Treatment	
  Track:	
  
Alterna.ves	
  to	
  Incarcera.on	
  and	
  
Encouraging	
  Care	
  
Ron	
  Smith,	
  MD,	
  PhD	
...
Disclosure	
  
•  Ronald	
  Smith	
  has	
  no	
  financial	
  rela.onships	
  
with	
  proprietary	
  en..es	
  that	
  pr...
Learning	
  Objec.ves	
  
1.  Analyze	
  alterna.ve	
  level	
  of	
  care	
  Community	
  Triage	
  Centers	
  to	
  dete...
Medica.on	
  in	
  Recovery	
  
Ron	
  Smith	
  md	
  phd	
  
	
   	
   	
   	
   	
   	
   	
  202	
  
3386543	
  
Disclosure	
  
•  Ronald	
  Smith	
  has	
  no	
  financial	
  rela.onships	
  
with	
  proprietary	
  
en..es	
  that	
  p...
Recovery	
  
•  I	
  don't	
  know	
  why	
  we	
  are	
  here,	
  but	
  I'm	
  pre]y	
  
sure	
  that	
  it	
  is	
  not...
Chief	
  Complaint	
  
•  “Anxiety	
  
•  “Depression”	
  
•  “Is	
  this	
  all	
  there	
  is?”	
  
•  “I	
  can’t	
  sl...
Ques.ons	
  
•  When	
  is	
  Medica.on	
  indicated?	
  
•  What	
  are	
  we	
  Medica.ng?	
  
•  When	
  can	
  Medica....
Ac.on-­‐	
  Responsibility-­‐	
  Medica.on	
  
•  Educate	
  yourself	
  about	
  the	
  medica.on	
  
•  Educa.on	
  your...
Bias……	
  Prejudice…..Life	
  Experience	
  
•  Ambivalence	
  
•  Big	
  Pharma	
  vs	
  Great	
  Pharma	
  	
  
 “Wi]genstein	
  was	
  the	
  only	
  man	
  
who	
  looked	
  puzzled	
  at	
  his	
  own	
  
lectures….for	
  this	
  I...
Primary	
  Drives	
  and	
  Neurosis	
  
•  “	
  Life,	
  as	
  we	
  find	
  it	
  is	
  too	
  hard	
  for	
  us.	
  It	
...
What	
  am	
  I	
  doing	
  here…why	
  wasn’t	
  
I	
  consulted?”	
  	
  	
  	
  	
  	
  Wi]genstein	
  
Chief	
  Complaint	
  
•  “Anxiety	
  
•  “Depression”	
  
•  “Is	
  this	
  all	
  there	
  is?”	
  
•  “I	
  can’t	
  sl...
Big	
  Pharma	
  
•  “Love	
  and	
  Other	
  Drugs”	
  
•  “Side	
  Effects”	
  
Paradigm	
  Shih	
  to	
  Meds.	
  
•  Doctors	
  of	
  “Medicine”	
  
•  Origins	
  in	
  Koch	
  and	
  Lister	
  ….An.b...
Educate	
  Yourself	
  
• “The	
  Power	
  of	
  Nothing”	
  
– Michael	
  Specter	
  	
  	
  The	
  New	
  Yorker	
  
• T...
The	
  Power	
  of	
  Nothing	
  
•  “Anything	
  that	
  gets	
  people	
  away	
  from	
  the	
  
conveyer	
  belts	
  t...
Educate	
  Yourself	
  
•  Anatomy	
  of	
  an	
  Epidemic	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  ...
Educate	
  Yourself	
  
•  Rethinking	
  Psychiatric	
  Drugs	
  	
  	
  	
  	
  	
  	
  	
  Jackson	
  
•  From	
  Melanc...
Recovery	
  
•  FOI	
  
•  Grow	
  Up	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	...
Family	
  of	
  Origin	
  Issues	
  
•  “I	
  am	
  acquainted	
  with	
  your	
  disposi.on…you	
  
are	
  irrita.ng	
  a...
YALOM	
  Existen.al	
  Psychiatry	
  
•  You	
  really	
  are	
  going	
  to	
  die 	
  	
  
•  Each	
  of	
  us	
  is	
  ...
YALOM	
  Existen.al	
  Psychiatry	
  
•  You	
  really	
  are	
  going	
  to	
  die 	
  	
  
•  Each	
  of	
  us	
  is	
  ...
Kierkegaard	
  
	
   	
  “What	
  am	
  I	
  doing	
  here?.......	
  
