At this year’s 50th annual CALTCM Meeting in Napa I viewed a pre-recorded session on Transinstitutionalization for Serious Mental Illness by Drs. George Woods, Glen Xiong, and Patricia Blum. Last Spring, I had a patient with a Mental Health Crisis that exposed serious gaps in crisis care not only at my facility, but within our county. At the In-The-Trench’s session on this subject, I was able to present this case to these experts and came away with very practical advice to address these gaps. 

Every county health department in California has a unique plan for the care of those with serious mental illness. Each health department has a Medical Director that oversees their system for caring for those with serious mental illness. Collaborative relationships with facility leadership are welcome. A facility Medical Director, DON, or administrator could contact their county’s mental health Medical Director to better understand their services and leverage their expertise to enhance the care provided. This Medical Director may also help you access mental health providers who could advise you on care questions on specific patients as well as the development of appropriate behavioral and  social programs.  

In addition, most counties now have mobile rapid response teams that can de-escalate crisis situations but then leave with the assumption your team has those crisis de-escalation skills. Would not it be better to collaborate with the mobile team to improve your facilities ability to deescalate mental health crisis?

 Historically, we have relied on the ER to manage a mental health crisis, but ERs are busy and typically exclude a medical crisis, perhaps give a dose of injectable antipsychotic medication, and then send the patient back to you. This again puts you at risk for continuing to be unable to manage what you previously had trouble managing.

In my case, I had a patient with dementia with a fixed paranoid delusion that became more intrusive and severe as I tapered chronic amitriptyline that had been prescribed  20+ years prior for peripheral sensory neuropathic pain and insomnia. This patient had newly diagnosed severe dilated cardiomyopathy with reduced ejection fraction (HFrEF) limiting the use of antipsychotics and providing another reason for tapering the amitriptyline. These experts advised a slow taper of amitriptyline by no more than 10-15%/week to avoid provoking insomnia and mania. I had begun to taper it much more rapidly and unknowingly may have contributed to his subsequent mental health crisis.

From a practical perspective, every facility must develop at least annually a self-assessment of their care capacity for potential admissions with serious mental illness or developmental delay. Once a PASRR Level 2 admission occurs, a detailed care plan for the specific needs of the resident in these areas must be documented and be available for review by CDPH. This requires a team approach that not only impacts the care after admission, but also the decision on whom to admit. 

Another excellent free resource for those with mental illness and substance use disorders, the Center for Excellence for Behavioral Health in Nursing Facilities was discussed by their Program Director, Jacob “Jay” Berelowitz, LNHA, LMSW, CPHQ, CCM in a live session at the 50th Annual Symposium in Napa in September.  There are excellent resources available including the availability of one-on-one professional technical assistance through their website, https://nursinghomebehavioralhealth.org/.  This can be extremely helpful and there is a variety of training and educational materials on the website.

Crisis mental health care can be incredibly stressful and frustrating. Armed with the above information, I believe most facilities should identify their care gaps and develop collaborative relationships within their county and communities that begin to address those gaps.