AAC Research Corner

Behavioral Health in Arkansas: Where we have been and where we are heading

Under Act 423 of 2017, “the Criminal Justice Efficiency and Safety Act,” the state of Arkansas established regional Crisis Stabilization Units (CSUs) that serve to provide individuals experiencing a behavioral health crisis access to mental health stabilization and detox services to avoid being booked into county jails. Diverting appropriate individuals to CSUs from jails is a legal and clinically appropriate manner of addressing the needs of a person with behavioral health issues. Upon arriving at a CSU, individuals are assessed, and treatment is initiated, including medication management if needed. The CSU also provides case management services such as assisting with application for insurance, including Medicaid, if the individual is uninsured; crisis referral for an independent assessment to facilitate enrollment in a Provider Led Arkansas Shared Savings Entity (PASSE) for those who are deemed to meet criteria for Serious Mental Illness; and referral for outpatient mental health, and substance use services housing. The CSU follows up with individuals regularly to ensure their ongoing compliance with treatment referral and recommendations to reduce future law enforcement contacts. CSUs are certified through the Arkansas Department of Human Services (DHS) Division of Provider Services and Quality Assurance as a freestanding Acute Crisis Unit (ACU).

During the initial study in support of Act 423 of 2017, the Council of State Governments recommended establishment of regional CSUs and possibly mobile crisis units. Arkansas has established four regional CSUs in Washington, Sebastian, Pulaski, and Craighead counties. These serve the most populated areas of the state. CSUs are accessible 24 hours a day, seven days a week. Mobile crisis services are available through the 12 contracted Community Mental Health Centers. During the Arkansas Sheriffs Summer Convention at Rogers on June 6, 2022, Gov. Asa Hutchinson, champion of diversion and justice reinvestment, voiced support for a need to establish a regional CSU in South Arkansas. We’ve made unprecedented strides in diversion and behavioral health during Gov. Hutchinson’s administration.

Since the first CSU opened in 2018 in Sebastian County, the four CSUs combined have admitted more than 8,000 individuals. Law enforcement or any Arkansas citizen in crisis may use any of the state’s four CSUs. However, individuals are not currently transported to CSUs via emergency transportation. Individuals in crisis anywhere in the state can be transported to CSUs by law enforcement, family, or anyone concerned.

Freestanding CSUs, which may have up to 16 beds, must be certified as ACUs and provide stabilization and referral services as a Medicaid enrolled provider. Certification as an ACU allows CSUs to be supported through Medicaid funding. Since Arkansas, through Medicaid Expansion, provides options for insuring most adults, CSUs may receive Medicaid funding retroactively for those individuals who apply for and meet the qualifications for Medicaid. Priority for admission to CSUs is given to law enforcement based on the unique diversionary role of the CSU.

DHS previously implemented policy to all Arkansas Medicaid enrolled Outpatient Behavioral Health Agencies to open Medicaid reimbursable ACUs and has recently updated the policy to allow hospitals to open acute crisis beds for adults and children. This allows for provision of acute crisis services within local communities — including critical access hospitals in rural areas of the state — and provides options for hospital emergency rooms for individuals presenting with mental health and substance use crises. According to DHS, allowing rural hospitals to create acute crisis beds will allow for more robust use of existing hospitals and their operations. Also, crisis beds within hospitals throughout Arkansas will allow for patients in crisis to access a crisis bed 24 hours a day, seven days a week. This also alleviates the transportation barrier often encountered for freestanding CSUs. Local hospital crisis beds will improve access and allow for integrated discharge planning, benefits assistance, and follow-up appointments. As with a CSU, an individual can be referred by law enforcement or through a health care provider, or they may present to the emergency room for services. Currently there are no hospitals operating CSUs within a hospital setting, though this is allowable based on changes to Medicaid policy and would be compliant with Act 423 of 2017.

Initially, we sought to keep up with Mississippi, which initially had eight regional CSUs in 2017. Now, Mississippi has 13 regional CSUs and 172 beds available. The hope is that this multi-faceted approach will offer better and more efficient services to our citizenry regionally in Arkansas. Sheriffs want to see the success of these programs. From a sheriff’s perspective the primary goal of diversion is achieved. Diversion was the primary goal of the 2017 Act and the justice reinvestment. We do not want the ability to use a CSU as an ACU or these other

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programs to adversely impact the number of beds and services available for diversion. Indeed, the hope is that this unique approach will result in better and more widespread services for Arkansans — and fewer mentally ill warehoused in county jails.

