Statement of Guiding Principles

for the Delivery of Behavioral Health Services

July 2001

The Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) and the private non-profit hospital community, with specialty hospitals in Maine providing inpatient psychiatric treatment, agree to work collaboratively toward ensuring that adults in Maine requiring psychiatric inpatient treatment receive such treatment in the optimal clinical setting available. The goal of this collaboration is to provide both voluntary and involuntary inpatient psychiatric treatment in a setting that meets the clinical needs of the individual and, whenever possible, is located within the individual’s geographic area. The clinical needs of the individual and the availability of hospital beds may preclude the assurance that all individuals will be hospitalized within their geographic areas.

DMHMRSAS and the community hospitals will strive to provide inpatient psychiatric services that focus on the stabilization of the psychiatric disturbance and the provision of treatment and interventions that will permit the individual to return to the community as soon as possible. DMHMRSAS will strive to assure that adequate services are available to support the timely discharge of patients from the inpatient setting to the community or to other alternative settings.

The purpose of this document is to provide clarity and unity of vision, a foundation for coordinated future planning efforts and to facilitate the development of an efficient, integrated continuum of acute and long-term psychiatric care for the citizens of Maine. The following are guidelines or guiding principles for the utilization of community, specialty and state-operated beds in determining the optimal clinical setting for an individual requiring inpatient psychiatric treatment.

Community Hospitals with Inpatient Psychiatric Units:
Community hospitals with inpatient psychiatric units and regional referral specialty centers will in concert strive to provide or arrange to provide all short-term (defined as less than 30 days) acute psychiatric care required to meet the needs of Maine citizens. Each of Maine’s community hospitals’ Boards of Directors will determine the level of inpatient psychiatric services provided at their respective institutions based on community need and consistent with available resources. The scope of those services may differ. The capability of each hospital to provide treatment for specific patient groups will be documented in admission criteria that will be available to Maine mental health providers and DMHMRSAS. Further, the capacity of each hospital psychiatric unit will vary over time based on patient acuity as well as the psychiatric unit’s staffing levels and utilization.

While the community hospitals will treat inpatients of varying levels of psychiatric acuity, the community hospitals may opt not to provide long-term psychiatric treatment (defined as greater than thirty calendar days). When the community hospital’s clinical staff determines that a patient will require extended treatment, the patient may be referred to a state-operated hospital. The individual’s clinical status while hospitalized will guide the determination of the need for extended treatment and the subsequent referral to a state-operated hospital. It is not expected that every patient with a thirty-day length of stay will be referred to the state-operated hospital.

Regional Referral Specialty Centers:
Maine currently has two Regional Referral Specialty Centers that provide inpatient psychiatric treatment: Spring Harbor Hospital and Acadia Hospital. The Regional Referral Specialty Centers Boards of Directors will define the scope of services provided at each institution as determined by an evaluation of community and regional need and available resources. Regional Referral Specialty Centers will also accept referrals from community hospitals based on patient acuity, specialty services available and capacity. Thus, the Regional Referral Specialty Centers will make every effort to accept referrals when community hospitals are unable to safely provide treatment for an individual due to clinical or risk issues; when an individual may need such specialty services as neuropsychiatry which are not available within the community hospitals; and when the community hospitals do not have the capacity to provide treatment. The ability of the Regional Referral Specialty Centers to accept a referral will be dependent upon their current bed availability and range of specialty services.

The Regional Referral Specialty Centers may also refer patients to a state-operated hospital when clinical staff determines that a patient will require extended treatment (defined as greater than thirty calendar days). The individual’s clinical status and progress while hospitalized will guide the determination of the need for extended treatment and the subsequent referral to a state-operated hospital. It is not expected that every patient with a thirty-day length of stay will be referred to a state-operated hospital.

