The Public Mental System in Washington
DC 2015
COL (ret) Elspeth Cameron Ritchie, MD, MPH
[email protected]
Slide 1
Outline
• Washington DC
• The DC Department of Behavioral Health
• “FD 12s”
• VA facilities in and around DC
• DoD facilities in and around DC
Slide 2
WASHINGTON, DC
unique characteristics
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A Tale of Two Cities
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“City-State” - Collapsed Political Structure
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Federal and Local Governments Co-Exist
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Under the Thumb of Congress
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Geographically Condensed
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Military all around
Veterans Affairs
– Home to Very High Income and Very Low Income
– Very Transient residents and multi-generational families
– State and local functions; Mayor is Governor, City Council is State
Legislature
– Relatively stable economy
– Small tax base (federal buildings, universities, hospitals, nonprofit
organizations)
– No vote in Congress, no 10th amendment protection
– No legislative or budget autonomy
– DC National Guard only activated by the President
– All urban, height restrictions on buildings
– 19 hospitals, 19 nursing homes, but no state prison
Slide 3
Washington, DC
a magnet
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Both home-grown and transient consumers
Consumers come to DC for a variety of
reasons:
– Some believe there are lots of jobs
– Some believe there are better services
– It’s easy to establish residency
– “Right to shelter” - access to housing for the
homeless
– “Someone put me on the bus to come here”
– Anger at government
– Perceived access to the government
– Monuments and free museums
– In love with the First Lady
– The Capitol is a target
– Veterans come to Washington DC
Slide 4
Slide 5
Saint Elizabeths Hospital
Early History
• Founded in 1852
– Dorothea Dix
• Government Hospital for the Insane 1855
• Hospitals for wounded Soldiers and Sailors in the Civil War
• 1916 Name changed to St Elizabeths
Slide 6
Saint Elizabeths Hospital;
Later History
• At peak
– 8000 patients
– 4000 staff
• First mental hospital to have a psychotherapy department
• Pioneering treatments
– Art therapy, dance therapy
– Psychodrama
• Steady decline in 1960s
– Transferred to DC 1987
• New hospital opened in 2010
– Census was at 315
– Now about 280 patients
• Both forensic and civil
Slide 7
St Elizabeths Hospital
• Psychiatry residency
• Psychology internship and residency
• Training for chaplains and dentists
• Forensic psychiatry fellowship
Slide 8
Department of Behavioral Health (DBH)
DBH is a Cabinet-level agency that
provides emergency care and
comprehensive mental health services
and supports to District residents in need
of the public mental health system. DBH
also evaluates and treats individuals
referred through the criminal justice
system.
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Wash DC DBH
• 19,000 patients in the community
• Mental Health Authority
64 NY Ave NE
• Access Help Line
• Comprehensive Psychiatry Emergency Program (CPEP)
• Mobile Crisis Services
• Homeless Outreach
• Core Service Agencies
• Government run clinics
– 35 K St NE
– 821 Howard Road (children)
• APRA
Slide 10
Access Help Line
• The Access HelpLine
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at 1 (888) 7WE-HELP or 1-888-7934357 is the easiest way to get connected to services
provided by the DBH and its certified mental health care
providers.
They are open 24 hours, 7 days a week.
Get emergency psychiatric care
Help with problem solving
Determine whether to seek ongoing mental health services
or other types of services
Find out what services are available
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Access to DBH Programs
Two Ways to Get Linked:
 Access Help Line: 1-888-7WE-HELP or
 Call CSA directly
Linkage to Services: Core Service Agency
 Intake Appointment
 Appointment with Psychiatrist
 Assignment to a CSW
Referral Into ACT (Assertive Community Treatment):
This is a separate process.
