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Creating and Sustaining High-Quality Crisis Servic ...
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Hello, and welcome. I'm Amy Cohen, Program Director for SMI Advisor and a clinical psychologist. I am pleased that you're joining us for today's SMI Advisor webinar, Creating and Sustaining High-Quality Crisis Services, a Systemic Approach. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. And now I'd like to introduce you to the faculty for today's webinar, Dr. Margie Balfour. Dr. Balfour is a psychiatrist and a national leader in quality improvement and behavioral health crisis services. She is the Chief of Quality and Clinical Innovation at Connections Health Solutions, which provides 24-7 access to mental health and substance use care throughout Arizona. Dr. Balfour is also an Associate Professor of Psychiatry at the University of Arizona. Dr. Balfour is the Doctor of the Year by the National Council for Behavioral Health for her work at the Crisis Response Center in Tucson. And she also received the Tucson Police Department's Medal of Honor for her efforts to help law enforcement better serve the population with mental illness. She has served on the Board of Directors of the American Association of Community Psychiatrists, the American Association for Emergency Psychiatry, and NAMI, Southern Arizona. Dr. Balfour, thank you for leading today's webinar. Well, thank you for having me. And so I'll go ahead and try to get started as quick as possible so there's time for questions. I have nothing to disclose. And our learning objectives for today are to define the elements of a crisis continuum, identify ways in which service providers and first responders can collaborate, and discuss strategies for using data to build and improve crisis services. So first I want to start with a case scenario. So it's Friday at 4.30 p.m. and the phone rings. So that's never good. Your spouse's boss says he needs help with his brother. And you're like, why are they calling me? Well, because you have a particular set of skills, you're a bona fide mental health expert, and you've acquired these skills over a very long career. So they expect you to know how to help this guy's brother. He's been texting family members saying he thinks he'd be better off dead. They're afraid he might hurt himself. Oh, and by the way, he might also have a drinking problem and need detox. So they want to know, what do you advise? How do you get this gentleman help at 4.30 in the afternoon on a Friday? Well, you could say, well, if he's got a psychiatrist or a therapist or a clinic, you know, call that clinic. We kind of know what happens there. So if this is a psychiatric emergency, please hang up and dial 9-1-1. Otherwise, stay on the line and ponder the kind of person who would call you in the first place in an emergency will be with you on Monday. So as we know, 4.30 on a Friday, you're not going to get much help that way. You can call 9-1-1, which unfortunately, this is an all too common scenario where, you know, people with mental illness and crisis, when they clash with the police often have tragic outcomes. So how do we do this without calling 9-1-1? Well, go to the ER. Well, we all know what happens in the ER. You know, people wait and wait and wait and don't get a whole lot of good psychiatric care in that setting. Well, you can go to the crisis center. Well, remember, this guy may have a drinking problem. Maybe he needs detox. All too often, you know, crisis centers will say, well, we do mental health, but not substance use. Well, there's a detox center. Well, often those places will be like, oh, we do substance use and not mental health. And remember, the guy is suicidal. So what we kind of have for people in crisis is often this scenario where it's just it's easier to get into heaven than to access psychiatric care. And what we're going to talk about today is a different approach where a behavioral health crisis is seen as an emergency, where it requires a systemic approach. Where you have the same quality and consistency as the response to heart attack, stroke, fire, any other emergency. But what we currently have is, like I alluded to before, if you call 911 and say you have chest pain, you get an ambulance. But if you say you're suicidal, you get Chief Wiggins. And, you know, why is this? There's plenty of, you know, there's there's years and years of history of why this is. But what it does is it really sets things up for some not so good outcomes. There's currently there's no official database of uses of force or officer involved shootings. But from large databases compiled by the New York Times and The Guardian, both estimate that about a quarter of officer involved shootings were linked to some kind of mental illness. And then furthermore, there's this phenomenon of suicide by cop where studies estimate different prevalence of it. But it's it's not uncommon for people to even have a mental health crisis. For people to even try to use these police encounters as suicide attempts. So not surprisingly, the prevalence of mental health, mental illness in the jails is much greater than that of the general population. There's over two million jail bookings of people with serious mental illness each year. And a NAMI survey revealed that about half of people with SMI report they've been arrested at least once. And there's kind of this myth that, well, at least they've gotten off the street and they're going to get some treatment that they need while they're locked up in jail. And that's actually not necessarily true. Only about a quarter of men and 14 percent of women get the formal substance abuse treatment they need while incarcerated. A lot of jails are doing the best they can and doing some progressive things. But really, it's not they don't have the policies and the staff and the set and the physical plan and the setup to really meet the needs of this population. Instead, people with mental illness end up being incarcerated twice as long. They're more likely to be assaulted or abused in jail. They're more likely to be put in solitary, which makes them worse than when they get out of jail. Their Medicaid's been turned off. They have hard time finding employment because of their history. They often lost the job they