Community-Based Crisis Services, Specialized Crisis Facilities, and Partnerships With Law Enforcement
Abstract
How a community responds to behavioral health emergencies is both a public health issue and a social justice issue. Individuals experiencing a behavioral health crisis often receive inadequate care in emergency departments, boarding for hours or days while awaiting treatment. Such crises also account for a quarter of police shootings and 2 million jail bookings per year, and racism and implicit bias magnify these problems for people of color. Fortunately, the new 988 mental health emergency number compounded with police reform movements have created momentum for building behavioral health crisis response systems that deliver comparable quality and consistency of care as we expect for medical emergencies. This paper provides an overview of the rapidly evolving landscape of crisis services. The authors discuss the role of law enforcement and various approaches to lessening the impact on individuals experiencing behavioral health emergencies, especially for historically marginalized populations. The authors provide an overview of the crisis continuum, including crisis hotlines, mobile teams, observation units, crisis residential programs, and peer wraparound services that can help ensure that linkage to aftercare is successful. The authors also highlight opportunities for psychiatric leadership, advocacy, and strategies for creating a well-coordinated crisis system that meets the needs of the community.
How a community responds to behavioral health emergencies is both a public health issue and a social justice issue. For too long, our institutions have been structured to produce terrible outcomes, beginning with the moment someone asks for help. Police—not ambulances or health care workers—are typically dispatched to respond to 911 calls for mental health and substance use–related emergencies. Consequently, individuals experiencing a behavioral health crisis account for a quarter of police shooting deaths and over 2 million jail bookings per year. Those who make it to the emergency department (ED) do not fare much better. Many EDs lack mental health services and can offer little other than medical clearance, sedating medications, and a referral to an inpatient hospital bed. Even if psychiatric consultation is available, it is difficult to create the safe and calming environment needed for effective treatment inside of the cramped and chaotic ED setting. As a result, individuals in need of more specialized care can spend hours, or even days, awaiting transfer to a psychiatric hospital. During this time, they are often kept in isolation, monitored by nonclinical personnel such as sitters, security guards, or police, and may be restrained to a gurney if they become agitated.
Fortunately, the conditions are ripe for transformative change. The new 988 Suicide and Crisis Lifeline number implemented in 2022 provides an alternative to 911 for anyone in the United States experiencing a crisis related to mental disorders or substance use. This new three-digit emergency number has the potential to catalyze a much-needed expansion of community-based crisis services that can better meet the needs of people experiencing behavioral health emergencies, similarly to how 911 stimulated the development of the emergency medical response (EMS) and trauma center system we take for granted today. As a next step, the Substance Abuse and Mental Health Services Administration (SAMHSA) has outlined a core set of crisis services in which everyone has “someone to talk to, someone to respond, and a place to go” (1). These initiatives have broad bipartisan support. Each state has received funds targeted for crisis services and are in various stages of planning and building mobile crisis teams (MCTs), behavioral health urgent care centers, crisis observation and stabilization centers, and crisis residential services. Furthermore, there is consensus among mental health advocates, police reform movements, and law enforcement agencies themselves that police should no longer be the default first responders to behavioral health emergencies. Community leaders are working to create alternatives that provide a “health-first” response that strives to connect individuals with crisis care instead.
As this burgeoning field continues to develop, it is important for psychiatrists to be familiar with the continuum of community-based crisis services and the role that law enforcement plays in crisis response. Crisis programs are a preferable alternative to calling the police or going to the ED, and psychiatrists must be able to not only make proper referrals but also educate patients and families about these options when developing safety plans for individuals in their care. Furthermore, building and maintaining a crisis system is a collaborative effort that spans many agencies, institutions, and stakeholders, and this rapidly growing field presents exciting new practice options and leadership opportunities for psychiatrists who want to be involved in shaping the face of crisis care in their communities.
