Transcript
Patagonia Health 0:05
Hello everyone. Good afternoon, good morning, wherever you are joining from, and welcome to today's Health Solutions webinar hosted by Patagonia Health. Today's webinar topic is 988, and national trends in behavioral health, crisis care. My name is Dayna Riddle, and I will be your moderator for today. You can go ahead and change the slide
Patagonia Health 0:38
Thanks. If you are not familiar with the GoToWebinar platform, look for the communications box on the right-hand side of your screen. All attendees will be muted throughout the presentation. This box is your way of letting us know if you have a question. The arrow in the little red box at the top of this communications box allows you to shrink or expand the box as necessary. If you have any questions during the presentation, please enter them into the Questions field in this box, and we will address them at the end of the presentation and change the slide.
Patagonia Health 1:15
Our presenter today is Margie Balfour. She is the chief of quality and clinical innovations at Connections Health Solutions. Dr Balfour is a psychiatrist and national leader in quality improvement and behavioral health crisis care. She is chief of quality and clinical innovation, like I said, and an associate Professor of Psychiatry at the University of Arizona. Dr Belfer was named Doctor of the Year by the National Council for Behavioral Health for her work at the Crisis Response Center in Tucson, and received the Tucson Police Department's Medal of Honor for helping law enforcement better serve people with mental illness. We are so happy to have her join us to share expertise and knowledge on behavioral health crisis care. I'm going to turn over the presentation to you, Dr Belfer, but I will be back with everyone at the end to help address your questions.
Margie Balfour 2:09
Well, thanks for having me. And so we're going to be talking about crisis care today. And really, the goal I like memes. If you know me, you know I like memes. And yeah, our goal is we're trying to get to like what's depicted here, which is, you know, the idea that we used to call police for mental health care just seems like something so ridiculous that people don't even believe it used to be true. And, you know, and right now, the current state in most communities is, if you have a medical emergency, you call 911,
Margie Balfour 2:43
And you get an ambulance, and someone comes who's trained to deal with your issue. They take you to an emergency room that's staffed with people who know how to take care of you if you need to get your if you need to be admitted to have more care. There's usually a bed upstairs for you in the same hospital, but if you have a mental health emergency, then you get the police, and that just automatically sets up things for some really bad outcomes. A quarter of officer-involved shootings are linked to a mental health emergency. Half of those occur in the person's own home. So it's, you know, people presumably asking for help. When you factor in race, you see even more disparities where black Americans are the highest at risk of being killed in a police encounter with mental illness. If people survive that encounter, then oftentimes, people end up in jail. Officers are getting more and more training on how to deal with mental illness, and they're told to de-escalate people and then divert them to treatment. But their first question is, often, we'll divert to what? Oftentimes, they take them to the ER. They have to wait there for hours and hours, and the path of least resistance, if there's nowhere else to take people, is jail. And so that's why the prevalence of mental illness in our jails and prisons is much higher of that in the general population. And there's sometimes this myth too, that, Oh, well, people will get the care they need in jail. Well, that's really not what they get. Actually, very few people get the treatment that they need. What they do get is they're incarcerated twice as long, at twice the cost, more likely to be assaulted when they come out, having lost their job, lost their housing, and then more likely to be rearrested. So that's not good, and the emergency room is not that great either.
Most ERs don't have any psychiatric services available, which sometimes is kind of mind-boggling. It's not like ers can go, well, we don't like those diabetic patients. We're just not going to do diabetes. But that's what happens in our ers. And without treatment, oftentimes, if there's no way to stabilize the person in the ER, they get put on a list to be transferred out to a hospital somewhere else, and people can wait for hours, or sometimes even days, waiting to be transferred. And so that puts the patients at risk. It puts the staff at risk. It costs a lot. It's just a bad experience. So we need to do something better. One model for trying to decrease this justice involvement. It's called the sequential intercept model, where the idea is if you can trace the path that people flow through the justice system.
Starts with a police encounter, 911, an arrest, being booked into jail, your initial appearance, etc. And the idea is that there are points along that pathway where the mental health system can intercept that person and keep them from going further and one intercept is at the point of the law enforcement contact. But it was recognized, actually, from a lot of work that was done right here in Pima County, where I'm at in Tucson, that if you have a really robust crisis system, you can prevent that law enforcement encounter altogether, and
Margie Balfour 6:04
And right now, the conditions are really right for this huge expansion in crisis care. It's kind of like a perfect storm, in a good way, because the 988, implementation, that's it's kind of like the first 911 call was, was back in 1968 and then in the 70s and 80s, was this huge expansion in the emergency EMS and trauma system that we take for granted. Today, we're kind of in that phase now for for mental health emergencies. And all the states got planning grants with 988 so every state is looking at its crisis system and figuring out, you know, how they need to build it. It's one of the few bipartisan issues, and there's been lots of money. COVID kind of shone a light on on the need for for mental health care, and it's something that people actually agree on. And then with the police reform movement, and there's a lot of stuff that people disagree on, and you know, in that those issues, but one thing pretty much everybody agrees on is that law enforcement doesn't need to be the default first responders for mental health emergency emergencies. And so, um, I was part of an organization that put out the this report called the roadmap to the ideal crisis system that was released by the National Council for mental well being. Where we the timing was, was great, because we've been working on this for a few years, and then it came out just in the middle of all of this, where we laid out, well, what should an ideal crisis system look like? And we made a couple of points that were kind of bold on purpose, which is that an excellent behavioral health crisis system is an essential community service, just like police and fire and EMS. I mean, we don't it shouldn't be something where, well, if we can scrape together some money and move it around, maybe we can fund some services that operate at like certain hours of the day, if it doesn't cost too much, like no one talks about that with medical emergency response, you just expect it, and that the same should be true for mental health and substance use emergencies, and that a crisis is important to have a system, not just a single crisis program. It's a multiple services, just like traumas, multiple different facilities and different services. And you need, you need all of that working together.
