Thursday, February 5, 2015

Kentucky Proposes NEW outpatient treatment bill – HB65, Representative Tom Burch

Please join me in thanking NAMI KY for supporting this important legislation. A special thanks to Dr. Sheila Schuster of the Kentucky Mental Health Coalition, (KMHC) and to Representative Tom Burch for making HB65 a reality.

Talking Points and Summary for HB65

In 2010, I started a blog campaign to advocate for a law, (similar to what other states had) that would assist an individual into treatment before they became dangerous to self or others, or before their lives were ruined forever … as our son and family has experienced the past 10 years.

Two years ago, in 2012-13, Rep. Burch and Sen. Denton both sponsored identical bills that strengthen and lengthen the current community based outpatient agreed order … under the KRS 202A.081. (This law has been on the books 32 years, but has been underfunded and rarely utilized.)

In 2014, after many testimonies to the Kentucky interim joint committee on health and welfare, 2 additional bills were sponsored. They were HB 221 and SB 50. 

At the legislative advocacy day in 2014, NAMI KY asked their legislators to combine both bills and pass a compressive bill that would help people before they reached KY’s strict inpatient criteria. NAMI KY, NAMI LEX, BH providers, advocates, family members and individuals living with a brain disease diagnoses … as well as Dr. Sheila Shuster (KMHC); worked through many tedious meetings, agreeing on language. HB65 is essentially the product of those meetings.

is in 2 parts. In the first section, Part 1 [Sections 1 – 3]: the language strengthens the already-existing law (KRS 202A.081) which permits persons involuntarily committed to the hospital to be discharged on the condition that they agree to – and comply with – court-ordered outpatient treatment. In section (1 an alternative sentencing is provided, with mechanism that will help connect the system to the patient.  In (2) AOT allows someone to live in the community under a court order.  Other additions to the first section are as follows:

•  Added … a peer support specialist or other supportive person present and “MAY” be asked to support the patient during this process.

•  Another addition added to HB 65 is: it renames this outpatient commitment process “a patient agreed order”.

•  In [Section 1 (4); p. 1] Requires the Department of Public Advocacy (DPA) to assign an alternative sentencing social worker to develop a treatment plan in collaboration with a community mental health center.

•  [Section 1 (6); p. 2] Requires the court to appoint a case management service or team employed by a community mental health center to monitor treatment and the patient’s compliance with the treatment.

•  [Section 1 (7); p. 2] It requires that the case management service or team report on the person's functioning, recommend community support services, and assist the person in applying for social services. [This is an important section, as it connects the CMHC to the patient, that may be unable to access housing or basic needs without a MSW.]

•  [Section 1 (7); p. 2] It requires that the case management service or team is available 24/7 and is adequately trained.

•  [Section 1 (8); p. 2] It requires that treatment providers use evidence-based practices as defined.

•  [Section 1 (9); p.2-3] Provides that failure to abide by the treatment plan may result in the patient being re-hospitalized if the hospitalization criteria are met, procedures are initiated via affidavit by the case management service or team, and that a mental health examination of the patient take place at a community mental health center.

•  [Section 1 (10); p. 3] With due process, permit the agreed order to be extended up to 3 additional orders of 60 days (total of 180 days) each after a hearing is held, with the same procedures and safeguards as for the initial hearing.

•  [Section 1 (11; p. 3] requires that services provided to the patient under the agreed order are covered by Medicaid.

•  [Section 1 (12) p, 4] Requires that the courts report each patient agreed order to the Cabinet. [This is very important, because in all my research as to why people can’t access OT … I learned that the state has never collected adequate data on the number of people who had actually received a community based outpatient agreed order.]

The most important part of HB65 is public safety. It will save lives. 
“It’s better to be ordered to receive medical help, access to resources, housing, etc., in a least restrictive environment ... than forced to become a criminal, trapped in jail/prison where a person will lose all civil rights, and will still not receive treatment.”


This bill creates new “outpatient” language and makes it possible for a provider or family member to commit an individual, who has anosognosia to outpatient services. This is the new section that would provide a person treatment before tragedy instead of waiting until they are homicidal, suicidal or become a felon; sentenced to long-term imprisonment. (In which case, they will lose all civil rights and not likely to receive treatment.)