Defining Crisis
Because crisis services are typically funded and regulated at the state or local level, there is substantial regional variation in terms of program definitions, financing, licensure, accessibility, and quality. Even the definition of crisis can vary. Some definitions focus on risk of harm, whereas others defer to the individuals to determine for themselves what constitutes a crisis. Systems are increasingly adopting the latter self-determination approach. The term crisis itself possibly perpetuates the stigma and disparities attached to mental health. Why use separate terminology to distinguish mental disorder and substance use emergencies from other types of health emergencies? Does this distinction make it easier to accept a lesser standard of care for behavioral health emergencies? In this article, the authors conform to the current usage of crisis as interchangeable with emergency. Behavioral health is used to encompass both mental health and substance use disorders and services, and the expectation is that all crisis services can address both.
Behavioral Health Emergencies and Intersection with the Justice System
As long as law enforcement remains the default first responder for behavioral health emergencies, a request for help places individuals in crisis at increased risk of incarceration and death, especially for people of color. In the United States, people experiencing behavioral health emergencies account for a quarter of police shootings, half of which occur in the person’s own home, with rates of death highest for Black Americans (2). Training programs can provide law enforcement with tools to recognize and de-escalate situations in which individuals are experiencing behavioral health emergencies, but officers often encounter barriers when trying to connect people to the treatment they need. For example, many EDs require officers to wait for hours while the person awaits transfer to a psychiatric hospital. Without an easy way for law enforcement to connect the person to needed treatment, people with mental illness are often arrested for nonviolent “nuisance” or “quality-of-life” offenses such as loitering or vagrancy, and the prevalence of mental illness and substance use disorders in jails and prisons are three to four times that of the general population (3, 4). For those struggling with substance use disorders, disparate sentencing penalties (e.g., harsher sentences for crack vs. powder cocaine) result in the excessive imprisonment of Black Americans (5). Unsurprisingly, Black Americans are less likely to call 911 for help with a mental health crisis (6).
In recent years, social justice and policing reform movements such as Black Lives Matter have increased the momentum for rethinking and reducing the role of law enforcement in responding to behavioral emergencies in favor of a “health-first” response, which instead routes behavioral health–related calls for service to clinical programs such as crisis lines and MCTs. Law enforcement involvement is unlikely to be eliminated, however, as some situations may pose an unacceptable amount of safety risk to civilian clinicians, and other behavioral health emergencies may not become apparent until after officers are on the scene for another issue. Even when clinical crisis options exist, civil commitment laws often require law enforcement to transport individuals to treatment facilities. However, a survey of law enforcement agencies estimated that 65% of these transports did not pose a risk of harm to others and could be completed by another entity (7). Many of these laws were written decades ago and should be updated to include earlier interventions and alternative crisis responses rather than relying so heavily on police.
The sequential intercept model (Figure 1) is a conceptual model designed to help communities plan services and protocols aimed at preventing or decreasing criminal justice involvement for people with behavioral health conditions (8). It describes the typical pathway through the criminal justice system and identifies opportunities for the health care system and other community programs to intervene. Intercept 1 focuses on programs that provide law enforcement and 911 call takers with tools and processes to recognize individuals experiencing behavioral health emergencies and connect them to treatment. The upstream Intercept 0 was added in recognition that an easily accessible crisis system can potentially prevent the 911 call or police interaction altogether.
FIGURE 1. The sequential intercept modela
aIntercepts 0 and 1 focus on programs that minimize law enforcement interactions and prevent the arrest of people experiencing behavioral health emergencies by instead connecting them to the treatment they need.
