Mental Health Services Act (Mhsa) Project

PROGRESS REPORT

MENTAL HEALTH SERVICES ACT (MHSA) PROJECT

FISCAL YEARS 2008/09 – 2010/11

Title of Project: “County Psychiatrist Training: Best Practices for Medication, Diagnosis and Treatment of Regional Center Patients with Mental Illness.”

Regional Center: San Gabriel Pomona Regional Center

Regional Center Project Manager: Dr. Stephen Mouton Phone: 909 868-7527

Email address:

Reporting Period:

1st Report 2nd Report 3rd Report 4th Report X 5th Report

(due 12/31/09) (due 6/30/10) (due 12/31/10) (due 6/30/11) (due 12/30/11)

6th Report 7th Report 8th Report Final Report

(due 6/30/2012) (due 12/31/2012) (due 6/30/2013) (7/31/2013)

Activities Phase: Development X Implementation X Evaluation X Completion

Activities to Date:

Trainings were conducted on September 14th, October 12th and November 9th. The three trainings conducted in 2011 were well attended and popular. Many former attendees of the Best Practices Training from earlier years had passed on registration information to their colleagues in their clinical settings. Because the training always involved a small group of Psychiatrists, the training itself encouraged the free flow of experiences, ideas and a “clubby” feeling among many of the Psychiatrists.

Psychiatrists sharing business cards and information with each other about common education, previous internships, fellowships and employers were common chatter among the attendees. Common and “off-label” uses of medications and their personal experiences with different medications in practice were discussed as it applied to the clients seen in the training. Recent studies and new unpublished research were shared informally among colleagues. The impact and potential impact of agency and political policies affecting the practice and reimbursement of psychiatric services were discussed. Additionally, the limitations of using different medications at a variety of dosages and the ordering of specific tests were frequently traded information related to treatment choices in group discussions. Dr. Craig Wronski, Triple Board Certified, Chief of Staff at College Hospital led the in-patient training.

The in-patient training included a folder of reference information (posted on the www.MHSA Grants.com web site.) A standing flip chart overview of the regional center system was presented to Psychiatrists. Unique aspects of the DDMI wing as California’s only private psychiatric hospital program exclusively for regional center clients with mental and behavioral difficulties were compared to typical psychiatric hospitals without specialty staff and BCBA behavior analysts.

Psychiatrists were toured through the DDMI wings to observe in-patient clients engaged in groups, unusual behaviors and in a variety of treatment milieus. Later, DDMI wing staff were brought into the training room to discuss how they handle different client situations and their unique role within the DDMI wing units. Medical case records were distributed to the trainees. The in-patient admission and treatment process were discussed in” round table fashion”. Discussions emphasized initial differential diagnosis, initial medications / response, course of changes to the meds and client response / side effects. The broader background dynamics and complications of legal, family and potential placement complications that affected the treatment choices were included in the review.

Clients were brought into the training room accompanied by one or more staff members to talk about their behavor experience prior to entering the DDMI wing and the changes that have occurred in their behavior since being engaged in the DDMI wing treatment milieu. Doctors in the training group asked questions pertinent to their history and medication. Impressions of the client, compared to medical records, were discussed within the group after the client left the room with DDMI staff.

In each in-patient training session, six clients were brought into the doctor’s lounge where the bulk of the training occurred. The clients varied in age, sex, functioning level, mobility and behavior / psychiatric illness. The “live” interaction and compare/contrast with actual medical records/history helped sharpen the psychiatrists understanding between the information presented in records, the appearance / perspective / response of the client and the treatment process/goals related to the successful stabilization and discharge of the client from the unit.

After lunch, Psychiatrists returned to their cars and drove 45 minutes (28 miles) to San Gabriel Pomona Regional Center and reconvened in a medium size conference room which served as a temporary out-patient clinic. Dr. Carlos Muralles, Medical Director of Alma Family Services led the out-patient training. The out-patient training began with an overview of developmental disabilities and the unique expression of psychiatric symptoms by levels of functionality and disability. A brief one-page background of each of the three clients were presented to the group prior to the appointment. The new out-patient client, accompanied by family members, staff, service coordinator and/or supervisor attended the initial 30 minute differential diagnosis interview of the client. At the conclusion of the differential diagnosis interview, the client was connected with the clinical director of Alma Family Services to continue out-patient treatment. While the client was out of the room, the Psychiatrists discussed their impression of symptoms, responses and history of the client presented during the out-patient interview.

In many cases, translators were involved for Spanish, Chinese and Thai speaking clients. Clients were chosen based on having extraordinary challenges. In some cases, clients with severe self-injurious behaviors were unable to remain in the interview room for the full 30 minutes and could be heard running up and down the hallway, sometimes banging their head against the adjacent walls. Other times, clients would have loud and repetitive moans or screams that would disrupt the interview process. In some cases, clients wanted to interact with the psychiatrists and would walk up to them, or push apart the tables or take the psychiatrist’s beverage or snacks. Cell phone video (passed around to the psychiatrists) was provided by one parent of a client who would head bang in the car while driving, unbuckle himself and grab the steering wheel while the parent attempted to drive. Some clients were non-verbal and signing or other communication was used as a form of response to questions by the Medical Director. The point of choosing high acuity clients, communication impaired and/or low functioning clients were to demonstrate interview adaptation techniques that could be used in practice as well as adapted to clients with less difficult behaviors.

Difficulties involved in the out-patient training were directly related to the high acuity of the clients being seen, resulting in disruption of nearby meetings and other client interactions occurring on the first floor at the regional center. Despite the difficulties, it presented the Psychiatrists attending the training an accurate “live” experience with how to handle high acuity, very difficult, low functioning and impaired communication clients in an out-patient setting.

15 Psychiatrists attended in clusters from LA County Department of Mental Health, DMH Downtown Mental Health Center; DMH AV Mental Health Center; Kaiser Permanante Mental Health Center and Rio Honda Mental Health Clinic.

Pre-Assessment Information included:

*Not all questions received responses; percentages based on total responses per question*

Are you a county employee? 0% No 100% Yes

Are you a county contractor of DMH / DCFS ? 93% No 7% Yes

Do you currently see DMH / DCFS Patients? 0% No 100% Yes

If yes, how many years have you seen regional center patients?

0 % Less than 2 years

50 % 3-5 years

33 % 5-10 years

17 % 10 or more years

Do you currently work in a hospital? 80% No 20% Yes

Would you like to receive a financial stipend for participating in the training? 100% No

Live Training Evaluation Questions

*Not all questions received responses; percentages based on total responses per question*

Did the training add to your knowledge about medication, treatment and monitoring of individuals with a developmental disability and mental illness