Margie Balfour 8:27
We we also talk about different design elements. Like many people, when you talk about crisis, people immediately want to jump to the services, phones, mobile crisis facilities. But we purposely didn't do that. We, we said, well, you if you're going to have a system, you need a structure to make sure that there's accountability and governance. And so that's what we started with. And then then we talk about the services on you layer on top of that, then the clinical practices and the complementary to SAMHSA guidelines that they recently put out as well. Those guidelines focus mostly on that service continuum, where the roadmap really talks about, in addition to that, how a community needs to have to organize its crisis system. And when talking about systems thinking, this really is a key feature. So, you know, this is, this is a Saturn five rocket. It's not the Elon Musk Twitter rocket that blew up. And, you know, it's this complex system. And a lot of times people want you, they want to come visit our crisis center, or they, you know, we're going to focus on one program. And that would be like, you know, that round thing on the right, like, I'm not sure what it is. I think it's a fuel tank. And if you understand, and, you know, get into detail about how that works, you still don't know how to make the whole rocket work. So you need all of these things working together.
Margie Balfour 9:46
The system is more than just a collection of services. It's when they're organized so that they're working together to achieve common goals, where this the system is more than the sum of its parts. And so what we've learned out here in Arizona, which is being looked at as kind of a national model for for what crisis systems can look like. There's kind of three key ingredients that we've learned. The first is accountability. So if you've got a system and you're trying to have you know you're defining common goals, and you want to make sure that you're meeting all those, how, who determines those and how do you hold the different pieces, the providers in the system, accountable to those goals? You need collaboration, and collaboration is good in healthcare in general, but for crisis, it spanned so many different disparate types of services you've got, you've got all the mental health stuff, you've got emergency rooms, you've got police and fire and schools when you're talking about youth. And so you really need a forum for people to to be able to include all those stakeholders and a culture of communication and problem solving, and I like to say, you want the culture to be let's figure out how to say yes, rather than look for reasons to say no, and then data. I'm nerdy. I like data. But if we are talking about common outcomes and achieving common goals, well how do you know if you've achieved those, or how do you know if you're not achieving those and you've got gaps that you need to do quality improvement around. And, you know, and having data to make decisions, so you need all these things. And people are always, you know, people are increasingly looking to Arizona as a model. And so, you know, what is so special about the Arizona system that it's getting all this attention? And it's not just the fact that we have all of our venomous animals.
Margie Balfour 11:40
It's that a lot of the concepts I was just talking about are baked into the structure of how we're financed and organized, and so it kind of illustrates why, how these things are important. So Arizona's, you know, our system is really kind of built in the backbone of Medicaid, and we're an interesting state. We were the last state to ever have Medicaid, and when I first moved here, I was all impressed about all of the great Medicaid we had. And you know the name of the department? I came from Texas, which is not really known for robustly funding Medicaid. And you know, when I came here, the name of the department was called Access. I'm like, that's so cool. It's all about access to care. And then I found out, if you read the tiny type, it stands for Arizona Healthcare Cost Containment System, which was not the nice, warm, fuzzy that I thought it meant, but it actually explains. Why would this, you know, kind of weird Red State out here develop this really robust crisis system, and they were the last state to do Medicaid one till the 80s. It was partially due to a lawsuit around mental illness, and then they to meet the terms of this 30-year settlement, they had to buy into Medicaid to provide those services.
And the story I heard was that the legislature wouldn't pass the bill to do it unless they have the name, like words cause containment, the name of the department. So they did that, and then the first thing they did was apply for a statewide managed care waiver, 1115 waiver, which they were the first state to ever do that. And if you're not a policy walk, what that means is, you go to the government and you say, give me the money that we would norm spend on just doing Medicaid the regular way, which is just, you have an office that just pays claims, give us that money, and we're going to contract it out to a like, usually, like a managed care entity to administer that, this whole system.
And in order to do that, you have to prove that you're going to spend the same amount of money or less, and the outcomes are going to be the same or better than it would be just doing it the default way. So from the very beginning, that means that people had to be thinking of the system, the healthcare system, as a system in terms of costs and outcomes. And the way that it's currently structured is they divide the state the three regions to the north, which is like Flagstaff, Grand Canyon, area Central, which is Phoenix area, Maricopa County, and a couple other counties. And then there's the South, which is where I'm at, in Tucson, Pima County, and then the rest of the South. And they put out a competitive bid, and RFP to be the regional behavior health authority. And then that regional behavioral health authority, or Reba, we call it for short, they contract with all of us, different providers, to actually provide the services. So they are this single point of accountability and governance that you need for organizing a system.