The Crisis Intervention Team (CIT) Model
CIT programs provide law enforcement with tools to recognize individuals experiencing a behavioral health crisis, de-escalate the situation, and divert the individuals to treatment instead of arrest (9). This model began in the late 1980s in Memphis, Tennessee, in response to a police shooting involving a Black man with mental illness. Its centerpiece is a 40-hour training that involves scenario-based exercises and the participation of community stakeholders such as clinicians, treatment agencies, people with lived experience of mental illness, families, and advocacy groups. Other core components include processes for 911 call takers to identify mental health calls and strategically dispatch CIT-trained officers to those calls; availability of a crisis facility where officers can quickly and easily drop off individuals in need of mental health care; and strong partnerships between law enforcement, advocacy organizations, and mental health systems. CIT International and the National Council for Mental Wellbeing recommend that all uniformed patrol officers receive a basic 8-hour training such as Mental Health First Aid for Public Safety, whereas the 40-hour CIT training is voluntarily undertaken by a subset of officers large enough to ensure 24/7 availability of trained officers to respond to mental health calls. This approach ensures both a basic level of competency among all officers and 24/7 availability of a self-selected group of CIT-trained officers with the interest and aptitude for responding to mental health crisis situations (10).
CIT encourages communities to adapt the model to its needs, allowing departments to develop their own curricula and tailor processes to work with local mental health systems. Although pragmatic, this approach creates research challenges (11). Without a standard implementation or fidelity tools to measure variability across programs, comparative research is difficult, and studies are often mixed or inconclusive. In addition, most studies focus on the effects of CIT training without addressing the other components of the model such as availability of crisis services and community partnerships (12). There is strong evidence that CIT training improves officers’ knowledge and attitudes about mental illness and treatment. CIT-trained officers are more likely to report verbal de-escalation as the highest level of force used (13) and use less force with more resistant subjects (14). System-level studies of outcomes pre- and postimplementation show increases in transports to mental health facilities (15); however, the effects are mixed on arrests (13, 16, 17) and overall cost-effectiveness (18, 19). Some of this variability may be related to officer selection. Newer research demonstrates that, compared with officers mandated to receive CIT training, voluntarily trained officers demonstrate better self-efficacy, de-escalation skills, and referral decisions. Even when physical force was documented, voluntarily trained CIT officers were more likely to refer to treatment services and less likely to make an arrest (20).
Another potential source of variation may be the availability of mental health crisis services in any given community (21). Although CIT is often thought of as a police training program, its creators continue to underscore that training is only one piece of a more comprehensive and community-based approach. Once officers are trained to identify a person in crisis and divert them to treatment, their first question is often “Divert to what?” Thus, the full CIT model recommends a crisis system that officers can easily access so that jail does not become the path of least resistance. In other words, the health care system should make it easy for officers to “do the right thing” and bring people in crisis to a place where they can receive care instead of jail.
The Crisis Continuum: Community-Based Alternatives to Hospitals, EDs, and Jail
Mental health systems should include a wide range of accessible treatment options so that each individual’s needs are met in the least restrictive, least disruptive, and most community-integrated setting possible (22). For people experiencing behavioral health emergencies, crisis services can serve this function by lessening the need for more restrictive levels of care such as the ED or inpatient hospitalization (23). The more robust the continuum, the more options for resolving the crisis in nonhospital settings. Like other essential safety net systems, crisis systems should be able to serve everyone, regardless of payer, age, or acuity, including those most in need of specialized psychiatric care such as people who are under involuntary commitment, who are highly agitated, or who have co-occurring needs related to substance use disorders.
SAMHSA’s National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit defines a core crisis continuum as consisting of three types of services: someone to talk to (crisis lines), someone to respond (mobile crisis), and a place to go (crisis facilities) (1). The National Council for Mental Wellbeing’s Roadmap to the Ideal Crisis System includes additional community-based programs such as crisis residential and outpatient wraparound services to ensure that the individual remains stable after the crisis or to prevent a developing crisis from escalating (24). It also discusses system design elements such as financing, oversight, and quality improvement, and it includes tools for communities to assess their progress.
