Everything you Should know about Title 33

1
Everything you Should know about Title 33

• provided by
• Tennessee Department of Mental Health and
  Substance Abuse Services
• Division of Mental Health Services
• Content guided by Title 33
• and TDMHSAS Rule 0940-3-8

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Objectives

• Participants will verbalize an increased
  knowledge of the laws that relate to the
  emergency involuntary hospitalization process
• Participants will demonstrate an increased
  understanding of how an individuals rights might
  be impacted in an emergency situation
• Participants will learn about resources available
  to individuals experiencing a behavioral health
  crisis

3
What is Title 33?

• Title 33 is the section of Tennessee Code
  Annotated that pertains to the laws and codes
  that govern mental health care here in Tennessee.

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Your Rights

• No person shall be deprived of liberty on the
  grounds that the person has or is believed to
  have a mental illness, a serious emotional
  disturbance, a developmental disability, or is in
  need of service for such a condition except in
  accordance with the provisions of this title.
• TCA 33-3-101

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Your rights

• Individuals with mental illness, serious
  emotional disturbance, or developmental
  disability have the same rights as all others
  except to the extent that an individuals rights
  are curtailed in accordance with Title 33 or
  other law.
• TCA 33-3-101

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Your rights

• Individuals with mental illness, serious
  emotional disturbance, or developmental
  disability shall be provided services or
  supports, to the extent that facilities,
  equipment and personnel are available, in
  accordance with community standards.
• TCA 33-3-101

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Your rights

• No individual shall be denied the right to
  dispose of property, execute instruments, make
  purchases, enter into contractual relationships,
  give informed consent to treatment, and vote,
  unless the individual is unable to make decisions
  or state or federal law allows denial. TCA
  33-3-102
• Providers under this title may not discourage or
  prevent an individual from exercising their right
  to religious expression. TCA 33-3-126

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access To your records

• If you are sixteen (16) years of age or older,
  you may request that your service provider tell
  you what records are being maintained and how you
  can access to them. Upon your written request, a
  service provider shall permit you, within a
  reasonable time, to review your record.
• There are certain exceptions to this disclosure
  which your provider must adhere to.    
• TCA 33-3-112

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Right to File for Writ of Habeas Corpus

• This is a request made to a court by an
  individual who believes they have been unjustly
  detained or taken into custody asking that a
  legal review of the custodial authority occur.
• If a court determines an individual has been
  unjustly taken into custody, the court may order
  the individual be released immediately.
• TCA 33-3-801

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Confidentiality

• Your service records shall be kept confidential
  and shall not be disclosed by any person except
  in compliance with this part.
• In order for your family, friends or advocates to
  get information about your care or treatment you
  must sign a release form authorizing the service
  provider to disclose the information to which you
  have consented.
• T.C.A. 33-3-103

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• Processes

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Voluntary Hospitalization

•  You or your conservator/guardian may request
  admission to a hospital or treatment resource for
  diagnosis, observation and treatment and if an
  examination by an admitting physician determines
  that there is a need for hospitalization you may
  be admitted.
• TCA 33-6-201 and TCA 33-6-202
• You may request release from the inpatient
  facility at any time during your stay but if
  professionals determine you present a risk of
  harm to yourself or others they may initiate the
  involuntary process. TCA 33-6-206
•  

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When Someone Is Experiencing A Behavioral Health
Crisis

• You or someone you know may be involved in a
  community based screening process completed by a
  physician, psychologist or Mandatory
  Pre-screening Agent (all crisis teams have MPAs).
• This may be done at an individuals home, an
  emergency department, jail or other community
  location.

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Tennessees crisis delivery system
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What is a Mandatory Pre-screening Agent?

• A qualified mental health professional (QMHP)
• Licensed to practice in TN
• Who has satisfactorily completed the required
  TDMHSAS training and designated by the
  Commissioner
• T.C.A. 33-6-427

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What is a QMHP?

• Licensed masters social worker with two years of
  mental health experience
• Licensed clinical social worker
• Licensed or certified martial and family
  therapist
• Licensed professional counselor
• Licensed nurse with a masters degree in nursing
  who functions as a psychiatric nurse

• Psychiatrist
• Physician with expertise in psychiatry
• Psychologist with health service provider
  designation
• Licensed psychological examiner
• Licensed senior psychological examiner
• T.C.A. 33-1-101 (20)

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An individual may be detained for the purpose of
a mental health evaluation

• If an individual is experiencing signs and/or
  symptoms of a mental illness or serious emotional
  disturbance that present a risk of harm to the
  individual experiencing the symptoms or to others
  they may be detained without a court order for an
  unlimited amount of time pending completion of a
  behavioral health evaluation.
• TCA 33-6-401

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Definitions

• Mental illness
• A psychiatric disorder, alcohol dependence, or
  drug dependence, but does not include
  Intellectual Disability or other developmental
  disabilities.
• T.C.A. 33-1-101(18)