	
   	
   	
   	
   	
  	
  
	
   	
   	
   	
   	
...
Yalom	
  
•  Momma	
  and	
  the	
  Meaning	
  of	
  Life	
  
•  The	
  Schopenhauer	
  Cure	
  
•  Existen.al	
  Psychiat...
Chief	
  Complaint	
  
•  “Anxiety	
  
•  “Depression”	
  
•  “Is	
  this	
  all	
  there	
  is?”	
  
•  “I	
  can’t	
  sl...
“Alexithymia”	
  
•  A	
  (without)	
  lexa	
  (words)	
  thymia	
  (feelings)	
  
•  HALT	
  
“Anxiety	
  is	
  the	
  Dizziness	
  of	
  
Freedom”	
  
Kierkegaard	
  
“Anxiety”	
  
•  Alone	
  
•  Annihila.on	
  
•  Sleep	
  
•  Nutri.onal	
  
Alone	
  
•  We	
  all	
  live	
  lives	
  of	
  solitary	
  confinement”	
  
•  Tennessee	
  Williams	
  
•  Love	
  is	
 ...
Abandonment	
  anxiety	
  
•  Primary	
  Fear?	
  
•  2001	
  
•  My	
  Life	
  as	
  a	
  Dog	
  
“Rapprochement”	
  
Margaret	
  Mahler	
  
Into	
  Ac.on	
  
•  Solve	
  Rapprochement	
  
– Wri.ng	
  
– Mee.ng(s)	
  
– Therapy	
  
– Medita.on	
  
– Sponsor	
  
Medica.on	
  
•  Low	
  dose	
  Lithium	
  
•  Low	
  dose	
  SSRI	
  
– Zoloh	
  
•  Beta	
  Blockers	
  
Depression	
  
•  Passivity	
  
– “The	
  passive	
  posi.on	
  of	
  infancy”	
  Klein	
  
•  Treatment:	
  
– Recovery	
...
“Depression”	
  
•  Sadness	
  
•  Passivity	
  
•  Grief	
  
•  Nutri.onal	
  
•  Technology	
  
Death	
  
•  “We	
  are	
  all	
  already	
  dying	
  and	
  we	
  will	
  be	
  dead	
  
for	
  a	
  long	
  .me”	
  
•  ...
Into	
  Ac.on	
  
•  Wri.ng	
  
•  Non	
  Verbal	
  
•  Service	
  
•  Mee.ngs	
  
•  Nutri.on	
  
•  Crea.ve	
  Process	
...
Medica.on	
  
•  An.depressants	
  
– Newer	
  
– Older	
  
Meaning	
  
•  Is	
  This	
  All	
  There	
  Is?	
  
Anhedonia	
  
•  Loss	
  of	
  Wonder	
  and	
  Awe	
  
•  Loss	
  of	
  Gra.tude	
  
Meaning	
  
•  “We	
  are	
  meaning	
  seeking	
  creatures	
  who	
  must	
  
deal	
  with	
  the	
  inconvenience	
  of...
Meaning	
  
•  Hero's	
  Journey	
  
– Odyssey	
  
– Crusades	
  
•  Spiritual	
  Journey	
  
•  Rela.onships	
  
•  Work	...
responsibility	
  
•  It	
  is	
  most	
  important	
  to	
  run	
  out	
  of	
  scapegoats	
  
•  We	
  must	
  live	
  w...
Isak	
  Dinesen	
  
•  “…All	
  sorrows	
  can	
  be	
  borne……	
  	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
...
Recovery	
  of	
  Desire	
  
•  Therapy	
  as	
  “Recovery	
  of	
  Desire”	
  