Someone to Talk to: 988 and Crisis Contact Centers
Crisis lines provide a low-barrier point of entry to crisis services by making it possible for anyone to ask for help quickly, easily, and, if desired, anonymously. Telephonic crisis counseling began in the 1950s with volunteer-staffed crisis lines, and since then, the field has evolved to encompass a wide range of programs that vary in scope, funding, and staffing. Today’s crisis contact centers may provide support by means of telephone, chat, or text by any combination of volunteers, peers, or clinical professionals. Suicide hotlines often include a mix of clinical professionals and volunteers, and “warm lines” are staffed by peers and focus on nonemergency calls for emotional support. In some communities, crisis calls have been handled by information lines such as 211 and 311 and help with connection to services that address social determinants of health such as food insecurity and transportation.
The National Suicide Prevention Lifeline was created by SAMHSA in 2005 to improve access and standardization by linking local crisis lines through a single toll-free number (1-800-273-TALK) that routes the caller to the nearest available call center. Since then, the Lifeline has grown into a network of about 200 call centers across the United States, staffed by call takers trained in applied suicide intervention skills training, and includes a specialized veterans crisis line, live Spanish-language services, translation services for more than 250 other languages, and capability for chat and text. In 2022, the Lifeline transitioned to a universal three-digit dialing code (988) administered by SAMHSA and Vibrant Emotional Health. This has catalyzed increased investment in developing 988 into an essential safety-net service with funding for strengthening infrastructure, expanding capacity, and raising standards. As 988 continues to rapidly evolve, the most up-to-date information can be found on SAMHSA’s 988 resource website (www.samhsa.gov/988) and on the https://988lifeline.org website itself.
Although 988 is sometimes referred to as “the 911 for mental health,” it is important to emphasize the ways in which 988 is different, especially for communities of color who may be understandably wary of calling 911. When someone calls 988, a trained crisis counselor will listen and collect information, provide support, and help connect the caller to resources. Most behavioral health–related crisis calls can be resolved in this manner. Studies of Lifeline call centers have found that callers have significantly decreased suicidality during the course of the call and that their hopelessness and psychological pain continues to lessen over the subsequent weeks (25). Of those receiving referrals to mental health services, over half report either following through with the counselor’s specific referral or accessing a similar service (26). In contrast, the 911 system is designed to quickly triage calls so that emergency personnel (i.e., police, fire, and EMS) can be dispatched to the caller’s location as soon as possible and generally does not attempt to provide counseling and crisis resolution over the phone.
Concerns have been raised on social media and other news outlets that 988 calls could lead to police involvement and involuntary treatment (27). In response, Vibrant Emotional Health and SAMHSA have emphasized that 988 does not have the ability to pinpoint a caller’s exact location and only involves law enforcement as a last resort if there is an imminent threat to life (28). In the first 6 months of 2022, only 2% of the Lifeline calls required the activation of 911, half of which occurred with the caller’s consent (29). Many crisis contact centers are working to further reduce law enforcement involvement by creating processes for 911 to route mental health calls to 988 instead of sending police. Others are developing “air traffic control” functions to better connect people to local crisis resources such as MCTs, outpatient appointments, and bed placement.
Someone to Respond: MCTs, Multidisciplinary Response Teams (MDRTs), and Law Enforcement Co-Responder Teams
MCTs are typically one- to two-person teams that respond to and provide interventions for individuals in crisis wherever they may be—at home, on the street, and so forth. In some communities, MCTs provide services to patients boarding in EDs who might not otherwise have access to a timely mental health assessment. These field-based interventions often eliminate the need to transport the patient to a higher level of care.
The scope and composition of MCTs vary widely and can include a mix of licensed or unlicensed clinicians, peers, nurses, and EMS clinicians. In addition, a variety of co-responder models are emerging in which a clinician or peer is paired with first responders such as police officers or EMS personnel. For this reason, they are sometimes called MDRTs. Team members may ride and respond together, arrive separately, or involve the clinician by means of phone or video. The use of MCTs and non–law enforcement MDRTs is considered a “health-first” response, because teams are composed of clinicians rather than law enforcement. Another health-first strategy is to recruit responders and peers who reflect the communities they serve, especially for communities of people who are Black, Indigenous, and people of color, who have a historical basis for distrust in the medical establishment (30).