had if they had one before they went in. And so not surprisingly, they're more likely to become homeless. And then re-arrested. And then all of these wonderful outcomes, we get it twice the cost of the pay of the cost to taxpayers. So they make it to an emergency room. It's not that great of a situation either. Most ERs report that people board waiting for psychiatric care for hours. Most ERs don't have much capability to provide psychiatric care in the ERs. So they, if your only choices are home or the hospital, many wait and default to the hospital and they're waiting for hours, sometimes even days for a hospital bed. And during this time, they're not getting much treatment. The environment is not really conducive to people in mental health crisis. You've been in ER. It's loud and noisy and just not very private. And so there's increased risk of both the staff of being assaulted and to patients of engaging in injuries and self harms. It costs a whole lot more. A lot of people, if you think about what happens in an ER, they put a sitter with the patient and that's a whole lot of costs. And then lost revenue could be up to $2,300 a day from just having that bed in the ER filled and not available to other patients. And it's just not a good experience for patients. So what we need is a systemic response to behavioral health crisis that delivers evidence-based care to the people who need it with measurable outcomes in the least restrictive setting that can safely meet the person's needs. And by the way, because I live in a red state and you got to speak red state sometimes to advocate for the things you need. And all of this is typically less costly than what we're currently doing. So why don't we have a national standard for crisis services? Well, there's a few reasons why that may be. There's no standard nomenclature for crisis services. So if I say a crisis stabilization unit, and I talk about that here in Arizona and California, that means something different in New York. That means it's probably something completely different. Crisis services, they fly under the federal radar because they're mostly financed by Medicaid and Medicaid's regulated at the state level. And as they say, if you've seen one state mental health system, you've seen one state mental health system. So there's no overarching kind of federal regulations that govern this. And then maybe stigma too. We have standards for EMS and emergency response, but mental health is always sort of seen as some extra thing that if we have funding, we might fund it. And so it doesn't get wrapped up into that typical emergency response. There's been some progress towards trying to develop some national definitions and standards. The links to these will all be in the PowerPoint. So I won't go through them all individually. But there is a call for a national standard for crisis systems. The 21st Century Cures Act created the Interdepartmental SMI Coordinating Committee, and its report a couple of years ago recommended a national standard for crisis care. And so in response, the Group for the Advancement of Psychiatry is developing a report that should be out the end of the year, early next year, that really talks about what do you need to have a system, a well-functioning crisis system that talks about things like the governance, the finance, and the services, and the best practices. And a lot of that is drawn from the successes in Arizona. So I'll be talking about what we've learned in our system. And if you know, and I'm using the word system rather than services, because that's a really important distinction, because what you really need is a, there's many, many services. And this is a slide that I stole from SAMHSA from years ago, that list, does a great job of listing a whole array and a whole continuum of crisis services, all the way from the early intervention to the response to aftercare. But the system is more than a collection of these services. They all need to work together towards common goals that you end up with a system that's more than the sum of its parts. And in our experience, there's three key ingredients for a system. One is accountability. So if you're saying that all these crisis services work towards common goals, well, who sets the goals? Who sets the system values and outcomes? Who's responsible for making sure that the system is performing the way that it needs to be? And so you need some mechanism of accountability. Collaboration. So crisis services in particular require a broad coalition of stakeholders, because you've got everyone from hospitals to mental health providers, to law enforcement, to schools. And so it's a very broad alignment. And so you really need a culture where people are communicating and problem solving together. And then data. If we're going to set goals and set outcomes and performance targets, how do we know if we're meeting those? How do we know what we need to improve? And having data so that you can make decisions based on actual data. So in Arizona, our structure kind of bakes in a lot of these features, which is important. So if you look, this is a schematic of the state. And what the state does is they divide the state into three regions where we have a behavioral health authority that governs those. And Arizona is an interesting state. Our state Medicaid, we were the last state to ever have Medicaid. So not just Medicaid expansion, but just Medicaid. And it wasn't until the 80s after, in response to a lawsuit around mental health, actually, that the state bought into Medicaid. And when I first moved here, I was from Texas, where Medicaid is funded about how you would expect Medicaid to be funded in Texas. And I came out here and I'm like, this is great. There's so much Medicaid. And the name of the department is called ACCESS. And I'm like, that's so great because that's all about access to care. Well, it actually stands for Arizona Healthcare Cost Containment System, which is not exactly what I thought it meant. But it's actually a, it explains kind of how our structure has baked in some of these features because we were the last state to ever have Medicaid, but the first state to have a statewide managed care waiver. So we have never had fee-for-service Medicaid. It has always been managed. And the advantage of that is from the very