Introduction In the aftermath of the murder of George Floyd, there has been an intense debate over the direction of police reform in the nation. However, whether reform will look more like defunding the police or reimagining the public safety paradigm, America’s approach to law enforcement is assuredly changing. That movement towards change― which is undoubtedly the result of the national demand for reforms― is evidenced by the number of jurisdictions that have begun to transform their emergency crisis systems into models that reduce the presence of law enforcement as responders to behavioral health crises.
This social justice issue will hopefully help us better understand the emergency crisis response systems that are newly emerging in reaction to the recent calls for police reform. There are a growing number of emergency crisis response models that are showing promise in facilitating increased non-police responses to crises. However, as these system changes occur, there is a simultaneous need for increased funding at the state and local levels to expand mobile crisis services and other community-oriented emergency response models.
Political pressure made it viral that jurisdictions nationwide are to make reforms that result in effective non-police, medically informed responses to mental health emergencies. As a result, a year after George Floyd's death, police reforms have been less than widespread. Despite slow and incremental changes, several cities have moved forward with reimagining aspects of police practices, especially in the area of behavioral health crisis intervention approaches. These jurisdictions soon recognized the best approach to reducing violent outcomes when police respond to behavioral health crises is to limit police involvement when necessary to protect public safety.
In addition, the brief will discuss the intersection of the existing 911 and emerging 988 suicide crisis response systems and their impact on reimagining emergency crisis response systems. In that the transition to a full continuum of crisis care will be a major expense for states and local jurisdictions, the brief will discuss state and federal funding options being made available to those governments. Finally, our analysis will touch upon the social work profession being a major stakeholder in both mobile crisis reforms and the development of a 988-suicide crisis system throughout the United States.
The impetus for federal, state, and local jurisdictions to initiate major changes in their 911 emergency responses was to minimize the frequency of police being the first responders to behavioral health crisis calls. However, there are also valid clinical and patient management reasons for shifting to crisis services models that prioritize behavioral health approaches absent of a law enforcement presence whenever possible. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) , when describing behavioral health crisis models ― A comprehensive and integrated crisis network is the first line of defense in preventing tragedies of public and patient safety, civil rights, extraordinary and unacceptable loss of lives, and the waste of resources. There is a better way. Effective crisis care that saves lives and dollars requires a systemic approach.
1
1.911 Emergency Crisis Services The three-digit 911 number was created in 1957 as a public safety measure that was first proposed by firefighters that recognized the need for a direct way for people to report fires. As a result, The Federal Communications Commission (FCC) joined with the American Telephone and Telegraph Company (AT&T) to strategize on establishing a universal emergency number. In 1968, AT&T announced that it would establish the digits 9-1-1 as the emergency code throughout the United States. By the mid 1980’s, over half of the United States population was using this universal emergency number. Currently, Americans use the universal emergency line, 911, throughout each of the 50 states with an estimated 240 million calls being made in the U.S. in a given year. In many areas, 80% or more are from wireless devices. As of February 2021, there were 5,748 primary and secondary Public Safety Accessing Points (PSAPs) and 3,135 counties, including rural and urban areas throughout the country. As the system became institutionalized as an effective emergency crisis paradigm, a basic model grew for integrating within the other public safety agencies such as fire, police, and emergency medical teams. Significantly, it soon became clear from a staffing standpoint, that the role of 911 dispatchers were the linchpin for operating an effective 911 service. While the emergency 911 number is available nationwide, policies that determine call routing and response are arranged at a local level (see APCO’s newly released standards on crisis intervention techniques, namely 3.1.1.1). The procedural deference to local-level agencies is due, in large part, to the wide variety of service availability across counties. Metropolitan jurisdictions may have several teams of first responders (e.g., police, fire, ems), or certain specialties (Crisis Intervention Team officers, community paramedics, SWAT teams), that require local-level organization.
Moreover, each county may have one centralized dispatch center, formally referred to as public safety answering points, or PSAPs, or it may involve a network of PSAPs who each have separate policies and procedures for handling calls and documenting information. Thus, any meaningful 911 practice reform requires local-level configuration. Important Role of 911 Dispatchers Many of the individuals who are seriously mentally ill encounter police during a crisis episode ― more often than not by way of a 911 emergency response. Problematic interfaces with traditional 911 response can result in ‘downstream’ criminal legal entanglement. Nationwide, people with behavioral and mental health challenges and cognitive disabilities are overrepresented in the criminal legal system. People with mental illness are locked up in U.S. jails 2 million times each year. Studies indicate more than a half of the total incarcerated population nationally has mental health issues. Solving the ‘downstream’ criminalization of mental illness requires ‘upstream’ interventions at the earliest possible opportunity. While the 911 call centers are an integral part of local government public safety departments, the most critical staff are the 911 dispatchers. 911 professionals ― also referred to as “dispatchers” or “call takers” ― are usually the first trained professional point of contact for an emergency crisis call from the public. These staff are essential to ensuring that the person(s) in crisis receive the help they seek. History has told us that “regardless of how organized a crisis system is“ … if a dispatcher responds to a mental health crisis call by sending armed police rather than a crisis team or an ambulance, the results can be tragic.” To state the obvious, dispatcher training is crucial to effectiveness. For instance, dispatcher training must include a standard operating procedure for handling possible mental health crisis calls.
2
Dispatchers are asked to obtain essential information, remain calm, calm the callers, and send the appropriate responders to the correct location. That latter step in the process is vital to this discussion about reimagining America’s emergency crisis response designs. For behavioral health crisis calls, the dispatcher must have a level of training that facilitates deciding whether the crisis call is strictly physical health-related, behavioral health, or strictly a call related to a crime. Though alternative crisis lines, suicide prevention lines, and the emergence of 988 create appropriate channels for triaging crises, the traditional 911 system still needs to handle mental health crises: if for example someone’s delusions present the pressing issue of an alien invasion, the appropriate resource, in their mind, will be 911. In short, 911 dispatchers must make instant decisions about whether the incident requires a law enforcement presence, behavioral health professionals, or a co-responder situation. For this reason, some believe it is time for national training standards for 911 dispatchers.