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Definitions

• Serious Emotional Disturbance
• A condition in a child who currently or at any
  time during the past year has had a diagnosable
  mental, behavioral, or emotional disorder of
  sufficient duration to meet psychiatric
  diagnostic criteria, that results in functional
  impairment which substantially interferes with or
  limits the childs role or functioning in family,
  school, or community activities and includes any
  mental disorder, regardless of whether it is of
  biological etiology.
• T.C.A. 33-1-101(22)

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Detaining for Examination

• Professionals who have the authority to detain
  for examination include
• law enforcement,
• physician,
• psychologist or
• a Mandatory Prescreening Agent
• T.C.A. 33-6-402

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Detaining for Examination

• A person cannot be deprived of liberty on the
  grounds that the person is believed to have
• a mental illness,
• serious emotional disturbance,
• developmental disability, or
• is in need of service for such a condition
• except in accordance with Title 33.
• T.C.A. 33-3-101

22

• The Process for Emergency Involuntary Psychiatric
  Hospitalization

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the Screening process may determine the need of
emergency hospitalization

• An individual may be admitted and detained by a
  hospital or treatment resource for emergency
  diagnosis, evaluation, and treatment IF AND ONLY
  IF
• T.C.A. 33-6-403

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To qualify for Emergency
Involuntary Admission

• An individual
• Has a mental illness or serious emotional
  disturbance,
• Poses an immediate substantial likelihood of
  serious harm because of the mental illness or
  serious emotional disturbance,
• Needs care, training, or treatment because of the
  mental illness or emotional disturbance, AND
• All available less drastic alternatives to
  placement in a hospital or treatment resource are
  unsuitable to meet their needs.

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How is Substantial Likelihood of Serious Harm
defined?

• IF an individual has
• Threatened or attempted suicide or to inflict
  serious bodily harm on him/herself OR
• Threatened or attempted homicide or other violent
  behavior OR
• Has placed others in reasonable fear of violent
  behavior and serious physical harm to them OR
• Is unable to avoid severe impairment or injury
  from specific risks
• AND there is a substantial likelihood that such
  harm will occur unless the person is placed under
  involuntary treatment
• THEN the criteria for substantial likelihood of
  serious harm can be met.
• T.C.A. 33-6-501

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What is a certificate of need?

• A Certificate of Need (CON) is a legal document
  which is required by the court for an individual
  who is admitted to an inpatient behavioral health
  treatment resource without the consent of the
  individual receiving services.
• To be admitted involuntarily there must be two
  Certificates of Need completed and approved by
  the court.

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About the Process

• A Mandatory Pre-screening Agent (MPA) must
  complete one of the two required CONs for a
  person with mental illness or serious emotional
  disturbance to be admitted to a Regional Mental
  Health Institute (RMHI) or private psychiatric
  hospital.
• MPAs are a part of every state crisis service
  providers crisis delivery system so if you call
  crisis you will likely be seen by a MPA.
• T.C.A. 33-6-105

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If a Mandatory Pre-screening Agent IS Not
Available

• If a MPA is not available within two hours, then
  a licensed physician or a licensed psychologist
  with a health service provider designation may
  complete the CON.
• The physician or psychologist must consult with a
  crisis team member regarding less restrictive
  alternatives.
• T.C.A. 33-6-105

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Requirement for Disinterested Professional

• If a person is to be admitted to a private
  facility, at least one (1) of the CONs shall be
  from a professional who is not an employee of the
  private facility.
• Employment as a faculty member by a school of
  medicine at a university or college associated
  with a hospital is not considered employment by
  the hospital
• T.C.A. 33-4-107

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Medical Considerations

• If an individual has a physical disorder that
  requires immediate care, the individual may be
  taken to the emergency department for medical
  treatment before being transported to the
  psychiatric inpatient facility.
• T.C.A. 33-4-104

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Available, Suitable Accommodations (ASA) Required

• What does this mean?
• This means that the hospital accepting the person
  for care and treatment must have enough staff and
  enough space to adequately meet the needs of the
  individual being hospitalized.
• This also means that there may be times that
  someone in need of emergency involuntary
  hospitalization is either sent to the next
  closest state hospital that has an empty bed or
  has to wait for a period of time for a bed to
  become available at the nearest state hospital.
• TCA 33-6-108

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Transportation to the inpatient psychiatric
hospital

• The Sheriff is obligated by Title 33 to provide
  transportation if a Certificate of Need for
  Emergency Involuntary Hospitalization has been
  completed and a confirmation number for an
  available bed has been provided
• The Sheriff may designate a secondary
  transportation agent(s) for the county such as an
  ambulance service
• T.C.A. 33-6-406
  
• T.C.A. 33-6-901

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Transportation to the hospital