•  “We	
  are	
  formed	
  by	
  what	
  w...
Sleep	
  
•  Ac.on:	
  
– Sleep	
  Hygiene	
  
– Stay	
  Up	
  
– Create	
  
•  Meds	
  
– Older	
  
– Newer	
  
– Melaton...
Ted	
  Kaptchuk	
  “The	
  Power	
  of	
  
Nothing”	
  
•  Program	
  in	
  Placebo	
  Studies	
  and	
  the	
  
Therapeu'...
Kaptchuk	
  
•  Larger	
  the	
  pill	
  greater	
  the	
  P	
  
•  Two	
  be]er	
  than	
  one	
  
•  Colored	
  be]er	
 ...
Kaptchuk	
  on	
  Morphine	
  
•  6-­‐8	
  mgms	
  MS	
  =	
  Placebo	
  
•  Must	
  increase	
  to	
  12	
  Mgms	
  to	
 ...
Kaptchuk	
  
•  Diazepam-­‐	
  
•  ……Has	
  no	
  discernible	
  effect	
  on	
  anxiety	
  unless	
  
a	
  person	
  knows...
Bible	
  
•  Ma]hew	
  9:22	
  “Thy	
  faith	
  hath	
  made	
  thee	
  
whole.”	
  
•  Mark	
  10:52	
  “Go	
  thy	
  way...
Faith is a knowledge within the heart,
beyond the reach of proof.
Khalil Gibran
Ac.on	
  Responsibility	
  Medica.on	
  
•  Educate	
  yourself	
  about	
  the	
  medica.on	
  
•  Educa.on	
  your	
  Ph...
Ac.on	
  Responsibility	
  Medica.on	
  
•  Iden.fy	
  the	
  specific	
  feeling	
  
•  Ac.on	
  
Ac.on	
  Responsibility	
  Medica.on	
  
•  Reserve	
  the	
  right	
  to	
  change	
  medica.ons/
mee.ngs/sponsors/therap...
Clement	
  Stone	
  
•  Freedom	
  to	
  Decide	
  
•  Influencing	
  Others	
  
•  Money	
  
•  Learning	
  Something	
  N...
“Tell	
  them	
  I	
  have	
  had	
  a	
  good	
  life”	
  
•  Wi]genstein	
  on	
  his	
  death	
  bed	
  
Amy	
  Roukie,	
  BS/MBA	
  
Senior	
  Vice	
  President,	
  Community	
  Triage	
  Center	
  Services	
  
WestCare	
  Fou...
• To discuss realistic options to implement in any community, as
an alternative to the more costly systems of emergency
re...
• Passed	
  in	
  1986	
  the	
  Emergency	
  Treatment	
  and	
  
Active Labor Act (EMTALA), requires all CMS-
participat...
• Adults	
  with	
  chronic	
  mental-­‐illness	
  and/or	
  	
  	
  
intoxica.on	
  exist	
  in	
  every	
  community	
  ...
•  Just	
  to	
  keep	
  these	
  individuals	
  cycling	
  through	
  these	
  
systems,	
  costs	
  are	
  tremendous	
 ...
•  As	
  an	
  alterna.ve	
  to	
  the	
  Emergency	
  Rooms,	
  this	
  is	
  a	
  mid-­‐level	
  
of	
  care	
  for	
  t...
•  The	
  CTC’s	
  are	
  posi.oned	
  to	
  care	
  for	
  those	
  who	
  
present	
  with	
  mental	
  health	
  and/or...
•  For	
  those	
  being	
  removed	
  from	
  a	
  public	
  situa.on	
  
without	
  formal	
  charges,	
  the	
  Civil	
...
•  Of	
  this	
  popula.on	
  seen	
  in	
  the	
  ER,	
  studies	
  of	
  the	
  CTC	
  
popula.ons	
  in	
  Nevada	
  ha...
•  Staffing	
  includes	
  Registered	
  Nurses,	
  Nurse	
  Prac..oners,	
  Case	
  
