They are calling 911 again_ A CIT response for frequent ...

They are calling 911 again?A CIT response for frequent callers.
Officer Chad Stiles, RN/ParamedicMilwaukee Police DepartmentCrisis Intervention and Homeless Outreach TeamAshley Steinberg, MPHOutreach Community Health Centers – PATH Supervisor
Why they call?
Reporting delusionsReporting hallucinationsReporting medical complaintsConfusionWelfare checksSomething isn’t “right”Complaining about nothing is being done when they report things
Why they call?
We trained them to!From young ages we are trained that if there is something wrong to call the police and tell someone.And… something is “not quite” right in some regard. So they call.
And callAnd callAnd callAnd callAnd callAnd call
Frequent callers can tie up:
Police resourcesFire/EMS resourcesMental Health resourcesEmergency Room resourcesPsychiatric center resourcesHomeless Services
Prevention of Problems and Complications
Costly emergency/crisis servicesJail/CitationsNo response directiveEvictions/homelessnessIncreased traumaUse of forceLoss of rapportPoor public image
What’s really going on?
Untreated mental healthUntreated medical conditionsAODAIntellectual/Developmental DisabilityLonelinessSecondary gainHomelessnessDementiaSomeunmet need
Delirium vs Psych
DeliriumRapid onset (hours/days)Waxing/WaningDecreased LOCPrimary Visual/Tactile HallucinationsAny Age, but more suspicious over 50y/oPsychiatricChronic/Gradual onset (weeks)Stays the same when presentAlert and Oriented X4 (person, place, time, events)Primarily auditoryTeenage years to mid-20’s
Steps of Engagement
IntroductionRapport buildingAssessmentReferralWarm hand off/Transfer of careDocumentation
Take a SAMPLE
Signs/SymptomsAllergiesMedications (Prescription/OTC/AODA)Past Medical/Mental HealthLast Oral Intake/Last SleepEvents (leading up to crisis)
‘Medical’ detective…
Dementia suspicion?Current stressorsCurrent/Past providersPsychiatry, Medical, Therapist,etc,Assessing dangerousnessProtection and access to firearmsSafety Concerns (falls, fire, electrical, health)
Checking records and gathering information
CAD recordsIncident reportsMental health contactsPublic records (court documents)Homeless historySocial MediaMedical information (with ROI or other legal means)
Collateral Contacts
FamilyNeighborsFriendsProvidersSocial workersOutreach/Shelter staffOther city departments (Fire, DNS, Health)
Rally the troops! - Crisis Staffing
Mental health providersEmergency DepartmentFire/EMS (Community Paramedics)Case managersPoliceTelecommunicators/DispatchersAging Resource CenterShelter/Outreach StaffOther resourcesVolunteer Groups/ResourcesChaplain
Case Study “A”
Female in 60’s32 recent calls for service in CAD in past three months when referred to CART, plus many more directly to district, supervisors, police and fire commission, Chief’s office, City Hall/Mayor’s OfficeReporting thefts, burglaries, strange things happeningComplaints that police were not doing anything or taking her seriously.
Case Study “A”
HoardingFire concerns including recent verified fire in basementFire evacuation concerns (multiple locks on doors, switching out with 30 new lock sets)Stroke with paralysisOther significant medical issues“Dementia” diagnosis (WI case law prevented ED)Paranoia about neighbors as suspectsNo evidence of entries
Case Study “A”
Current services in place including part time in-home caregiverNeighbors report strange behavior including past nudity outdoorsUnreliable with medication complianceNo grounds for current emergency detention (past 24 hour limit)Likely to decompensate to dangerousness
Resources used
Department of Neighborhood ServicesMilwaukee Fire DepartmentMilwaukee County Department on AgingMilwaukee CountyGero-Psych TeamFamily Care TeamHome Care GiversFriendsFamily refused to be involved
Case Study “A”
Redirect calls with strict limits to CARTInvestigative alertAll contacts/calls documentedEventually able to refer for Chapter 55 – Emergency Protective Placement and GuardianshipIn-home assessment by doctorRapport buildingCasual discussions for information gatheringDocumenting all refusals for assistance
Case Study “M”
Female in her early 70’s+40 calls for recent service, additional calls several per day, most calls in the evening (suspectedsundowning)Reporting delusions and audible hallucinations regarding neighborForgetful but no known official dementia diagnosisNo psychiatric history except anxiety
Case Study “M”
Calling to report people taking money from her account, however checks were written by her.Would respond to audible hallucinations in front of us as if talking to the neighborDid allow us to take her to the ER and was admittedFamily reports odd behavior but were not helpful or involved
Case Study “M”
Repeated safety checks when we called (smoke detector, stove, food)Notifying care team/case manager who was unaware of police calls for serviceDocumenting all refusals for assistanceIn-home assessment by doctorChapter 55 protective placement and guardianship established
Case Study “E”
Approximately 60 y/o maleHistory of homelessness and schizophrenia“Pleasantly psychotic”1-2 calls per day for over two months from citizens requesting welfare check of him sleeping on heating vent in the streetWould deny SI/HI, and move along voluntary when engaged by police, but would return to the vent
Case Study “E”
Repeated behavior cause for concern despite warnings of danger. Lack of insight into problem.Obtained statements from street outreach workers of observation of sleeping in streetDocumented refusals for housing, shelter, and servicesResulted in a three-party petition followed by emergency detention
Case study -“E”
Organic brain disorder in additional to mental healthOn commitment and will likely need locked supportive housing due to elopement risk
Case Study “T”
Female in 40’sHistory of Paranoid SchizophreniaVery stable and pleasant when on medsOff medications, now escalating to crisisPast history shows several decompensations to dangerousness requiring emergency detentions>75 recent calls for service, sometimes several per day reporting delusions
Case Study “T”
Reporting sexual assaults by Jesus and spirts, thefts, and voodoo cursesEviction notice due to disruptive behavior, pending homelessness for entire familyCurrently does not meet criteria for ED, but occasionally will go voluntarily.Services in place including, CSP, therapy, psychiatry, benefits
Case Study “T”
Collaboration with PATH in case of homelessness prevention.One way communication with therapist and psychiatry office (due to lack of ROI) to provide information about escalating behaviorCoordination with Community Support Program (CSP) Case ManagerRedirection of calls for service to CART to avoid citations/arrest for 911 abuse.Eventual voluntary stabilization through engagement
Case Study “C”
Female in 70’sHistory of Schizophrenia and additional medical problems152 calls for service (1-10 per day) reporting shootings, rapes, stabbings in the neighborhood or rambling of numbers and addresses and people.Occasionally wandering to nearby stores to report situations when unable to access phone
Case Study “C”
Lives with elderly husband and son with MI, brief stay at CBRFMedications compliant but MI is somewhat treatment resistantDenies SI/HI/AVH but “pleasantly” psychoticDoes typically not rise to level of EDPsychiatric state deteriorates when medically compromised (UTI, DVT)
Case Study “C”
Will go voluntary… now used up all inpatient days for psych.To be continued…
Goals
CrisisInterventionand stabilizationTherapeutic, non-punitive, supportive and trauma informed approachReduction in calls for serviceRecovery
Questions?
Contact info:Chad [email protected] [email protected]