• If it is determined during the screening process
  that the person does not require physical
  restraint or vehicle security, these people may
  transport the individual to the hospital at the
  transporters expense
• one or more friends
• neighbors
• mental health professionals
• familiar with the person
• relatives of the person
• member of the clergy
• T.C.A. 33-6-901

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Transportation

• The person or persons providing transportation
  must provide proof of current automobile
  insurance to the sheriff before transportation
  can occur.
• T.C.A. 33-6-901

35
Court Process Upon Admission

• Immediate notice is provided to the court upon
  admission.
• Probable cause hearing within (5) five working
  days.
• With court approval, continued stay for up to 15
  more days.
• Court may approve indefinite stay after that
  time.
• T.C.A. Section 33-6-421(-423)

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Limits of confidentiality

• Information may be disclosed without the consent
  of the individual receiving services if it is
• Necessary to carry out duties under this title
• Necessary to assure service/care in least drastic
  means that are suitable to the service
  recipients liberty and interests
• A service recipient moves from one service
  provider to another and exchange of information
  is necessary for continuity of service
• T.C.A. 33-3-105

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If the MPA Does not recommend inpatient care

• The MPA or the MPAs designee will
• Assess the availability of alternative services
  and offer referral, if appropriate and
• Follow-up with the individual within 12 hours of
  the assessment
• T.C.A. 33-6-106
• MPS Rule Chapter 0940-3-8-.05(9)

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If hospitalization is needed but doesnt occur-
what can I do?

• Work with your regular mental health provider to
  get an expedited appointment.
• Work with the crisis service provider to
  establish a crisis management plan.
• Call your Managed Care Organization for guidance.
  
• Ensure support systems are available as much as
  possible.
• If concerns persist, ask for a re-evaluation by
  crisis and the inpatient provider to determine
  whether a change in status now results in
  hospitalization.

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If hospitalization is needed but doesnt occur-
what can I do?

• If you or your loved one does not meet emergency
  hospitalization criteria you may still be able to
  seek non-emergency admission under Part 5 by
  filing a complaint with the court clerk.
• This requires that the person be examined by two
  physicians or one physician and one psychologist
  who both agree that the person needs.
• TCA 33-6-504

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If hospitalization is needed but doesnt occur-
what can I do?

• If you are concerned that your loved one might be
  unable to make sound decisions for themselves due
  to the symptoms of a mental illness or serious
  emotional disturbance you may seek a conservator
  to help the individual with their treatment
  decisions.
• Conservators/ guardians with power of attorney
  for health care decisions have the authority to
  sign someone in for care and treatment if
  clinically indicated.
• Title 34

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• Mental Health Declaration for Treatment TCA
  33-6-1001
• http//www.state.tn.us/mental/t33/DHMT_FORM.pdf

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What is a Mental Health Declaration for Treatment?

• The DMHT is a legal document where individuals
  can write down their wishes in case of a mental
  health crisis which may include
• The mental health treatments and medications that
  are okay with them and any that are not okay.
• What it looks like when the individual is in a
  mental health crisis and need help.
• Which hospitals and which mental health agencies
  are preferred.
• TCA 33-6-1001

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Declaration for Mental Health Treatment

• Even though mental health professionals will
  attempt to conform to the wishes of the
  individual as outlined in the DMHT, those wishes
  may be overridden if emergency involuntary
  psychiatric hospitalization is required or the
  individuals life or health is at risk .
• TCA 33-6-1006

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Dmht facts

• Generally, the physician or other service
  provider will follow the Declaration only when
  you lack capacity to make informed mental health
  treatment decisions. TCA 33-6-1002
• A Declaration is not related to payment for
  services and cannot require hospitalization in
  the absence of medical necessity. When
  completing a Declaration, you should consider the
  limitations of your insurance benefits.
• TCA 33-6-1012

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Dmht Facts

• A declaration for mental health treatment is good
  for two (2) years, for a lesser period if so
  stated, or until revoked, whichever is sooner.
  TCA 33-6-1003
• A declaration is effective only if it is signed
  by the individual creating the declaration and
  two (2) competent adult witnesses and is not
  signed on the premises of a mental health service
  provider. TCA 33-6-1004

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DMHT Facts Continued

•  If the physician or other provider is unwilling
  at any time to comply with the declaration for
  mental health treatment, the physician or
  provider may withdraw from providing treatment.
  TCA 33-6-1005
• The declaration for mental health treatment shall
  remain in effect and shall be superior to the
  powers and duties of an appointed conservator
  with the authority to make mental health
  treatment decisions. TCA 33-6-1007

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• If Crisis Services are needed
• Statewide Toll free Crisis Number
• 1-855-CRISIS1 (1-855-274-7471)
• National Suicide Prevention Lifeline
• 1-800-273-TALK(8255)
• Always call 911 if life or death emergency

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Presenters

• Sejal West, MA Assistant Commissioner, Division
  of Mental Health Services
• Melissa Sparks, RN, MSN TDMHSAS Director of
  Crisis Services and Suicide Prevention