 Work with Homeless Outreach and ACT Coordinator
Comprehensive Psychiatric Emergency
Program (CPEP)
• Free standing facility on grounds of DC General
• Not affiliated with a medical Emergency Room
• 202-673-9319
• Patients routinely brought by police (2/3rds) on an “FD-12”
• Residents rotate there; “terrific experience”
Slide 13
Comprehensive Psychiatric Emergency
Program (CPEP) (202) 673-9319
– Adults experiencing a psychiatric or emotional crisis can
be treated at CPEP, an emergency facility located on the
grounds of the old DC General Hospital (voluntary and
involuntary)
– Transfer to a community hospital if longer inpatient stay
needed
– Extended Observation Beds (EOB) up to 72 hours
14
Inpatient Hospitals - Adults
Voluntary and Involuntary
 United Medical Center (Short Term)
 Providence Hospital (Short Term)
 Washington Hospital Center (Short Term)
 Psychiatric Institute of Washington (Short Term)
Voluntary
 George Washington University Hospital
 Howard University Hospital
 Georgetown University Hospital
 Sibley Hospital
 Veterans’ Administration Hospital
 Veterans only, can accept voluntary
Involuntary
 St. Elizabeths Hospital (Long Term)
 Civil and forensic
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Mobile Crisis Service
• Mobile Crisis Services (MCS)
– Call (202)673-9300
– Serving Adults
– Available 9am-1am - 365 days a year
– Co-located with CPEP
• ChAMPS
– Children
– 202-481-1450
Slide 16
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Provides crisis assessment and interventions to homeless
persons who may be experiencing a mental health crisis
whether on the streets or in homeless shelters
Outreach occurs weekly in most shelters and drop-in
programs for case consultation and linkage to services
There are expanded day services at the Hermano Pedro Day
Program, located at Sacred Heart Church
Community Psychiatry Rotation through the St. Elizabeths
Psychiatry Residency Program
Community and Provider Trainings
Traveler’s Aid Vouchers
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(202) 671-0388
hours of operation (M-F ; 9 am –
9 pm)
Slide 17
Government run
adult clinic
• 35 K St, NE
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“old DC CSA”
Services for Adults who are DC residents
Cultural competency clinic
Hearing impaired
Residents and forensic fellows rotate through
• Patients can walk into the clinic at 35 K St, NE
and be seen the same day without an appointment from
8:30 am to 3:00 pm. If possible, please call ahead and
forward any clinical information that you have. (202)
442-4202
Slide 18
Pharmacy Services
• Individuals who are uninsured can get prescribed medication
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at the DMH pharmacy located at 35 K Street NE
Hours are M-F 8:30am – 5:00pm
Call (202) 442-4954 if you need assistance
19
Core Service Agencies and other helping
agencies
• CSAs:
– Community Connections, Green Door, Pathways, Anchor,
Hillcrest, etc
– Adult and child services
• Other helping agencies
– Miriams’ Kitchen
– SOME
• Emergency Food, Shelter and Health Care Directory 2011
– www.ifcmw.org
Slide 20
Outpatient Forensic Services
• Crisis Intervention Training for
Metropolitan Police Department
• 35 K Forensic Services
– “OPD” Outpatient Department
• NGRI patients
– Competency restoration
21
Urgent Care Clinic
• DC Superior Court
• Individuals referred by judges—primarily from misdemeanor
and traffic court—who may show signs of mental illness,
have been diagnosed as mentally ill, or show signs of both
mental illness and substance abuse are seen at an urgent
care clinic located on the ground floor of the DC Superior
Court.
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Other Services
• Supportive employment
• Range of housing programs—
– 24/7 Community residential Facilities (“CRFs”)
– Supported independent living
– Rent subsidies
Slide 23
Child services
• Government run child clinic
– 821 Howard Road
• School based mental health programs
• ChAMPS
• Children’s National Medical Center (202) 476-5000 and
PIW (202) 885-5800
– Provides on site emergency psychiatric services
and inpatient hospitalization for children
– Children’s only takes younger children
– PIW can handle older, those involved in legal system
Slide 24
CHILD PSYCHIATRY PRACTICE GROUP
(PPG)
• 821 Howard Road, SE
• 3 Child & Adolescent Psychiatrists
• Each M.D. outplaced one day per week
– 35K, Community Connections, Fihankra Place
• Primarily medication management
• 3 basic encounter types
– Walk-ins, scheduled intakes, follow-ups
• Provides psychiatric urgent care
School Mental Health Program
• DMH operates a school based program in a growing number
of public and public charter schools that offers prevention,
early intervention and clinical services to youth and their
families.
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FD12 APPLICATION FOR
EMERGENCY ADMISSION
• FD-12 is written by (1) physician of the person, (2) law
enforcement officer, or (3) officer-agent of DMH.