The flaws in the call centers and Cleveland’s dispatch process are evident. After reading the call-takers notes, the dispatcher ― who is responsible for determining the level of emergency of 911 calls ― made it a code one priority emergency and told the responding police officers that “In the park by the youth center, there’s a black male sitting on the swing. He is wearing a camouflage hat, a gray jacket with black sleeves. He keeps pulling a gun out of his pants and pointing it at people.” 911 call-center staff perform a critical function in emergency response. Because they are the first point of contact for callers, call-takers have a unique opportunity not only to provide the resources callers ask for, but the ones they actually need. For example, they may be important team members of diversion programs that help keep people out of the justice system. They may assist in building a record that can supplement law enforcement’s ability to identify and document escalating intimate partner violence. With appropriate training, they can even help interrogate caller motives and determine the best response to emergency and non-emergency calls. Dispatchers face the fragmented, jurisdictional nature of their work, which means that standardization, support, and even training vary by locality. Dispatchers ― being the first point of contact ― more frequently have had to handle a troublesome number of calls that are motivated to misuse law enforcement for the caller’s own racially motivated reasons. Such calls can have tragic implications when the police arrive on the scene. It is important to note that 911 dispatchers― because of the nature of their work― can experience secondary trauma on par with other first responding professions.
A compounding factor to the 911 call center process is that the decision-making structure of 911 often involves a layered approach to processing an emergency call. The awful police shooting of 12year-old Tamir Rice in 2014 is a case in point. The person reporting his concerns about Tamir’s behavior told the 911 call taker that “There’s a guy with a pistol.” “It’s probably fake, but he’s pointing it at everybody.” “Probably a juvenile.” However, the call-takers' electronic notes failed to mention that the person reporting the situation had repeatedly said he thought the gun was fake and that Tamir was a juvenile. The dispatcher completely mischaracterized the information given by the person who initiated the 911 call. The police arrive at the park, and within two seconds of getting out of the vehicle, Loehmann shoots and kills 12 years old Tamir Rice. The prosecutor said in a statement that the 911 call-taker and dispatcher made errors and “were a substantial contributing factor to the tragic outcome. Because of the layered structure and lack of strict adherence to electronic note taking, a well-meaning 911 caller describes what he sees, but as that information is passed on through the dispatcher the responding police are making life and death decisions with distorted fact” 3
2. Impact of National 988 Crisis Line on Behavioral Health Response System
Intersection Between Reexamining 911, Emergence of 988 and the Reimagining Policing Movement Though not planned for or anticipated, there was an intersection between:
Implementation of 988 Service in 2022 The relative success of 911 call centers as the singular national emergency crisis structure will need to adapt with the now-approved national suicide prevention 988 national call center system. While the 911 service responds to a broad range of emergencies, it lacks the capacity to effectively respond to and direct the many behavioral healthrelated emergencies to the proper stabilization and linkages to care ―other than law enforcement.
The national police reform movement―sparked by the death of George Floyd― calling for nonpolice responses to behavioral health crises. Pre-existing advocacy to revamp the nation’s 911 emergency response systems, and the finalization of plans to implement the 988 suicide prevention hotlines.
In August 2019, the Federal Communication Commission (FCC) recommended the use of 988 as the 3-digit code for the National Suicide Prevention Lifeline as a result of a successful advocacy campaign. In July 2020, the FCC made official rules changes to establish 988 as the national emergency phone number to connect people in crisis to connect with suicide prevention and mental health crisis counselors. Other relevant information about 988 includes:
The confluence of these events has become the catalyst for a comprehensive transformation of the nation’s approach to emergency responses as it relates to behavioral health. It should be mentioned that the ongoing movement toward non-police community-based responder models and the transition to a national 988 suicide hotline will initially cause a degree of uncertainty and overlap. This is because until the two systems are fully integrated, police dispatchers will refer general behavioral health (including suicide calls) to both 911 and 988.
The transition to 988 will result in phone service providers directing all 988 calls to the existing National Suicide Prevention Lifeline by July 16, 2022. The transition time gives phone companies time to make necessary network changes. It additionally provides time for the National Suicide Prevention Lifeline to prepare for a likely increase in the volume of calls following the switch. Adopting of the new standards is intended to make crisis- suicide intervention and prevention easily available all Americans. In its literature, the FCC refers to the implementation of 988 as “an easy-to-remember 988 as the ‘911’ for suicide prevention and mental health crisis services…”
Though 988 originated through federal policy, its successful implementation will largely hinge on local-level system coordination. While some metropolitan jurisdictions have non-police mobile crisis teams with emergency response capacity, many rural and small urban communities do not. Moreover, the expertise to triage crisis needs within a complex, ever-shifting behavioral health service network of provider agencies and eligibility criteria requires a high level of local-level system expertise. As these systems advance, jurisdictions will need to be aware of all possible local behavioral health diversion programs that will assist police―who previously would be the first responder― with connecting individuals to appropriate clinical interventions.
4
This coordinated approach has a goal of continually emphasizing a clinician-only response, as much as possible. This approach also conforms with the 988 objective to quickly link those experiencing mental health, substance use, or suicide crisis to the level of care without depending on the traditional 911 response.
3. Movement Towards Reimaging Emergency Crisis Response Paradigm The emergence of the so-called “defund the police” initiatives had a significance beyond the political controversy that it generated. An underlying premise in the phrase “defund the police” is that social programs such as mental health services could be expanded by reinvesting funds from law enforcement budgets. While there was resistance to the phrase “defund the police”, some federal, state and local officials embraced the concept of reinvestment to disentangle people with mental illness from the criminal legal system by implementing non-police behavioral crisis responses, most of which feature community-based programs staffed by behavioral health clinicians trained to assess and respond to mental health crises. While there is still a question about how far law enforcement reforms have gone in most of the nation’s states and local jurisdictions, there is ample evidence that ― when it comes to re-modeling the emergency crisis response (911) systems― a significant number of local governments reinvested law enforcement funds to fund innovative emergency response programs that greater reduce the presence of police as first responders. The decision to reinvest funds for expanding non-police community-based mental health crisis response models achieves three critical objectives:
1. To implement changes that will likely lead to a meaningful reduction in the number of violent and lethal police encounters involving people with SMI or SUD, 2. To free up police officers’ duty time for clear public safety activities as opposed to being de facto clinical social workers, and 3. Improve linkages to post-crisis care, as the traditional police-toemergency department model struggles to connect individuals with social service systems in the days and weeks following an acute incident.
