailing instructions outlined in Section 5.b. of this document.
5. Basic OPC follow-up requirements: All Consumers discharged from inpatient care must be seen face to face within 5 working days of discharge. This applies to consumers placed on OPC as well. The designated provider will provide assertive follow-up as described below for consumers on OPC:
   
   
   • The designated provider will conduct outpatient face-to-face assessment and follow-up treatment with the consumer at the level clinically appropriate to the consumer's needs and condition. Some consumers may need daily contact while others may need weekly contact. No consumer shall be seen less than once every two weeks unless they are in a 24 hour supervised (FCH, Group Home) setting and are stable. If the provider feels the consumer needs to be seen less than bi-weekly, then a MD must review the need to continue the OPC and document the contact.
   • If the provider feels that the consumer no longer meets the criteria to continue the OPC, then the MD can sign a Change of Commitment form and send one copy to the Clerk of Court in the county the order dictates (which is the county of supervision) and one to the OPC Access Worker who will log the termination of commitment. *
   • If the consumer fails to comply or clearly refuses to comply with all or part of the prescribed treatment, but the consumer does not meet commitment criteria, the provider shall make all reasonable efforts to solicit the consumer's compliance. These efforts should be documented in a letter to the court by the clinician. The provider should complete a new Examination and Recommendation for Involuntary Commitment (signed by the MD/PhD). These two documents, along with the clinician's letter, should be sent to the Clerk of Court where the commitment is being supervised along with a Request for Supplemental Hearing (Outpatient Clearly Refuses to Comply with Treatment AOC-SP-221) form. A copy of the Request for Supplemental Hearing should be sent to the OPC Access Worker.
   • If the consumer fails to comply but does not clearly refuse to comply, (i.e., the consumer has a pattern of scheduling appointments but does not show up) the provider can request the court to order the consumer taken in to custody for the purpose of a face to face evaluation. This is done by completing a Request for Transportation Order and Order (Outpatient Fails but Does Not Clearly Refuse to Comply with Treatment AOC-SP-220).
   • If the consumer is non-compliant and cannot be located for a pick up order, then the following reasonable professional efforts should be made by the provider:
     
     
     1. Reasonable effort is defined as documentation of at least one of the following within one week of the initial missed appointment: (1) a visit with the consumer in his/her home or (2) a rescheduled office appointment that the individual keeps or (3) a phone conversation with the individual about the services being offered or (4) at least three attempts to contact the individual at his or her last known address.
     2. If the three attempts are unsuccessful these efforts should be documented in a letter to the Clerk of Court in the supervising county and a Change of Commitment form should be completed. A copy of both these forms should be sent to the Clerk of Court and a copy of the Change of Commitment should be sent to the OPC Access Worker. *
   • If the consumer moves to another state, a Change of Commitment form should be completed and sent to the Clerk of Court. Another copy of the form should be sent to the OPC Access Worker. The relevant facts should be documented in the consumer's chart.
   • If the consumer on OPC intends to move or has moved to another county within the state, the provider shall request that the Clerk of Court in the county where the OPC is supervised to schedule a hearing. The MD/PhD should fill out a new Examination and Recommendation for Involuntary Commitment) and send it to the Clerk of Court with a completed Request for Hearing. A copy of the Request for Hearing form should be sent to the OPC Access Worker.
   • Twenty days prior to the expiration of the OPC the clinician should review the case with a MD and determine if the consumer still meets the criteria for OPC and whether it needs to be extended. If the consumer has been compliant and no longer meets the criteria then a Change of Commitment form can be signed at the expiration of the commitment and sent to the Clerk of Court and a copy to the OPC Access Worker.
     
     If the provider feels the consumer continues to meet the criteria for the OPC and a rehearing is needed, then the MD/PhD will need to complete an Examination and Recommendation for Involuntary Commitment. The clinician should send it with a Request for Hearing form to the Clerk of Court and a copy of the Request for Hearing to the OPC Access Worker.
   • If a consumer on OPC is involuntarily committed to an inpatient facility on a new petition, then the OPC is terminated and a Change of Commitment form should be sent to the Clerk of Court and the OPC Access Worker.

* If the consumer is initially committed as a result of conduct resulting in the consumer being charged with a violent crime, including a crime involving assault with a deadly weapon, and the respondent (consumer) was found incapable of proceeding, a hearing must be scheduled to make any changes in the commitment. When there is doubt about the reason for the initial commitment the Clerk of Court should be contacted for clarification.

Charlie Schoenheit
Director of Services Management
Western Highlands Network
356 Biltmore Avenue
Asheville, NC 28801
Telephone: (828)258-3511 x2219
FAX: (828) 225-2779
E-Mail: Charlie@westernhighlands.org
Website: westernhighlands.org