One of the important and often overlooked parts of the crisis continuum is how people are transported throughout the experience of a crisis episode. This begins with how an individual finds their way from wherever they are the community when a psychiatric crisis strikes to the first point of in-person treatment and ends with how they are transported to the next destination (e.g., to an inpatient psychiatric unit or back to their home). There are many ways this part of the crisis experience can go well or go poorly. Too frequently, people who reach out for help in a crisis are unnecessarily restrained or even handcuffed in a law enforcement vehicle, often resulting in significant trauma and reluctance to ask for help in the future. Negative transport experiences have a major bearing on how a person perceives the experience of care and of reaching out for help. For this reason, providing welcoming, safe and supportive transportation is an essential service in the ideal crisis system.
The accountable entity working with the community collaborative should establish a comprehensive transportation plan for individuals in behavioral health crisis, both to the crisis center and from the crisis center, as well as between other locations in the continuum as indicated. The plan should focus on the following:
A comprehensive transportation plan in an ideal system maximizes transportation in the least restrictive safe setting and minimize overutilization of law enforcement or EMS for routine transport. The transportation plan includes defined capacity and roles for:
There should be clear standards and decision algorithms around which types of transportation are most appropriate with respect to time and types of psychiatric crises. Attention should be paid to how people are communicated with throughout the process – from first point of contact – with clarity and transparency about what to expect in the process.
There should be a strong message to use the least restrictive form of transportation with particular emphasis on reducing the use of restraint. There are examples of innovative solutions to solve for this issue, including use of specialty mental health transportation services to replace law enforcement transportation which have resulted in the reduction or elimination of restraint. These solutions require significant coordination and communication between public and private entities and are dependent on strong vision and strong leadership.
In rural East Texas, a multi-county collaboration coordinated by Burke Center in Lufkin developed a plan by which off-duty or retired law enforcement officers could transport non-violent individuals to the crisis center (with payment and liability coverage) in lieu of either expensive ambulance or on-duty law enforcement being used for transport.
Because in most instances, transportation is not paid by insurance, the accountable entity and crisis coordinator need to work with the community collaborative to develop a plan for payment of a full range of transportation services. This requires recognizing the value of saving time for law enforcement and avoiding over-utilization of expensive ambulance services. In addition, the crisis hub/crisis coordinator needs the ability to authorize transportation funds 24/7, when indicated, to ensure that individuals get to or from the crisis center to the crisis bed or hospital.
EMS systems often manage a range of transportation options of different cost levels, not just ambulances. EMTs are commonly underutilized as first responders and have much more capacity than law enforcement, given their training in making protocol-based medical decisions under pressure and in crises. With adequate resource support, they would be better positioned than law enforcement to be first contact for someone in psychiatric crisis. Further, it is essential to pursue current efforts to change insurance requirements, including CMS regulations, to permit EMS to transport patients to crisis centers and not just to ERs to reduce unnecessary ER visits simply to comply with regulation and provide clients what they need. The recently announced Emergency Triage, Treat and Transport model demonstration in Medicare is an example of this more flexible approach. Emergency Triage, Treat, and Transport (ET3) Model | CMS
Transportation access, timeliness and cost are important quality metrics that should be monitored and continuously improved as part of the crisis system’s quality assurance/performance improvement (QAPI) plan.