5
The Community Responder Model In the previous section, we referred to the critical role that 911 dispatchers play in making sure that the appropriate responders react to crisis calls. It is relevant to note that a significant number of the calls are not true emergencies. In fact, many 911 calls are related to quality-of-life and other low-priority incidents. Such calls must be answered in a timely manner and do not require the police ― particularly behavioral health calls. An analysis conducted by the Center for American Progress (CAP) and the Law Enforcement Action Partnership (LEAP) examined 911 police calls for service from eight cities and found that 23 to 39 percent of calls were low priority or nonurgent, while only 18 to 34 percent of calls were life-threatening emergencies. While it is without doubt that many 911 calls require an emergency police response, dispatching law enforcement to calls where their presence is unnecessary is a waste of police resources. The fundamental premise of the community responder concept as articulated by adherents to the model, is that they are better suited to provide effective responses to 911 calls related to nuisance complaints and lowlevel nonviolent incidents. However, there is an important distinction to be made when comparing responders. In the Community Responder approach, their qualifications as non-police responders would differ from that of behavioral health and social service professionals who answer such calls. The main distinction is that Community Responders are seen as “credible messengers” —individuals with strong ties to the community ― who often have a history of being directly affected by violence or justice system involvement. Therefore, they are viewed as being better able to connect to community residents in responding to behavioral health and other non-violent 911 crisis referrals.
6
But even in situations where there is a threat of or actual violence, recent outcome analyses suggest the credible messenger approach has played an integral role in violence interventions. Within the Community Responders structure, credible messengers usually serve outreach workers, known as “violence interrupters,” ― trained to mediate conflicts before they turn violent. Adherents point out that when asked to intervene in potentially violent incidents, interrupters have the credibility and the skill set to diffuse the situation and encourage healthier responses to conflict. Evidence of the credible messenger’s approach’s effectiveness can be found in a study of Sacramento, California program, where researchers found that credible messengers intervened in nearly 70 instances of imminent gun violence and mediated 220 conflicts over a twoyear period from July 2018 to April 2020. The program suggested that community responders contributed to a 14.3 percent decline in firearm violence in the target communities.
Mobile Crisis Teams (MCT) According to the Substance Abuse Mental Health Services Administration (SAMHSA), mobile crisis services have the “capacity to go out into the community to begin the process of assessment and definitive treatment outside of a hospital or health care facility.” The definition also describes mobile crisis teams as providers of mental health crisis stabilization and behavioral health assessment services to individuals in locations outside of a traditional clinical setting. While the primary objective of MCT is diverting individuals from psychiatric hospitalizations, MCT also focuses on reducing arrests of mentally ill offenders. Mobile teams are better suited as responders because they include a specially trained psychologist or social worker, a community paramedic, and a peer support expert― ideally someone with lived experience in recovery from alcohol or drug abuse and perhaps homelessness. For the most part, MCTs serve those who are experiencing acute and severe mental illness, in situations with a high potential for violence, experiencing SUD-related overdose or emotional crises and those with long histories with both the criminal justice and mental health systems. The efficacy of the MCT intervention is driven by accurate assessments that allow for expeditious decisionmaking on the specific treatment needed. Above all, MCT staff must be skilled in crisis triage stabilization services. The following are selected examples of MCT designs and functioning models. For MCTs to be the most effective, collaboration and compatible modes of communication is necessary between the crisis services.
Another example ― among many more cities ― of this trend is also occurring in the city of Charlotte, North Carolina. The SAFE Coalition led by Charlotte community leaders, submitted a report and recommendation for the city to address violent encounters with police during behavioral health emergency crisis responses. In the introduction to their report, the coalition provides their stated purpose for urging the city to adopt innovative changes to emergency crisis responses. The part of the statement captures the sentiment of reformminded groups, it is as follows: SAFE Coalition NC and Promise Resource Network, advocating on behalf of the equitable treatment of black, brown, and marginalized communities, and for those living with mental health diagnoses…’present a shared vision for a city-sponsored, community-based, non-police, crisis response team to respond to non-violent, non-criminal, mental and behavioral 911 CFS in Charlotte…”
Mobile crisis services are increasingly in vogue. Notably, MCT gained currency when units were deployed from the beginning of the COVID pandemic to triage and refer individuals experiencing medical emergencies to the appropriate level of treatment. The COVID-related expanded use of MCT coincided with the public demand for reimagining the public safety paradigm―which motivated communities to turn to MCT as a primary resource for responding to 911 behavioral health emergency calls instead of police. Supporters of MCT argue that 24/7 mobile crisis, saves lives, and is cost-effective. Moreover, mobile crisis units have the capability to reach marginalized populations― and divert people from the emergency room and criminal justice system. 7
Need for MCT National Standards Just as 911 call centers are structured at a local level, MCT service capacity and eligibility also varies substantially between counties. While some teams have the ability to respond 24/7, anywhere in a county, many only operate during business hours or only respond to institutional healthcare facilities (i.e., emergency departments). Moreover, MCTs are almost never connected to traditional 911 dispatch centers, requiring individuals to know a specialized phone number local to their area. Some MCTs receive immediate referrals from local law enforcement, but others do not. Workforce barriers prevent service expansion to broader call volumes, as the limited supply of mental health professionals would, understandably, prefer not to take on the proverbial Friday night 3am calls. However, experts are quick to add that, given the expanded utilization of MCT services ―and with the emergence of the soon to be active 988 Suicide Prevention Hotline ―it is time for a national standard for providing mobile crises services. The Importance of Data Collection to Developing Mobile Crisis Standards As state and local jurisdictions inevitably move to an integrated 911 and 988 system which will be greatly supported by MCT, there will be a high budget price-tag expanding MCT capabilities. To convince governments to cover those costs, the MCT model must demonstrate it is cost-effective. In theory, and in limited studies, MCTs do prevent overall behavioral health system costs through the management of severe risk. Psychiatric inpatient stays can cost over $1000 per night per person and are the predominant driver of mental health care costs; most MCTs exist to screen out individuals who may warrant these hits to Medicaid expenditures. Strong empirical cost-benefit analysis may help justify the investment in MCT infrastructure, but such studies are limited or dated (Scott, 2000). The pathway to showing cost-effectiveness is comprehensive quality outcome data. Yet, as stated by #CrisisTalk, “it’s not simply the lack of data that’s problematic, but also, there’s no standardization. There isn’t even agreement on what defines a mobile crisis team, let alone best practices protocols ―the design of [MCT] by the design of [MCT] by service organizations has historically been extremely idiosyncratic,” How States Are Expanding Crisis Intervention Service Many states and localities are rethinking their crisis response systems to incorporate mobile crisis intervention teams into its continuum of services and link individuals in crisis to follow-up behavioral health treatment and recovery services. States are anticipating the mobile crisis state option as an essential resource ―available beginning in April 2022― to fund comprehensive and integrated crisis infrastructures that likely will: • Stabilize individuals in crisis; • Avoid costly and traumatic psychiatric inpatient care for those who do not need it; • Connect individuals in behavioral health crises to appropriate follow-up health service; • Reduce the stigma associated with a behavioral health crisis; and • Limit the reliance of communities on police as first responders.