Margie Balfour 14:28
The other kind of innovation is that they braid the funding together. So most states have a Medicaid department, and then they have some other department, like the Department of Behavioral Health, and the in that department gets, like the federal block grants from SAMHSA or in state and local funds for crisis and they usually trickle it down to like some kind of county based or some kind of regional behavior health authority. But those pots of money are separate, and in Arizona, everyone is entitled to crisis services for at least that for. 24 hours, regardless of who your payer is. And so because all of that money is together, we don't have to worry about what the payer source is for someone.
When we see someone, we get paid up front. They're paying for capacity for us to be there, like in the firehouse model, so that whenever someone arrives that we're we're there standing by, and then on the back end, they are able to then look at the services we provided and say, okay, these 500 people had Medicaid, we'll put them in the Medicaid bucket. These 200 people didn't have Medicaid, we'll put them in the federal block grant bucket, etc, so that everyone has so we don't have to worry about that. And you get kind of more efficiency and economies of scale of pooling your money that way and the services that we provide.
One of the reasons why this works is because the clinical goals and the physical goals are very closely aligned. So what I want as a psychiatrist is I want my patients to not be in jail, to not be in the emergency room, to not be locked up involuntarily in the hospital if they don't need to be, and if you're paying for stuff, you want that same thing, because it's a lot less expensive to be doing well on community based care versus in ers and hospitals and jails. So whether you're coming at this from a clinical or social justice or responsible stewardship of taxpayer funds, it makes sense to have this crisis system, and so that's why there's been so much investment in it over the years, because it just makes good clinical and good fiscal sense.
Margie Balfour 16:32
Another way to kind of look at it is that you can think of your services aligned along this continuum of what we like when behavior health, we often talk about the least restrictive setting, the least intrusive setting in the community as much as possible. And those least restrictive settings are like what was just saying are the least costly settings. So you can line your services up along that continuum. And the most community-based thing is to be able to pick up the phone and call somebody. So these are numbers from our southern Arizona crisis system. And in Pima County, which is where I'm at the crisis line, which is now 988, they get about 7000 calls a month, and then they are able to resolve about 80% of those on the phone via telephonic counseling. But also, because we have this overarching, you know, kind of call them our benevolent overlord, sometimes our regional paper Health Authority, they're able to tell all their contracted clinics, well, you have to have crisis appointments. You have to put them in this software that the crisis line has, so that if part of what it takes to resolve your crisis in the middle of the night is to say, well, we have you an appointment for tomorrow at 1130 they can do that for crises that need a higher level of intervention than We have mobile crisis.
So there's about 16 mobile teams that cover Pima County, different numbers of them at different times of the day. A couple different agencies do it, but because it's all coordinated, they all have the same software on the phones and GPS tracking and and all that. And then the crisis line can see where they are, and then they dispatch the one that can respond the fastest, and it's usually, these are clinical only teams, so not law enforcement in these teams, and it's either clinician or a peer or two clinicians, and then they are able to, if they do a face to face intervention in the field, they resolve about 70% of those people who still need a higher level of intervention. We have crisis facilities, and I'll talk about ours in more detail a little bit later. But these facilities are meant as an alternative to the ER and hospitals, where people can, most people, either through or walk in urgent care or through 23 hour observation. When they stay overnight, most people can get their crises resolved and be discharged back out into the community within that 24 hours. And then there are various post-crisis wraparound services. We have a post crisis transition in our Phoenix location, down here in Tucson, there's a peer agency that does post crisis wrap around.
There's various crisis, residential crisis respite for people that are less acute that either the people can access those directly, or sometimes we step down to them after we've stabilized some of the crisis, and then at every point along here, because we're trying to keep people out of the out of the law enforcement and justice system, and there's easy access for them. So the idea is, if it's law enforcement that has the patients we're trying to keep out of jail, then we need to treat them as a preferred customer, and make it easy for them to connect them to care rather than arrest them. Kind of make be the path of least resistance, because they're getting lots of great training, but then we need to make it easy for them to do the right thing. So the crisis line, they have staff that are co located in Tucson, 911, and so they're able to intercept calls right there and resolve, you know, most of them via the phone, but if not, then they can dispatch a mobile team and have it go through this whole clinical pathway and not involve police at all, mobile crisis teams.
So if I have a crisis in my house and I call, you know, they have an hour to get to me. But if police are in the field. Need a mobile team. Their contracts have things written in them that say things like, you have to respond in half that time for law enforcement. So because of this contracting system that we have, you can bake those incentives in, and then the crisis facilities are really geared towards making it easier for police to drop people off there than than to jail. So they have five to 10 we get people out in like five minutes. We never turn law enforcement away. And so you take all of these things together, and they all contribute towards a system with this common goal of keeping people out of jails and ers and hospitals. So now I'm going to kind of go over just sort of some national trends in these kind of basic components of crisis systems. And so first is the someone to call. So these are our crisis contact centers, which is kind of the new term for call center, because now 988 and the call centers, they do more than just phone calls. They do text and chat as well.
