Advanced Mental Health Care 101: Supported Mental Healthcare Options
Kaitlyn (Kait) Oudt
Employee Benefits Specialist providing group benefits analysis & consultation to insurance professionals ? Mental Health Guru ? Digital Media Specialist, Content Creator, Strategist
In the field of mental and behavioral healthcare, managing severe mental illness and complex mental health challenges requires a nuanced approach that goes beyond traditional treatments. Individuals and their families now have access to a range of advanced options that respect autonomy and ensure comprehensive care.
These options include initiating conversations about voluntary psychiatric treatment programs, utilizing legal tools to outline specific treatment preferences, and employing supported decision-making frameworks that empower individuals with disabilities through trusted supporters.
Today's conversation aims to highlight the transformative potential of advanced mental and behavioral healthcare options, emphasizing the evolution of treatment modalities and the crucial role of personalized, compassionate care in enhancing quality of life and empowering individuals in their healthcare journey.
?? Interested in reading past guides on how to navigate mental & behavioral health emergencies, involuntary holds, and conservatorship? Check out past editions of Working Well to read the comprehensive guides!
A Few Definitions to Kick Off the Conversation
Just 65.4%?of U.S. adults with serious mental illness received treatment in 2021. 1 in 20 U.S. adults experiences serious mental illness each year.
According to the NIMH, Any mental illness (AMI) is defined as a mental, behavioral, or emotional disorder. AMI can vary in impact, ranging from no impairment to mild, moderate, and even severe impairment (e.g., individuals with serious mental illness as defined below).1 in 5 U.S. adults experience mental illness each year. In 2021, this equated to 57.8 million Americans over the age of 18. This number represented 22.8% of all U.S. adults.
In 2021, among the 57.8 million adults with AMI, 26.5 million (47.2%) received mental health services in the past year. This means that 52.8% of adults struggling with mental illness went untreated that year.
Serious mental illness (SMI) is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment that substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI. 1 in 20 U.S. adults experiences serious mental illness each year.
In 2021, an estimated 14.1 million U.S. adults (5.5%) had Serious Mental Illness (SMI). The prevalence was higher among females (7.0%) than males (4.0%). Young adults aged 18-25 had the highest prevalence of SMI (11.4%), compared to those aged 26-49 (7.1%) and 50 and older (2.5%).
Plan In Advance for a Mental Health Emergency
Planning in advance for a mental health emergency could look like planning for yourself, or planning in advance to help a loved on with a diagnosed mental health condition. Over the past few weeks, we've talked about navigating mental health emergencies, involuntary holds, and conservatorship.
The options we're talking through today can help ease stress and confusion when a more serious emergency arises. They can also help keep things on track after your loved one starts a new treatment plan or returns home from a hospitalization.
?? Psychiatric Advance Directive (PAD): A Psychiatric Advance Directive (PAD) is a legal document that allows individuals to outline their preferences for mental health treatment in advance of a crisis when they might be unable to make decisions for themselves. This directive can include instructions about medications, hospitalization, and other treatments. It can also designate a trusted person (agent) to make decisions on their behalf if they become incapacitated. The purpose of a Psychiatric Advance Directive (PAD) is to ensure that an individual's mental health care wishes are respected and followed during times when they are unable to communicate or make informed decisions due to their mental health condition. It provides a way for individuals to maintain some control over their treatment and care during a mental health crisis.
?? Voluntary Psychiatric Treatment: Talk to your loved one about voluntary mental health treatment programs. Utilizing psychiatric advance directives (PADs) to outline preferred treatments and appoint decision-makers.
?? Designation of a Healthcare Surrogate: For those who haven't completed an Advanced Healthcare Directive (AHCD), a healthcare provider might suggest designating a surrogate to assist with medical decisions if the individual becomes incapacitated. This surrogate designation is temporary, lasting for the duration of treatment or hospitalization or up to 60 days. If no surrogate is pre-designated, a healthcare provider can appoint one from a list of close relations or friends.
?? Physician Orders for Life-Sustaining Treatment (POLST): A POLST is a medical form for immediate end-of-life treatment decisions, like CPR or ventilator use. It complements an AHCD by focusing on specific urgent care preferences, including comfort measures and hospice care.
?? Advanced Healthcare Directive (AHCD): An AHCD is a legal document in which a person outlines their medical treatment preferences and appoints someone to make healthcare decisions on their behalf if they become incapacitated. This includes end-of-life wishes, pain management, and organ donation. The California Office of the Attorney General offers a sample AHCD.