Under Arkansas law, individuals who have committed a crime and are suspected to have a mental disease or defect are ordered to DHS for evaluation for fitness and responsibility. Individuals who are evaluated and found to be unfit to stand trial may be ordered into DHS custody for restoration treatment and detention, or they may be released to receive treatment through the Forensic Outpatient Restoration Program. After receiving restoration treatment and education the unfit defendants are re-evaluated for fitness. The DHS Division of Aging, Adult, and Behavioral Health Services is responsible for the management of the forensic population including coordination of restoration and treatment services for individuals who have been found unfit to stand trial.

The Arkansas State Hospital (ASH) is the state’s only statefunded acute psychiatric hospital with 200 beds— approximately 185 of which are allocated for adults and the rest allocated for juveniles. Arkansas is ranked 46th in the United States in the number of state hospital beds per capita. Individuals experiencing acute psychiatric episodes and meeting criteria may be civilly committed to ASH, or individuals who meet acute psychiatric criteria undergoing restoration may be admitted to ASH for stabilization and restoration treatment. Because ASH is the only state-funded acute inpatient facility, there is always a waitlist for admission. There simply are not enough state hospital beds.

Arkansas also has acute inpatient facilities funded through private insurance, Medicare, and Medicaid, as well as through state general revenue allocated to the 12 Community Mental Health Centers available for stabilization of acute psychiatric episodes. Individuals may be civilly committed to any appropriate facility for treatment and stabilization if they are unable to consent to treatment due to their mental disease.

During the 93rd General Assembly, Act 587 of 2021 was passed. It permits law enforcement to transport persons in crisis to sobering centers. Sobering centers may be associated with CSUs or ACUs but can also stand alone. These facilities provide recovery and recuperation for people who are experiencing the effects of alcohol. Although sobering centers are designed for intoxicated persons, this is helpful for the mentally ill population because these individuals typically use alcohol to self-medicate. Individuals transported to a sobering center get recovery rather than being sent to a county jail. This is another option that provides recovery as opposed to cycling these individuals through overcrowded jails, as do CSUs and ACUs.

It is crucial that mentally ill individuals have access to behavioral health care services and home and community supports after release from ASH or another acute inpatient psychiatric facility to prevent them from relapsing.

In 2019, DHS transformed the behavioral health system by moving away from a medical treatment model for the treatment of individuals with Serious Mental Illness to a Home and Community Based Model. This new model allows Medicaid to pay, through the PASSEs, for home and communitybased services, including Therapeutic Communities, which provide treatment settings that provide supervision, support, and monitoring for individuals with the highest level of need. These Therapeutic Community settings offer a safe, secure option for individuals who do not meet the criteria for inpatient acute admission but need a secure setting to remain safely in the community. Facilities like Birch Tree Communities and Mid-South Health Systems offer step down programs, which allow individuals living with serious mental illness to recover in a safe, supported, and monitored environment. For most, this means reintegration into the community with home and community-based supports; for others, that means diversion from ASH to a more appropriate setting. DHS continues to work with providers to expand home and community-based services in the state to meet the needs of individuals with Serious Mental Illness.

DHS is working with the PASSEs to develop an enhanced care coordination process whereby individuals who are identified by DHS or by an individual PASSE will receive an enhanced level of care coordination. This includes professional clinical support with the goal of identifying home and community-based needs and coordinating care in an appropriate setting, which may be a Therapeutic Community or at home with intensive home and community-based services based on individual assessment needs. This system could provide diversion from jail into community settings such as Therapeutic Communities. Through this system, the state hopes to alleviate the strain placed on the legal system by early identification of those individuals at most risk due to a serious mental illness or intellectual disability. Through the continued development of capacity within the home and community-based provider network, individuals with Serious Mental Illness would work toward recovery and improved quality of life.

The Sheriffs are proactive advocates for the mentally ill in Arkansas. Mental illness is not a crime, and the mentally ill should be afforded treatment. It’s the duty of the state of Arkansas to provide for the treatment of the mentally ill by virtue of Article 19, § 19 of the Arkansas Constitution. We are a good-faith partner with the state of Arkansas. We have seen improvement in recent years in establishment of regional CSUs in Arkansas. We are hopeful that the approach being pursued by the state of Arkansas results in expanded diversion of the mentally ill away from our jails statewide.