New outpatient criteria in Section 6: 

Section 6.  New
·    No person shall be subjected to court-ordered AOT unless she would otherwise:
o   1) present a threat of danger to herself or others;
o   2) cause severe mental, emotional, or physical harm;
o   3) have significantly impaired judgment, reasoning, functioning, or capacity to recognize reality; AND
o   4) have a substantially diminished ability to make informed decisions regarding his or her need for sustained medical treatment.
o   Furthermore, the patient must be unlikely to adhere to outpatient treatment on a voluntary basis based on a QMHP’s
·      1) clinical observation;
·      2) review of treatment history, AND
·      3) anosognosia.
·      The AOT must be the least restrictive alternative mode of treatment available.
Section 7.  New
·      The QMHP who examines the respondent must provide a written treatment plan that includes “reasonable opportunities” for the involvement of both the patient and anyone else she wants on board, any advance directive already executed by the patient, and evidence-based practices.

Section 8. New
·      At the hearing, respondent shall be:
o   Represented by counsel
o   accompanied by a peer support specialist or “other person in a support relationship” AND
o   “Afforded an opportunity to present evidence, call witnesses on his or her behalf, and cross-examine adverse witnesses.”
·      The court may conduct the hearing in the respondent’s absence
·      The QMHP who recommends court-ordered AOT shall testify at the hearing.
·      The court must find clear and convincing evidence that the patient meets the criteria in Section 6 of this bill to order AOT, but the court is not compelled to do so. In other words, the evidence that the respondent needs AOT must be clear and convincing to even consider issuing the order. The court can still choose not to issue the order even with clear and convincing evidence.
Section 9.  New
·      After ordering AOT, the court appoints a case management service or team employed by a CMHC who shall
o   Monitor the patient’s adherence to the order and
o   Report to the court “descriptive of the person’s functioning.”
·      The service or team shall be available 24 hrs/day
Section 10.  New
·      Failure to comply “may constitute” grounds for a physician to order a 72 hour hold.
·      Failure to comply is not grounds for contempt of court.
Section 11.  New
·      At any time during the treatment, the patient may move the court to stay, vacate, or modify the order.
·      A QMHP may move the court to change the order
o   “material change” means an addition or deletion of one of the services from a treatment plan.
·      Within 30 days of the expiration of an order, the original petitioner may petition for an additional period of AOT.
o   The procedure is the same as the first petition, except the parties may mutually agree to waive the hearing.
Section 12.  New
·      The services for the order “shall be authorized by the Department for Medicaid Services [DMS] and its contractors [MCOs] as Medicaid-eligible services and shall be subject to the same medical necessity criteria and reimbursement methodology as for all other covered behavioral health services.” emphasis added.

[Currently, even if treatment programs and resources are available for individuals with brain disease, SMI ... if the patient does not believe they are have symptoms, or has anosognosia, there is little hope they can access services. This in turn, sets the individual and the mental health system up for failure.]

See NAMI Kentucky's sample letter to the Kentuky legislature here:

Danger and Violence Reduced after Outpatient Treatment 

• 55% fewer recipients engaged in suicide attempts or physical harm to self

• 47% fewer physically harmed others

• 46% fewer damaged or destroyed property

• 43% fewer threatened physical harm to others

• Overall, the average decrease in harmful behaviors was 44%

• 74% fewer participants experienced homelessness

• 77% fewer experienced psychiatric hospitalization

• 56% reduction in length of hospitalization

• 83% fewer experienced arrest

• 87% fewer experienced incarceration

• 49% fewer abused alcohol

• 48% fewer abused drugs

Consumer participation and medication compliance improved with Outpatient Treatment 
• Number of individuals exhibiting good adherence to meds increased 51%.

• The number of individuals exhibiting good service engagement increased 103%.

Consumer Perceptions Were Positive after Outpatient Treatment 

• 75% reported that AOT helped them gain control over their lives

• 81% said AOT helped them get and stay well

• 90% said AOT made them more likely to keep appointments and take meds.

• 87% of participants said they were confident in their case manager's ability.

• 88% said they and case manager agreed on what is important to work on.

Info from: March 2005 N.Y. State Office of Mental Health “KendraŹ¼s Law: Final Report on the Status of Assisted Outpatient Treatment.”