Incident review committee reports record 64 reportable incidents and rising youth acuity

Janet Thibodeau, co‑chair of the incident review committee, told the Tompkins County Community Services Board that the committee reviewed 64 reportable incidents in 2025 and is pursuing several corrective measures to reduce harm and improve care coordination.

"We reviewed 64 reportable incidents for both PROS and the clinic," Thibodeau said, and broke the total down to 18 deaths (14 natural causes, two fatal overdoses, one car crash and one homicide), 33 suicide attempts (including 22 nonfatal overdoses), and 13 incidents categorized as crime in the community. The committee, she said, focuses on learning from incidents and tightening processes to mitigate future risk.

The report stressed three primary corrective areas: screening and diagnosis for co‑occurring substance‑use disorders, improved coordination of care internally and with external partners, and more person‑centered services. "About a little more than 75 percent of our clients have had a substance‑use assessment," Thibodeau said, and "about 49 percent of our clients receive medication‑assisted treatment for opioid, nicotine and alcohol." She noted those figures reflect improvements but also gaps in documentation and access.

Thibodeau outlined practical steps already underway: expanded Narcan distribution (the agency renewed its opioid overdose prevention program and now offers kits, fentanyl/xylazine test strips and informational brochures on multiple floors and to the public); tighter electronic health‑record screening workflows that require completion of substance‑use screeners before clinicians can sign comprehensive assessments; and partnership with Genoa Pharmacy to support on‑site medication access and prior‑authorization assistance.

The committee emphasized timely handoffs after hospital discharge. Thibodeau said the organization now has an Epic Care link to the county hospital that gives clinicians read‑only access to discharge summaries, and a designated psychiatric practitioner attends weekly hospital treatment meetings to coordinate ongoing care. The board also heard about a court navigator position to provide intake and short‑term clinical support at criminal court and about the county's care‑team model, which pairs clinicians with law enforcement for daytime co‑response and was designated an OMH mobile crisis team in 2025 to enable crisis billing.

School‑based services were flagged as a priority: the clinic operates 14 school satellites and reported serving about 543 youth in 2025, offering roughly 165 hours of school‑based services in the sample month. Thibodeau said the IRC has increased focus on youth acuity and suicide‑prevention training for clinicians.

The committee recommended continued attention to documentation, targeted outreach to the small share of clients responsible for a large portion of medical utilization, and hiring a utilization specialist to review charts for those at highest risk. Thibodeau said some increases reflect better reporting and clinician education as much as new incidents, but she also acknowledged genuine rises in deaths and suicide attempts.

The board asked the committee to provide age‑specific breakdowns and additional data; Thibodeau said she could share further detail after the meeting. The committee also pointed board members to a sheriff's department dashboard for community response and outcome data as an external data resource.

The committee's next steps include sending requested breakdowns to the board, continuing coordination with hospitals and courts, and maintaining expanded Narcan and MAT access.