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
In an ideal crisis system, it is critical to have adequate staff capacity, in terms of numbers, credentialing, background and expertise. This section focuses on the standards for staffing capacity (see "Basic Clinical Practice” for more on staff competencies and practice guidelines).
The staff composition of an ideal crisis continuum, and each program within the continuum, must reflect the volume of service provided and the variety of crisis needs of the community it serves. To do that, adequate numbers of staff and an interdisciplinary team of staff are required. With regard to adequate numbers of staff, precise staffing patterns will vary based on the type of program and level of service intensity provided. Discussion of exact staffing ratios for each component is beyond the scope of this paper; however, if too few staff are present, the program will not function properly and more individuals will need to be served at a higher level than might otherwise be the case.
It is helpful to discuss the importance of adequate staffing for the crisis center itself. Using the projected volume figures from the program in Phoenix, Arizona (see “How Does Your Crisis System Flow?”), crisis center staffing can be planned based on the expected crisis flow. For example, in a catchment area with 250,000 people, the expected number of crisis presentations is 500 per month (17 per day, averaging six per shift). Therefore, the capacity of front-line crisis workers needs to be able to address six crises on average with plans for routine surge capacity so the system does not get backlogged. Assuming that each individual in crisis will require three hours of intervention on average, with some requiring individual attention, it is clear that each shift needs to be planned to have no less than 24 person-hours of frontline staff availability (or at least three full-time staff members’ time). Similar calculations should be applied to the whole crisis system, so that crisis response is not constantly understaffed resulting in dangerous delays for both clients and first responders.
With regard to the composition of staff teams, multiple types of expertise are required and the ability to work as an interdisciplinary team to flexibly respond to individual needs, not as parallel separate individual disciplines in separate silos. The staff must be able to collaborate easily to triage effectively; engage individuals and families who are in crisis; gather information to perform effective clinical assessment from individuals, families and other collaterals; provide urgent treatment; and assist individuals and families in crisis transition to the proper level of ongoing care. For a crisis team to work efficiently, there needs to be contribution from multiple disciplines, and all team members, regardless of discipline, must be sufficiently trained and knowledgeable to carry out their specific tasks while understanding and supporting the unique skills and knowledge of the other team members.
There should be minimal duplication of work and all team members should collaboratively provide care, treatment and education for the clients. The team should function so all team members are co-occurring competent working with people with any combination of mental health and SUD issues and cross-cover and function to support the most highly credentialed team members (e.g., physicians and nursing personnel) to help them practice to the top of their license. For example, all staff can be expected to take pulse and blood pressures, while the nurse interprets the results and makes decisions accordingly.
The accountable entity ensures that all programs in the crisis continuum have funding to support adequate staffing of an interdisciplinary team. The staffing pattern is calculated using real data for each type of program with planned surge capacity and backup plans to cover absences. Program rates are based on actual staffing cost needs to produce the desired level of service in the context of network access and adequacy and regularly reviewed as part of the system QI plan to look at instances of under- or over-staffing and continually improve. The composition of the interdisciplinary team in the crisis hub/crisis center and in other settings, as appropriate, is designed to meet the following standards:
All crisis programs are ideally comprised of an interdisciplinary team with an appropriate range of credentials and expertise. The ideal team is two or more people working cooperatively toward a common goal. Each team should have provision for an appropriately licensed or credentialed clinician (sometimes called qualified mental health professional) to be available on-site or on call to cover each shift, in accordance with the level of care provided. The higher the level of care (the greater the intensity of service provided), the higher the total number of staff per client served and the greater proportion of people with more training and experience. The essential components of a functional team include the correct mix of crisis team members with the client as team co-leader, plus engagement of collaterals such as family, friends and other non-crisis providers of care and services. The team should include capacity to incorporate all the expertise described here. The size of the team and the precise numbers of staff in each category must be commensurate with the level of need and the volume of services provided by the crisis program. The team make-up can change as the individuals’ needs change. For example, if the person in crisis has housing needs, a housing specialist or housing intact person may temporarily join the team. There are, however, core team members who are consistently available for continuity, including:
Crisis clinicians: There are clinicians who are skilled in doing initial triage, crisis assessment, provisional diagnosis, crisis planning and crisis intervention. They are commonly master’s level clinicians from any discipline, frequently licensed professional counselors or licensed marriage and family therapists (LMFTs), but in some settings may be bachelor’s level crisis clinicians with training and supervision that qualifies them to perform crisis intervention and crisis care management. Clinicians can also begin short-term, crisis focused and motivational treatments.
Psychiatric care providers: The crisis team has psychiatric care providers available on-site or on call who can initiate medication treatment if needed. These clinicians can be MDs, doctors of osteopathy, advanced practice registered nurses, nurse practitioners (NPs) or physician assistants (PAs), depending on state licensure and regulations, and can distinguish between the need for emergency treatment, urgent treatment and ongoing care.