Although an increasing number of communities across the United States are dispatching these teams instead of law enforcement, with favorable results (31), more research is needed to determine which models work best for which populations and communities. Qualitative studies indicate that most people prefer MCTs or co-responder teams to police-only teams (32). In particular, they value responders with mental health knowledge, verbal de‐escalation skills, and a compassionate, empowering, and noncriminalizing approach (33). Studies of other outcomes have been mixed (11). One review of police and mental health co-responder programs concluded that these programs decreased arrests and the amount of time officers spent handling mental health calls, but evidence was limited for other impacts (34). However, applicability of these studies across communities is problematic because of the wide variation in team composition, hours of operation, available resources, geography, and so forth. In the meantime, communities will have to tailor programs to fit their needs as best practices emerge.
A Place to Go: Specialized Crisis Facilities
Crisis facilities can serve as a safe and therapeutic alternative to hospital EDs, inpatient psychiatric units, and jails. A good working knowledge of, and relationship with, the programs available in the local community can open new opportunities for providing safe and effective care in less restrictive community-based care instead of inpatient admission. However, crisis programs vary widely in scope, capability, and populations served. Some are designed for individuals with low acuity who primarily need peer support and a safe place to spend the night, whereas others can treat individuals with the highest acuity presenting with suicidal behaviors, acute agitation, and substance intoxication. Some are freestanding, whereas others are embedded in or attached to hospital EDs. Furthermore, because most crisis services are financed and regulated at the state level, facility licensure and nomenclature differ widely from one state to another, rendering the term crisis stabilization unit meaningless. Expert reports such as SAMHSA’s National Guidelines for Behavioral Health Crisis Care (1) and the National Council for Mental Wellbeing’s Roadmap to the Ideal Crisis System (24) have attempted to catalog types of programs, but no standard classification system yet exists. For now, communities should focus on clearly defining the population that can be served in each facility. Lack of a shared understanding of admission and exclusion criteria can lead to unsafe conditions (e.g., when an individual with high acuity is sent to a program that is unable to safely address their needs) and delays in treatment (e.g., disputes over whether a program should accept a referral).
Medical capability.
Crisis facilities vary in their capability to manage co-occurring medical issues. Terms such as medical clearance and medically clear are imprecise and being supplanted by more useful and descriptive discussions of assessing medical stability and managing acute medical and nursing needs (35, 36). As a general rule, crisis facilities should be able to care for individuals who, if not for their behavioral health emergency, would be able to return home without the need for home health or other specialized nursing care. Crisis programs should have clear admission criteria and the capability to screen for medical conditions that require further evaluation and treatment. However, programs should avoid blanket requirements that all referrals receive screening evaluations in the ED. Routine screening labs are not supported by the evidence and are of little clinical utility (36); and from a systems perspective, sending all referrals through the ED defeats the purpose of creating such programs as an alternative to the ED. The use of standardized screening protocols and regular communication between ED and crisis program leaders can help facilitate smooth referral processes and prevent disagreements.
Behavioral acuity.
Crisis facilities vary in their ability to manage individuals with high acuity, and clear expectations and referral processes are needed to ensure that individuals are matched to a program that can safely and effectively meet their needs. A crisis system should be able to serve everyone in need of crisis care, including those who are acutely agitated, violent, suicidal, or have substance use disorder needs. Unfortunately, this population with high acuity is often excluded from crisis programs, even though they are most in need of specialized crisis care. In addition, local processes for civil commitment may determine the types of facilities available to those under emergency detention or involuntary commitment. Without a viable option for these individuals with the highest acuity, the crisis continuum is incomplete, and communities can be left wondering why they invested in crisis services yet still have problems with ED and jail utilization.