8
03 San Diego County Office of the District Attorney
01 Michigan's Behavioral Health Justice Fund Michigan’s Behavioral Health Justice Fund - is a legislative solution, recently passed in 2021. The legislation creates funding for localities to implement broad diversion programs, along with specific funding for community mobile crisis response teams, which are multi-disciplinary. The community mobile crisis response teams consist of clinicians, peer support recovery specialists,s and those with lived experience - all of which aim to assist an individual with a behavioral health crisis seek the support and services they need in lieu of incarceration. The program creates coordination between community agencies and law enforcement agencies, requiring priority is given to counties without an urbanized area and those of at least 50,000 people. Through the Behavioral Health Justice Fund communities seeking funding must adhere to crisis response best practice standards.
As a part of San Diego County (California) Office of the District Attorney’s Blueprint for Mental Health Reform: A Strategic New Approach Addressing the Intersection of Mental Health, Homelessness and Criminal Justice in San Diego County report, the County detailed its plan to revamp its behavioral health crisis response system. Their motivation for this action is summed up in the statement by the San Diego County District Attorney, as follows: “Statistics demonstrate San Diego County, like the rest of our nation, is facing significant challenges in serving individuals with mental illness who intersect with our criminal justice system”. The San Diego County’s blueprint makes important recommendations which include: Develop a system of timely follow-up care to connect a person to appropriate services and levels of care after a mental health crisis involving law enforcement or other first responders. Build regional Crisis Stabilization Centers, or Mental Health Urgent Care Centers, using a “no wrong doors” approach that can provide walk-in mental health and substance use disorder services and safe alternatives to jail or emergency departments. Support the creation and expansion of crisis/de-escalation training for law enforcement and 911 dispatchers countywide. Invest in and create data systems that can timely match appropriate information across different systems to provide both criminal justice and health care data. Create guidelines and structure for mental health diversion that ensures public safety and equal access and equitable treatment for all participants. Increase access to walk-in urgent mental health services by expanding hours of availability. Work collaboratively with community partners to expand outreach and prevention programs and encourage the utilization of peer support.
Evaluation is critical for community-based mobile crisis response teams to determine the success of their three-year proof of concept. Michigan’s program will require one evaluation entity to examine specific metrics.
02 Common Ground - Michigan Common Ground, located in Oakland County, Michigan, is a community-based mental health organization that offers comprehensive one-stop crisis services, including a crisis hotline, mobile response units, and facility-based services and referrals to crisis stabilization beds. Common Ground’s crisis service, managed by its urgent care branch, anticipates it will serve as many as 15,000 people a year. They will develop collaborative referral relationships with hospitals and other behavioral health providers in the community to connect individuals to ongoing services as appropriate. The urgent care service will complement the new Michigan Crisis and Access Line, known as MiCAL, The Michigan Department of Health and Human Services selected Common Ground to staff a new 24-hour crisis call and text/chat hotline and a peer recovery “warmline” for anyone in need of behavioral health or crisis response services. 9
04 Albuquerque Community Safety — Albuquerque, New Mexico
Emergency Medical Team (EMT), and a crisis worker trained in social and behavioral health services. CAHOOTS uses a collaborative emergency response approach that allows staff to receive crisis calls through police dispatchers from Eugene’s 911 system. The dispatchers are trained to screen for non-violent, behavioral health focused situations and route calls directly to the CAHOOTS team. The specialized team responds – without police officers – to first assess the situation.
Since February 2018, the Albuquerque Police’s Mobile Crisis Team was a co-responder approach that consisted of unarmed police officers and mental health professionals responding to mental health crises. The two-person teams consisted of one MCT-trained law enforcement officer and an MCT-trained master’s level behavioral health clinician. That program was seen as being relatively successful. The New Mexico’s Institute for Social Justice reported that almost half of the more than five thousand calls received since the program began have been suicide or behavioral health incidents.
As in most collaborative approaches, CAHOOTS has an agreement with law enforcement that allows them to request immediate police backup if there is real or potential danger. Absent such danger, the team’s primary objective is to stabilize the individual in the community setting. In the event the team determines there is an urgent medical need or behavioral health crisis, the team will make a referral, or provide transportation to the next appropriate level of care. In 2019, of the 24,000 CAHOOTS calls received, police backup was requested only 150 times.
In 2020, in response to public pressure to reform the city’s police, the mayor of Albuquerque announced a plan to restructure the MCTs by creating a new cabinet-level department focused on first responders for mental health crises. The Albuquerque Community Safety (ACS) department― serves in collaboration with the Albuquerque Police Department and Albuquerque Fire Rescue. This inter-agency group is charged with delivering what officials refer to as a “civilianstaffed, public health approach” to public safety and mental health. The ACS department is staffed by trained professionals such as social workers, housing and homelessness specialists, violence prevention and diversion program experts. Albuquerque’s trained 911 dispatchers will have the option to send ACS personnel to respond to crisis calls when a community safety response is more appropriate than an armed police officer.
06 San Francisco's Street Crisis Response Team (SCRT) The Street Crisis Response Team (SCRT) responds to 911 calls regarding people experiencing behavioral health crises. The Street Crisis Response Team is part of San Francisco’s efforts to develop alternatives to police responses to non-violent calls, which advances the mayor’s roadmap to fundamentally change how the city handles public safety, and is also a major step in implementing Mental Health SF.