Managers,	
  Counselors,	
  a	
  Medic...
PERSON
IN
CRISIS
LAW
ENFORCEMENT
EMERGENCY
ROOM
EMERGENCY
RESPONDERS
COMMUNITY
PROVIDERS
MENTAL
HEALTH
CTC
Several levels ...
•  AVERAGE	
  COST	
  PER	
  ENCOUNTER:	
  
•  	
  	
  	
  	
  	
  	
  	
  	
  	
  
•  Ambulance:	
  	
  	
  	
  	
  	
  	...
• Nevada	
  CTC	
  admissions:	
  5,770	
  
• Average	
  length	
  of	
  stay:	
  3.5	
  days	
  
• Recidivism	
  rate:	
 ...
• If	
  the	
  same	
  5,770	
  clients	
  had	
  one	
  encounter	
  
each,	
  at	
  $12,591,	
  there	
  would	
  be	
  ...
Amy	
  L.	
  Roukie,	
  MBA,	
  Senior	
  Vice	
  President,	
  
WestCare	
  Founda.on	
  
Email:	
  amy.roukie@westcare.c...
• Universal	
  Health	
  Insurance	
  Mandates,	
  And	
  
The	
  Emergency	
  Care	
  Myth	
  	
  
• by	
  Amesh	
  Adalj...
Tx 5 smith roukie
Tx 5 smith roukie
Tx 5 smith roukie
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Treatment: Alternatives to Incarceration and Encouraging Care -

