A crisis has no schedule. Frequently in the middle of the night, individuals and families conclude all other options and supports have failed, and handwringing in distress reach out to 911, call local hotlines or visit emergency departments. They may not be able to articulate it clearly, but they are seeking recovery and help that is safe, effective and delivered with the utmost care.
Yet, until recently many public and private funders have not prioritized behavioral health crisis services. There have been a number of organizations that have led a focus on these important services despite the challenges (Behavioral Health Response, Centerstone America, Arizona’s Crisis Response Network, Didi Hirsch and MHMRA of Harris County, to name just a few), but nationwide there are many gaps and inconsistencies. There is high value placed on the public safety system and medical emergency infrastructure, including 911, ambulance and fire response, but this has simply not been the case for psychiatric emergency care.
There are real signs that this is changing quickly and that perhaps the day for crisis services has begun. In 2013, California, Colorado and Georgia initiated more than $200 million in behavioral health crisis systems of care. Governors and legislators called for a full array of crisis services, from peer operated warm lines, statewide crisis line, mobile outreach, respite, 24/7 walk-in and crisis stabilization units. Also this year, OptumHealth who has done innovative crisis work for many years in Pierce County, Washington introduced hotlines in New Mexico and Idaho bringing the total of single statewide models nationwide to four (Georgia’s Crisis & Access Line launched in 2006 and Colorado will start later this year), all with expectations for high technology and skilled clinicians.
Why now? There are several key factors that seem to be fueling this new trend. First, federal, state, and local policy makers are seeing the importance of mental health in public safety. The Washington Post reported in September that the American public now believes improvements to the mental health system of care are more important than gun control in preventing future tragedies (a shift since 2011 and Tucson). Communities that lack comprehensive or even basic professional behavioral health crisis services are seeing the need for change.
Second, the high cost and high use of hospitals and emergency rooms have researchers and policymakers focusing on the effectiveness of behavioral health crisis services in communities that are fortunate to have such services. Some of the best outcomes and cost savings in behavioral health have been achieved by well-integrated systems of care that meet the needs of individuals and families in crisis. For example, Scott (2000) reported in his study of mobile crisis response that those situations that were handled by community-based mobile teams were substantially more likely to result in no hospitalization (55%) than were crises handled by police (28%). In Georgia and Delaware, the Department of Justice and Departments of Behavioral Health settlement agreements include elements such as a statewide crisis line, mobile crisis response services, and development of short-term crisis stabilization units as key interventions to assist with individuals being served in the community as opposed to in hospital settings.
Third, as we continue to evaluate what it means to be trauma informed, it is becoming clear that we could do better at eliminating forced and intrusive treatments. In addition to being cost effective, peer warm lines, crisis and access lines and mobile response offer engaging and collaborative alternatives. Peer leaders and advocates will continue to question whether we are doing everything possible to reduce the occasions where an individual is shackled and placed in the back seat of a patrol car because other alternatives don’t exist. As communities increase their investment in public safety, it is an opportunity and challenge as enhanced crisis systems create respectful, engaging and collaborative care and relationships while avoiding the pressures for increased involuntary treatment.
As we move into this new era, how do we improve and support excellence in crisis systems of care? At the 2014 National Council conference, there will be a first ever special track for crisis. Crisis Response Network’s CEO Suzanne Rabideau and I have hosted with National Council two conference calls to solicit feedback and over 60 organizations have participated. There is a rich diversity, with agencies that deliver only crisis care and others where the services are just one of many business lines. Some host a crisis call center, deliver mobile crisis or have facility-based crisis stabilization and/or respite, while others offer a full continuum of services.
One thing all these organizations have in common is that they have struggled with where to find the resources for clinical best practices, cutting edge research and technology, standard operating procedures, etc. Together with National Council we are formulating a behavioral health crisis system of care work group that will help bring these resources together, and the crisis track at the Washington DC May 2014 conference will be an important first step in this new journey.
Prior to 2000, there were several hundred crisis call centers across the country, underfunded, fragmented and lacking in credibility with policy makers and funders. Many of the advocates and researchers in the field publically questioned their value and effectiveness. No more. In just over a decade, the National Suicide Prevention Lifeline under the leadership of SAMHSA’s Richard McKeon and Lifeline’s John Draper introduced a host of resources, supports and best practice standards that have been informed by top researchers and changed the field. Their reach has been international. I was recently in the crisis system of care center in Belfast and noticed on their wall that they were using the Suicide Risk Assessment Standards and Emergency Intervention Guidelines developed in the US.
What SAMHSA and Lifeline have done with suicide hotlines, together with National Council we can do with behavioral health crisis systems of care? It’s really about bringing together our collective experience and expertise and developing a professional orientation and community for these vital services. When it’s 2:00 am and an individual or family is frightened by the spiral of mental health or addiction issues, they deserve an immediate, professional and caring response that meets their level of need. As we come together to discuss excellence in behavioral health crisis systems of care, everyone will benefit.
*Note: I recently left my position as Vice-President of Clinical & Program Outcomes with Magellan Health Services to lead a new joint venture of the nation’s most innovative leaders in crisis services as CEO & President of Crisis Access, LLC, a partnership between Recovery Innovations, ProtoCall Services and Behavioral Health Link.