Defend the Alamo: Crisis Mental Health Care Must Be Transformed

shutterstock_9835540Vastly outnumbered. Ill equipped. Foraging for resources. The nation’s Emergency Departments are the Alamo of mental health access and care.

The recent headline was not surprising: “8 in 10 ER Docs Say Mental Health System Is Not Working for Patients.” The survey by the American College of Emergency Physicians (ACEP) of 32,000 physicians, residents and medical students working in hospital emergency departments concluded that “boarding” wait times for psychiatric inpatient needed to be reduced and more training and education of staff about psychiatric emergencies was required.

Sheree Kruckenberg is Vice President Behavioral Health for the California Hospital Association, which represents 400 hospitals and health systems. Her April 2015 open letter drew similar conclusions:

“The increasing dependence on… hospital EDs to provide behavioral evaluation and treatment is not appropriate, not safe, and not an efficient use of dwindling community emergency resources. This includes not only hospitals, but emergency transportation providers and law enforcement. More importantly, it impacts the patient, the patient’s family, other patients and their families, and of course the hospital staff.”

The Emergency Nurses Association (ENA) has reported similar challenges with a shortage of tailored education and training. According to the National Alliance on Mental Illness (NAMI), many patients and families are displeased with their experience in the ED because of wait times and a lack of respect.

Everyone seems to agree with the problem.

The solution doesn’t seem as clear. ACEP is leading a response with a larger group of partners to form the Coalition on Psychiatric Emergencies, also known as “COPE,” with the goal of improving mental health and addiction care in EDs.

History would suggest those reinforcements aren’t coming in the numbers necessary. By the time the mental health crisis reaches the Alamo, the battle is already lost.


Our country’s approach to crisis mental health care must be transformed. It is the time, and we have the tools to prevent tragedies like these:

  • Unspeakable family pain: In November 2013, Virginia State Senator Creigh Deeds told CNN that he was alive for just one reason: to work for change in mental health. Just a week earlier, his son “Guss” stabbed him 10 times and then ended his own life by suicide. This happened only hours after a mental health evaluation determined that Guss needed more intensive services, but unfortunately, he had to be released from custody before the appropriate services could be found.
  • Psychiatric “boarding”: The month prior, the Seattle Times concluded their investigation of the experience for individuals with mental health needs in Emergency Departments. “The patients wait on average three days [emphasis mine] — and in some cases months — in chaotic hospital EDs and ill-equipped medical rooms. They are frequently parked in hallways or bound to beds, usually given medication, but otherwise no psychiatric care.” In 2014, the state supreme court ruled the practice of “psychiatric boarding” unconstitutional.
  • The wrong care, in the wrong place, compromising other medical urgent care: In April 2014, California approved $75 million for residential and crisis stabilization and mobile support teams. This investment was based on the belief that 3 out of 4 visits to hospital emergency departments for mental health and addiction issues could be avoided with adequate community based care.
  • Thousands of Americans dying alone and in desperation from suicide: And, in 2015, the National Action Alliance for Suicide Prevention launched the Crisis Task Force, with the goal to provide stronger 24/7 supports to the 9 million Americans at risk each year. Over 115 people per day in the US die alone and in despair.

Four different compelling reasons. Public safety. Civil rights. Extraordinary and impactible waste of public funds. And, the opportunity to address one of our most intractible human problems. The time is now, and the burning platform is clear.

It does not have to be this way. In a few states and communities acroos the U.S., solutions are in place. But until now we do not have the vision or will to approach crisis care with national resolve and energy.

Three examples highlight what can be done differently.

  • Power of Data and Technology. The Georgia Crisis and Access Line utilizes technology and secure web interfaces to provide a kind of “air traffic control” that brings big data to crisis care and coordination in real time.
  • Power of Peer Staff. People, Inc.’s Living Room, peer staffing and retreat provide safety, relief and recovery in environment more like the home than the institution.
  • Power of Going to the Person. Colorado Access’ mobile crisis teams don’t wait for law enforcement to transport a person in need to the hospital. They go to the person. Colorado is the first state to prove this can be done in urban, rural… and yes, even frontier areas.

Now is the time for a new approach.

Absence of data and coordination on ED wait times, access, outcomes and crisis bed availability Publically available data in real-time dashboards
“Cold” referrals to mental health care are rarely followed up, and people slip through the cracks Direct connections and 24/7 scheduling
EDs are the default mental health crisis center Mobile crisis provides a non-law enforcement  response that often avoids ED and institutionalization
Crisis service settings have more in common with jails Crisis service settings—the urgent care units for mental health–look more like home settings
Despair and isolation worsened by trying to navigate the mental health maze Crisis care with support and trust: what you want and need, where you want and need it

California, Colorado, Georgia and Washington State were driven to new approaches because of vastly different primary drivers, but five key elements stood out.

  1. The Expansion of Community Based Mobile Crisis Services to a 24/7 outreach and support with a contractually required response time (Colorado and Georgia)
  2. The introduction of Crisis Stabilization Programs that offered 23 hour observation and sub-acute short-term stays, at lower costs and without the overhead of hospital-based acute care
  3. Crisis triage call centers with strong use of technology and information across a system of care, leveraging big data for performance improvement and systems accountability while providing high touch support informed by suicide prevention best practices
  4. The engagement of peer staff, trauma informed care principles and recovery cultures to improve the experience and outcomes
  5. The involvement of government leaders, with activating legislation in California and Colorado, key engagement of the governor in Colorado and Georgia, and the judicial branch (DOJ, Supreme Court) in Georgia and Washington State

2016-01-19_14-45-49Now is the time for crisis, and we can do far better.

Our society takes for granted a national emergency medical response system. 911 centers with high technology to assure individuals with other medical problems do not fall through the cracks. These have transformed stroke and heart attack care. Ambulance services go to the person directly to assure immediate life-saving care, with  emergency medical services in every area of the country, urban, rural and frontier. We can do the same for other brain health crises. We must.

Defend the Alamo.


Note: In 2015, the National Action Alliance for Suicide Prevention launched a consensus expert task force on crisis that I have co-led with Dr. Mike Hogan. He and I co-authored the majority of the blog above and this content will appear in the foreword to the upcoming white paper, “Crisis Now: Transforming Services is Within Our Reach.” 

Also, the #NatCon16 conference in Las Vegas March 7 – 9 will host its 3rd annual crisis track, featuring a stellar line-up including Carolina Healthcare’s Dr. John Santopietro, Beacon Health Options’ Dr. Chris Carson, ConnectionsAZ’s Dr. Margie Balfour and Community Health Network’s Dr. Marlon Rollins and Suzanne Clifford and others. Click here for more info.

Finally, I would like to credit the leader of RI Crisis Leon Boyko, who developed the “Defending the Alamo” metaphor. Since beginning with RI International in 2014, he has partnered with health leaders in Arizona, California, Delaware, North Carolina and Washington State to launch half a dozen new recovery-based crisis stabilization and crisis respite programs. 



One thought on “Defend the Alamo: Crisis Mental Health Care Must Be Transformed

  • I wonder if another element at play is the self selection process someone goes through when seeking help. An emergency room is widely considered by the general public to be a familiar safe place to seek care while psychiatric care centers still feel daunting and stigmatizing. The care RI International and others take to make these centers welcoming and comfortable is a great first step. I’m curious about what other changes (legislative, perceptual, cultural?) will need to occur before those needing help can confidently walk through the doors of a psychiatric care center instead of an ED.

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