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Tx 5 smith roukie

  1. 1. Treatment  Track:   Alterna.ves  to  Incarcera.on  and   Encouraging  Care   Ron  Smith,  MD,  PhD   Amy  Roukie,  BS/MBA   Moderator:  Van  Ingram,  Execu.ve  Director,  Office  of   Drug  Control  Policy,  Commonwealth  of  Kentucky    
  2. 2. Disclosure   •  Ronald  Smith  has  no  financial  rela.onships   with  proprietary  en..es  that  produce  health   care  goods  and  services   •  Amy  Roukie  has  no  financial  rela.onships  with   proprietary  en..es  that  produce  health  care   goods  and  services  
  3. 3. Learning  Objec.ves   1.  Analyze  alterna.ve  level  of  care  Community  Triage  Centers  to  determine   if  it  addresses  the  needs  of  their  communi.es  with  regards  to  ER   diversions,  dealing  with  the  volume  of  the  homeless,  indigent  and   underserved  mentally  ill  and  substance  abusers  and  treatment  resistant   popula.ons.     2.  Evaluate  the  cost-­‐effec.veness  of  this  level  of  care  in  rela.on  to   Emergency  Responders,  Emergency  Rooms,  jails  and  otherwise  improper   placements  especially  in  urban  areas  located  across  the  country.     3.  List  three  ways  that  medica.ons  alone  are  not  effec.ve  for  the   treatment  of  substance  abuse  49     4.  Outline  three  examples  of  science  suppor.ng  the  use  of  Twelve  Step   interven.ons  in  promo.ng  long-­‐term  recovery.     5.  Outline  the  barriers  that  commonly  exist  to  u.lizing  psychosocial  and   spiritual  interven.ons  in  prescrip.on  drug  treatment  and  ways  to   overcome  these  barriers.  
  4. 4. Medica.on  in  Recovery   Ron  Smith  md  phd                202   3386543  
  5. 5. Disclosure   •  Ronald  Smith  has  no  financial  rela.onships   with  proprietary   en..es  that  produce  health  care  goods  and   services  
  6. 6. Recovery   •  I  don't  know  why  we  are  here,  but  I'm  pre]y   sure  that  it  is  not  in  order  to  enjoy  ourselves.     •  Ludwig  Wi]genstein    
  7. 7. Chief  Complaint   •  “Anxiety   •  “Depression”   •  “Is  this  all  there  is?”   •  “I  can’t  sleep”  
  8. 8. Ques.ons   •  When  is  Medica.on  indicated?   •  What  are  we  Medica.ng?   •  When  can  Medica.on  be  Deferred?   •  What  are  the  Problems  of  Overmedica.on?  
  9. 9. Ac.on-­‐  Responsibility-­‐  Medica.on   •  Educate  yourself  about  the  medica.on   •  Educa.on  your  Physician  about  Addic.on  
  10. 10. Bias……  Prejudice…..Life  Experience   •  Ambivalence   •  Big  Pharma  vs  Great  Pharma    
  11. 11.  “Wi]genstein  was  the  only  man   who  looked  puzzled  at  his  own   lectures….for  this  I  think  very   well  of  him  indeed.   G  E  Moore  to  Bertrand  Russell  
  12. 12. Primary  Drives  and  Neurosis   •  “  Life,  as  we  find  it  is  too  hard  for  us.  It  brings   us  too  many  pains,  disappointments  and   impossible  tasks.  In  order  to  bear  it  we  cannot   dispense  with  pallia.ve  measures.       •  Work,     •  powerful  diversions  of  interest,     •  and  intoxica7ng  substances  which  make  us   insensi.ve  to  it…...something  of  this  kind  is   indispensible.”   – Civiliza.on  and  Its  Discontents  S  Freud   »  S  Freud  
  13. 13. What  am  I  doing  here…why  wasn’t   I  consulted?”            Wi]genstein  
  14. 14. Chief  Complaint   •  “Anxiety   •  “Depression”   •  “Is  this  all  there  is?”   •  “I  can’t  sleep”  
  15. 15. Big  Pharma   •  “Love  and  Other  Drugs”   •  “Side  Effects”  
  16. 16. Paradigm  Shih  to  Meds.   •  Doctors  of  “Medicine”   •  Origins  in  Koch  and  Lister  ….An.bio.cs   •  Huxley   •  Freud   •  Brainwashed  “The  Seduc.ve  Appeal  of   Mindless  Neuroscience”  Satel  and  Lilienfeld  
  17. 17. Educate  Yourself   • “The  Power  of  Nothing”   – Michael  Specter      The  New  Yorker   • The  Truth  about  Drug   Companies      Marcia  Angell        NYRB  
  18. 18. The  Power  of  Nothing   •  “Anything  that  gets  people  away  from  the   conveyer  belts  that  move  from  the   pharmaceu.cal  houses  to  doctors  to   pa.ents….anything  is  worth  considering….we   need  to  stop  pretending  that  it’s  all  about   molecular  biology…       •  Kaptchuk  
