State and local governments have been playing an increasingly central role in behavioral health crisis models of care that provide early intervention. A new issue brief from the Milbank Memorial Fund argues that especially in the wake of COVID-19, such investments could improve outcomes and save money by reducing the need for emergency department visits, unnecessary hospitalizations, and the involvement of the criminal justice system.
A behavioral crisis model typically assembles a network of services comprising: a 24-hour crisis call center hub; community-based mobile crisis teams; and facilities designed to stabilize patients, the report notes. The issue brief makes the case that mental health crisis programs have shown good results both clinically and fiscally. “States are playing a growing role in implementing comprehensive programs that are funded through Medicaid, state-only revenue dollars, county and local monies, and donations and investments by insurers and private health care organizations within the community.”
The three-pronged behavioral health crisis model is based on the 2016 “Crisis Now” recommendations developed by the National Action Alliance for Suicide Prevention and refined by the global consultant RI International.
The Milbank issue brief, authored by Stuart Yael Gordon, director of policy and communications for the National Association of State Mental Health Program Directors (NASMHPD), provides in-depth assessments of programs in three states: Arizona, Georgia and Tennessee.
The report cites one study of the Crisis Now system in Maricopa County, Arizona, which includes all three core components. Its deployment led to a potential reduction in inpatient spending of $260 million, after adding the $100 million investment in crisis continuum.
Gordon noted that although many states are trying to make sure that all three behavioral health crisis program components are available to residents, others have implemented crisis service models that contain at least some of the elements in the Crisis Now model. “In addition,” he wrote, “services may be managed regionally or locally, so services may be available in one part of a state but not another. Often, as is happening now in Arizona and as occurred in Georgia, the success of the model in one community leads to its expansion throughout the state.”
The issue brief concludes by noting that to achieve a consistent and comprehensive approach to behavioral health crisis, advocates must work to create a sustainable funding stream that supports the model.
Progress on comprehensive crisis response is happening at the county level as well. For instance, working in partnership with cities across Contra Costa County in California, Contra Costa Health Services (CCHS) has launched a comprehensive review of existing behavioral health crisis response services to develop a vision for how to connect residents with the most appropriate resources where and when they are needed.
In collaboration with city leaders through the Contra Costa Public Managers Association, community stakeholders, service providers and staff from across the county recently participated in a multi-day workshop to identify current resources and next steps. Workshop participants included those working in crisis response, community-based organizations, schools, police and dispatch, as well as clinicians and persons and family members with lived experiences.
The process prioritized these areas of focus for the next steps:
• Identifying a single number to call for behavioral health crisis response;
• Establishing a mobile crisis 24/7 response;
• Evaluating non-police mobile crisis team composition; and
• Identifying alternate destinations for those experiencing behavioral health crisis.
In a separate blog post on the Milbank Memorial Fund website, Rachel Block detailed some lessons from a forum of state health policy leaders about expanding and sustaining a behavioral health crisis system. Key findings from the state leaders’ experience include:
• Keep the vision of a consistent, comprehensive, and coordinated system of behavioral health care in mind even though these systems are often built incrementally.
• Engage a wide variety of sectors, including health care, law enforcement, judiciary, and social services, early in the process.
• Understand that funding complexity (using Medicaid, state general funds, local contributions, and various grants) makes it challenging to build a sustainable model.
• Collect data and report on program outcomes to sustain political and funding support.
Block also wrote about another promising development — the creation of a nationwide “988” line. In October 2020, President Trump signed the National Suicide Hotline Designation Act, making the 988 line the universal telephone number to reach national crisis services. Milbank has noted that implementation of the three-digit call number will make crisis services provided by a lifeline more instantly accessible and thereby more effective in responding to personal mental health crises, suicidal ideation, and drug overdoses.
She concluded her blog by referencing the death of Daniel Prude in police custody in Rochester, N.Y., this past March hours after being released from a hospital emergency room. Block wrote that this demonstrates the tragedy that can result from a poor response to a behavioral health crisis. “Federal designation of “988”and state and local efforts to knit together call centers, mobile responses, and stabilization services give some hope that better behavioral health crisis systems are possible. With this model in place, the next frontier will be a stronger, follow-up support system for ongoing community-based behavioral health care.”