05 CAHOOTS—Eugene, Oregon One of the most well-known community mobile mental health crisis response programs is the Crisis Assistance Helping Out on the Streets (CAHOOTS) program. Led by the White Bird Clinic, a Federally Qualified Health Center (FQHC) located in Eugene, Oregon. CAHOOTS’ structure consists of two-person teams: one medic, nurse,
10
The SCRT pilot program collaborates with the San Francisco Department of Public Health and the San Francisco Fire Department with significant support from the Department of Emergency Management. The San Francisco Police Department will also be a key partner in the transition of certain types of 911 calls to the new teams. Each team includes a community paramedic, a behavioral health clinician, and a behavioral health peer specialist. The new program aims to provide an appropriate non-law enforcement response to behavioral health emergencies in San Francisco and divert individuals in crisis away from emergency rooms and criminal legal settings into behavioral health treatment. In addition, the SCRT aims to provide trauma-informed clinical interventions and care coordination for people who experience behavioral health crises on the streets of San Francisco.
To some degree, the increased interaction between law enforcement and the SMI population can be traced back to the 1960s when deinstitutionalization was a well-intentioned national policy to treat people with mental illness in the community rather than in mental institutions — that essentially failed. Instead of institutionalized SMIs being treated in community health programs, many wound up on the streets and in and out of jail for minor offenses such as vagrancy and disorderly conduct ― which of course greatly increased police being first responders to mental health-related incidents. Recent studies have established that the mentally ill population in prisons and jails is larger than those hospitalized. In addition, 40 to 50% of patients receiving services in U.S. community mental health systems have a history of criminal arrest. More recently, the focus on encounters between law enforcement and SMI (and those with other behavioral health conditions or disabilities) has been on violent and deadly interactions. In 2015, the Washington Post conducted its ongoing count of officer-involved shooting deaths of the mentally ill. At that time, nationwide, as many as 25% of the people who are shot and killed by police officers suffer from acute mental illness. More recent data from the Post’s 2018 count show that of 1,165 civilians who were fatally shot by police, 200 were confirmed to be SMI. Given these and other documentation, it is evident that operational and policy changes need to be made―nationally― to emergency crisis response systems.
4. Diversion From Police Encounters and Frequent 911 Calls Overview of Impact of Law Enforcement Encounters with People with Disabilities It is essential to begin this discussion by providing background information on the recent history of law enforcement encounters with persons with serious mental illness (SMI), and current data on the violent nature of such encounters. For many decades, law enforcement has been a de facto component of the American mental-health system. It has been estimated that about 2 million people with serious mental illness are arrested and booked into jails in the United States each year. Similarly, it has been suggested that 1 in 4 Americans with mental illness has a history of at least one police arrest. These SMI and police interaction data are highly relevant when we realize that it has been determined that the odds of being killed during a police encounter are 16 times as high for individuals with untreated serious mental illness as they are for people in the broader population.
While we use the term behavioral health throughout this brief, the point must be made that those with serious mental illness and those substance use disorder crisis responses (SUD) are equally exposed to mistreatment during a law enforcement encounter. This distinction is necessary because the current opioid epidemic has seen high rates of overdose deaths and those who die from contaminated drug supply crises. The history of drug policies that favored criminalization over public health in dealing with SUD, the nation has also seen persons with Opioid Use Disorders (OUD) die at high rates during encounters with law enforcement officers ―much of which comes from the use of potentially lethal restraint methods to subdue agitated individuals during a pretextual police stop. 11
Pre-arrest diversion programs provide an alternative outcome. Designed to reduce the number of persons who are arrested and placed in jail because of a mental health problem, these programs shift responsibility for rehabilitation from the criminal justice system to the mental health system. Instead of punishment, prearrest diversion steers people toward treatment and support for their mental health problems ― RTI International. Diversion programs are complementary to non-police crisis response models in that they both have the objective of reducing encounters between police and individuals who are experiencing a behavioral health crisis. The following are diversion approaches that are nationally recognized as best representing practices. Sequential Intercept Model (SIM) SIM helps communities identify resources and gaps in services at each intercept and develop local strategic action plans. The SIM mapping process brings together leaders and different agencies and systems to work together to identify strategies to divert people with mental and substance use disorders away from the justice system into treatment. Intercept 0: Community Services Involves opportunities to divert people into local crisis care services. Resources are available without requiring people in crisis to call 911, but sometimes 911 and law enforcement are the only resources available. Connects people with treatment or services instead of arresting or charging them with a crime. Intercept 1: Law Enforcement Involves diversion performed by law enforcement and other emergency service providers who respond to people with mental and substance use disorders. Allows people to be diverted to treatment instead of being arrested or booked into jail. Intercept 2: Initial Court Hearings/Initial Detention Involves diversion to community-based treatment by jail clinicians, social workers, or court officials during jail intake, booking, or initial hearing. Intercept 3: Jails/Courts Involves diversion to community-based services through jail or court processes and programs after a person has been booked into jail. Includes services that prevent the worsening of a person’s illness during their stay in jail or prison. Intercept 4: Reentry Involves supported reentry back into the community after jail or prison to reduce further justice involvement of people with mental and substance use disorders. Involves reentry coordinators, peer support staff, or community in-reach to link people with proper mental health and substance use treatment services. Intercept 5: Community Corrections Involves community-based criminal justice supervision with added supports for people with mental and substance use disorders to prevent violations or offenses that may result in another jail or prison stay.
12
Youth Diversion and Crisis Care Services The exposure of youth to violent encounters with law enforcement is an everyday occurrence. Quite often, these encounters are byproducts of mental health crises. In referring back to the case of 12 year old Tamir Rice, his death was a direct result of a police response to what can easily be seen as a youth in an emotional crisis that led to his waving a toy gun in a threatening manner. Similarly, 16 year old Ma'Khia Bryant was shot to death by law enforcement officers who responded to the 911 crisis. Both cases ―which involved Black youths― exemplify the need for alternative and diversion crisis response systems programmatically designed for youth in crisis. he spotlight that reimagining police and the emergence of a 988 national suicide crisis line, and a re-designed crisis response paradigm has prompted a review of continuum of crisis care for youth. Nationwide, youth in psychiatric crisis often are frequent users of psychiatric crisis services, including 911 crisis calls and being in and out of hospitals. The director of programs for a major psychiatric facility that serves youth suggests that the continuum of crisis services in children in distress is insufficient. An option is specialized diversion programs that prioritize stabilization through Intensive Home Treatment. While this approach is not a mobile crisis service, it is a vital referral resource for mobile crisis teams responding to 911 calls ― together they are integral to the crisis continuum.
