Crisis Model

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In 2010, the Milbank Memorial Fund published the landmark “Evolving Models of Behavioral Health Integration in Primary Care” with its five stage framework. Crisis Access Holdings, LLC has modified the Milbank collaboration continuum (original citation Doherty, 1995) for evaluating crisis system community coordination and collaboration (see table below).

Milbank Memorial Fund, Close and Fully Integrated

In our model, the highest level requires shared protocols for coordination and care management that are “baked into” electronic processes, not simply add-ons. For a crisis service system to provide Level 5 “Close and Fully Integrated” care, it must implement an integrated suite of software applications that employ online, real-time, and 24/7:

Key Elements Level 5 Crisis System (Air Traffic Control Approach)

Status Disposition for Intensive Referrals There must be shared tracking of the status and disposition of linkage/referrals for individuals needing intensive service levels, including requirements for service approval and transport, shared protocols for Medical Clearance algorithms, and data on speed of accessibility (Average Minutes Till Disposition).
24/7 Outpatient Scheduling Crisis staff should be able to schedule intake and outpatient appointments for individuals in crisis with providers across the state, while providing data on speed of accessibility (Average Business Days Till Appointment).
Shared Bed Inventory Tracking Intensive services bed census is required, showing the availability of beds in crisis stabilization programs and 23-hour observation beds, as well as private psychiatric hospitals, with interactive two-way exchange (individual referral editor, inventory/through-put status board).
High-tech, GPS-enabled Mobile Crisis Dispatch Mobile crisis teams should use GPS-enabled tablets or smart phones to quickly and efficiently determine the closest available teams, track response times, and ensure clinician safety (time at site, real-time communication, safe driving, etc.).
Real-time Performance Outcomes Dashboards These are outwardly facing performance reports measuring a variety of metrics such as call volume, number of referrals, time-to-answer, abandonment rates and service accessibility performance. When implemented in real-time, the public transparency provides an extra layer of urgency and accountability.

The Inspiration

In 2010, the Milbank Memorial Fund published the landmark “Evolving Models of Behavioral Health Integration in Primary Care,” which included a continuum from “minimal” to “close fully integrated” that would establish the gold standard for effective planned care models and change the views of acceptable community partnership and collaboration. Prior to this, coordination among behavioral health and primary care providers had frequently been minimal or non-existent and it would have been easy to accept any improvement as praiseworthy.

In fact, the Milbank report portrayed close agency-to-agency collaboration (evidenced by personal relationships of leaders, MOUs, shared protocols, etc.) at the lowest levels of the continuum and insufficient. They described these community partnerships and their coordination as minimal or basic, citing only sporadic or periodic communication and inconsistent strategies for care management and coordination. They called for frame-breaking change to the existing systems of care, and their report continues to reverberate throughout the implementation of integrated care.

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