Margie Balfour 20:57
And so nine eight eights are new, less, not quite a year old, yet. It was implemented in the mid, mid July last year. It's our new three digit number for behavioral health emergencies. What it does is it replaced the 800 number that you would often see advertised everywhere, that was the National Suicide Prevention Lifeline. And it's different than 911911, is all managed locally. This is like 200 and probably more now call centers all across the country that are part of this network, and then you dial this national number, and then it routes you to the different call centers, and if one of them is too busy and can't take a call, then it will roll over to another one, so that someone always is able to, you know, get the phone answered. Like I said, it does call, text and chat. Now there's national standards that are overseen by SAMHSA, and then they kind of have a single administrator. What was like the organization that was the Lifeline is now been renamed vibrant emotional health, and so you can read more about what all they do on those websites.
But it's also important to note, though, that 988 is just the beginning. So if you look at like all of the crisis calls that are out there, there's a whole lot more. So there's other lines that weren't part of the lifeline. So for example, the crisis line I was just telling you about was not part of the lifeline prior to the 988 thing. So there's all these and lots of places have 211, and 311, that were doing crisis stuff that was not part of the lifeline. So there's all these other lines that have crisis calls. And then if you look at 911 it's estimated, conservatively, that about 10% of 911 calls nationwide could potentially be handled by behavior health. And so you add all that together. And so it's not 3 million calls, which is what 988, kind of started with in a year. It's, it's, could be over 40 million. And so, you know, today we can't imagine 911 with all the response that goes with it. And this 988 is kind of the first step towards starting to have a similar on par with 911 system for for substance use mental health emergencies. So what happens after the call when 988 first launched back in last July, immediately, there was a lot of this social media backlash. And they said, this is some of the you know, post off of Instagram around don't call 988 don't post it. Don't share it. It's not friendly. And what they were talking about is this is because when people sometimes, if you call the lifeline, people are afraid that the police would be sent on you. So you call nine eight, they're going to send the cops on you. And you know what I just showed was all geared towards not sending police.
But the reality is, is what happens when you call 988, at this point is, is dependent on where you live. So the lifeline and vibrant quickly put out some data when the social media stuff was happening, they quickly put out some data to try to counter that. And if you look nationwide, only about 2% of lifeline calls activate 911, to do an act of rescue because they're afraid of a threat to life, and half of those are with that caller, consenting to it. But that's that's nationwide averages. What happens in your local community is very dependent on the options that you have. So if you have mobile teams and crisis services like that, then it's much less likely that there's going to be a police response, because there are all these alternatives. But if a community doesn't have anything else, then they may have to resort to police more often. So that's one of the other reasons why it's really important to start building out these crisis services the 90. Eight and call centers and 911 call centers, which are called Public Safety Answer Points or PSAPs. All across the country, there's like, 9000 911, centers, and they all operate.
They have national standards, but they still have locally, like, there's a lot of variation in how they they do things that they're urban versus rural, and just all these different variations. And so local crisis lines, 988, lines and PSAPs, they're really, over this last couple of years, have been experimenting on how can they be integrated. And there are some models that where it's just coordinated, coordinated, where there's like a kind of a back door line, where 911 can send a behavior health call. Some are co located, where they're staff that are on site, where they're helping identify calls that need to be transferred to an off site, 988, center, and all the way to integrate it, which is what Tucson does, where there's crisis line staff in 911 that has full access to their system, and also full access to the crisis line and mobile team dispatching system. And the goal is to get it where we have what we call a health first response, which is, whenever possible, you're sending clinical staff and not law enforcement staff to these emergencies. Okay, so someone to respond.
So mobile teams, there's lots of different models for mobile teams. And again, it's sort of like, sort of the theme is that the whole field is kind of still experimenting. Then different communities are at different levels of development. Have different needs, rural and urban, and, you know, all these different different populations, tribal nations. So, so right now, like there's a lot of variation, and in the types of teams that are out there, this is a survey that was done, and also, too, a lot of this stuff is one of the reasons there's so much variation is because crisis services, for so long, it's mostly funded by this at the state level, either by Medicaid or local funds. So there's not like these overarching national standards or even national data. So a couple of colleagues of mine, Matt Goldman and Preston looper, did the first ever survey of trying to figure out, like nationwide, what's the landscape look like for mobile teams. And so I kind of represented the different composition with M and M's. This was before M M's, all of a sudden, got controversial, but you've got, most commonly, you see these clinic clinician only mobile teams, which you've got a licensed clinician and unlicensed clinician, or a clinician and a peer. In rural areas, sometimes there are person teams that have, maybe some kind of have iPads with, like a, like a telemed backup type thing. Then there's co responder teams.
The CO responder is a clinician plus some kind of first responder. Sometimes that's law enforcement. Sometimes it can be EMS or fire as well. And then there's multi-disciplinary teams, which have all three like so you have a clinician and a paramedic or an EMT and police as far as well. Like, which is better? Or how do you choose a model? And we really need more research and and also. And it's not just like, Well, which one is, quote, more effective, but which one works better in different pop in different communities as well. A big question is the role of police. So studies show, when they've done studies that clinician only, mobile teams do decrease hospitalization and Ed utilization, and they're cost effective. Outcome studies with the police co responders are mixed. So some show show good outcomes, some show no difference. A lot of that is just because, I mean, we just, we just need more studies. And then in qualitative studies, though, where they ask people like, what do you prefer? Most people say they prefer a clinician only, or a clinician with a co responder team, with a clinician on it to just police only teams and also, I think when you're designing crisis systems, you need to acknowledge that, especially in bipoc communities, there is a long standing and, you know, well founded distrust of 911, police and healthcare systems, one of the strategies for having mobile teams that look more like the community that they're serving is really to bring peers aboard. So these are people with lived experience with mental illness. You look the demographics of most like mobile team clinicians.