13
5.Funding Expanded and Restructured Behavioral Health Crisis Services
The momentum for redesigning crisis services in America is rapidly moving forward. It should be no surprise that this state-by-state transformation is very costly. Therefore, Medicaid has emerged as the foundation for funding the transformation. In a number of ways, the federal government passed laws and enacted policies that encourage crisis response redesign. For example, Congress recently authorized financial incentive for states to advance crisis services through Medicaid. In addition ―as previously discussed― implementation of “988” as a crisis response number to address suicide risk and other behavioral health crises has brought additional attention for crisis response redesign.
Medicaid Expansion Critical Police respond to a wide range of situations beyond crimes — everything from traffic stops to domestic disputes to homelessness. They are also generally the first responders in situations involving mental health or substance use crises. This unexpected, largely unrecognized role reflects an unmet need for behavioral health care, gaps in community-based services for mental health and substance use disorders, and policies that criminalize mental illness.
A few facts about how crisis services and emergency psychiatric services use Medicaid are as follows: In 2018, 44 percent of facilities reported accepting Medicaid and having a crisis intervention team to handle acute mental health issues on or off-site. Fewer facilities offered psychiatric emergency walk-in services and accepted Medicaid (28 percent). Facilities that offered psychiatric emergency walkin services had specially trained staff to provide services Access to mental health services for adults covered by Medicaid crisis intervention services enable individuals, family members, and friends to cope with an emergency while helping the individual function as a member of the community
“…as communities across the country try to reduce violence during police encounters, access to mental health and substance use services for people who are experiencing crises must be part of the solution. Medicaid is a primary coverage source for crisis and other behavioral health services, making it a key policy lever. What’s more, Medicaid was just strengthened in the American Rescue Plan Act of 2021, which offers a new financial incentive for states to provide mobile crisis response to people experiencing mental health or addiction crises.”― Georgetown University Health Policy Institute As the new behavioral health crisis paradigm evolves, Medicaid agencies are playing a growing role―along with the states― in constructing a coordinated continuum of behavioral health care. Some states have developed crisis systems to intervene when an individual is experiencing a behavioral health crisis. These crisis systems triage and assess individuals and connect them with the appropriate level of care. Ultimately, the goal of crisis services is to resolve behavioral health crises so more intensive services are not needed. The strategy for a defined and coordinated crisis services is to reduce inappropriate use of psychiatric hospital beds, decrease stays in hospital emergency departments, and reduce the need for law enforcement to respond to behavioral health crises. Though the role of Medicaid still needs to be refined, Medicaid programs are currently in place to support crisis continuums.
The costs of implementing a crisis continuum are significant. However, in the long run there can be anticipated cost savings through the reduction of inpatient hospital and emergency department use. The crisis continuum can also reduce costs to jurisdictions by diverting individuals from the criminal justice system. For example, the crisis system in Maricopa County, Arizona ―which includes all three core service components ― made an original $100 million investment in developing its crisis continuum but realized close to $260 million budget-saving stemming from reduced inpatient care.
14
States across the nation are working to upgrade their emergency crisis systems before 988 comes to fruition on July 16, 2022. However, implementing a seamless, comprehensive crisis system comes at a cost. As people with serious mental illness tend to have overlapping risk factors of poverty, many people who experience mental health crises are often on Medicaid or are uninsured, making it difficult for public entities to secure reimbursement. While public mental health agencies can bill Medicaid for some crisis services, the code can only be used if the team discovers the person’s name and insurance status, which are not always accessible in emergency situations. As such, agencies may be reluctant to start or expand a mobile crisis team, knowing that many of the crises they attend may be non-billable services. Some of the mobile crisis units are managed by programs with well-developed networks of services, including social work/case management, counseling, clinical care, and substance abuse treatment. The problem is that crisis response programs are often responsible for identifying funds to cover the costs of the important services. While many mobile crisis units receive reimbursement from third-party payers such as insurance companies, the revenues may not be adequate to maintain the necessary staffing levels — sometimes affecting their ability to respond to a crisis promptly. For example, in reaction to continued advocates’ calls to reallocate police department funding to mental health resources and other social programs, the Montgomery County, MD Council will expand its mobile crisis response unit by almost $600,000. The county’s Behavioral Health and Crisis Services currently receives approximately $5.5 million to operate a two-person mobile crisis response unit. The additional $592,000 would be used to expand the response team from one to six units across the county, with at least one social worker in each unit. Additionally, the county would deploy mental health professionals instead of police when there is a resident in need of psychological assistance.
According to the council, is intended to “reduce the need for police response or [to] assist police in de-escalating and addressing from a health and human service perspective situations that arise from an underlying behavioral health issue.” Certified Community Behavioral Health Clinics The proliferation of Certified Community Behavioral Health Clinics (CCBHCs) are raising the standards of crisis response. The CCBHC model offers new funding and reimbursement mechanisms to 340 existing behavioral health service organizations across the country who applied for the implementation. CCBHC sites are specifically mandated to expand 24/7 crisis response services as part of its contractual service agreement. Moreover, the new structure requires service provision regardless of a person’s eligibility, so crisis services can be supported whether someone’s mental health diagnosis is mild, moderate, or severe and persistent. The criteria expansion is key to crisis service expansion, as it widens the door to service for anyone in crisis, not just those with severe and persistent concerns. The exciting new funding model has shown promise in its demonstration and expansion sites across the country, but several states, counties, and public service providers have not received CCBHC funding, and remain limited in their crisis service provision to traditional Medicaid reimbursement. Strategies for Funding Expanded Emergency Behavioral Health Crisis Services In making recommendations on options for overcoming that barrier, the National Association for Behavioral Healthcare ― a leading national behavioral health organization ― takes the position that states will likely be able to access several existing Center for Medicaid Services (CMS) initiatives that will fund the transition to a fully deployed 988 behavioral health crisis service. It is assumed that such CMS initiatives are potential resources as funding streams for crisis stabilization services. This option was actually articulated in a November 2018 letter from CMS to state Medicaid directors titled Opportunities to Design Innovative Service Delivery Systems for Adults with a Serious Mental Illness or Children with a Serious Emotional Disturbance.
