NHH Involuntary Admissions

New Hampshire Hospital (NHH) provides inpatient psychiatric treatment to patients admitted on an involuntary basis through an emergency admissions process, a non-emergency court order, or on a limited voluntary basis, depending on the availability of facilities. Most admissions to NHH are through the Involuntary Emergency Admission (IEA) process (pursuant to NH state law, RSA 135-C:27-33).

NHH does not provide walk-in emergency or crisis services. Contact your local hospital Emergency Department or the local Community Mental Health Center (CMHC) serving your region of residence for an in-person evaluation.

The IEA process begins with a visit to a local hospital Emergency Department or CMHC, and the completion of an IEA Petition requesting admission to New Hampshire Hospital. The person being admitted must pose a likelihood of danger to self or others as a result of a mental health condition. The person who signs the petition is the "Petitioner." Other witnesses to the person's behavior may also describe those behaviors on the petition.

IEA Petition forms are available at local police departments, Community Mental Health Centers (CMHC), and hospital Emergency Departments. The Petitioner may bring the person to the local hospital Emergency Department or CMHC for evaluation, or ask the local Police Department for assistance in transporting the person. A Complaint and Prayer form can be completed, and if signed by a Justice of the Peace, will direct law enforcement officers to transport the person to the Emergency Department or CMHC.

A doctor at the Emergency Department or CMHC will perform a medical evaluation, and a psychiatrist or a mental health clinician will perform a psychiatric/mental health evaluation. The results of the evaluations must be included with the Petition.

If the doctor determines that an involuntary inpatient admission to NHH is appropriate, the Emergency Department will make arrangements with the NHH Admitting Department for the person to be transported to NHH. Due to limited bed capacity, he person may not be immediately transferred to NHH.

Upon arrival at NHH, the person will be assigned a room in one of the acute psychiatric treatment units. The person will meet with an assigned mental health treatment team to discuss treatment options, and to develop a treatment plan. The treatment team includes a psychiatrist, primary nurse, social worker, mental health worker, rehabilitation specialists, and a medical doctor if needed. The patient's progress is monitored daily by the treatment team, and other treatment options are considered in light of the patient's progress. When the treatment team determines that the patient no longer poses a likelihood of danger to self or others and is stable [see RSA 135-C:27 IEA Criteria], the treatment team will discharge the patient from NHH back to their home, and arrange for follow-up treatment at the patient's local Community Mental Health Center.

Within three days of the Certificate (page 7 on the IEA Petition) being signed b a physician, physician's assistant or APRN (not counting Sundays and holidays), a court hearing is scheduled to consider whether there was reasonable cause to admit the person to NHH, due to alleged behaviors that were dangerous to self or others, as a result of mental illness. This provides the patient with the opportunity to object, with an assigned attorney, to the involuntary admission to NHH.

IEA Hearings are convened by the 6th Circuit Court – District Division, and take place in the IEA Court Room on the second floor of NHH. They are scheduled on Mondays, Tuesdays, Wednesdays and Fridays. These hearings are closed, non-public hearings. Family members, friends, or onlookers are only allowed into the courtroom by agreement of all parties.

The Petitioner must either attend the hearing, or be available by telephone. If the Petitioner does not attend, or is unreachable by phone, the Court will dismiss the petition and the patient will be immediately discharged from NHH and allowed to return home to their residence, unless the patient agrees to stay and receive treatment.

At the hearing, the Hearing Officer "swears in" the Petitioner and asks questions about the behaviors described on the petition. A court-appointed attorney, assigned to represent the patient, may ask the Petitioner further questions. Any other witnesses who included allegations or information on the petition may also be questioned about the behaviors they witnessed. Testimony will only be taken from witnesses named on the petition.

After the hearing, the Court will issue an order as to whether reasonable cause was found. If reasonable cause is not found, the case will be dismissed, the petition and supporting documents will be sealed, and the IEA will be annulled. The patient will be discharged from NHH within 24 hours of receipt of the written order, unless any further IEA petitions, or other admissions criteria, are received.

If reasonable cause is found, patients may be required to remain at NHH for no more than a total of 10 days (not counting Saturdays and Sundays) from the date of the Certificate is signed. However, the treatment team may, at any time, discharge the patient from NHH when they determine that a patient no longer is in such a mental condition that she or he poses a likelihood of danger to self or others as a result of mental illness.

If, after 10 days, the treatment team determines that the patient is not able to safely return to the community, they will file a further non-emergency Petition for Involuntary Admission with the 6th Circuit Court – Probate Division, in Merrimack County (pursuant to NH state law, RSA 135-C:34-54).

The Court will schedule a hearing within 15 days of receiving the petition (not including weekends or holidays). When the hearing is convened, the Court will then consider whether a longer period of involuntary admission will be necessary to treat the patient's symptoms of mental illness.

Probate hearings are convened every Thursday in the probate courtroom on the second floor of New Hampshire Hospital. The hearings are conducted by a 6th Circuit Court – Probate Division judge. These hearings are closed and non-public. Additional witnesses or onlookers are only allowed into the courtroom by agreement of all parties.

The IEA Petitioner and witnesses may be called to testify at the probate hearing, as well as others named on the Petition for Involuntary Admission who have witnessed potentially dangerous behaviors, including law enforcement officers, and NHH staff.

Members of the patient's treatment team will testify as to the patient's symptoms, psychiatric diagnosis, treatment plan, prognosis, and progress-to-date in recovering from mental illness. An independent court-appointed psychiatrist will also interview the patient and present a report to the Court, providing the Court with a second opinion.

