Elements of the continuum

CRISIS CENTER OR CRISIS HUB

In an ideal system, there needs to be a secure physical location (crisis center) that provides a place for people in behavioral health crisis to go or be brought by law enforcement or other first responders that is an alternative to going to an ER or to jail. In some communities, this location may also represent a crisis hub and function as the centerpiece for coordination of all the crisis services provided in the community. In other communities, the crisis coordination or hub function may be assigned to a crisis call center which may operate at another location and/or may coordinate multiple crisis centers (as in a large urban area). The crisis center - which may also be called a crisis access center, crisis response center or other term - is the ideal system go-to location for 24/7 behavioral health crisis response and crisis system coordination in most communities. In some communities, the current crisis center is an adaptation of an ER-based psychiatric emergency service, such as an EmPATH model.

Although these can be very effective – and certainly better than not having such services – it is generally recommended to have crisis centers that are not based in hospital ERs and to have psychiatric capacity in ERs as well (see Psychiatric Emergency Services in Role of Hospitals in Crisis Services for more information).

This is a culture change. If individuals in behavioral health crisis are taken to, or advised to go to hospital ERs, hospitals are seen as the appropriate places for these issues to be addressed. If there is another community entity responsible for where the vast majority of people in behavioral health crisis are brought that also coordinates access to a complete continuum of services and has dedicated resources that allow for high quality medical triage and ambulatory intervention, mental health and/or substance use disorder evaluation, observation, initiation of treatment and connection with community-based resources, the system culture shifts dramatically to a different and more efficient and effective conceptualization of how to respond to people experiencing a behavioral health crisis.

While the evidence base regarding the effectiveness of specific non-hospital based crisis services remains limited, available studies demonstrate reductions in hospital admissions, as well as short- and longer-term subjective and objective improvements in mental state, favorable client satisfaction and reductions in family/natural support burden relative to hospital-based services (Lloyd-Evans, 2009; Murphy, 2015).

When calling a behavioral health service provider, it is extremely common to hear a voicemail that says something like, “If this is an emergency, proceed to the nearest emergency room.” In many, if not most, communities, hospital ERs remain the most common “front doors” to behavioral health services. Unfortunately, they often lack the capacity to make the most appropriate linkages to effective community services and supports, and as soon as one walks through that front door, their likelihood of being hospitalized goes up enormously.

There is a vital role for both ERs and inpatient hospitalization within the crisis services continuum, typically for those with high acuity and/or imminent dangerousness. In the absence of a full array of crisis services, those beds are often unavailable to those who need them most, as they are often utilized by patients who could be safely served in less restrictive settings. This results in long waits and boarding in emergency rooms, (Nordstrom, 2019; Schwartz, 2016) often without initiation of optimal treatment and/or transport to other hospitals that may be far from the person’s community and natural supports.

This is another culture change. If individuals in behavioral health crisis are taken to, or advised to go to hospital ERs, hospitals are seen as the appropriate places for these issues to be addressed. The system culture can shift dramatically if another community entity is responsible for caring for the vast majority of people in behavioral health crisis that also coordinates access to a complete continuum of services and has dedicated resources that allow for high quality medical triage and ambulatory intervention, mental health and/or substance use disorder evaluation, observation, initiation of treatment and connection with community-based resources. This model represents a more efficient and effective conceptualization of how to respond to people experiencing behavioral health crisis.

In most larger communities, the ideal crisis center is a freestanding 24/7 entity that may or may not be proximal to other 24-hour locations, such as ERs or police stations. The nature of the crisis center may vary depending on the type of community. In some communities, crisis centers will serve both children and adults; in other communities, there may be separate settings for children and adults. In some smaller communities, the freestanding crisis center may be open for less than 24 hours and because of low volume of need, coverage is provided through mobile crisis support and/or telemedicine – possibly from a regional crisis hub – at a local ER during the night shift. In more remote systems, a regional crisis hub may project services through telehealth to locations that serve multiple functions. As previously noted, in some communities many of the components of the crisis continuum, including crisis care coordination, are located within the crisis hub location; in other communities, most of those components are located elsewhere and/or operated by different provider organizations.