  19. 19. Educate  Yourself   •  Anatomy  of  an  Epidemic                                    Whitaker   •  Comfortably  Numb                                                                Barber   •  Selling  Sickness                                                              Moynihan   •  Crea.ng  Mental  Illness                                            Horwitz  
  20. 20. Educate  Yourself   •  Rethinking  Psychiatric  Drugs                Jackson   •  From  Melancholia  to  Prozac                  Clark   •  Your  Drug  May  Be  Your  Problem    Breggin  
  21. 21. Recovery   •  FOI   •  Grow  Up                                            (Steps  and  Erikson)   •  Learn  to  Play                              (Freud  and  Smith)   •  Encounter  the  Shadow              (Jung)   •  Discover  the  Archetype            (Jung)     •  Lose  yourself  to  a  cause            (Shaw)  
  22. 22. Family  of  Origin  Issues   •  “I  am  acquainted  with  your  disposi.on…you   are  irrita.ng  and  unbearable  and  I  consider  it   impossible  to  live  with  you”….such  a  living   literary  journal  as  you  would  like  to  be  is  a   boring  and  hateful  thing  because  one  cannot   skip  pages  or  fling  the  whole  rubbishy  thing   behind  a  stove,  as  one  can  with  the  printed   one”…   •   Johanna  Schopenhauer  to  her  son  Arthur    
  23. 23. YALOM  Existen.al  Psychiatry   •  You  really  are  going  to  die     •  Each  of  us  is  ul.mately  alone     •  Meaningless     •  Responsibility  
  24. 24. YALOM  Existen.al  Psychiatry   •  You  really  are  going  to  die     •  Each  of  us  is  ul.mately  alone     •  Meaningless     •  Responsibility   •  Medica'on  Anyone?  
  25. 25. Kierkegaard      “What  am  I  doing  here?.......                          Why  wasn’t  I  consulted?”  
  26. 26. Yalom   •  Momma  and  the  Meaning  of  Life   •  The  Schopenhauer  Cure   •  Existen.al  Psychiatry  
  27. 27. Chief  Complaint   •  “Anxiety   •  “Depression”   •  “Is  this  all  there  is?”   •  “I  can’t  sleep”  
  28. 28. “Alexithymia”   •  A  (without)  lexa  (words)  thymia  (feelings)   •  HALT  
  29. 29. “Anxiety  is  the  Dizziness  of   Freedom”   Kierkegaard  
  30. 30. “Anxiety”   •  Alone   •  Annihila.on   •  Sleep   •  Nutri.onal  
  31. 31. Alone   •  We  all  live  lives  of  solitary  confinement”   •  Tennessee  Williams   •  Love  is  not  enough  but  it  sure  helps   •  Kopp    
  32. 32. Abandonment  anxiety   •  Primary  Fear?   •  2001   •  My  Life  as  a  Dog  
  33. 33. “Rapprochement”   Margaret  Mahler  
  34. 34. Into  Ac.on   •  Solve  Rapprochement   – Wri.ng   – Mee.ng(s)   – Therapy   – Medita.on   – Sponsor  
  35. 35. Medica.on   •  Low  dose  Lithium   •  Low  dose  SSRI   – Zoloh   •  Beta  Blockers  
  36. 36. Depression   •  Passivity   – “The  passive  posi.on  of  infancy”  Klein   •  Treatment:   – Recovery    (Discovery?)  of  Agency  
  37. 37. “Depression”   •  Sadness   •  Passivity   •  Grief   •  Nutri.onal   •  Technology  
  38. 38. Death   •  “We  are  all  already  dying  and  we  will  be  dead   for  a  long  .me”   •  “You  can  run  but  you  can’t  hide”  
  39. 39. Into  Ac.on   •  Wri.ng   •  Non  Verbal   •  Service   •  Mee.ngs   •  Nutri.on   •  Crea.ve  Process  
  40. 40. Medica.on   •  An.depressants   – Newer   – Older  
  41. 41. Meaning   •  Is  This  All  There  Is?  
  42. 42. Anhedonia   •  Loss  of  Wonder  and  Awe   •  Loss  of  Gra.tude  
  43. 43. Meaning   •  “We  are  meaning  seeking  creatures  who  must   deal  with  the  inconvenience  of  being  hurled   into  a  universe  that  intrinsically  has  no   meaning”  
  44. 44. Meaning   •  Hero's  Journey   – Odyssey   – Crusades   •  Spiritual  Journey   •  Rela.onships   •  Work   •  Philosophical  Materialism  
  45. 45. responsibility   •  It  is  most  important  to  run  out  of  scapegoats   •  We  must  live  within  the  ambiguity  of  par.al   freedom,  par.al  knowledge,  par.al  power  