beginning, it's had to be thought of as a system. And so over the years, there's been a lot of investment in crisis services because of that. So the way that it's structured is you've got our Medicaid department, ACCESS, and they divide the state into three geographical regions. And they contract for a regional behavioral health authority to manage all of the crisis care in that region. And so we're the southern regions, the dark, the dark side, the dark shaded part. And our regional behavioral health authority is currently Arizona Complete Health, which is part of Centene. And so they get all of the Medicaid money. They get SAMHSA block grant money. They get state general funds. There's some local funds for crisis care. And all of that is braided into their funding stream. And then they subcontract with all the providers. So you've got a single point of accountability that is the funder for all these different services. And then providers like us contract with them. What this means for crisis is so we've got a centralized planning at the REBA level, centralized accountability, because they're holding all of our providers accountable, and then alignment of the clinical and financial goals. So if you think about, again, it helps to speak red state sometimes, if you think about what do I want as a psychiatrist is I want my patients to not be in jail if they don't need to be, not be in the emergency room or the hospital if they don't need to be. And if you're paying for stuff, you want those same things too, because being in the hospital, in the jail, in the emergency room is expensive, and being well in the community is less expensive. So you've actually got those goals being aligned pretty well. And so for that reason, over the last 20 years or so, Arizona has invested a whole lot in crisis services. And then if you've got this central point of accountability where if some of the different providers aren't kind of working in concert, then you've got like the conductor here saying, hey, we need to help get you back in line. So sometimes I call them our benevolent overlords. So when we're talking about justice involvement, which is a very timely topic now, there's a framework for trying to use the mental health system to decrease justice involvement called the sequential intercept model. And you may have heard of this. It's basically, it's pretty simple. It says there's a pathway that people follow in the justice system, all the way from arrest to being booked to having their initial appearance and so forth. And at every point of that pathway, there's an opportunity for the mental health system to intercept that person and get them into care instead and out of the justice system. And so crisis services are right here at this intercept zero and one at the level of preventing people from being arrested. And with our structure, there's actually, it lends itself to having some strategic thought in designing the services towards goals like this. So this is sort of an example from a few years ago where our governor said he wanted to look at, he was doing this kind of lean government initiative where he made the department head start to share budgets with each other. Because if you think about it, for people being incarcerated, if you're in charge of Medicaid and someone's incarcerated, it doesn't hurt your budget at all. Actually, it kind of helps it because that person's sort of off your spreadsheet, because that's a whole different department that pays for that. But ultimately, it all comes from the same place. So our governor had had the department head start to meet with each other and share their budgets and come up with some kind of higher level goals. And one of these was to reduce justice involvement for people with SMI. So then access our Medicaid department that when they contract with their regional behavioral health authorities or their Medicaid managed care organizations, they included requirements targeted at reducing justice involvement. So when they put out their RFP for people to bid, for the companies to bid to be these REBAs and things, they said in their RFP, explained to us how you will reduce justice involvement. So then the REBA, which is our acronym for Regional Behavioral Health Authority, they're at risk. And so when they contract with their subcontractors like us, they build in incentives and contract requirements and things like that, that are designed to create the processes needed to reduce justice involvement. So for example, when we're talking about that intercept zero or one, where we're trying to prevent people from being arrested, well, who has the patients that we're trying to keep from being arrested? It's law enforcement. So there's this idea of treating them as a preferred customer, so it's easier for them to hand off people into services. And so that the crisis line, we've got 911 calls that get transferred to the crisis line, dedicated law enforcement number to make it easier for them to interface with the crisis line. Our mobile teams have performance measures on them, where they're supposed to respond to someone in crisis in the community within an hour. But if it's a law enforcement officer calling them needing help from a crisis mobile team, they have to be there in half the time. And then as I'll talk about in more detail, our crisis centers are really set up to have quick and easy drop off for law enforcement. And so as a result, we try to decrease justice involvement for everyone. And this is kind of a schematic that sort of shows us in a different way, where you've got your person in crisis, and we want to do everything as possible in this least restrictive setting out in the community and get their needs met that way, which also tends to be the least costly. So it starts with someone in crisis, and they can call the crisis line. The crisis line takes about 10,000 calls a month. They cover, you know, covering Southern Arizona. They're able to resolve about 80% of those cases on the phone. So they'll get a clinician who can help with crisis counseling. They also can make people appointments. The REBA requires all of the mental health providers to have, to put appointments under this appointment system that they have. So even if someone's calling at like 2 a.m., they can say, well, we can get you in to see someone, you