?? Power of Attorney (POA): A POA allows someone to designate another person to make financial or other decisions on their behalf. It can be durable, lasting as long as the POA exists, or springing, activated by a specific event such as incapacity. A sample POA is available from the Sacramento County Public Library.
?? Living Trusts: A living trust places a person’s assets under the control of a trustee. Most set themselves as the trustee, naming a successor to take over upon their death or incapacity. This ensures continuous management of their assets.
?? Special Needs Trusts (SNT): An SNT allows a person with disabilities to remain eligible for public benefits like SSI and Medi-Cal while having additional assets. More information is provided by the Department of Health Care Services.
?? Representative Payee: Appointed by Social Security, a representative payee manages Social Security or SSI payments for someone unable to do so themselves. They ensure bills are paid and the beneficiary’s needs are met. The Social Security Administration offers more details on this program.
?? Assisted Outpatient Treatment: Assisted Outpatient Treatment (AOT) offers court-mandated, intensive community-based mental health care for individuals with severe mental health disabilities. These individuals do not meet the criteria for involuntary hospitalization under the Lanterman-Petris-Short (LPS) Act but are experiencing a decline in their condition and refuse to seek treatment. AOT is only implemented if the person has a history of not following treatment plans, which has led to previous hospitalizations, incarcerations, or dangerous behaviors.
?? Supported Decision-Making: This option allows individuals with disabilities to make their own decisions with the help of trusted supporters, such as family, friends, or professionals. These supporters assist in understanding, considering, and communicating decisions, but the final choice remains with the individual. This process does not involve the courts; more information can be found at The Arc of California.
?? In-Home Support Services (IHSS): Utilizing programs to provide personal care and support services within the home environment. The In-Home Supportive Services (IHSS) program provides in-home assistance to eligible aged, blind, and disabled individuals as an alternative to out-of-home care and enables recipients to remain safely in their own homes.
?? Legal Advocacy Services: Seeking assistance from legal advocacy organizations that can provide representation and support for individuals with mental health conditions may be a helpful resource to explore. Check out Mental Health Advocacy Services, Inc. (MHAS) -they provide free legal services to people with mental health disabilities.
?? Assertive Community Treatment Program: The Assertive Community Treatment (ACT) program offers treatment, rehabilitation, and support services using a person-centered, recovery-based approach to individuals who have been diagnosed with severe and persistent mental illness. Individuals receive ACT services including assertive outreach, mental health treatment, health, vocational, integrated dual disorder treatment, family education, wellness skills, community linkages, and peer support from a mobile, multidisciplinary team in community settings.
?? Full-Service Partnerships (FSP): Adult Full Service Partnership (FSP) programs offer comprehensive support that includes housing assistance, employment services, and educational opportunities. These programs also provide mental health services and integrated treatment for individuals dealing with both mental health and substance abuse disorders.
What is Mental Health Self-Direction?
Mental health self-direction is rooted in recovery, independence, self-sufficiency, and personal choice principles. It emphasizes that individuals with serious mental health conditions can set and achieve meaningful goals for themselves. This approach allows participants enrolled in publicly funded programs to manage a monthly budget and purchase goods and services that support their recovery and independence goals. For instance, funds may be allocated towards education, stable housing, or fitness memberships, depending on individual needs and aspirations.
The self-direction model operates on the principle of "nothing about us without us," ensuring that individuals have a central role in decision-making processes related to their own lives and services. This includes developing comprehensive life plans tailored to personal strengths and community resources. Support brokers, often peers with lived experience in mental health recovery, play a crucial role in guiding participants through plan development, implementation, and adjustments as circumstances evolve.
Monitoring and quality management mechanisms are in place across states to ensure responsible use of funds and effectiveness of services, with financial management services available to assist participants in budgeting and financial responsibilities. Overall, self-direction in mental health has proven effective and cost-comparable to traditional service models, offering flexibility and empowerment to participants in managing their mental health recovery journeys.
Self-direction approaches generally share the following basic elements:
?? Looking to learn more about the fundamentals of self-direction? Check out this helpful resource.
Mental Health Self-Direction vs. Self-Determination
Mental health self-direction and self-determination are related but distinct concepts. Mental health self-direction specifically targets individuals with serious mental health conditions, organizing publicly funded services and supports to emphasize recovery, resilience, stability, and autonomy. This approach gives individuals control over an individualized budget and often involves working with a support broker with personal experience with the mental health system.
