CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS  Office of the Chief Medical Officer  Clinical Operations  Hands-On Intervention for Involuntary Hospitalization  SC - 13   Category: Special Considerations  Published Date: February 2025

PARAMETER GOAL Provide guidance on using Hands-on Interventions during 5150, 5585, or 5446 involuntary hospitalizations. Provide guidance on the appropriate management and coordination of Hands-on Interventions to effectuate such hospitalizations. Ensure that Hands-on Interventions are conducted in the safest possible manner. Improve client outcomes by improving access to effective hospitalizations and ensuring meaningful attempts at coordination of care between inpatient and outpatient treatment teams.  TERMINOLOGY Hands-on Intervention: The application of physical contact to restrain a client for the purpose of keeping clients and staff safe during an involuntary hospitalization. Intervention Director: A Mental Health Clinical Supervisor or above who is highly experienced with LPS authorizations; this individual is responsible for ensuring all aspects of planning, briefing, Hands-on Intervention, debriefing, and efforts to ensure continuity of care are undertaken for a particular case in accordance with this practice parameter. Hands-on Staff: Staff that are appropriately trained, have demonstrated proficiency, and have expressed willingness to applying Hands-on Interventions. Hands-on Staff members must be identified for each intervention and should appropriately match client’s height and build to ensure that the intervention is implemented safely and effectively. Safety Briefing: An on-site meeting of all involved staff that occurs prior to initiation of hands-on intervention. All involved staff will discuss plan and all relevant safety concerns and risk factors. Debriefing: A meeting of all involved staff that occurs after the completion of the hands-on intervention. All involved staff will constructively discuss the intervention for the purpose of ensuring continuity of care and improving the safety and efficacy of future interventions. Staging Location: A location with reasonable proximity to the site where Hands-on Intervention will take place that will allow for congregation of staff for Safety Briefing prior to intervention. This location is also utilized as an arrival point for an ambulance.  MEASURES Planning: Should be undertaken in advance of on-site Safety Briefing and Hands-on Intervention. Identify need for Hands-on Intervention to effectuate an involuntary hospitalization. Hands-on Intervention is permissible if the two following criteria are met: Legal justification exists for involuntary hospitalization in that the client poses a danger to self or others or presents as gravely disabled. All possible attempts at voluntary participation with treatment and/or transportation for involuntary treatment have failed or are deemed to be too dangerous to attempt. Identify Intervention Director for specific Hands-on Intervention. Determine whether Hands-on Intervention is both safe and practicable. Review the following aspects of client's history and current presentation: History of aggressive behavior/violence and weapon/dangerous object possession Check in with family or collaterals about access to guns or lethal weapons. If possible, check with Law Enforcement for criminal history and firearm registration status. Check social media for any recent threats or violence. History of responses to previous crisis interventions and detainments for involuntary hospitalization Medical history and current physical health considerations Physical presentation and stature (e.g. height, weight, ambulatory capacity) Information provided by client and/or collaterals relevant to the safe utilization of Hands-on Intervention Language and expression preferences Comprehension capacity Evaluate client surroundings and scene safety: Nearby objects that may be hazardous and/or weaponized Accessibility of client’s space (e.g. Will staff and gurney be able to fit through entryways? Are doors locked?) Determine appropriate Staging Location for safety briefing of staff and ambulance arrival point Potential for bystander interference and need for crowd control Potential for collateral or bystander influence/interference and potential need for managing this influence/interference DMH staff are not permitted to physically touch, restrain, contact any individual who is not the subject of this intervention and permitted by law. Presence of potentially harmful animals Assess and prepare for any special circumstances Assess necessity and availability of resources and partners: Identify number of staff necessary to utilize Hands-on Intervention safely and effectively in this circumstance A minimum of 6 Hands-on Staff are required for any use of Hands-on Intervention. Determine method of transportation for client to treatment facility If Hands-on Intervention is to be utilized, ambulance transport with restraint is likely to be the most appropriate method of transportation. Assess need for Law enforcement/Mental Evaluation Team (MET) partner involvement: When possible, DMH staff should attempt to complete intervention without request for Law Enforcement assistance to reduce the possibility of use of force by law enforcement personnel. Law Enforcement Agency involvement should be avoided whenever possible to reduce unnecessary use of force. Law Enforcement should be involved when both: An imminent threat to the safety of others is posed by client or bystanders near client that cannot be safely managed by DMH staff. This justification is communicated to program management, if practical. To extent necessary to avoid outside interference, notify on-site bystanders/workforce of plans to assist client in accessing treatment For minors and dependent adults, notify accompanying adults and guardians of plan and determine appropriate level of involvement Develop strategic plan for Hands-On Intervention. Plan must account for and mitigate each risk factor identified in the above articulated process. Develop plan for care after hospitalization. Plan for treatment and/or housing The plan should be feasible and provided to hospital upon admission of client. Team should assess and plan for follow up with hospital to ensure coordination of care or successful linkage to appropriate resources. Safety Briefing: An on-site safety briefing must occur following the above-described Planning measures. Intervention Director will gather all involved staff at staging location for mandatory safety briefing. Staff that do not participate in briefing are not permitted to participate in any Hands-on roles during the intervention. Briefing will be led by the Intervention Director or their designee and must review the following components: Concisely discuss purpose of intervention. Briefly review case. Describe legal and clinical justification for involuntary treatment. Explain plan for coordination of care for client following intervention. Discuss all safety concerns and risk factors identified in “Planning” section above. If client’s presentation or circumstances have changed and now include imminent threat to safety of others or self that cannot safely be managed by DMH staff, Law Enforcement should be contacted and plans for Hands-on Intervention by DMH staff should be discontinued. Solicit feedback from involved staff to ensure staff willingness to participate and that all identified safety and risk factors have been accounted for. At this time, if any staff person reports being unwilling to participate, they should be excused from the intervention.  