The standard of evidence is higher at the probate hearing than at the initial IEA reasonable cause hearing. Witnesses must be eyewitnesses to behaviors, and second-hand testimony (hearsay) is not usually allowed. Witnesses may be cross-examined by the court-appointed attorneys representing the patients, or by the patient if the patient chooses not to have an attorney represent him or her.

If the Court finds clear and convincing evidence that the patient is "in such mental condition as a result of mental illness as to create a potentially serious likelihood of danger to himself or to others," the Court may issue an order for continued Involuntary Admission to New Hampshire Hospital for a period of up to 5 years. The Court may also allow for a Conditional Discharge from NHH during that time period.

A Conditional Discharge is a doctor's order that allows a patient to return to the community from NHH before the order for involuntary admission expires, so that the patient may be in a less-restrictive setting and receive continuing outpatient treatment at the Community Mental Health Center in the region where the patient resides. Conditional Discharges are allowed under NH state law RSA 135-C:45(II) and RSA 135-C:50-51.

When a patient is "Conditionally Discharged," the NHH and Community Mental Health Center treatment teams specify a list of conditions that the patient must adhere to upon return to the community. These conditions often include taking medications on a regular basis, attending appointments at the Community Mental Health Center, refraining from substance abuse, avoiding certain activities, and not engaging in dangerous behaviors. The patient must agree that she or he understands and commits to follow these conditions over the Involuntary Admission period of time specified in the court order.

If the patient agrees to the conditions, she or he is returned to the community, and appointments are scheduled at the Community Mental Health Center for the patient to begin outpatient treatment.

• Signatures for Conditional Discharge
• Continuation of Conditional Discharge
• Transfer/Revisions

If a Community Mental Health Center (CMHC) representative receives evidence that a patient has not followed one or more of the conditions agreed to on the Conditional Discharge order, or has engaged in dangerous behaviors, a staff member from the CMHC may revoke the patient's Conditional Discharge, and return the patient to NHH. CMHC staff are required to explain the revocation documents to the patient and offer a copy.

Revoking a patient's Conditional Discharge is a three- or four-step process. Staff must make reasonable efforts to locate the patient and direct the patient to attend an examination to evaluate the patient's mental condition. If necessary, staff can request a law enforcement officer to locate the patient, if the patient is not readily available, and bring the patient to the examination.

Once located, staff offer copies of documents and explain the revocation process to the patient. They conduct an examination, and after evaluating the results of the examination, a Community Mental Health Center psychiatrist or Advanced Practice Registered Nurse (APRN) may direct staff to temporarily revoke the patient's Conditional Discharge. The patient is then transported back to New Hampshire Hospital.

Upon re-admission to NHH, the patient's NHH psychiatrist will conduct a further evaluation of the patient's mental status. If circumstances warrant, the psychiatrist may issue an Absolute Revocation of the patient's Conditional Discharge, explain it to the patient, and offer the patient a copy of the documents. If the patient wants to appeal the Absolute Revocation of the Conditional Discharge, an appeal hearing will be scheduled within 5 working days.

• Absolute Revocation of Conditional Discharge Notice
• Proposed and Temporary Revocation of Conditional Discharge Notice

The DHHS Administrative Appeals Unit (AAU) schedules and conducts hearings for patients who appeal a Revocation of Conditional Discharge (RCD). (RSA 135-C:51, and Administrative Rules He-M 609.06 and He-M 609.07).

The AAU is independent of New Hampshire Hospital and other DHHS divisions. It conducts impartial hearings and renders decisions in accordance with the requirements of NH Statutes and Administrative Rules. While these hearings are formal legal proceedings, they are conducted in an informal manner, allowing patients who challenge a NHH decision to explain to an impartial hearing officer why they object to the revocation.

At the hearing, the hearing officer will review documentary evidence of the procedures followed in revoking the patient's Conditional Discharge. The hearing officer will hear testimony, under oath, from the doctors and staff involved in the revocation, and allow the patient and the patient's appointed attorney to question and cross-examine those witnesses.

Within 3 working days after the hearing, the AAU will issue a final written legal decision that may uphold or reverse the decision to revoke the patient's Conditional Discharge. If the decision is reversed, the patient may be discharged back to the community under the terms of the original Conditional Discharge. If the decision is upheld, the patient may continue treatment at NHH until the treatment team determines the patient is once again stable and ready to be conditionally discharged home again.

Patients admitted to NHH for psychiatric care on an involuntary basis may refuse any or all medications proposed by the treatment team, unless the patient has a guardian. NHH staff must gain the informed consent of the patient or guardian before administering medications.

However, if a patient's condition deteriorates into a psychiatric or medical emergency requiring treatment, the psychiatrist can request authorization to administer medications on an emergency basis, without the patient's consent, for up to 45 days (pursuant to Administrative Rule He-M306).

Once the psychiatrist makes a request to administer emergency treatment, the patient is appointed an attorney and the AAU schedules an administrative hearing within three days.

Once the hearing begins, the hearing officer is responsible for determining that: 1) the patient lacks the capacity to make an informed treatment decision; 2) a medical or psychiatric emergency exists; 3) the proposed treatment is the least restrictive appropriate alternative available; and 4) a reasonable person would consent to the treatment.

Only two Emergency Treatment Authorization requests may be approved during any single admission period. For chronic cases, the treatment team will assess the patient's need for the appointment of a guardian.