know, the day after tomorrow on 11 o'clock, is that okay? And that often can help resolve the crisis. If they can't resolve that, resolve it over the phone, they are the centralized dispatch for our crisis mobile teams. So those are typically two-person teams of clinicians, and they can go out into the field and evaluate the person there and do a face-to-face. And if they do a face-to-face evaluation out in the field, they typically resolve over 70% of those from that interaction. The person's still too acute to be stabilized in the community, they can come to one of our crisis facilities. So we operate one of the largest, which I'll talk about. They're scattered throughout southern Arizona. So in the more rural areas, there's some smaller ones as well. So that each one is probably at most an hour and a half drive to get to one of them. So Arizona is very spread out. And then there are post-crisis wraparound services to help people remain stable. At every point in this continuum, there is easy access for law enforcement. So there are crisis line staff co-located in the 911 call center that can intercept calls that are better taken care of by the mobile team versus police. As I was saying before, the mobile teams have to respond quicker to police. And our crisis centers are really set up for fast and easy drop-off. So as a result, all of this is designed to decrease jail, ER, and inpatient hospitalization. So that's what it looks like on a nice, pretty schematic. In reality, though, there's many, many services, and it may be difficult for someone to figure out which ones to access. So another important system value is that all of the services in the crisis system operate with this culture of no wrong door. So if an officer who's been trained in mental health first aid, CIT, they've been trained to recognize people in mental health crisis and get them to treatment. And if they go to one of these services and it's, quote, the wrong service, we don't put that back on the officer and say, well, put that person back in the back of your cop car and drive them somewhere else. Because once you do that, they'll never spend the time to bring someone to services again. We say, thank you, sir. May I have another? And then we, on our end, will route that person to where they need to be. So everyone operates with this culture of we will help get the person to where they need and not send the patient or the officer on some wild goose chase to try to get them the right crisis services when they're in crisis in that moment. So I'm going to talk about, at the center of this in Tucson is our crisis response center. This was built by Pima County with bond funds back in 2011. And it was really meant to be, their goal was to decrease the amount of people in jails and the emergency rooms. So currently we serve about 12,000 adults and 2,400 youth per year. It is the main law enforcement receiving center with this no wrong door approach. And we don't have exclusions for people being too acute, too educated, too intoxicated or the wrong payer. We take everybody. Our services include, there's a 24-7 urgent care clinic where people can just walk in, like I'm new to town, I need to be hooked up with services or I'm out of my meds, I need a med refill. There's the heart of the operation is our 23-hour observation unit, which I'll talk about in more detail in a minute. And then for the adults, we have a short-term subacute inpatient with 15 beds where people stay about three to five days. It was really meant to be a place where the community coalesces around crisis care. So there's space for co-located community programs that have over the life of the building, we've had various agencies in and out of there. For example, a peer run post-crisis wraparound program. We have volunteers come in to do pet therapy and other cool things. And it's part of this really cool campus where in our building is the crisis call center also, which we run by a different agency, but we collaborate with very closely. It's on the campus of basically the county hospital, which is Banner University of Arizona Medical Center. And their emergency department is connected to our building via a breezeway. The bond also built a 66-bed inpatient hospital, which was run by Banner University. And that's where most of the involuntary commitments go. And there's a mental health court right there in it as well, where they both do all the mental health care or all the mental health commitment hearings, but also they do some low-level criminal warrant resolutions and things like that. So I was saying, we take everybody, there's no wrong door approach. Connection, so we're one of the organizations that contracts to do these services. Our corporate mission statement is, we address any behavioral health need at any time. And I put that up there not as like an ad, but because that is really the attitude that you have to have to make this work. Many of you have probably heard of CIT, crisis intervention training, and a lot of people, it's often sort of thought of as just the training component, but if you actually go and dig up the old CIT original papers that described what they did out in Memphis, they really talk about how it's a community approach and it's not just training, because you're training officers to recognize mental health issues and then take them to treatment. And if you're supposed to divert them from jail, their first question is divert to what? So a very important component of making CIT work is having what they call a receiving facility. And these are the criteria for what that facility should do back from those original CIT descriptions. And I've highlighted these two in the middle because we go around the country, we do consulting and stuff. And these are the two hardest to do well. This is where we see people make mistakes and then make a crisis center that's not functioning the way it needs to be. And this is the no clinical barriers to care and minimal turnaround for law enforcement. And by no clinical barriers to care, what we mean is truly no wrong door and that we take everyone. So a lot of places sometimes you'll hear, well, they can't be, they're too acute, they're too drunk, they're too violent, they're too this, they're too purple, they're too whatever. We take everyone. We do have some medical