Hospitals and other behavioral health services providers in North Carolina will face new regulations next year concerning the involuntary commitment and voluntary admission of patients undergoing mental health crises. In fact, the regulations affect not only providers but also impact law enforcement agencies and local governments that transport patients in crisis. 

The changes are the result of Senate Bill 630, which the North Carolina General Assembly passed earlier this summer. The legislation generally aims to improve the delivery of behavioral health services in North Carolina by revising provisions of Chapter 122C of the General Statutes governing involuntary commitments and voluntary admissions. The 36-page piece of legislation consists of three significant additions to Chapter 122C:

1. An added procedure for voluntary admissions of incapable adults.
2. Changes to the involuntary commitment process.
3. A requirement that local area authorities implement “community crisis services plans” related to involuntary commitment proceedings.

Voluntary Admission of Incapable Adults

The new law added a procedure for the voluntary admission of “incapable” adults to hospitals. Previously, the statute only addressed the voluntary admission of minors and incompetent adults who have been adjudicated incompetent by a judge because they are unable to manage their own affairs due to mental illness or intellectual disability

State law will now include the voluntary admission of incapable adults who, in the opinion of a physician or eligible psychologist, are unable to make and communicate mental health treatment decisions.  When an incapable adult has authorized a health care power of attorney, the health care power of attorney can seek voluntary admission for the patient and submit a written request for discharge. Upon receiving the written request, the hospital has 72 hours to discharge the patient or petition to have the patient involuntarily committed. However, the facility may not hold a voluntarily admitted incapable adult for more than 15 days.  In the event that the voluntarily admitted incapable adult needed treatment in excess of 15 days, the patient would either have to be involuntarily committed or emergency guardianship obtained.

Commitment Procedures

The new legislation makes more modest changes to the procedure for involuntary commitments, but it largely remains unchanged. As an overview, involuntary commitment procedures typically begin when an affidavit and petition are filed in state court attesting that an individual is mentally ill and either dangerous to him/herself or a danger to others. A magistrate judge then issues a custody order authorizing law enforcement to take the individual into custody and transport him or her to a facility where a “commitment examiner” conducts the first examination of the patient. Commitment examiners are typically physicians or eligible psychologists, but the new law has expanded the definition to include other licensed, trained professionals such as clinical social workers and physician assistants as long as they are certified by the Secretary of Health & Human Services to perform commitment exams.

The commitment examiner must determine whether the patient is eligible for inpatient commitment, outpatient services, or not in need of treatment at all. The new law also requires the examiner to conduct a “health screening” to determine whether there exists an emergency medical condition that could result in serious jeopardy to the individual’s health. If the examiner determines that the patient is eligible for inpatient commitment, law enforcement must transport the patient to a 24-hour facility, where he or she will undergo a second examination. If the second commitment examiner confirms the patient is eligible for inpatient commitment, the patient remains in the 24-hour facility and awaits a district court hearing, where the court will either order further inpatient commitment, outpatient commitment, a combination of the two, or discharge the patient.

Community Crisis Services Plans

There are several moving parts that must be coordinated in the involuntary commitment process. Expediting the safe transportation of patients and ensuring that there is a facility available and prepared to conduct the examinations as soon as possible are critical to providing the best behavioral health care to patients in such a pivotal moment of their lives. To facilitate the custody, transportation, examination, and treatment of respondents to commitment proceedings, the new law requires area authorities to implement “community crisis services plans.”

Each community crisis services plan must have a “local area crisis plan” for specific regions, which require the following:

1. Each city or county must enter into transportation agreements with local law enforcement or alternative private companies designated to handle custody and transportation of patients.
2. Each LME/MCO must contract with area facilities prioritized and designated as the facilities to provide the health screenings and first examinations to meet the needs of its local planning area.
3. The local area crisis plan must identify training for law enforcement or other personnel designated to handle transportation and custody.

These changes generally apply to hospitals that are under contract with area authorities or LME/MCOs to provide behavioral health care services to patients in a particular area of the state.

The transportation agreements must be submitted to local authorities for review by January 1, 2019.  These authorities include magistrate judges, county clerks of court, LME/MCOs, and the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. The crisis plans must then be implemented by October 1, 2019. Over time, we will see whether the implementation of the community crisis services plans will allow the commitment proceedings to run more smoothly.

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