You know, it's mostly white, mostly female, and so, you know, bringing in peers is a good way to be recruiting from that community that you serve. So then facilities, so now you need a safe place to go. So this is a quote. I quoted myself. I know that sounds kind of narcissistic, but I did because we recently wrote a paper on this about trying to start to categorize some of. Facilities. And because, like I was saying, a lot of these crisis services are pretty much financed at the state level. They say you've seen one state mental health system. You've seen one state mental health system. Everyone does it differently. If you put 10 people in a room and say, Do you have crisis stabilization units in your state? And they go, yes. And then you go, does that look like they're going to be 10 totally different things. So that term CSU doesn't really mean anything at this point. This is a schematic where I was just trying to make some sense and kind of like come up with some kind of way to start to categorize them.
Margie Balfour 30:37
And there's certain things that all crisis centers should do, you know, they should all do treatment universities, like having just a holding area to wait to send someone else. You know, they should be safe and therapeutic and have peer support, care, coordination, be trauma informed, be able to handle both mental health and substance use. But then there's a lot of variation in how they're licensed. Do they take involuntary what's the acuity the patients that they take? Etc. So they try to start to categorize them in terms of the acuity of the people that they see and the intensity of the program of the services. So, you know, on the on the left side is kind of like the level one trauma center for for crisis facilities. So these would take people who are involuntary, danger to self, danger to others, agitated, intoxicated and withdrawal. And then, if you're familiar with the locus, it's a level of care utilization system. It's like a it's like the ASAM for behavioral health. And then, you know, there's the ASAM, which talks about how much it really comes down to how much medical nursing involvement you have, and what are your safety standards? So at the very left over here is the kind of your level one trauma center that has hospital level safety standards, staff, 24/7 by psychiatrists, nurse practitioners, nurses, etc, and able to do medically supervised detox. And so our facility kind of fits over here. On the other end of the spectrum, you have low acuity, low intensity.
So these are people who mostly need engagement. Maybe need a little structured environment, a safe place to stay overnight, staffed mostly by peers, not much medical or nursing, if at all. Or maybe they have someone on call, and that's hugely important too, because if people really need that level of care, it's overkill to bring them to one of these high acuity facilities. And also they may not want to, you know, it's not that they may not be in the environment they want to be in if they don't need that. And so then they may wait until their crisis gets worse if they don't have a lower acuity option. So that's really important. The problem is these ones in the middle, where there's just so much variation, and it's really important to have a clear understanding of what the capabilities of each facility in your local area are. What are the admission criteria? Who can they take? Who can they safely take care of? Because otherwise, you may have mismatches where you're sending someone there who can't safely be taken care of, or there are all these disputes and fights over who should take whom. So our facility is a good example of that, that category on the left, kind of like the level one trauma center for crisis, and it was built with Pima County bond funds back in 2011, the county owns the building. They lease it to the Reba for $1 a year. And then all of the cert, which is like the best rent ever, and then all the services, though, are funded via that Medicaid system with the braided funding that I showed before. And that's important, because a lot of communities are now starting to want to build crisis centers, and they're wondering how they're going to pay for it. And this is another one of these kinds of parity things. Like, we don't go, well, where in the county budget or the city budget, can we take money away from the police or some other municipal thing so we can take care of these heart attack patients? Like, you know, you don't hear people talk like that. That just sounds, you know, ridiculous. We expect the health care system to finance health care, and the same is true for behavioral health, that is, health care.
And so the money, that's why it's sustainable, is because the funding is coming via the health care system. The county just had to. They built us a beautiful building, and then they maintain it. We serve about 12,000 adults and 2400 kids per year. There are a couple of different levels of care. So we have for both adults and kids separately, 24/7 urgent care, where anyone can walk in be like a new to town, need to be connected to services, need a med refill, things like that, where people are typically in and out within a couple hours, kind of one and done. Then we have our 23-hour observation unit, which I'll talk about in more detail. And then for people who need to stay a little bit longer, we have it. For adults, we have a sub-acute inpatient unit, and it's part of this cool campus. It's adjacent to the crisis line, so there's space for that in there. It's next to the county hospital. So there's a breezeway that connects over to the emergency. The room that's run by a different organization is run by Banner University of Arizona. And then the bond also built a 66-bed inpatient hospital that is also run by the university, and that's where mostly involuntary civil commitments go.
And there's a mental health court right there, too. But you don't need all that. We have a very similar facility in Phoenix that, you know, is not next to an ER, but, you know, we have protocols to send people to the ER if we need to. What are the things that make this work, you know, I was mentioning that kind of like divert to what question. And many of you may have heard of CIT crisis intervention training. It's the training that law enforcement gets. It's like becoming the gold standard for how law enforcement should train their officers around mental health. It's a 40-hour training, and it teaches people how to recognize mental illness, how to de-escalate. Involves a lot of people from the community coming in to do the training, but the people it's creators, continue to remind people that it's not CIT is not just the training, it's a whole community response to people in crisis, and part of that response is having a place for officers to bring people so that it's easy for them to do the right thing and use their training. And if you dig up the original CIT manifesto from the 80s. It lists out what this ideal, what they call a receiving center, looks like. And I highlighted the two in the middle because that's what we see when we go around the country. Those are the hardest to do well, the no clinical barriers to care, and the minimal turnaround time. And what this means is you need to be easier to use than jail. You drop off time is less than 10 minutes, and then never turn police away, which means taking everyone, so a lot of behavioral health. Sometimes we get a reputation where it's easier to get into heaven than access to a mental health facility.