exclusionary criteria, but we try, we sort of use this figure out how to say yes, rather than look for reasons to say no approach where we try to figure out, can we take care of this person? And we never turn law enforcement away. So some people ask, well, what do you do if they have a medical issue? Well, first of all, the police are actually better at realizing who needs an emergency room versus a mental health facility than you would think. They're actually quite good at it. But every once in a while, we do get someone who needs medical care. And if you think about it, cause people go, well, I don't want the risk of taking a medically unstable person. Well, think about the flip side. If the police bring you a medically unstable person and you go out there and look at that person and go, oh yeah, they're too medically unstable. Put them in the, you unmedically trained law enforcement officer, put them in the back of your unmedical cop car and then drive them off of our property to some ER somewhere. And something happens to that person, like which is more risky. So our philosophy is, and our CMO likes to remind us, we did all go to medical school to be a psychiatrist so we can, we can treat some medical emergencies, but we, we bring them in and then we arrange for the transfer to the emergency room rather than put that back on the officer. And there are studies that show that having a receiving center like this decreases arrest. It reduces ED boarding and it reduces people going to the hospital unnecessarily. The other big component is easy access for law enforcement. So we, again, we sort of say, well, if law enforcement has the patients that we want to keep out of the hospital or out of jail, we need to treat them as a customer just as much as we treat our patients as a customer. So it's critical to have their own dedicated entrance. Now we also have this fancy gated sally port, which is nice. It's not necessary, but the officers really like it and they were involved in the planning of the building where people buzz a buzzer, the gate opens, it closes behind them. So if the person were to try to run, then it's a, it's a, it's a secure place. What's critical is that they have their own entrance, they're not traipsing people through the waiting room, you know, with all the stigma of, of you know, of, of having law enforcement bring people in and also they're, they're law enforcement officers. And so there'll be you know, before, when we first took over the CRC, they would be like walking all over the place and they need to make a copy. They need to go to the bathroom, get some water, and they've got their guns on in the clinical area. And so then we have to ask them to take their guns off. If you've ever asked a law enforcement officer to take their gun off, they don't like it. So we said, well, let's get them everything they need back here. They've got their own bathroom. They've got an office where they can do their clinical paperwork and stuff like that. We've got refreshments for them. And so they really liked that they they told us it takes about 20 minutes to book someone in the Pima County jail. I think they lied. It takes a bit longer than that, but we've set our performance target to be 10 minutes or less turnaround so that they prefer to come to us, that we are easier to access in the jail. Then once our patients are in with us, I'm like, I was saying the heart of the facility is this 23 hour observation unit. It's locked. It's we try to provide a safe and secure therapeutic environment. It's an open area rather than rooms like you would have an emergency room. There's a few reasons for that. If people are potentially a danger to themselves or others, the way you keep them safe is to continuously observe them. And also because think about what happens in an emergency room where people are in these rooms by themselves and they take everything out of the rooms. They can't hurt themselves. They put a sitter with them who's usually the policy says they're not supposed to talk to them about why they're there. So then they sit in a room and stare at the wall for 12 hours. That is not very therapeutic. Back before we had beds, the old psych hospitals had open areas for what we call milieu therapy. And then even today, most psych units have that day room for that therapeutic milieu. And so that's the other reason why we have it open. And then as far as what happens in a 23 hour observation unit, this is where we really do the heart of our work around crisis stabilization. So we have this culture shift where we don't ever, hardly ever, if someone first comes in no matter how acute they are, we don't assume they're going to the hospital. We say, well, we're going to go to 23 hour ops and we're going to assume that we can resolve this crisis. And we do that through interdisciplinary teamwork. So we have 24 seven psychiatric provider coverage, either a psychiatrist, nurse practitioner, PAs. We have peers with lived experience who are a huge part of our team. That's a picture of them over here. We have nurses, techs, case managers, therapists, our unit coordinators. We try to intervene as early as possible. So one of our important metrics is our door to doctor time. We try to keep that around 90 minutes or below. And the interventions could include medication. We do detox. We can start buprenorphine if we need to. We have groups, peer support. Our social workers are immediately on the phone, talking to family, trying to find out what's going on, talking to the clinics, trying to coordinate care. And then really collaborating with the outpatient system to figure out what does this person need in order to be stable in the community. And then after 23 hours, if we haven't been able to stabilize them, then we pursue inpatient hospitalization. And so as a result, even though pretty much to be on the observation unit, you meet medical necessity criteria for inpatient. So danger to selves, danger to others, acutely psychotic, agitated, 60 to 70% of those folks are able to discharge the community the next day. Law enforcement is a huge partner with us. And they have a very robust training model to have their officers recognizing when people need mental health care and getting them into treatment. All of their officers receive mental health first aid