• FD-12 authorizes immediate detention of person who
FD-12 writer has reason to believe is mentally ill and
likely to injure self or others as a result of mental
illness.
• Subject of FD-12 is transported to Comprehensive
Psychiatric Emergency Program (CPEP) or a hospital for
psychiatric evaluation.
• Based on evaluation, CPEP or hospital can release for
community treatment, detain for treatment, or
hospitalize.
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FD12 APPLICATION FOR
EMERGENCY ADMISSION
• The FD12 must contain FACTS and not mere
conclusions.
• The FD12 should contain observations
of/conversations with the alleged mentally ill
person which demonstrate the reason for
taking the person to CPEP or a hospital for
evaluation.
• The FD12 will be used both for immediate
detention and for future decisions; it is a very
important document.
• Please type, if at all possible.
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LEGAL DEFINITION OF
LIKELIHOOD OF INJURY
• The term "injure" is not to be interpreted narrowly.
• Likelihood of injury to self or others means the person
is likely to do or not do some act which is likely to
result in harm to self or others, as a result of mental
illness.
• Physical injury or violent crime is not required. The
acts may be violent or non-violent, intentional or
unintentional.
• Likelihood of injury includes circumstances where the
person is likely to inadvertently be in a position of
danger because of mental illness or the person is
unable to take care of self, as a result of mental illness.
• It is enough to be likely to commit a criminal act which
will expose the person to arrest, trial and conviction, or
that it is likely to expose the person to violent
retaliating acts by the victim of the crime.
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LEGAL DEFINITION OF MENTAL
ILLNESS
• The phrase "mental illness" means a psychosis
•
or other disease or disorder which
substantially impairs the mental health of a
person.[1] A person is mentally ill if the person
suffers from an abnormal condition of the mind
that substantially affects mental or emotional
processes, and substantially impairs
behavioral controls.[2]
[1] See D.C. Code §21-501 (1981 ed.); In Re
Rosell, 547 A.2d 180 (D.C. 1988).
• [2] See In Re Rosell, 547 A.2d 180 (D.C. 1988);
Bethea v. United States, 365 A.2d 64, 92, n.61
9D.C. App. 1976) citing Dixon v. Jacobs, 138
U.S.App.D.C. 319, 325, n.17. 427 F.2d 589, 595,
n.17 (1970).
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Relationship Between DBH, the VA and the
Military
Slide 31
Homeless Veterans
Slide 32
Overall themes
• Disconnects between Department of Veterans Affairs
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system and public mental health
Disconnects between military, veteran’s administration,
academics and public mental health system
– At least in Washington DC
– Military residents rotate through CPEP
– Residents do rotate through VA
• Disconnects between programs and psychiatric societies
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and state mental system
SAMSHA Policy Academy
Slide 33
VA in Washington DC
• Hospital in Wash DC serves National Capital Region (NCR)
– Homeless outreach
– Supported employment
• Various residential/nursing facilities outside region
• “Central” VA in downtown DC
• Vet Centers
• Community Based Outpatient Clinics (CBOCs)
Slide 34
Military in and around Wash DC
Walter Reed Army Medical Center—closed
Slide 35
Walter Reed National Military Center—in
Bethesda
Slide 36
Pentagon
Slide 37
Other Military Facilities in the NCR
• Andrews Joint Base
• Bolling Joint Base
• Ft Belvoir with new community hospital
• Quantico Marine Base
• Ft Meade
• Defense Center of Excellence
• National Intrepid Center of Excellence
Slide 38
Current efforts
• Single POC at VA for patients in the public mental health
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system
Getting patients into systems of care and supported
employment
Combined homeless outreach meetings
Asking question at Access Help Line “Are you a veteran?”
Office of the Attorney General teaching VA on commitments,
involuntary hospitalization, etc.
Discussing with psychiatric societies
Institute of Psychiatric Services
Coming Home Project
Slide 39
Training Law Enforcement
Slide 40
Schools and Veterans
Increasing number of
Veterans organizations
in schools
Slide 41
Future efforts
• SAMSHA Policy Academy
• Greater interaction of VA, military, public mental health,
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academic medicine
More organized community supports for returning veterans
Further training of law enforcement
Slide 42
Questions/Discussion
[email protected]
Slide 43