And so our goal is not to be like that. So we want you to like, instead of like, saying, well, you're too agitated, you're too violent, you're too intoxicated, you're too you know, whatever. We want those high acuity people, because they are the people who are most in need of specialized care. You know, they're the ones that you want not to be in the ER. And so they can be highly intoxicated, they can be violent, they can be involuntary or voluntary. And we do all this without using security guards, because our philosophy there is, if we're going to train our staff when we train them a lot, and so they're the experts on de-escalation. So why would we default to somebody with less training when we get someone who was highly acute? Another thing that makes law enforcement want to use this kind of service is quick and easy access for them. So they have their own entrance. What officers don't like is waiting. They don't like being turned away. They also don't like taking their guns off and parading people through the front lobby in handcuffs and stuff. So they have their own, and we have a secure sally port that locks behind them.
They have their own office where they can do all their paperwork in the restroom and some refreshments so they don't have to go wandering around the building while our staff asked them about taking their guns off. And this is our study that was done by the Vera Institute of Justice that showed in Tucson, that showed that people with for mental health calls their officers were less likely to arrest people, and when they did the qualitative part of the study, the officers attributed that to having a place like the CRC where they can drop people off on the observation units.
So this is our youth observation unit, and it has chairs and an open area. The reason why it's open is for a few reasons. One is, if it's you're trying to keep people safe, then you want to be able to continuously observe people. So having the open area versus like individual rooms, like you would have in an ER, helps us do that. Also, because in an ER, if you go there for mental health, they put you in a room by yourself. They take all the stuff out of it, the higher sitter to watch you is not supposed to talk to you, and then you spend all that time, hours, sometimes days, just in isolation, which is not therapeutic. And we know in behavioral health, that's why psych units today have that kind of living room area in it, that social interaction has therapeutic value.
So there's stuff going on, there are groups that our peers are running, and patients can talk to each other, and staff and patients are interacting, and our peers are interacting with them. So, you know, there's therapeutic activity going on, and then flexibility, so we never are full for the police. So if we get surges in volume, then having it be open allows us to accommodate those surges like that. And as far as what happens. So we have an interdisciplinary team. We have 24/7 coverage with our psychiatric providers, peers, nurses, techs, and case managers, and we start with this assumption. We don't go. Oh, you're really sick. We need to look for an inpatient bed for you. We go, oh, you need to be in the office. Conservation unit. Now we're going to try to resolve your crisis, and then we'll start treatment early. We can start meds. We can, like I said, we can do a detox. We can start Suboxone, we do groups and peer support, and then at some point
Margie Balfour 40:14
within that 24 hours, we reassess them, and if they're getting better, then we continue on with with getting them connected to the services they need in the community, only if they're not better, then we start looking for them an inpatient bed, and so we're able to discharge most to community based care. We also look at what percent start off involuntarily, that we're able to engage in involuntary services too, because that's the Least Restrictive thing, substance use. We, we, we have a lot of substance use as well. If you look at our data, about 15% come in saying, I'm here for a substance use issue, but about two thirds actually have a substance use diagnosis or tox results, and it's mostly meth followed by alcohol, you know. And it's just really important, like mental health and substance use services should be integrated, and you should this kind of illustrates how you should expect that people have a co-occurring substance use and have the ability to deal with that as well.
So then law enforcement, they're a huge partner of ours, and we're very fortunate, especially down here in Tucson, because we have a very progressive police department. But all around the country, officers and police departments are recognizing that there needs to be a better way. They need to collaborate with the mental health system to get people into care, because, like, one kind of common adage is, you know, you can't arrest your way out of this problem of them interfacing with people with mental illnesses they're not well equipped to. So Tucson Police follows the recommendations by the National Council and CIT, where CIT is more effective when it's voluntary, where officers who want to take it, versus being voluntold. But all officers get basic Mental Health First Aid training, which is eight hours. And then most of their officers have the 40-hour CIT training. Then they have some specialized units that get more advanced training, like motivational interviewing and trauma-informed care.
This is kind of what you hear a lot about CO responders. And in our system, we've moved towards talking about a collaborative response, because the more options you have. It's not necessarily a co-response; it's collaboration. And if you look at the circle at the top, if you think about crisis, this is kind of how we organize our response, there's acute, there's the acute crisis, which is a discrete event where there needs to be de-escalation intervention. It's high urgency. But then, after the crisis, as the crisis resolves, you need to make sure that people are getting connected. And then as the crisis develops, there's an opportunity for outreach to make sure that you know, you get people connected to care early, maybe it doesn't evolve into this acute crisis. And so you need to pay attention to both sides of the cycle to keep it from continuing. And so if you look over in the orange side again, we want to do a health first response. So we don't want to send the police unless absolutely necessary. And so, if there's no safety risk, then it should be completely the responsibility of the mental health system to deal with these crises. So that's where the crisis line, the mobile teams, and the facilities come into play. If there is a safety risk, then there are multiple different options to collaborate based on the needs of that situation. Sometimes, the fastest thing is to recognize, you know, at the point of the 911 call, this is mental health, they're going to need to go to the CRC and just send a CIT trained officer sometimes, yeah, like, if there's someone where the police are supposed to pick them up and they won't come out of their house and they're suicidal, you know, sending the mobile team out to assist the police there.