training, which is an eight-hour training. CIT, the research shows that it's best when it's done voluntarily versus being voluntold. And so they've done things to incentivize CIT training so that about 80% of their first responders and 911 call takers have gone through the 40-hour training voluntarily. We participate in that training. And then they have specialized units that are all CIT trained. So they're SWAT and hostage negotiators. And then their mental health support teams, which I'll talk about in a second. This is an innovation that TPD has really led. So they have, in addition to the CIT trained officers who can respond to emergencies 24-7, those are officers that do other things. The MIST team is a dedicated team where they do nothing but mental health. And they have a group of officers that really focus on providing service to people and transporting people in a safe way. We have a whole lot of civil commitment, assisted outpatient treatment here in Arizona. And so people who are needing to be picked up because they're not adhering with their treatment plan or they're decompensated, or people who have civil commitment orders to bring them in for evaluation, that's all they do is they deal with that population. They are able to locate over 95% of the people with commitment orders. Before that, it wasn't tracked very well, but it was probably like 20 or 30%. They wear plain clothes. So this looks like a cop car, but it is a plain car. They wear plain clothes. And since they're working with this population on a regular basis, they develop relationships, they recognize patterns. They can tell us when someone is decompensated, or they can tell the clinics about things going on in the neighborhood that they wouldn't necessarily know. And then the really innovative thing is their detectives that focus on prevention and safety. So the way they explained it to me was, and I never really thought about this before, being not a law enforcement person, is that it's really odd to have detectives who investigate things that are not crimes. So if you think about it, like if you get robbed, you get a robbery detective. If there's a murder, there's a homicide detective. But if you call and say, my neighbor, I'm concerned about them because they're acting funny, there's no weird stuff detectives. And so that's what these detectives do, is when they get cases like that, or if they're flagged, other officers flagged them as mental health, then they investigate and they try to find out what's going on with that person, see if they're connected to treatment and they've fallen out, or do they need to be connected, and really trying to prevent people from falling through the cracks. This was created after the Jared Loeffner shooting in which Congresswoman Gabrielle Giffords was shot, where they were wondering like, how did he fall through the cracks? And we want to prevent this from happening again. And so that's where this whole system, in terms of the law enforcement side, was born. Some data. So like I was saying, the police, they prefer to use us rather than the jail because we get them turned around quickly in 10 minutes or less. So the orange dots on this graph is our median turnaround time. The bars are the law enforcement drop-offs per month. And what's also interesting is in most places I've been, because we have a much larger facility up in Phoenix that gets about 700 to 800 law enforcement drops a month. We've done this in other cities in Texas and other places. And pretty much everywhere else I've been, most of the law enforcement drops are involuntary. They're being brought in on whatever your local emergency hold is, 5150 Baker Act, that kind of stuff. In Tucson, this light part of the bars are their voluntary drops. So this is really a testament to the Tucson Police Department and their approach towards mental health, where they are actually proactively engaging people and saying, hey, wouldn't you like to be brought to treatment? We can take you to the CRC. And one of our docs calls it the Uber police. But they really do do some proactive engagement and try to bring people in for help. As a result, the red line here is the number of mental health transports per year. And you can see that's been going up and up and up. Sometimes the question is, is this good or is this bad? We look to see if there's people who are going through multiple times. We have processes in place for that, which I'll touch on in a minute. But for the most part, we think this is a good thing, because it's more people being brought to treatment rather than to jail. There's and we've got some data that suggests that there's less justice involvement because of that as well. If you look at things that our people tend to get picked up on and taken to jail for, it's what law enforcement calls nuisance calls. So these are things like civil disturbance, drinking in public, vagrancy. We were working with this group in Ohio. They have aggressive jaywalking is what they often use, which I don't even know what that is. But you can see over the years, that's been decreasing. And also a culture change in how law enforcement responds to crises. So if someone is suicidal and there's an involuntary emergency order to pick them up and bring them in because they're suicidal and officers go to the house, they knock on the door and that person says, I'm not coming out. In most jurisdictions, that's considered a barricaded suicidal person and is an automatic call to the SWAT team, which is my law enforcement buddy says, if they're not going to come out for my two plainclothes guys, they're not coming out for 30 guys in a tank. So it's just really not the way to handle these situations. And so since the development of these MIST teams, they've stopped doing that. And so you can see the decrease in these suicidal barricade calls. And if you're trying to make a financial case for this, it pays for itself because each one of these is like $15,000 with all the toys and the overtime that it costs to call SWAT team out, plus SWAT team doesn't like it. There's lots of other collaborations that have been being developed also. So we've got co-responder teams where there's now a mobile crisis clinician and a police department mental health detective. They do follow-ups for high-risk individuals. They've been able to