  46. 46. Isak  Dinesen   •  “…All  sorrows  can  be  borne……                                              ……if  you  can  put  them  in  a  story                                                                        ……..about  them…”  
  47. 47. Recovery  of  Desire   •  Therapy  as  “Recovery  of  Desire”   •  “We  are  formed  by  what  we  desire        John  Irving   •  Men  as  desiring  machines              Baudrillard               •  Girls  vs  Sex  and  the  City                                                                                                                          
  48. 48. Sleep   •  Ac.on:   – Sleep  Hygiene   – Stay  Up   – Create   •  Meds   – Older   – Newer   – Melatonin  
  49. 49. Ted  Kaptchuk  “The  Power  of   Nothing”   •  Program  in  Placebo  Studies  and  the   Therapeu'c  Encounter     – Harvard  Beth  Israel  Deaconess  Medical  Center  
  50. 50. Kaptchuk   •  Larger  the  pill  greater  the  P   •  Two  be]er  than  one   •  Colored  be]er  than  white   •  Blue  to  sleep  be]er  than  red   •  Green  best  for  anxiety  
  51. 51. Kaptchuk  on  Morphine   •  6-­‐8  mgms  MS  =  Placebo   •  Must  increase  to  12  Mgms  to  surpass  placebo  
  52. 52. Kaptchuk   •  Diazepam-­‐   •  ……Has  no  discernible  effect  on  anxiety  unless   a  person  knows  he  is  taking  it…….  
  53. 53. Bible   •  Ma]hew  9:22  “Thy  faith  hath  made  thee   whole.”   •  Mark  10:52  “Go  thy  way;  thy  faith  hath  made   thee  whole”   •  Luke  7:50  “Thy  faith  hath  saved  thee;  go  in   peace.”   •  Luke17:19  “Arise,  go  your  way:  your  faith  has   made  you  whole.”  
  54. 54. Faith is a knowledge within the heart, beyond the reach of proof. Khalil Gibran
  55. 55. Ac.on  Responsibility  Medica.on   •  Educate  yourself  about  the  medica.on   •  Educa.on  your  Physician  about  Addic.on  
  56. 56. Ac.on  Responsibility  Medica.on   •  Iden.fy  the  specific  feeling   •  Ac.on  
  57. 57. Ac.on  Responsibility  Medica.on   •  Reserve  the  right  to  change  medica.ons/ mee.ngs/sponsors/therapists/  especially   psychiatrists   •  Get  a  second  opinion     •  And  third  
  58. 58. Clement  Stone   •  Freedom  to  Decide   •  Influencing  Others   •  Money   •  Learning  Something  New  
  59. 59. “Tell  them  I  have  had  a  good  life”   •  Wi]genstein  on  his  death  bed  
  60. 60. Amy  Roukie,  BS/MBA   Senior  Vice  President,  Community  Triage  Center  Services   WestCare  Founda.on   amy.roukie@westcare.com   www.westcare.com  
  61. 61. • To discuss realistic options to implement in any community, as an alternative to the more costly systems of emergency responders. • To define financial resources to support these alternatives which are community-based and demonstrate buy-in from the community and connection to the law enforcement community. • To explore options for these services from medical to social interventions, case management and success rates.
  62. 62. • Passed  in  1986  the  Emergency  Treatment  and   Active Labor Act (EMTALA), requires all CMS- participating hospitals to provide emergency care to all individuals seeking care irrespective of ability to pay. •  According to the Centers for Medicare and Medicaid Services (CMS), amounts to 55% of emergency care. (A.Adalja, M.D) •  Across the nation the Mentally-ill and/or intoxicated individuals creating over-crowding, long wait times and impacting care in the Emergency Rooms.
  63. 63. • Adults  with  chronic  mental-­‐illness  and/or       intoxica.on  exist  in  every  community  and  are   the  “highest  system  users”  cos.ng  the   community  millions  of  dollars.       • Impact  the  Emergency  Rooms,  Law   Enforcement,    Emergency  Medical  Services,   Ambulance,  Paramedics,  Jail,  Court  rooms,   Mental  Health  hospitals,  etc.      
  64. 64. •  Just  to  keep  these  individuals  cycling  through  these   systems,  costs  are  tremendous  including  .me  and   money.   •  Most  .mes  individuals  cycle  through  these  systems   of  care,  several  .mes  a  week,  a  month  or  some.mes   even  in  a  day,  and  there  is  nothing  done  to   intervene.   •  What  can  be  done  to  stop  the  cycle  and  was.ng   money?  