15
With the passing of the Cures Act in 2016, CMS added a new initiative to the Substance Use Disorder (SUD) model which gave states assistance to expand access to care for SMI and SUD populations enrolled in Medicaid. This provision not only included mental health and primary care integration, and improved treatment access, but also asked states to include in their funding application, a full assessment of their existing SMI/SUD provider capacity, including provider gaps in behavioral health crisis stabilization services. To get around Medicaid Congressionally imposed spending authority, CMS is allowed to use Section 1115 Medicaid demonstration waivers ― that allow states to seek special demonstration project funds for innovative models for meeting a critical health/behavioral health need for Medicaid beneficiaries. With the 988-transition nearing, more states are currently able to apply for applicable 1115 demonstrations. States also have the option of using existing Medicaid regulations to expand their crisis care infrastructure for 988. For example, the aforementioned CMS letter to state Medicaid directors clearly states that Medicaid can be a source of funds for crisis stabilization programs ― without a section 1115 demonstration and even crisis call centers. Existing Federal Funding and Proposed Federal Legislation The demand for an overhaul of the nation’s behavioral health emergency crisis response systems has not gone unheard by some members of Congress and the White House. There are several funding bills that have been introduced that target funding for non-police behavioral health crisis services. The following is a list of current and potential federal funding sources. • The American Rescue Plan Act of 2021 (ARPA) includes assistance to states to provide community mobile crisis intervention services for a five-year period beginning in April 2022. This support comes in the form, an 85 percent enhanced federal matching reimbursement rate for qualifying services for the million in state planning grants to for the first three years of a state’s coverage of an emergency mobile crisis. As an additional incentive to expand mobile crisis, ARPA includes $15 million in state planning grants to support detailed amendments to their existing mobile crisis plans ―or submit a Medicaid waiver request (e.g., Section 1115, 1915(b) or 1915(c)) to fund the mobile crisis service expansion. • Medicaid Demonstration Waivers ― There has been a long-standing rule in the Social Security Act which states ― for Medicaid purposes―that federal reimbursement is not available to institutions for mental diseases (IMD). Over the years, Section 1115 Medicaid demonstration waivers have been used to circumvent IMD exclusion. The rationale for the waivers was to encourage states to come up with innovative ways to provide newly emerging essential services for Medicaid eligible individuals. With transformative changes to 911 emergency crisis systems and the imminent start of the 988mental health/suicide prevention call centers, 1115 waivers are deemed to be a viable route for supplemental funding of mobile crisis services. Behavioral Health Crisis Services Expansion Act ― This legislation is intended to “empower communities to establish a continuum of care for individuals experiencing mental or behavioral health crises, and for other purposes.” The bill was introduced by Senator Cortez Masto (D-NV). The crisis response continuum will include the following components: • Crisis Call Centers. —Regional clinically staffed crisis call centers that provide telephonic crisis intervention capabilities. • Mobile Crisis Response Team —Teams of providers that are available to reach any individual in the service area in their home, workplace, or any other community-based location of the individual in crisis in a timely manner. • Crisis Receiving and Stabilization Facilities — Which are subacute inpatient facilities that provide shortterm observation and crisis stabilization services to all referrals. • 3 (B) Short Term Crisis Residential Services —A direct care service that assists with deescalating the severity of an individual’s level of distress or need for urgent care associated with a substance use or mental health disorder in a residential setting. • Behavioral Health Urgent Care Facilities — Are ambulatory services available 12–24 hours per day, 7 days a week, where individuals experiencing crisis can walk in without an appointment to receive crisis assessment, crisis intervention, medication, and connection to continuity of care. 16
6. Workforce Implications of Crisis Services When discussing emerging behavioral health crisis service models, it is equally important to talk about the workforce implications ― including social workers ―of a transforming national behavioral health crisis service. Crisis services have always been dependent on a workforce that includes licensed behavioral health professionals, and ― in some cases―non-degreed or credentialed staff such as peer support specialists. It should be mentioned that there is a point of view that peer specialists and unlicensed staff are not a substitute for trained clinical providers. On the other hand, some studies suggest that volunteers and peers perform better in crisis situations than clinically trained professionals; some clinicians may be more steeped in academic backgrounds than ‘street smarts’ and be overly focused on diagnostic criteria than basic empathy and listening skills needed in crisis situations. In any event, as behavioral health crisis services expand and develop universal staffing standards, the workforce will need to be expanded accordingly. Some examples where this workforce will be needed are in crisis service components including the following: Crisis call lines. With the imminent arrival of the national 988 crisis system, it is anticipated that there will be an increased demand for non-licensed and less credentialed staff to operate their crisis lines. For example, in Colorado, peers and bachelor-level crisis counselors staff address pre-acute crises situations, while credentialed crisis counselors and licensed clinicians address acute crises that require more intensive or specialized intervention. Mobile crisis teams. The workforce composition for Mobile Crisis Teams will vary from state to state, and county to county ― with a priority being placed on efficiently using licensed clinicians to provide remote consultation or oncall supervision. Again, in Colorado, a peer specialist and a bachelor's-level clinician work together to respond on-site to a crisis ― with licensed clinicians being immediately available via telehealth. Crisis centers. As the nation’s behavioral health crisis service models proliferate, crisis centers will likely expand the use of a workforce that is a mixture of peer and highly trained clinicians to facilitate reducing the length of emergency hospitalization stays, to decrease the need for behavioral health professionals. The argument is that peer and bachelor-level staff are key to stabilizing individuals in crisis and coordinating their care.
As behavioral health crisis service models grow, a primary goal will be to quickly stabilize individuals, who are in crisis, in less intensive settings. To achieve that goal, the workforce will have to have a mix of peer, mid-level, and highly trained clinicians. However, given the workforce shortage of licensed and credentialed clinicians ― especially in rural areas, it will be more probable that states will opt to plan a behavioral health crisis workforce that is less dependent on professionals with higher levels of training.