decrease the amount that they end up doing paperwork for involuntary hospitals from 60% when it was just the MIST detectives to 20% now that they've got the clinician with them. There's a deflection program where they have a SAMHSA grant funded peer co-responder goes with them for substance use calls and overdoses, and they have the option to not arrest people for certain amounts of possession. And so in the first 18 months, they've diverted 1,500 people to treatment instead of arresting them. And then the newest is a homeless outreach team that's mostly focused on our parks where they're engaging people in services, and they've housed 200 people in the first year of that program. And next I'm going to talk, because I want to be mindful of time, so I'll kind of run through this kind of quickly, about how we use data to improve care. I mentioned there's no standard for crisis services. There's no standard for the metrics either. We developed this framework back when we took over the Crisis Response Center, and we use what's called a critical to quality tree where you articulate the value that you're trying to provide, and then map discrete metrics onto those values. And so we looked at, you can see these values are similar to the Institute of Medicine's goals for improving health care with some tweaks that are mental health specific, such as doing things in the least restrictive way, and doing things in partnership with the community. So for example, these are kind of the core ones out of that big list, where you look at our length of stay and door-to-doctor time, like I mentioned, when we talk about least restrictive, we mean restraint use, but also least restrictive in terms of disposition. So we track that 60 to 70% that we send home instead of the hospital. We also look if they came in involuntarily, are we able to convert them to voluntary status even if they do go to the hospital? Our restraint use, that's lower, it typically is lower than the Joint Commission's national average for inpatient psych units, but we have the ability, and we do everything that we can to avoid doing seclusion restraint, but it's important that we have the ability to do that because otherwise, if you don't do seclusion restraint, that means that you turn away anyone who might need it, and then that threshold always moves up and up and up until it's like they give you the side-eye wrong, they say, you're too acute, you can't come to this facility. Then what happens is that they get turned away, they go to the ER where they don't really have the capability to de-escalate folks in that environment as well, so they get restrained in the emergency room, or they get taken to jail where they get restrained. So we feel that we're better able to deal with this population. And also, another important point is that we also do all this without using any security, so we use our behavioral health tech staff, they get extensive training, and so we figure it doesn't make any sense to default back to someone who has less training to help with our agitated people, so we don't use any security. The police turnaround time I mentioned, we measure patient satisfaction, and also our return visits within 72 hours. And because we developed this framework for our two centers, our one in Tucson and our larger one in Phoenix, our Regional Behavioral Health Authority has since required the other crisis centers to adopt this same framework, so now you've got a common metric framework being used for multiple centers where then our Regional Behavioral Health Authority can actually look at performance and trends across the system. And we've got some other partners who've used this in other states as well. And then, moving kind of beyond our walls, we also sort of see the crisis center and our data as an opportunity to improve the whole system. That's why I love this quote from Brene Brown about maybe stories are data with the soul, because every crisis visit is a story about how someone could not get their needs met in the community, so what if we turn these stories into data, and then we can look at trends about things that need improving in the system. And so kind of what I mean by everything is a story, if you ask people, like, well, why are you here when you're doing your assessment, and you get stories like this, I couldn't get in to see my doctor at the clinic, there's a problem with the pharmacy, I can't get my meds refilled, I can't get my case manager on the phone, things like that. And so, well, let's look at these trends and see what we can learn from them. And so we set up a partnership with our Regional Behavioral Health Authority where we send them a daily data feed, which allows them to then analyze that data more in real time, rather than wait the three months it takes for claims to come back. And doing this in a collaborative way, this kind of illustrates the power of this, this is one of the first collaborations we did using this, where we know how many people are coming in from each clinic, but one, like, Clinic A may be responsible for, like, 1,000 patients, and Clinic B may be responsible for 8,000 patients, and so just knowing the absolute number doesn't really give you a picture of how many of their members are in crisis. We have the numerator, the REBA has the denominator, and so if you look, all these lines are clinics, and so the orange line, even though it was a smaller number, because they were a smaller clinic, you could see they were an outlier, where a lot more of their patients were coming in in crisis, and so maybe they need some help. We, one of our largest projects that we have done using this partnership is what we call our Familiar Faces Plan, so these are our high utilizers, but we thought familiar faces sounded nicer. So we developed a criteria for the top 20% of people using our facilities, and do a rolling list of those people per month, and then the REBA helps convene multi-agency team meetings where we discuss with that person what's going on with them, what do we need to do differently for them, and then we flag their charts so that we can implement that plan, and it's pretty simple, like here's one of the warnings, which is do not discharge before we have an adult recovery team meeting, is the team meeting term, and then you need to call Jerry, and there's