No unwilling staff person should be directed to participate. Review plan for Hands-on Intervention. Describe client’s current physical positioning and presentation Describe how staff will approach client to initiate Hands-on Intervention Describe how/where gurney will be positioned Describe anticipated response from client and the level of force needed to maintain safety during hands-on intervention Discuss plan and process for discontinuing the intervention in the rare instance that may be necessary Solicit questions and feedback from involved staff Assign roles to each involved staff person. Hands-on Staff should be aware of their expected role Involved staff not planning to engage in hands-on intervention should be assigned to one of the following roles: Communication with client Crowd control Gurney/EMT management Surrounding objects/special circumstances management Brief Ambulance Personnel on plan and expectations of them. TREATMENT STRATEGY Hands-on Intervention should only be utilized when a plan can be developed that reasonably mitigates or addresses all identified risk factors. No unwilling staff person should be directed to utilize Hands-on Intervention. Hands-on Intervention should be guided by the principles of Care and Safety. Care: Staff will treat people served with respect, dignity, and empathy at all times. Interventions are undertaken to promote well-being and independence. Coordination of care is planned to ensure hospitalization is effective. Safety: Harm to clients and staff is minimized with careful planning and effective interventions. To avoid escalation of client behavior and confusion, voluntary offers of treatment and Hands-on Intervention should not be conducted in the same interaction. All possible attempts at voluntary compliance with treatment and/or transportation for involuntary treatment have been attempted and refused prior to the initiation of a hands-on intervention. Hands-on Interventions should be applied expeditiously and without warning to avoid escalation of aggression and risk of harm. Safety increases with each staff present for a Hands-on Intervention. If identified or potential risks given client’s history and presentation cannot be mitigated or addressed with planning, Hands-on Intervention should not be used. In such circumstance, when Hands-on Intervention is not possible, a client may be left in place. Appropriate information and resources should be provided to client and/or bystanders in an effort to appropriately respond to client’s circumstances.  PROVISION OF SERVICE Staff engaging in Hands-on Intervention should only utilize skills and principles taught in Hands-on Training. Skills and principles taught in this training are designed to avoid unnecessary use of force and injury to clients and staff. Once Hands-on Intervention has been initiated, it should not be terminated until client is safely secured on the gurney and the ambulance has safely departed. In the rare instance where an intervention needs to be discontinued due to safety concerns, the intervention team will have a prior discussed plan which will dictate the process for discontinuing the intervention.  OUTCOMES AND MONITORING A debriefing of all involved staff is a necessary and mandatory component of each Hands-on Intervention. Debrief will be led by the Intervention Director. Debrief should occur immediately after the patient has departed the scene, if possible and safe to do so. If not possible, reconvene elsewhere or via video conference. The following components must be addressed in each debriefing: Health and safety of client and all involved staff Document safety incidents in accordance with DMH Policy 109.01. Any staff person injured or otherwise involved in a safety incident should be provided with an Industrial Accident packet and information regarding the Employee Assistance Program. Expressions of recognition and gratitude for staff involvement Review of plan for ongoing coordination of care for client Constructive review of successful aspects of planning, briefing, and Hands-on Intervention Constructive review of aspects of planning, briefing, and Hands-on Intervention that were unsuccessful or could have been accomplished in a safer or more effective manner To ensure continuity of care, follow up linkage to appropriate ongoing treatment or resources, must be undertaken following each Hands-on Intervention. STAFF TRAINING Crisis Prevention Institute: Non-Violent Crisis Intervention Training Field Safety Training Hands-On Training  SUPERVISION AND CONSULTATION Decisions to utilize Hands-on Intervention must be made in consultation with another appropriately experienced and trained Hands-On supervisor at the level of Mental Health Clinical Supervisor/Supervising Psychologist/Sr MHC RN or higher. The use of physical interventions is a practical decision involving risk assessment and planning that are outside the scope of typical clinical training. As such, use of this intervention must only be undertaken when multiple staff in positions of authority with sufficient training in Hands-on Intervention are involved and/or consulted. Leadership at Program Manager level or higher must be notified and approved of plan to utilize Hands-on Intervention prior to initiation of intervention. The priorities of safety, client care, treatment continuity, and constructive debriefing should be emphasized and modeled in all communication between staff, supervisors, and managers involved in Hands-on Interventions.  RESOURCES California Office of Patients' Rights Advocacy Training 2018, Disability Rights Communicating a Plan for Involuntary Psychiatric Admission: A Standardized Patient Workshop Intervention for General Psychiatry Residents MedEd PORTAL, October 17, 2023 Policy 307.02 Lanterman-Petris-Short Detention SB 43 and CARE Court: Community FAQ Disability Rights, February 1, 2024 Substance Abuse and Mental Health Services Administration: Civil Commitment and the Mental Health Continuum: Historical Trends and Principles for Law and Practice Substance Abuse and Mental Health Services Administration: National Guidelines for Behavioral Health Crisis Care, Best Practice Toolkit The ethical dilemma of involuntary mental health treatment: Wbur, April 17, 2024 Welfare and Institutions Code, § 5150 and 5585.55