On the other hand, self-determination is a broader concept applicable to various aspects of life, centered on the idea that individuals have the right to make their own choices and control their own lives. It encourages setting personal goals and making decisions across different contexts, such as education, employment, and personal relationships. While both emphasize personal choice, control, and empowerment, self-direction is a structured program within the mental health system, whereas self-determination is a universal principle applied to a wide range of life decisions.
Self-Determination Initiatives
The concept of self-determination is best thought of as a spectrum, with individuals with full decision-making capacity at one end and those needing more support due to limited capacity at the other.
The Department of Developmental Services (DDS) highlights the Self-Determination Program (SDP), initiated through SB 468 (Emmerson) in October 2013 under Governor Edmund G. Brown Jr.
Initially limited to 2,500 individuals during its implementation phase, the SDP has since expanded. As of July 1, 2021, all eligible individuals receiving services from a regional center can participate in the SDP, which offers them greater freedom, control, and responsibility in choosing services and supports aligned with their Individual Program Plan (IPP).
Person-centered planning is integral to SDP. It focuses on the individual's aspirations and preferences. It allows individuals to lead the planning process, involving others only if desired, such as family or friends. The resulting IPP outlines specific goals and necessary services to achieve them.
Eligibility for SDP extends to regional center consumers with developmental disabilities as defined by Welfare and Institutions Code 4512. Participants must agree to program terms, including orientation, engagement with Financial Management Services, and managing a personal budget for eligible services. Notably, individuals residing in long-term healthcare facilities can transition to SDP if they meet certain criteria, fostering community integration within 90 days as part of the person-centered planning process.
?? Want to learn more about self-determination initiatives? Mental Health America has an interesting take on self-determination that you may find interesting. Here's their position on self-determination.
Full-Service Partnerships (FTS)
The Adult Full Service Partnership (FSP) programs provide intensive outpatient services tailored for adults with serious mental illness. These programs cater to individuals involved in the criminal justice system and those frequently using inpatient psychiatric care. Services include outreach, intensive case management, psychiatric care, vocational support, peer support, transportation assistance, housing placement, benefit acquisition, counseling, and therapy. The FSPs use the Assertive Community Treatment (ACT) model, delivering culturally competent and comprehensive community-based services through a multidisciplinary team approach, promoting health, recovery, and wellness.
FTS Programs in Orange County
Youthful Offender Wraparound (YOW): Provides Full Service Partnership (FSP) for youth and young adults (ages 12–26) with serious emotional disturbances or severe mental illness. Services include support for those on probation or with juvenile justice involvement, offering crisis services 24/7.
Collaborative Courts: This program targets children and youth (up to age 26) referred by Orange County Juvenile Court. It provides FSP with comprehensive mental health services and crisis support as needed, enhancing coordination with legal and social services.
Project FOCUS: Serves children, youth, and Transitional Age Youth (TAY) up to age 26, focusing on those at risk of homelessness or with severe mental illness. Offers culturally diverse support including crisis services, educational assistance, and family support.
Project RENEW: Addresses the needs of children and youth (ages 0-18) with severe emotional disturbances, emphasizing support for families at risk of homelessness. Provides a Wraparound model with 24/7 crisis services, aiming to enhance family stability and youth development.
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STAY (Support Transitional Age Youth): Supports Transitional Age Youth (ages 16-25) dealing with serious emotional disturbances or mental illness, often facing homelessness or psychiatric emergencies. Offers comprehensive services and crisis support to aid in community integration and self-sufficiency.
Telecare and Orange (TAO): TAO serves adults with serious mental illness who are underserved, homeless, or at risk of homelessness, and may also have co-occurring substance use disorders. It operates in multiple locations including TAO North (Anaheim), TAO South (Costa Mesa), and TAO Central (Garden Grove), with specific contact details available for each location.
Opportunity Knocks (OK): OK focuses on adults with serious mental illness who have a history of incarceration or involvement in the criminal justice system, and who may be experiencing homelessness. It is located in Garden Grove, CA, with contact available at (714) 620-8131.
Striving Towards Enhanced Partnerships (STEPS): STEPS supports adults with serious mental illness who are transitioning from long-term care facilities or participating in the Assisted Intervention (AI) Court. Located in Santa Ana, CA, STEPS can be contacted at (714) 245-6881.
"Whatever It Takes" (WIT): WIT serves adults with serious mental illness participating in the WIT Court in collaboration with Orange County Superior Court. Located in Santa Ana, CA, WIT can be reached at (714) 361-7950.
Assisted Outpatient Treatment (AOT): AOT serves adults who meet specific criteria, whether court-ordered or voluntary participants, aiming to provide necessary outpatient treatment. Located in Santa Ana, CA, AOT can be contacted at (714) 795-3444. More information is available on their AOT page.