Finally, there can be different arrangements for providing crisis coordination for the crisis system – in this report, it is termed the “hub function.” While it is common and convenient for the crisis coordination function and the individual role of the crisis coordinator to be co-located and conjoined with the crisis center, those functions can be physically separate in some communities, and may be provided by different contracted agencies. This might be relevant, for example, in a large urban county in which there are four regional crisis centers, each one provided by a different vendor and coordinated through a hub that is provided by either the accountable entity directly or by another vendor to avoid bias or conflict of interest. This might also be relevant in a rural region where clients and services are geographically spread and the hub function is designed to coordinate across multiple small crisis centers that in turn coordinate services in their own geographies, but none is large enough to serve as a regional service hub or access center in its own right.

Regardless of the relationship among the different components of the continuum, the core secure crisis center function is an important centerpiece of the total continuum with characteristics described in this report.

With the exception of a requirement for operating a non-hospital secure facility, the functions of a crisis center related to 24-hour access and response are all certification requirements for CCBHCs. Those CCBHCs without non-hospital secure crisis centers may collaborate to provide these services through relationships with medical emergency rooms, first responders and other community partners.

Measurable Criteria for an Ideal System

The accountable entity works with its community crisis collaborative to design, implement and finance one or more secure non-hospital crisis centers that serve its region in accordance with network adequacy and geographic access standards (see “Accountability and Finance”), the crisis centers are adequately staffed (see “Adequate Multidisciplinary Staffing”) and provide the following minimum array of services, either directly or through telehealth, as appropriate:

• 24/7 telephone access.
• 24/7 walk-in services.
• 24/7 access for first responders, including for clients are who brought in on involuntary status.
• Medical triage, screening and intervention for individuals without emergent medical concerns.
• Assessment, intervention, care coordination and disposition for individuals of designated ages with any combination of behavioral health concerns.
• Capacity for extended evaluation and continuing observation. National Council for Behavioral Health 91
• Access to emergent psychiatric intervention and initiation of MAT for addiction.
• Access to peer-support workers to provide outreach and engagement.

The accountable entity identifies one or more crisis centers or, in some instances, an independent vendor in a separate location to serve as hubs for the designated community or communities. The hub oversees the functioning of the crisis center services and also oversees and coordinates the activities and services of the full crisis continuum, some of which may be provided on-site as part of the crisis center or housed at the crisis center location, including:

• Crisis coordination for the whole system.
• Crisis call center, including warmline, suicide prevention hotline, 911/988 triage.
• 911 dispatch with capacity to triage calls to 988 and the crisis call center.
• Client tracking and care coordination.
• Mobile crisis teams.
• Co-response teams with first responders.
• Medical screening and intervention and coordination with ERs.
• Telehealth and telepsychiatry consultation to general ERs and other locations.
• 23-hour observation beds.
• Crisis stabilization, crisis residential and peer respite services.
• Crisis/respite housing.
• Substance use disorder stabilization and treatment.
• Psychiatric inpatient services.
• Follow-up clinics.
• Intensive community crisis intervention (individual and team-based services, office-based and home-based services).

The accountable entity ensures that the crisis hub assumes responsibility for coordination and information sharing between the various services, client tracking through the continuum and the collection of relevant data that contributes to performance monitoring of identified quality metrics (see “Quality Metrics”).

The types of services within this continuum have been evolving and expanding in response to the frequent over-reliance on the most costly and restrictive settings, specifically emergency rooms and in-patient hospital units (Allen, 2002 and Substance Abuse and Mental Health Services Administration [SAMHSA] Crisis Services, 2014).

The following sections represent the core elements of the array of crisis services that have been shown to be both clinically- and cost-effective and should be available to all individuals within a community (TAC, 2005; Pinals, 2017; Lloyd- Evans, 2009) Any missing component along the continuum logically leads to an over-reliance on the next, more resource intensive service.