Nursing: Nurses are essential to oversee medical screening and evaluation, provide and monitor medications and interface with nursing personnel at referring and receiving programs. Depending on the type and intensity of services, during any shift, nursing may be on-site or on call and may involve RNs or licensed vocational nurses/LPNs. There also needs to be an individual designated as a nursing supervisor, who will be on-site or off-site depending on the number of nursing staff or extent of nursing coverage.
Social worker: Social workers, LMFTs or other clinicians trained in family engagement can gather historical information, family and social contacts and begin linkage to other services and care in the community.
Substance use disorder clinician: There are team members who are certified or licensed SUD specialists and/or individuals who have SUD experience. These team members support the ability of all team members to work with individuals with SUD/COD in crisis.
Peer specialists: Peers are essential team members who specialize in welcoming and engaging clients, helping educate clients about crisis program services and process and facilitating community transitions as community bridges.
There must be functional mechanisms to ensure successful team operation. A team administrator is also a clinical leader of any discipline (e.g., psychology, social work, psychiatric nursing) who has oversight of the internal operations of the program, including fiscal management, staffing and schedules, reporting and evaluation of services, tracking of outcomes, etc., and coordinates external relationships National Council for Behavioral Health 125 with other services. Open and regular communication between team members with clear expectations and accountability is essential. Team members must be accountable for completing their tasks and there must be shared responsibility for risk and outcomes. In the ideal team, all members can Identify and value the unique roles and contributions of other team members and trust them to carry out their roles. It is also important for all team members to actively seek out collaboration with others and to actively contribute to the overall functioning of the team. The team can share essential information through face-to-face meetings, shared medical records and supervision. The team can identify measurable goals and objectives, work collaboratively and not competitively in solving problems and cross-cover to manage immediate clinical and program needs.
Medical director: The medical director may be on the premises or off-site depending on the type of program and oversees all medical care and consults with the other team members for individuals with complex medical or behavioral health needs. The role of medical director is a certification requirement for CCBHCs.
The team should reflect the ethnic, cultural and linguistic composition of the community served and have access to translators for any anticipated need, including American Sign Language (ASL).
In an ideal crisis service system, reliance on the most resource-intensive, costly and restrictive service settings, such as ERs and acute inpatient hospitalization, is minimized. The extent a full array of high-quality clinical and psychiatric services is available within the crisis setting will directly impact the degree to which emergency and inpatient settings may be avoided. Given the importance of the quality of clinical and psychiatric evaluation and intervention in the functioning of not only a crisis center, but the entire crisis continuum, it is critical that experienced clinical leaders (e.g., clinical psychologists, social workers, psychiatric nurses) and psychiatric providers are part of the leadership team in the ongoing design, implementation and oversight of crisis services. Unfortunately, in most crisis systems clinical and psychiatric leadership is not built into the design from the beginning. For this reason, it is especially important to emphasize that this is a necessary component of an ideal behavioral health crisis system, just as medical emergency services are expected to have physician leadership.
In addition to clinical medical leadership (CML) generally, there is a clear need for access to specialty consultation, coordinated by the crisis coordinator and clinical/medical director. In an ideal crisis service system, the continuum of services will respond to diverse populations who may present with varying degrees of frequency. This may include individuals of different ages, with different disabilities (e.g., intellectual and developmental disabilities (I/DD), BI, dementia), different cultural backgrounds and different conditions (e.g., OUD, eating disorders). Because it is impractical to maintain 24/7 on-site availability of expertise in all these diverse populations in all parts of the crisis system, the system needs to have a provision for accessing specialty consultation as needed.
The accountable entity incorporates clinical and psychiatric leadership into the design of the crisis continuum. This position may be embedded in the crisis hub, working with the program leader of the crisis center, but ideally has responsibility for the functioning of the crisis continuum, working collaboratively with the crisis coordinator. The credentials and time commitment of the clinical leadership (crisis system clinical director) and psychiatric leadership (usually called the crisis system medical director) may vary depending on the size of the crisis system and usually includes a combination of on-site (or telehealth) clinical and administrative time, plus on-call availability. In some systems, particularly in rural and frontier areas, the lead clinician on-site might be a licensed professional counselor or equivalent master’s professional supported by a doctoral level psychologist or more senior master’s level clinician, and the lead psychiatric care provider on-site will be a nurse practitioner or physician’s assistant supported by a medical director offsite, often by telehealth. In these instances, the crisis coordinator, clinical director (who may also be the crisis coordinator), lead psychiatric care provider and medical director work collaboratively to provide clinical and administrative leadership to the crisis continuum.