And then, when you look at the blue part, this is your outreach and your follow-up that's less urgent, and usually multiple touches, if there's no safety or criminal risk, again, it should be completely the responsibility of the mental health system. Our Reba here in Tucson has what they call Second responders to do some of that follow-up, like peer wrap-around services, things like that, and then. But if there is some kind of safety or criminal component, then that's where CO responder, peer co responders, we've used those a lot in our system, where they follow up after overdoses or after they've they have the discretion to not arrest people for substance use, and they follow up with those if there's cases of public safety risks, like threats of shootings and things like that. And they also have a homeless outreach team, and all of those teams have an officer and appear with them. I'm going to skip that in the interest of time, so there's time for. They do questions well, briefly. So their specialty teams, those are plainclothes officers, and so you know that helps to de-escalate people in unmarked cars. And then they have their detectives that are looking at people falling through the cracks to get them connected to the mental health system, rather than it escalating to something that has to go through the criminal system. So they're trying to prevent criminal system involvement in some of their outcomes. So this is our law enforcement drop-offs with the youth is green, and then the adults are blue, and then the turnaround times are in orange. And so you see, we're getting people out in five minutes or less.
The light blue bars are people who are volunteers. Most of the time when police drop people off in most communities, it's usually on whatever your involuntary hold is, but Tucson Police, it's a testament to how, how much they've bought into being able to handle mental health issues is that they actually are able to engage with people and have them, you know, come voluntarily to the crisis center. If you look at these, they are like the things that tend to land people with mental illness in jail, or what are called nuisance calls, or lifestyle crimes, things like drinking in public, vagrancy, which I'm still not sure what that is. We're working with a group in Ohio. They have aggressive jaywalking. But these are the, you know, these things, these low-level things that people tend to get arrested for with mental illness. You can see those have gone down. They used to call when someone had to get, you know, I was mentioning before, have to bring someone in because there's an involuntary pickup order, and they're suicidal.
And you go to the house, you knock on the door, and then they say, No, I'm not coming out. That's technically a barricaded suicidal person, which in many cities, the default response to that is to call the SWAT team out, which my my my police buddy says that if they're not coming out first two plainclothes guys, they're not coming out for 30 guys in a tank. So it doesn't make any sense. So instead, they work with the mobile teams and those specialty teams to try to talk the person out. And you can see the cost savings on that. You know, this justifies another thing that justifies taking this approach. This is the program where the peer is with the officer, where they do a deflection if people have substances, they do what they call a deflection, which is that they don't arrest them, and they try to connect them to care instead. And their data shows that most people, like up to 70%, accept that deflection, and the officers actually prefer it, because it's faster to do a deflection than to arrest them. This is some data showing the kind of return on investment. This is from the Phoenix system, and it looks at savings in terms of both the inpatient care the emergency room costs, and also in the years of psychiatric boarding, but also, if you look at the time, instead of officers spending all their time waiting around in emergency rooms, you can calculate that out to FTE of police back on the street. And this is from Arizona Medicaid, showing the return on investment of what they've invested in crisis services, which they see as a $370 million return on investment. One thing to note, though, is that there's really no contribution from Medicare or commercial insurance. So people go through this whole system, and if you have you know, like your private insurance, ultimately crisis services end up getting paid out of the indigent care bucket, because private insurance doesn't pay for crisis so there's some bills in Congress that are floating around to require all health insurance to pay for these services. You should tell your congresspeople to do that.
Margie Balfour 48:48
And then, just to wrap up with, is there a group that wrote the roadmap to the ideal crisis system that report we recently put out, really brief, like a five-page brief on quality measurement and crisis services? And we thought, rather than just a prescriptive list of measures, that wouldn't really be helpful, because communities are all in just different developmental phases of where they are with the crisis services. So, rather than that, we talked more about approaches to developing measures, and we talked about a kind of conventional framework where you map how the person goes through the crisis system. You know, from being identified to triage to having, you know, be admitted somewhere, to having a crisis intervention, to be discharged. And you know, you can, you can create measures that reflect whether each of these steps occurs the way it needs to occur. And then we also should do an alternative, what we call a person-centered approach, where we came up with a nifty little acronym that spells access to help, but you talk about what your system values are? So, for example, we talked about the least restrictive, least intrusive. So like that schematic I showed before, where every single service, every single component. Own. It is measuring something that reflects that, like, what percent do we resolve without sending on to a higher level of care, for example? And then, just to finish, I talked a lot about the Tucson system as an example, and it didn't happen overnight. It took 20 years to build that. You can see that in recent years, there's been exponential growth. But you have to start somewhere. Everyone has to start somewhere. And, you know, really started 20 years ago, which is one mental health court and CIT program, and it kind of took off from there. So with that, and you're welcome to have copies of these slides now, some links for some, you know, other resources, but happy to take questions.
