Opinion | Health systems, Community Mental Health must learn to work together

Recently, Gov. Gretchen Whitmer convened an expert roundtable to focus on the importance of addressing Michigan’s mental health crisis. In advance of the State of the State address, the governor indicated that she would address the topic in the speech and that behavioral health would be an important consideration as she makes difficult budget decisions for 2022 and beyond. One fundamental step she can recommend is for health care systems and community mental health agencies to focus on education and collaboration.

In 2016 and 2018, the Legislature modified the Mental Health Code to make Michigan a national leader in promoting earlier intervention for those suffering from a serious mental illness by making Assisted Outpatient Treatment (AOT) more readily available. As a result of these modifications, Michigan’s standard for ordering involuntary treatment does not require an immediate threat of harm or immediate danger to self or others. Instead, the immediacy of the threat of harm governs whether hospitalization or outpatient treatment should be ordered.

AOT is a less restrictive method of treatment than inpatient psychiatric hospitalization and is also highly successful in preventing the need for hospitalization for persons with serious mental illness. AOT can be ordered for persons at substantial risk of serious harm due to an inability to understand their need for treatment and a demonstrated unwillingness to voluntarily adhere to treatment. Counties are beginning to see success in implementing these measures; however, a lack of understanding of the changes in the law and a lack of collaboration between stakeholders is impeding successful implementation.

Petitions for mental health treatment are typically filed with the probate court by private and public hospitals with the majority being filed by private hospitals. Although some petitions are filed directly with the court, those petitions may not proceed without two clinical certificates being filed with the court from the hospital where the individual is being held. Many individuals are brought to emergency departments by law enforcement who fill out the petition that initiates the process. However, evidence from across the state suggests that the majority of those petitions are not filed with the court.

For those petitions that are authorized to be heard, the lack of collaboration is most evident in the fact that nearly 60 percent of those petitions do not make it to the hearing stage because individuals are either discharged from inpatient psychiatric care, sign in voluntarily, or sign a deferral before the hearing occurs. These actions (collectively referred to as “Discharge”) typically result in dismissal of the petition.

This would not be a problem if individuals were connected to outpatient treatment at Discharge. Unfortunately, few of these individuals are actually connecting to treatment upon Discharge. Yet, to initiate the petition, these individuals were screened, had two clinical certificates finding a need for hospitalization, and were hospitalized pending a court hearing scheduled seven days later. While the immediate threat of harm and the need for hospitalization may have dissipated, many of these persons have evidenced non-adherence and yet require continued treatment to stay well and avoid repeat hospitalization. The lack of collaboration between hospitals, mental health service providers, law enforcement and the probate courts results in continuous recycling of persons with serious mental illness through acute care hospital emergency departments, inpatient hospitalizations, jails, and probate courts. Yet, the data clearly demonstrates that AOT can substantially reduce hospitalization, length of hospital stays, and emergency department use as well as reduced involvement with the criminal justice system.

As the system adjusts to the changes in the statutory language, it is important to remember that Michigan no longer requires an immediate risk of harm before ordering involuntary treatment. The immediacy of the risk of harm governs the choice of inpatient hospitalization or outpatient care, like other illnesses. Training across systems needs to occur to help judges, law enforcement, hospitals and mental health treatment providers learn more about the specifics of the new standard for treatment and AOT.

For example, in Wayne County, DWIHN (Detroit Wayne Integrated Health Network, the community mental health agency for Wayne County) serves about 38,000 persons with serious mental illness. Over the last 5 years, 16,000 petitions for involuntary treatment were filed in the Probate Court for 9,000 persons, many of whom are served by DWIHN. Six hundred of these persons, less than 1 percent of the persons petitioned, accounted for 34 percent of all petitions filed. Fifty-seven of these persons had at least 10 petitions in that time frame. In the last year, the inpatient psychiatric hospitalization cost for these 57 persons was nearly $5 million. One individual had 56 emergency department visits. None of these individuals were placed on AOT, which potentially represented a lost opportunity to decrease hospital and emergency department use and secure major cost savings as well as improved health status. Both the lack of awareness of the new law and the lack of coordination is costing scarce resources and even worse, costing lives.

Collaboration and coordination between hospitals, emergency departments in acute care hospitals, community mental health agencies, law enforcement and the probate courts are critical to ending this tragic cycle. For example, the Center for Behavioral Health and Justice has reported that persons in jail who had a connection to CMH in the prior year were significantly more likely to engage in treatment after release and had a significant decrease in the number of jail stays after the CMH program. Similarly, persons in the hospital that are released to a CMH program are far less likely to return to the hospital or an emergency department.

This experience has been validated by the success of new AOT programs in Genesee, Huron and St. Clair Counties. The key to their success has been close collaboration between the hospitals and CMH, with support from the jails and the probate courts. Having hospital, court and jail liaisons makes the process work and helps facilitate a smooth transition from system to system with quarterly meetings of the agencies keeping the program on track.

The challenges to success for those who are hospitalized for inpatient psychiatric care include the 60 percent of petitions dismissed before the hearing due to the patient signing a voluntary or deferral, or the patient being discharged from inpatient psychiatric care without consideration of securing an AOT. It is likely that individuals could benefit from AOT, and that effectively using AOT as an option, along with collaboration across systems could reduce the likelihood of those individuals returning to the same systems over and over and enhance their opportunity for recovery.

Fidelity to Michigan law relating to the voluntary, discharge and deferral features of the Mental Health Code will create the opportunity to reduce reliance on hospitalization, in addition to the other well-established benefits of treatment. To make this work, hospitals, emergency departments, mental health providers, jails and probate courts need to collaborate with one another and manage their resources collectively in order to fully activate the power of what an AOT can offer.