In addition, CML should be present throughout the entire continuum of crisis services, as follows:
Any agency providing behavioral health crisis services should have designated CML with a substantive role in the leadership team. This requires adequate time commitment for administrative leadership, apart from time for direct clinical service. It also requires a meaningful level of authority in the organizational hierarchy
The clinical leader/clinical director should be a licensed mental health clinician, such as a doctoral level psychologist, master’s level social worker, master’s level psychiatric nurse practitioner (following state regulations regarding scope or similar level of practice) or a psychiatric PA working in a meaningful supervisor relationship with a psychiatrist. The clinical director/clinical leader must have demonstrable clinical training from a recognized and reputable educational program.
The clinical medical leader/director should be a psychiatric care provider, either an MD or DO, a psychiatric nurse practitioner (following state regulations regarding independence), or a psychiatric PA working in a meaningful supervisor relationship with a psychiatrist. The medical director must have demonstrable clinical training from a recognized and reputable educational program.
The CML should have demonstrable clinical experience with the populations to be served within the crisis setting, including those with serious mental health and substance use disorders and with working in crisis and/or emergency settings.
The CML should have demonstrable knowledge of community psychiatry - and systems of care generally - with the expectation of gaining a sophisticated understanding of the local systems of care.
The clinical and medical leadership must be appropriately licensed and credentialed in a manner similar to that which occurs in a psychiatric inpatient setting.
Clinical and medical leadership collaborate with each other, administrative leadership, nursing leadership and staff to ensure efficient and effective service delivery.
The clinical director oversees the work of all non-medical clinical staff and establishes standards for crisis work, oversees training and competency development and ensures adherence with practice guidelines and protocols.
The clinical medical director oversees the clinical work of all medical, psychiatric and nursing providers to ensure provision of highly competent psychiatric and medical practices.
Both clinical and medical leadership meaningfully participate in multidisciplinary team processes to ensure quality outcomes and standards of care are met.
Meaningfully participate in quality assurance and improvement processes directed at key outcomes.
Uphold and model the mission, vision and values of the organization in all interactions.
Provide leadership in engaging challenging systems, families and clients.
Comply with all relevant regulations, policies and procedures.
Meaningfully participate in identifying needed training and ongoing education for all licensed and unlicensed clinical, medical, psychiatric and nursing staff to meet position competency.
The accountable entity must ensure that the crisis hub provider has a clear mechanism for funding and arranging both emergent and urgent access as needed to specialty assistance with populations with unique needs that may not be met by the staff available on-site. This access to specialty assistance should be available to all crisis providers in the continuum.
At minimum, the following areas of specialization should be available:
In many systems the full array of specialists may not be available in each local community, county or region and may only be available through a consultation network provided at the state level, sometimes with an academic partner that is accessible to each community crisis system as needed.
Although peer support is considered part of the composition of multidisciplinary team staffing for crisis services, it is essential to emphasize the importance of peer services. The participation of peer specialists (both certified mental health peer specialists and SUD recovery peer specialists, often called recovery coaches) across the continuum of care must include the expertise of people with lived experience in every program. Peer support services and staffing are certification requirements for CCBHCs.
Direct peer involvement in behavioral health treatment grew from the mental health civil rights movement of the 1980s. Peer participation in all aspects of behavioral health care hinges on the value of lived experience in providing care. In crisis intervention, peer providers who have “been there” offer an invaluable perspective to consumers, families and providers that can significantly enhance engagement, hope and safety. In the rapidly proliferating emergency service initiatives to engage individuals with SUD, especially in the context of opioid overdose and peer providers (and especially those with lived experience of MAT), offer direct intervention for individuals in crisis because of addiction, offering counseling and immediately linking consumers to treatment services, including facilitating agreement for immediate initiation of MAT.
There is extensive literature on peer involvement in providing behavioral health services. Peer involvement has, for example, been the standard of care on assertive community treatment teams since prior to the establishment of the Dartmouth Assertive Community Treatment Scale in 1998. Peer involvement is recommended by the Schizophrenia Patient Outcomes Research Team and SAMHSA.
Further, consumer peer input is essential to developing an ideal crisis system and system of care and peer/providers partnerships are key to the ongoing evolution of care.
In addition to providing direct services, direct peer involvement should be present on the community’s crisis collaborative and peers should be active in providing advocacy, education and support.
The accountable entity should purposefully work with community stakeholders to include identification, training and employment of certified peer specialists, including recovery coaches and family partners for children in crisis, throughout the crisis continuum, including participation in the community crisis collaborative.
Supervision and training: There should also be provision in the crisis continuum for supervision of peer support staff, ideally by other peer supporters with more training and experience, as well as provision of peer support training in crisis work and continuing education.
Roles for peers that should be included in the planning and design. The accountable entity should seek to include peers in each of these areas and to have a metric for continuous improvement of peer involvement in all areas as part of its overall QAPI plan.
Peer support for Mr. Y at almost any point in his behavioral health crisis would have been extremely helpful. Someone with lived experience might have been able to build trust and provide Mr. Y with reassurance and an enhanced sense of safety early in the crisis and helped him navigate the system and begin mapping his recovery plan as he progressed.
