The Crisis Roadmap
Crisis Continuum
Values-Based System and Program Design
Measurable Criteria for an Ideal System
Services Address The Continuum of the Crisis Experience
Creating Safe Spaces That Are Warm, Welcoming and Therapeutic
Measurable Criteria for an Ideal Crisis Space
Safety and Security Practices That are Both Safe and Welcoming
Measurable Criteria for Safety and Security Practices That are Both Safe and Welcoming in an Idea System
Treat Law Enforcement as a Preferred Customer
Measurable Criteria for an Idea Crisis Continuum That Treats Law Enforcement as a Preferred Customer
Crisis Center of Crisis Hub
Call Centers and Crisis Lines
Deployed Crisis-trained Police and First Responders
Medical Triage and Screening
Mobile Crisis
Behavioral Health Urgent Care
Intensive Community-based Continuing Crisis Intervention
23-hour Evaluation and Extended Observation
Residential Crisis Program Continuum
Role of Hospitals in Crisis Services
Transportation and Transport
MOBILE CRISIS
Mobile crisis, working independently or as co-responders with law enforcement, has become established as a necessary element of any ideal crisis continuum. (SAMHSA, 2020). Mobile crisis services are a certification requirement for CCBHCs. In this model, the client is seen in person, where they are (i.e., the help comes to them). Mobile crisis can provide proactive engagement and outreach not only to a wide variety of service settings (e.g., emergency rooms, clinics, housing programs, criminal justice settings), but can also prioritize crisis response to individuals and families in their own homes or even on the streets.
Responsive mobile crisis (conducted without law enforcement as much as possible) makes access to help easier and decreases the likelihood of unnecessary ER visits and arrests. The rapidity of response is critical: help should be able to be on-site within one hour of the request, preferably sooner. The expectation is not that the crisis will be fully resolved by the visit, but that the acuity of the crisis can be de-escalated to the extent that an initial evaluation can be done on-site and a plan can be established for appropriate, short-term follow-up.
Smart Justice Project - Improving The Crisis Continuum In North Texas
In Dallas, Texas, the W.W. Caruth Jr. Foundation at the Communities Foundation of Texas provided a $7 million multiyear grant to fund the Smart Justice Project, a collaborative effort between Meadows Mental Health Policy Institute, the Caruth Foundation, the City of Dallas, Dallas County, Parkland Health and Hospital System and other community stakeholders. The goal of the project was to transform crisis services and improve continuity of care for people in Dallas with mental health needs. It aimed to embed the psychiatric crisis response system within the emergency system response to medical crises; improve identification, assessment, and diversion to community treatment of individuals admitted to the Dallas County Jail; implement a real-time data system to quickly identify individuals with more intensive needs when they present for crisis services and then link them to appropriate care; and expand the continuum of psychiatric services in Dallas County.
Since 2015, the project has made significant progress towards its goals. It expanded assertive community treatment (ACT) and Forensic ACT services in Dallas and established two intervention and treatment programs for those experiencing early psychosis. The project also established a psychiatric extended observation unit at Parkland Hospital and a multidisciplinary team, consisting of a paramedic, law enforcement officer, and mental health professional, that responds to people with mental health needs in crisis in the community (the Rapid Integrated Group Health Team Care or RIGHT Care). In addition, the project helped Dallas County officials and the Dallas County Criminal Justice Department to improve mental health triage processes in the Dallas County Jail. Furthermore, Loopback Analytics (a private company), along with the Dallas-Fort Worth Hospital Council and the North Texas Behavioral Health Authority, created a data analytic platform that notifies in real-time when a potential Smart Justice client enters an ER, which has resulted in nearly 5,600 notifications. The result of these efforts has been the expansion of the crisis care continuum in North Texas.
Given the increasing concern about adverse outcomes resulting from law enforcement involvement in behavioral health crises, reconceptualization of the role law enforcement should play in mobile crisis services is imperative. The mobile crisis team can work in concert with police to minimize risk of aggression and facilitate next steps, support the individual in crisis if the person is able to remain in the community, divert from inpatient hospitalization to less intensive interventions (such as crisis beds) when possible and facilitate non-traumatic, supportive transportation to crisis center or hospital when necessary and appropriate. To maintain people in the community, a critical component of mobile crisis services is its capacity for rapid follow-up and short-term case management to maintain close and frequent contact with the individual while facilitating linkage with appropriate community-based services and supports.
Mobile crisis staff must be trained and skilled in engagement and de-escalation strategies. They also tend to work best in pairs. In many settings, mobile crisis teams are tied to the 911 response system and a mental health mobile crisis worker will go on-site along with a CIT-trained first responder (e.g., law enforcement officers). When traditional 911 responders are not a part of the team, mobile crisis typically requires that the client indicate willingness to accept the on-site visit. It is important, however, that the mobile crisis balances care about entering unsafe situations with a proactive willingness to engage with people in trouble, without creating unnecessary or arbitrary rule that limit the scope and effectiveness of the team (e.g., there is not a rule that precludes a mobile crisis team from visiting someone who may be using substances).
In an ideal crisis system, mobile crisis team coverage is usually available 24/7. However, in some smaller systems, low utilization in certain time slots (e.g., midnight-8 a.m.) may result in limitation of mobile crisis coverage to 16 hours per day.
Measurable Criteria for an Ideal Crisis System
The accountable entity should work in coordination with the community crisis collaborative, the crisis hub and crisis providers to fund and implement adequately staffed mobile crisis team coverage for the community. The mobile crisis team should meet the following criteria:
24/7 coverage with two people and/or co-responder teams.
Clear protocols that guide or limit response to unsafe situations, but do not have arbitrary rules that limit access (e.g., no visits to anyone with active substance use, no visits to anyone with a history of violence and/or no visits to anyone with a medical history).
Clear protocols and metrics for providing mobile crisis response in a full range of locations, such as homes, shelters, schools, housing programs and on the streets.
Capacity to respond to calls within one hour more than 90% of the time.
Close coordination with the crisis hub and all the other components of the crisis continuum: Commonly, mobile crisis base of operations is co-located with the crisis hub.
Staffing includes multidisciplinary team with peers, access to senior clinical back up, and access to psychiatric care providers ideally through telehealth platforms that can be brought to the scene and can also facilitate documentation and communication.
Capacity to perform the following functions in the community:
- Assessment.
- Crisis intervention (including de-escalation and development of crisis plans).
- Supportive counseling.
- Collaboration with families and natural supports.
- Information and referrals (including to community-based mental health services).
- Transportation (directly or indirectly).
IN THE STORY OF MR. Y:
A mobile crisis team would likely have been able to effectively work with Mr. Y and the store owner to resolve his behavioral health crisis.