17
Social Workers’ Role in Behavioral Health Crisis Services From a social work perspective, of the many reforms in law enforcement and changes in how public safety policies and practice are modified, it is the national transformation of behavioral health crisis structure that impacts the profession the most. Given the confluence coincidence of the reimaging law enforcement movement and the simultaneous emergence of the 988-emergency suicide crisis system, there will be a near-certain paradigm shift in behavioral health crisis response. Social workers are an essential part of the behavioral health crisis responder workforce. The profession must have a voice in this transition. It may not be common knowledge, but social work practitioners account for the largest percentage of the behavioral health workforce in the United States. For that reason, social workers could, and should,become primary responders to emergency behavioral health crises. As a profession, social workers have a firm understanding of barriers, gaps, and needs of those experiencing a behavioral health crisis. Therefore, the profession is positioned to add to the national-level dialogue on improving the behavioral health crisis care continuum. In addition, the National Association of Social Workers (NASW) has, for many years, had a voice in the policy and practice debates related to the country’s community-based behavioral health system, reimagining the criminal-legal system, advocating for expanded behavioral health funding from Medicaid/Medicare, and third party payors such as private sector insurers. All of these debates intersect with the current wave of transformation across the national behavioral health crisis continuum. Social workers have come to understand how interdisciplinary multi-sector collaboration is essential to improve behavioral health crisis services for those who need them. This includes working with other stakeholders to re-engineer crisis services and integrate the 988 call center systems into comprehensive seamless (non-law enforcement) services, accessible to all individuals needing emergency care. In the National Association of Social Workers’ (NASW) social justice brief ― Reimagining Policing: Strategies for Community Reinvestment (socialworkers.org)― we speak to those issues. As the country has moved towards meaningful reforms in policing in the area of emergency behavioral health crisis response, references to this transition have been increasingly evoked. As a leading criminal justice reform organization, Social Workers address crises regularly and without an armed police officer standing in front of us. Often, the presence of an armed officer escalates a crisis that could have been better handled by mental health professionals alone. While it is an accurate description, the statement does not capture the long history of social workers as behavioral health crisis responders. During the community mental health movement of the 1960s and the movement to end homelessness of the 1980s, street outreach, mental health stabilization beds, and mobile crisis teams were components of community outreach models. Amid major system changes, prompted by a need to reimagine behavioral health crisis response models, the social work profession is being called upon to utilize its unique skills in helping to improve the nation’s emergency crisis services. As the 911 and 988 systems continue to evolve, the profession must remain intimately engaged with government and non-governmental stakeholders in assuring that a revamped behavioral health system addresses issues of racial equity and the need for quality comprehensive services, especially for marginalized populations. Social work has lent its policy and service delivery perspective to the debate about law enforcement reforms, and social workers should continue to push for reform until crisis systems can respond to anyone, anywhere, at any 18 time with dignity and respect.
RECOMMENDATIONS Given documented evidence-base of community-based models, the Biden Administration and Whitmer Administration should prioritize technical assistance and financial support for localities interested in piloting non-police behavioral health response. Public health experts have long been insisting that state mental health and substance use services has long been inadequately funded. Increased behavioral health funding must coincide with the movement to non-police community emergency response services. It is recommended that providers adhere to Substance Abuse Mental Health Services Administration’s (SAMHSA) best practices to meet the minimum expectations to Operate Mobile Crisis Team Services by: Incorporating community peers within the mobile crisis team. Responding without law enforcement accompaniment unless special circumstances warrant their inclusion. Implementing real-time GPS technology in partnership with the region’s crisis call center hub to support efficient connection to needed resources and tracking of engagement; and Scheduling outpatient post-crisis follow-up appointments in a manner synonymous with a warm handoff in order to support connection to ongoing care. Reimagined behavioral health crises should consider establishing secure crisis center(s) linked to enhanced urgent care accessible in the community. Comprehensive behavioral health crisis care services should operate from an ethics perspective to ensure that no one is turned away from services when needed. Comprehensive mobile crisis must have the capacity and trained staff to respond to both adult and children behavioral health emergencies; along with enhancing the current children’s mobile crisis capabilities. Social workers should maintain a clear separation from law enforcement by resisting being embedded as direct employees of law enforcement agencies. Instead, social work crisis providers are ideal as members of community-based crisis response systems such as mobile crisis units, and as co-responders in collaboration with law enforcement.
19
Conclusion The intersection of the reconfiguration of behavioral health crisis response services, triggered by the reimagining policing movement and the transition to the 988 crisis line, has the potential to be truly transformative. Recent social movements have shown how national service delivery models can be prompted to make important changes in their structure and design relatively quickly. For example, the influence of the reimagining policing movement has been responsible for affirming that non-police community-based responders is a viable approach to behavioral health crisis services.
Resources
What is clear is that the intersection of what could be seen as disparate national events ― the reimaging policing movement and the emergence of the 988 crisis call centers― could enhance the nation’s capacity to provide comprehensive behavioral health services to individuals in crisis. Of equal importance, the renewed national emphasis on community mental health ― and corresponding de-emphasis on police involvement ― could result in lowered numbers of police encounters that result in deaths and serious injuries to individuals experiencing behavioral health crises.
Mental Health America and Vibrant Behavioral Health - FAQ for Understanding 988 and How It Can Help with Behavioral Health Crises. FAQ with vibrant FINAL COPY.pdf (mhanational.org)
The hope is that behavioral health stakeholders, including social workers, become galvanized in a collective effort to reshape the approach to behavioral health crisis services in a way that both creates an effective crisis service continuum and accommodates the integration of a cohesive 988based crisis response model, in 2022 and beyond.
The Action Alliance- 988 Crisis Response: Policy Messaging Toolkit 988_policy_messaging_toolkit.pdf (theactionalliance.org) Common Ground – Commongroundhelps. org #Crisis Talk- The Troubling History of 911 and How 988 Can Avoid the Same Missteps. The Troubling History of 911 and How 988 Can Avoid the Same Missteps - #CrisisTalk (crisisnow.com) Harvard Kennedy School Program for Criminal Justice Policy and Management Integrated Health Care and Criminal Justice Data — Viewing the Intersection of Public Safety, Public Health, and Public Policy Through a New Lens: Lessons from Camden, New Jersey (harvard.edu)
Michigan Department of Health and Human Services Michigan Behavioral Health Crisis Service CMHSP 2020 Survey Results The Group for the Advancement of Psychiatry Roadmap for the Ideal Crisis System: Essential Elements, Measurable Standards and Best Practices for Behavioral Health Crisis Response Treatment Advocacy Center: Overlooked in the Undercounted overlooked-in-the-undercounted.pdf (treatmentadvocacycenter.org) Network 180 - Network180 | Network 180 SAMHSA - National Guidelines for Behavioral Health Crisis Care national-guidelines-for-behavioral-health-crisis-care02242020.pdf (samhsa.gov) Well- Being Trust. Building Blocks: How Medicaid can Advance Mental Health Mental Health and Substance Use Crisis Response. WBT Medicaid and MH Report.indd (wellbeingtrust.org)
20