State-Operated Psychiatric Hospitals:
Maine has two state-operated psychiatric hospitals: Augusta Mental Health Institute (AMHI) and Bangor Mental Health Institute (BMHI). These hospitals, primarily AMHI, will provide all adult forensic services for the state. Both state-operated psychiatric hospitals will provide long-term inpatient psychiatric treatment, psychosocial rehabilitation, as well as specialized treatment for persons with a dual diagnosis consistent with mental health combined with a history of trauma and/or a mental health diagnosis coupled with mental retardation. The state facilities will also provide safety net services for acute inpatient psychiatric treatment as needed.

As the “safety net” for acute psychiatric inpatient treatment, the state-operated psychiatric hospitals will accept referrals of individuals unable to be served by the community hospitals or the Regional Referral Specialty Centers. Following the implementation of a Process Improvement Collaborative described later in this document, the role of the State Psychiatric facilities is intended to evolve toward a more focused, specific forensic, specialty and long-term care function. The state-operated psychiatric hospitals will also continue to treat patients unable to be served safely within the community hospital network due to the individual’s actual or potential for violence or self-harm. The state-operated hospitals will serve individuals whose clinical needs cannot be appropriately met in other hospitals. The decision that an individual would be best treated within a state-operated hospital will be made consistent with AMHI/BMHI admission criteria. Further, the state-operated psychiatric hospitals will accept referrals for individuals requiring extended treatment and psychosocial rehabilitation as determined by the referring community hospital and or regional specialty referral center clinical team. The transfer process will include discussion between the psychiatric staff of the sending and receiving hospital. The state-operated psychiatric hospitals will use best efforts to affect such a transfer within five working days of notification. Should issues arise concerning the appropriateness of the transfer, each case will be discussed retrospectively with the relevant clinical teams.

System Development:
DMHMRSAS and the community hospitals in Maine providing inpatient psychiatric treatment also agree to work collaboratively to facilitate the timely admission to an inpatient psychiatric bed for individuals requiring such treatment and to engage in process improvement efforts to assist in system planning that supports high quality treatment. The following collaborative efforts will help achieve these goals:

Census Bulletin Board:
Each community hospital, Regional Referral Specialty Center and state-operated hospital will provide information about the availability of psychiatric beds at their hospital at least thrice daily to a Census Bulletin Board located in an easily accessed Web Page. The Web Page will also provide a link to the admission criteria for each of the psychiatric inpatient settings. The Census Bulletin Board will provide information to clinicians who are seeking hospital admission for an individual, with the goal of reducing the time required locating an appropriate inpatient psychiatric bed.

The Census Bulletin Board will begin as a pilot project. The effectiveness of the Census Bulletin Board in decreasing the time required to locate an appropriate inpatient psychiatric bed will be evaluated. Continuation or refinement of the Census Bulletin Board will be based on this assessment.

Community Resource Bulletin Board:
DMHMRSAS will collaborate with contracted outpatient and residential service providers to develop a Community Resource Bulletin Board on an accessible Web Page that will indicate the current availability of various community programs in order to assist in patient referral, placement and hospital discharge planning. The Community Resource Bulletin Board will include information on the availability of crisis stabilization beds, residential support beds, treatment programs, and chemical detoxification beds. The Web page will also include the admission criteria for each of the listed interventions.

The Community Resource Bulletin Board will also be initiated as a pilot project. The effectiveness will be assessed and the continuation or refinement of the Community Resource Bulletin Board will be based on this assessment.

Interagency Process Improvement/System Planning Board
An Interagency Process Improvement/System Planning Board, composed of representatives from the community hospitals, the Regional Referral Specialty Centers, the state-operated hospitals, contracted outpatient and residential service providers and DMHMRSAS, will be established. The purpose of this effort is to ensure consistent, systemic movement toward the role definition outlined in this document. The board will establish baseline data to assist in evaluating the delivery system performance. This type of assessment will permit the identification of opportunities for improvement.

While recommendations and summary data used by the Board will be developed to assist in system planning, the data that identifies or may lead to the identification of any patient or provider will be considered elements of a confidential quality improvement program and not subject to public review.