The Level of Care Utilization System (LOCUS) is a useful standardized framework for determining the appropriate level of care. Need is assessed on six dimensions: risk of harm; functional status; medical, addiction, and psychiatric comorbidity; recovery environment—both level of stress and support; treatment and recovery history; and engagement and recovery status (37). Facility-based services typically fall under LOCUS level 5 or 6. Level 6 includes inpatient-level care. Level 5 includes residential care and encompasses a range of medical and nursing involvement. The final assessment synthesizes all of these dimensions to guide decision making. For example, someone who expresses suicidal ideation may be able to be managed in a crisis residential setting (LOCUS level 5) if they are highly engaged, hopeful that treatment will be helpful, and nonviolent. Conversely, suicidal ideation may require a higher acuity setting like 23-hour observation (LOCUS level 6) if the person is poorly engaged, highly agitated, and so forth.
High-intensity and high-acuity crisis programs (LOCUS level 6).
These programs can care for the individuals with the highest acuity, including those who may be actively suicidal, acutely agitated or violent, intoxicated or in withdrawal, or those who may have involuntary legal status. The availability of a facility to accept law enforcement dropoffs is a critical component of the CIT model, and these programs often serve as the “receiving center” for local law enforcement. To incentivize the police to bring people for treatment, the center must have 24/7 availability, rapid (10-minute) dropoff times, and a policy of never turning officers or paramedics away (38, 39).
Care is provided by interdisciplinary teams that can include psychiatrists and other psychiatric providers, nurses, social workers, case managers, behavioral health technicians, and peers. Psychiatric coverage is typically on site or on call 24/7. These units are not simply holding areas for boarding patients awaiting transfer to an inpatient unit but rather short-term intensive treatment programs. Ideally, they blend the hospital-level safety standards with the more holistic and person-centered aspects of the recovery model to create a safe and therapeutic milieu. Some are designed as an open area with recliner chairs to facilitate continuous safety monitoring and interpersonal interaction. With rapid assessment, early intervention, and proactive discharge planning, most individuals treated in this setting can be stabilized and discharged to community-based care within 24 hours. This level of crisis care is associated with reduced rates of inpatient psychiatric hospitalization, ED boarding, and arrest (40–42).
These high-acuity and high-intensity programs vary widely in licensing and nomenclature. They may be part of or adjacent to an ED, part of or adjacent to a psychiatric hospital, or freestanding. Regional dedicated psychiatric emergency programs accept transfers from multiple EDs in a given area. Other commonly used terms for this level of care include 23-hour observation, crisis receiving center, psychiatric emergency services, and comprehensive psychiatric emergency program.
ED-affiliated crisis programs (LOCUS level 6).
Community-based programs are typically considered preferable settings for crisis care because they provide a less “medicalized” environment and because they help avoid unnecessary use of local hospital EDs. However, there are also situations where the ED is, indeed, the appropriate level of care because of co-occurring medical conditions such as overdose, serious self-injury, severe intoxication or withdrawal, vital sign abnormalities, altered levels of consciousness or delirium, and so forth. These are not isolated or unusual cases—rather, the numbers of behavioral health presentations to hospital EDs have risen over 50% in the past decade and now constitute 12%–15% of U.S. ED visits (43).
Despite the numbers, most hospital EDs are not designed with patients with behavioral emergencies in mind, and their often noisy, claustrophobic, and hectic environments can lead to worsening symptoms (44). It is this concern that has driven much of the emphasis on community-based crisis alternatives to EDs. Given that individuals experiencing behavioral emergencies will still come to EDs even when a robust array of community crisis programs exists, it is incumbent on hospitals to improve their behavioral emergency protocols and treatment environments and recognize that crisis intervention efforts should not end at the hospital doors. Furthermore, smaller communities may not be able to sustain a stand-alone community-based crisis facility that can accommodate the highest levels of behavioral acuity; therefore, quality emergency psychiatric care within the ED remains a vital component of the crisis system.