For further inquiries about FSP programs in Orange County, including eligibility and services provided, individuals are encouraged to contact the Adult FSP Coordination Office at 714-850-8402 or email program leaders Annette Mugrditchian, Jenny Hudson, or Chi Lam. These programs are committed to supporting recovery and well-being through collaborative services across Orange County.
Assisted Outpatient Treatment (AOT)
?? Who qualifies for Assisted Outpatient Treatment (AOT)?
To qualify for Assisted Outpatient Treatment (AOT), an individual must meet specific criteria:
Additionally, for AOT to be mandated, it must be demonstrated that:
?? What mental illnesses qualify?
To receive Assisted Outpatient Treatment (AOT), an individual must have a serious mental illness that is severe and persistent. This illness should interfere significantly with daily living and hinder independent functioning without long-term treatment and support.
Examples of qualifying mental illnesses include schizophrenia, bipolar disorder, post-traumatic stress disorder, major affective disorders, and other severe mental disorders.
?? Who can refer someone for Assisted Outpatient Treatment?
Referrals for AOT can be made by:
?? What happens after a referral?
After a referral, the DMH AOT Outreach and Engagement Team reviews and investigates to determine if the candidate meets AOT criteria. If so, they offer an initial treatment plan and contact the individual repeatedly for 30 days to encourage voluntary treatment. If the individual refuses, the team prepares documents for a court petition. The Medical Director of DMH reviews the evidence, and if sufficient, the County Counsel files a petition. A Public Defender is assigned, and a court hearing is held within five days to decide on treatment. If AOT is ordered, the individual must participate in a treatment program with community-based support. Persistent refusal can lead to involuntary hospitalization for up to 72 hours.
?? Types of treatment services available + duration
AOT offers community-based treatment through two main services:
The court can order AOT for up to six months. If further treatment is needed, the program director can request an extension for up to 180 days before the initial order expires.
Psychiatric Advanced Directives
?? Can I create a legally binding psychiatric advance directive (PAD) in California?
Yes, California's Health Care Decisions Law allows for the creation of a PAD. You can appoint an agent to make decisions on your behalf if you're unable to do so, and provide instructions on your desired health care, including psychiatric treatment. Disability Rights California offers resources, including a recommended (though not mandatory) statutory Advance Health Care Directive (AHCD) form. Check out their guide here and also hang onto the Trainer’s Manual on the subject of AHCDs for easy reference.
?? Can I specify instructions for psychiatric medications and hospitalization in my PAD?
Yes, you can outline instructions for psychiatric medications and hospitalization within your PAD. However, it's important to note that while you can refuse medications and hospitalization in your PAD, state law might still mandate hospitalization in emergencies.
?? If you'd like to read up on more FAQ's about PAD's, check out this resource.
Some Questions to Consider When Making a Plan
Because every individual is different, it's important to take unique needs into consideration.
If you're creating a plan on behalf of a loved one, it's important to sit down and have this conversation together if possible. Ultimately, you're creating a game plan in the first place to help your loved one achieve their goals and ensure they can live a happy and fulfilling life. In addition, these plans create a guideline for how emergencies will be handled in the future. Take time to listen, ask important questions, and understand their personal priorities without bias.
If your loved one is capable of creating a plan independently and does not want you to be involved in this process, ask if there's someone else they'd feel comfortable trusting with this information. Approach the conversation from a place of empathy and understanding. If they create a plan on their own, ensure someone has a copy of their wishes that can be accessed if a mental health emergency arises.
If you're creating a plan for yourself, it's important to be clear and direct when drafting up your wishes. Keep a copy in a safe place for yourself and give a copy to trusted loved ones or friends who will assist in the process, if needed. Creating a designated folder or binder and be a great way to keep everything in one place. Down the road, it can be helpful for family members to understand your preferences, wants and needs while making decisions on your behalf.
To get you started, here are some things that you could consider:
Who
What
Where
When
Why
How
When you ask yourself these questions, you will start to identify particular needs. Once you have an idea of the issues that need attention, it will be easier to make proactive decisions regarding care initiatives. It's a good idea to jot down these ideas in case they are needed in the future!
Disclaimer: The information provided is for general informational purposes only and should not be construed as professional, medical, or legal advice. Readers should consult with appropriate professionals regarding their specific circumstances and needs. The author and any associated entities shall not be liable for any losses, injuries, or damages arising from the use of or reliance on the information provided in this article. By accessing and reading this article, you agree to release the author and any associated entities from any and all liability.
Additional Sources + Citations