Patagonia Health 50:41
Thank you so much. Yeah, as a reminder, feel free to use the chat button or the Questions button to ask a question. Someone did ask about if there would be a recording of this presentation. Yes, there will be. We will send that to you a few days after and also, like Marjorie said, a copy of the slides as well. There's a lot of great information in here, so feel free to browse through that and all of the links that she's graciously provided for us. Just a few questions, at least on our end, is, you know, Tucson is such a great example, and if you aren't living in Tucson, how do you how do you know if you are referring patients or clients to 988, if there is a center in their area that that will take will take them.
Margie Balfour 51:35
So in that roadmap, there is sort of a self-assessment tool for communities to start to look at, where are we in terms of crisis, like, where are we in terms of having that oversight and collaboration? Where are we in terms of our services and things like that? And that was really meant to help communities get together and spark discussion. And so if you really encourage, if communities are working on the crisis, the system is just, first of all, just getting together and getting people at the table to start talking about this and mapping out what exists. I was recently, last week, I was giving a talk in Wisconsin to the state that a state crisis conference there, and there were people from this one county that came up to me afterwards, and they were like, you know, I was like, you know, they were, they broke out in their accounting groups and, and this one guy was like, Yeah. And I was talking about how we don't have this, we don't have that. And then, you know, someone else was there, well, actually, we do have that and, you know, so just from meeting people and learning what exists is, you know, that's the first place to start, and that doesn't cost anything. It's really mapping out the system and then figuring out ways to make sure that there are ways for people to communicate.
Patagonia Health 53:00
for sure. Thanks. Another question we have is, do you all ever run into staffing issues or shortages of folks with a behavioral health background or training?
Margie Balfour 53:09
Yeah, I mean, like everywhere, yeah, everywhere is having staffing issues. And so, you know, we're no, you know, stranger to that. And so we, I think we, like everybody else, are looking at ways to recruit, ways to retain. We recently started our own peer certification program. So most states for peers, like, there's a state certification so that they can bill and, you know, be reimbursed for all the services and stuff. And you know, we were finding it was hard to get people in. There were wait lists and things like that. And plus, you know, those programs weren't really geared towards being a peer in a crisis setting. So we created and got it approved by the state to be able to train people ourselves, so that also allows us to recruit people who don't already have the certification help them get the certification we've been working on, you know, creating more of career ladders, so that, you know, people start off in one position, but then there's, there's the ability to elevate versus leave if they feel like they need to, to, you know, advance so, you know, no different, I think, than everybody else,
Patagonia Health 54:17
Those are good tips. You talked a little bit about holding providers accountable, and maybe, like, some decision data, data-driven decision making, things like that. Can you talk a little bit more about that, and kind of where you're finding this data? How are you applying the data to making decisions, things like that?
Margie Balfour 54:33
Sure, so, you know, so we have, we've kind of create, like, we've defined our sort of set of metrics, which is some of the I think they're in, they're referenced in the roadmap report where and then our regional behavior health authority base basically adopted that framework, and so all the crisis centers under them are using those similar metrics. So that's one thing too, is to have. We want to be on the same page. One thing we've also done is we, you know, collaborate closely with our regional Behavioral Health Authority. That's why, you know, saying they're like our benevolent overlords, and they want to manage the whole system. And you know, they want people, you know, they want it to be working well and not have people in crisis. If you think about it, every crisis is kind of like a root cause for someone not getting their needs met in the community.
And so we've worked with them to help kind of harness crisis data to use that to look for gaps, and for them, since they're basically like an insurance company, their data comes mostly from claims, and so at best, they're looking 90 days back in the past from claims. And so we worked out a program with them where we were sending them, like, daily data feeds of who's coming through, and then they're able to analyze that data. And kind of, you know, like, for example, we can say, well, you know, these are all the people who came through, and these are the clinics they were attached to. But we don't know, like, how many total people the clinic has, so we don't have a denominator. Is that, like, 1% of all of their people, or is that 10% and so they're able to use, you know, the data, they have to be able to analyze that and look for outliers and say, Oh, this clinic maybe they need some help, because a disproportionate percentage of their members are ending up in crisis.
We did a project with our youth unit where we looked at what schools, when the mobile teams were being dispatched, and when people were calling 911, from the schools, and the police were bringing them from the schools. And so we looked to see where they're with them. You know, we fed them that data, and they analyzed it to see whether outlier schools, and then they were able to target some in-school services on certain days for those schools. So that's kind of an example of how you can you can look at all of that data to identify gaps and improve services.
Patagonia Health 56:55
Great. Thank you. Somebody mentioned a grant that is being used to reimburse crisis services for individuals not covered by Medicaid. Can you repeat the name of that grant?
Margie Balfour 57:05
Well, those, every state gets what they call a block grant. So it's not like a grant you apply to. It's like, it's the way that SAMHSA, which is the administration, the federal administration that funds mental health that you know, outside of Medicaid, they every state gets a Mental Health Block Grant and substance use block grant, and then the states have a lot of discretion on how they use those funds. And so what Arizona has done with it in terms of crisis, is, sorry, is that if you're not Medicaid eligible, then those funds can often be used to fund the crisis services for those people.
