Frontier Health provides a wide range of mental health services to the eight-county Northeast Tennessee region which includes Sullivan and Hawkins, and it also provides some mental evaluation services in Wise, Lee and Scott counties in Virginia.
Sherri Feathers is senior vice president of specialty services at Frontier Health, and Kathy Benedetto is senior vice president for children’s services, but also responsible for forensic and assessment division.
They are not legally permitted to discuss specific cases.
Hypothetically speaking, when you have a patient repeating a cycle of arrest and release over and over, whose responsibility is it to try to stop this cycle?
Benedetto: “Some of our most challenging situations are patients who might go to the hospital, get assessed, get the treatment they need, get the medications they need, and then just don’t do the follow-up on an outpatient basis. We have very good resources to do follow-up and connect with those patients. Jail liaisons. Care managers who meet with patients in the home.
“But we do have a handful of patients, who with all those supports we provide, still refuse to come in, or think they’re fine without their medication. Then we have a really challenging situation with the police, with the courts, and honestly, with our own treatment team, because we want our patients to follow our recommendations.”
Is there a time when you say this has gone on long enough, and this person needs to be committed?
Benedetto: “We can only do that if they meet the criteria at that time to be committed because you’re literally taking someone’s rights away.”
Feathers: “What we see with some of the chronically mentally ill, they may look fine at one moment, but in the next few days if they stop taking their medication they become very psychotic. At that time, they’re reassessed by the Crisis Team, and if they do meet criteria and they are considered to be a danger to the community, they would be committed and placed in a psychiatric location. But hospitalization is short term. The goal is to get people stabilized and to send then home with support and follow-up care. We have a lot of folks who are chronically mentally ill who agree to go to group homes, and they agree to those types of services. But sometimes we send folks to group homes, and after awhile they decide they want to leave. There are a lot of folks who are mentally ill, but they are not incompetent, so they can make their own decisions.”
Benedetto: “We have chronically mentally ill patients who take their mediation, learn to manage their symptoms and function very well in their families, in their jobs and in the community. We celebrate those.”
What can be done about the patient who doesn’t want help?
Feathers: “That’s a tough question. The most important thing for a person who is chronically mentally ill is support. Someone needs to reach out to that person and provide some support services. It’s a tough situation because we often see folks who are homeless and chronically mentally ill, and they don’t have the family and support.”
Benedetto: “We can’t treat them if they don’t come, and they have to want to come. It’s voluntary.”
What can you learn from a mental evaluation?
Feathers: “There are two different types of assessments we do. Our mobile crisis team sees folks in emergency rooms, in doctor offices and throughout the community. We see people who are in an immediate crisis. They may be suicidal. They may be homicidal. They may be in the community experiencing some psychosis that places them at risk to themselves and others.”
Benedetto: “We performed approximately 8,500 mobile crisis evaluations 2016-17 in the eight-county region. That’s up from 2015-16 when it was approximately 6,500, and the year before it was 6,400. Only about 50 percent of those who receive a mobile crisis evaluation end up spending time at a psychiatric hospital such as Woodridge, Peninsula or Moccasin Bend. Some of those who don’t go to a hospital will go to an outpatient facility, detox or they may go to our crisis stabilization unit.”
What’s the difference between assessments done by the mobile crisis team and a court-ordered evaluation?
Benedetto: “Frontier Health has a contract with the Department of Mental Health that provides support and funding for us to do limited forensic assessments. Those forensic assessments are limited to a pretty narrow scope of evaluation. For the most part those are ordered from the bench, from our judges, and when we get a court order for a forensic assessment, typically what they’re asking for is criminal responsibility or competency to stand trial. Can the person participate in their own defense? Are they competent to stand trial? Those are done by psychologists, psychiatrists, and we are answering that specific question. That’s not what kind of medication do they need to be on or what kind of treatment do they need. Those kind of things are done through our outpatient centers.
“The level of care we’re missing here is our outpatient centers because we can have a judge, an attorney, a physician, a school system — any number of people refer a patient to us. Or the patient can refer themselves to us. ‘I’m in trouble. I need help. What kind of services do you offer?’ That’s another kind of evaluation we offer on the outpatient side. The problem with that evaluation is it’s typically voluntary. We don’t mind at all if the judge orders those evaluations to happen. It’s just for those evaluations to happen the patient must be willing to go through that.
“Frontier Health has criminal justice liaisons in each of the jails in Northeast Tennessee, and those liaisons typically work with the judges, the district attorney, the defense attorney, the nurses in the jail to identify those inmates who are at-risk, to be sure they are connected with services after they leave jail, to prevent them from recidivating. The goal is to make sure their treatment is continued with outpatient services.”
Can’t you do both types of evaluation at the same time?
Benedetto: “The courts are busy, and once in awhile it could happen that we get the forensic assessment ordered, when really what they want to know is, what kind of treatment does this person need, and are they a danger to themselves or others? Do they need to go in the hospital? Those orders can be a little bit confusing at times depending on how they’re written and what they receive.”
What are the criteria for commitment?
Feathers: “We’re looking at all kinds of different things. We do a Columbia suicide assessment to look at past history, suicidal or homicidal attempts, past psychiatric history of psychosis. We speak to family members, we speak to the physician who is in charge of the case. We’re also looking at medication, current psychiatric history, and we’re assessing their living functioning to determine the proper level of care. Are they a danger to themselves, a danger to others, or a danger to the community?”