  65. 65. •  As  an  alterna.ve  to  the  Emergency  Rooms,  this  is  a  mid-­‐level   of  care  for  those  with:   –  Intoxica.on/Substance  Abuse   –  Mental  Illness   •  Assessments  for  inpa.ent  &  outpa.ent  services   •  Ini.al  case  management  services   •  Referrals  &  service  linkages   •  Safe  &  effec.ve  treatment  op.ons  for  early   interven.on   •  Discharge  planning   •  Clients  served  are  ohen  homeless,  uninsured,  under-­‐ insured  &  indigent  
  66. 66. •  The  CTC’s  are  posi.oned  to  care  for  those  who   present  with  mental  health  and/or  substance  abuse   issues  as  well  as  non-­‐acute*  medical  condi.ons.   •  As  an  alterna.ve  level  of  care,  they  are  equipped  to   handle  the  non-­‐violent  behavioral  health,  and   intoxicated  clients  in  the  community.   *Non-­‐acute  is  defined  based  on  medical  status  of  the  individual   and  the  type  of  interven.on  indicated.  
  67. 67. •  For  those  being  removed  from  a  public  situa.on   without  formal  charges,  the  Civil  Protec.ve  Custody   detainees,  for  example  are  taken  to  the  CTC  in  lieu  of   the  ‘drunk  tank’  in  jail.   •  Engagement  in  substance  abuse  or  mental  health   treatment  is  also  a  poten.al  in  this  environment.   •  Case  Management  and  discharge  planning  are  the   keys  to  ini.a.ng  change  in  this  popula.on.  
  68. 68. •  Of  this  popula.on  seen  in  the  ER,  studies  of  the  CTC   popula.ons  in  Nevada  have  shown  97%  have  no  acute   medical  issues,  only  behavioral  health  problems.   •  They  are  held  in  the  ER  for  assessments,  medical  clearance   and  the  lack  of  available  psychiatric  beds  in  the  community.     There  are  few  discharge  op.ons.   •  If  released,  there  are  concerns  about  liability,  so  ER’s  are   caught  in  the  bind  between  discharging  with  no  plan  and   opening-­‐up  beds  for  the  medically-­‐acute.  
  69. 69. •  Staffing  includes  Registered  Nurses,  Nurse  Prac..oners,  Case   Managers,  Counselors,  a  Medical  Director  and  on-­‐call   Psychiatrists  with  the  ability  to  accept  pa.ents  24-­‐hours  per   day/  7  days  per  week.   •  Medica.ons  are  provided  for  those  in  need  of  stabilizing   chronic  but  exacerbated  medical  condi.ons  and  for  any   medical  issues  during  detoxifica.on.   •  Low-­‐level  medical  procedures  can  be  performed,  however   CTC’s  are  not  intended  for  that  purpose.  
  70. 70. PERSON IN CRISIS LAW ENFORCEMENT EMERGENCY ROOM EMERGENCY RESPONDERS COMMUNITY PROVIDERS MENTAL HEALTH CTC Several levels of intervention can occur with this one person. With the Community Triage Center approach, there is one intermediate level of care where all issues can be addressed
  71. 71. •  AVERAGE  COST  PER  ENCOUNTER:   •                    •  Ambulance:                      $1,267     •  Hospital:                              $10,324    (billed  charges)   •  First  Responders:      $1,000  per  incident   •  Per  encounter  es.mate:  $12,591*   •  *data  from  Washoe  County  Report  on  Serial   Inebriates  2013.  
  72. 72. • Nevada  CTC  admissions:  5,770   • Average  length  of  stay:  3.5  days   • Recidivism  rate:  30.6%   • Total  costs:  $3,806,695/  year  
  73. 73. • If  the  same  5,770  clients  had  one  encounter   each,  at  $12,591,  there  would  be  $72,667,380   in  costs  to  the  community  versus  $  3,806,695   for  the  same  clients  at  the  CTC’s!       • Total  savings:  $68,860,685  
  74. 74. Amy  L.  Roukie,  MBA,  Senior  Vice  President,   WestCare  Founda.on   Email:  amy.roukie@westcare.com   Website:  www.westcare.com  
  75. 75. • Universal  Health  Insurance  Mandates,  And   The  Emergency  Care  Myth     • by  Amesh  Adalja,  M.D  retrieved  August  12,   2013  from:   h]p://www.forbes.com/sites/realspin/ 2012/10/08/universal-­‐health-­‐insurance-­‐ mandates-­‐and-­‐the-­‐emergency-­‐care-­‐myth/  

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