Jerry's cell phone number. So it's pretty simple. When we first did this, there were 64 people on the initial list, and we, a year later, only seven of the 64 were still on the list, and only 37 met that high utilizer criteria total, so not only did individuals get better, but by doing this and looking at system issues, we decreased that churn of people coming through multiple times, and this is kind of an example where we had a lady who was, she would get lonely during the weekend, that would trigger her feeling overwhelmed and suicidal, and we kept trying to, she had a clinic, but she was never in the clinic because she was always with us, and they had a peer assigned to her, but she never would call the peer because she knew us, and on the one hand, you could say, well, she's health-rejecting, she's not doing what she says, she's noncompliant, but we said, well, let's look at this as a strength. It's not that she can't form treatment relationships, she has a very great relationship with us, she feels safe here, she knows our staff by name, we need to help her develop that same kind of relationship with her clinic, and so her plan was we got, well, they were doing some outreach where they would call her at the times where they knew she was vulnerable, but then also whenever she did come in, the plan was simple, which was call the clinic and get the peer down here ASAP so that they can start to meet and develop a relationship, and so if you see in that first quarter, she had 14 visits in that time period, same time period a year later, just one, because she was engaged in the clinic, and this is kind of where we sort of tell our, when we're doing our clinical training with our residents and staff of be a detective, not a bouncer, so don't end it, well, they don't need to be here, and let's see what they actually need, and let's partner with the patient and quote the system to get their actual needs met. In youth, we also looked at our trends, these are weeks, visits per week, and so you can see it's very closely mapped to what's going on in their school, so we're like, well, how can we address this proactively? The REBA looked at, this is number of schools and county by the number of mobile crisis team activations sent to that school, and so you can see there's a couple outliers, and so they did some pilots where they put behavioral health services in the schools to try to decrease that, and so there was a decrease in those 72-hour readmissions on the youth unit as well, and then I just want to end with this, because I know we have, we're blessed with a wonderful system, it didn't happen overnight, so if you're looking at this going, well, gee, where do we even start? It took a long time to get to where we are, but towards the end, you can see the growth just becomes exponential, there's like way more things on the timeline, so, but really, it comes down to, these are kind of our key lessons learned, is that don't reflexively jump to we need more beds, we want to stabilize the crisis in the least restrictive way, which then is a good investment, because it turns out to be the least costly, that you need governance and payment structures to help incentivize these programs, to be data-driven and values-based in your decision-making, have a lot of collaboration, and really, the culture, and if I could pick two things about the culture, it's no wrong door, and let's figure out how to say yes, rather than look for reasons to say no, and with that, I will end, I also want to mention that we are, the Department of Justice has a series of learning sites for mental health and law enforcement collaboration, where you could actually, they can fund a visit, where you could spend a couple of days out here, and talk to all of our system partners, so there's a link to that, if you're interested in that, and with that, I will end.
Video Summary
This transcript discusses a webinar titled "Creating and Sustaining High-Quality Crisis Services, a Systemic Approach" by Dr. Margie Balfour. The webinar is part of the SMI Advisor program, an initiative focused on implementing evidence-based care for individuals with serious mental illness (SMI). Dr. Balfour, a national leader in behavioral health crisis services, introduces the importance of a systemic response to behavioral health crisis. She emphasizes the need for a crisis continuum and collaboration between service providers and first responders. Dr. Balfour also highlights the role of data in building and improving crisis services.<br /><br />The transcript mentions the Crisis Response Center (CRC) in Tucson, Arizona, which provides 24/7 access to mental health and substance use care. The CRC operates with a "no wrong door" approach, meaning they accept all individuals in crisis and collaborate with law enforcement for timely drop-off. The CRC includes an urgent care clinic, a 23-hour observation unit, and a short-term subacute inpatient facility. The webinar also focuses on collaborations with law enforcement, including Crisis Intervention Team (CIT) training and specialized units such as the Mental Health Support Team (MIST).<br /><br />The transcript emphasizes the use of data to improve crisis care, including the development of metrics and performance targets. The Familiar Faces Plan identifies high-utilizers and convenes multi-agency team meetings to discuss their needs. The partnership between the CRC and the Regional Behavioral Health Authority allows for real-time data analysis and system improvements. The transcript concludes with key lessons learned, including the importance of least restrictive crisis stabilization, governance and payment structures, a data-driven and values-based approach, collaboration, and a culture of "no wrong door" and saying "yes" to patient needs. The transcript also mentions the opportunity for site visits through the Department of Justice's learning sites program.<br /><br />Note: The transcript has been summarized for clarity and brevity.
Keywords
Creating and Sustaining High-Quality Crisis Services
Systemic Approach
Dr. Margie Balfour
SMI Advisor program
Serious Mental Illness
Crisis Response Center
Tucson, Arizona
Collaboration with law enforcement
Data-driven crisis care
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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