EmPATH (emergency psychiatry assessment treatment and healing) units are one example of a hospital-affiliated solution. These units are independently run specialized care settings directly affiliated with hospital EDs that provide a more spacious, comfortable, and homelike alternative to the typical ED environment (45). By utilizing the existing hospital infrastructure, EmPATH units can be scalable solutions for communities that cannot support a large stand-alone community-based crisis center. They can also be an important component of the regional crisis continuum of care, serving as that system’s designated site for the highest acuity emergency behavioral health interventions. EmPATH units have been shown to decrease ED boarding, length of stay, inpatient psychiatric hospitalization, and 30-day readmissions while also improving outpatient follow-up attendance and patient satisfaction scores, all in the context of less than 1% use of physical restraints or other coercive measures more common to the traditional ED experience (46).
Inpatientlike, subacute, and extended observation units (LOCUS level 5 or 6).
These units can be good options for individuals who need several days of stabilization but are too acute for lower-intensity programs. Acuity, intensity, and staffing vary depending on the program and state regulations. Some are indistinguishable from locked inpatient units, whereas others are residential units with high medical and nursing involvement.
Lower intensity and lower acuity crisis stabilization units (LOCUS level 5).
These programs are typically unlocked residential facilities that serve individuals who are voluntary, nonviolent, and motivated for help, and they are good options for individuals who need a more structured and safe recovery environment because of housing instability or a stressful home environment. Some programs accept direct police or mobile team dropoffs for those who meet admission criteria. The acuity of the individuals served in each setting depends on the level of medical and nursing involvement. Psychiatric coverage is typically a mix of on-site and on-call coverage, and nursing involvement can range from 24/7 on-site nursing care to various combinations of on-site and on-call coverage. Staffing often includes a combination of peers, social workers and therapists, behavioral health technicians, and sometimes EMTs.
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Detoxification centers provide medically supervised detox, typically with 24/7 on-site nursing care and a high level of medical and psychiatric involvement.
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Sobering centers provide primarily psychosocial and peer support with less medical and nursing involvement.
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Crisis residential programs offer intermediate-term (days to weeks) stabilization in a residential setting with high to moderate medical and nursing involvement.
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Crisis respite and peer respite programs have low medical and nursing involvement and are primarily staffed by peers and other social services staff.
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Living rooms provide residential or respite services in a homelike environment with a high level of peer involvement and various levels of medical and nursing involvement.
Behavioral health urgent care and walk-in crisis clinics (LOCUS level 4 or below).
Even in an urgent situation, it is not at all uncommon for waits on the order of a month or more to see a therapist and often longer for a psychiatrist. Instead of waiting for the situation to further deteriorate, individuals can seek care from urgent care clinics that provide same-day or walk-in access for assessment, crisis counseling, medication management, care coordination, and bridge services until the individual is connected to appropriate outpatient care.
After the Crisis: Postcrisis Care
Linkage to aftercare is a key component of a successful discharge plan, with earlier appointments (within 3 days) associated with higher attendance and longer community tenure after discharge (47). However, many barriers conspire to prevent individuals from successfully connecting with the services they need, such as transportation, difficulty in navigating complex systems, or ongoing symptoms of the issue related to the mental disorder or substance use disorder that contributed to their crisis in the first place. Good discharge planning can prepare for and mitigate some of these barriers, especially when combined with collaborations with community-based programs that can give the person extra support in the days or weeks after a crisis. Models include predischarge interventions such as psychoeducation and structured discharge planning, postdischarge interventions such as follow-up phone calls and case management, and transitional interventions that engage with people before discharge and continue for some period of time after discharge. These interventions can be performed by facility-based staff or through collaborations with other community-based agencies. For example, an ED might partner with a crisis line to perform follow-up phone calls (48) or with a peer-run agency or community mental health clinic for postcrisis wraparound or case management services. Small study sizes and the wide variability in program elements, intensity, and duration make comparative research between different models difficult (49), but best practices are emerging. In particular, follow-up “caring contacts” such as phone calls and postcards have been studied as a suicide prevention intervention, with promising results in terms of efficacy and cost-effectiveness (50, 51)
Discussion
Crisis Systems versus Crisis Services
Although each of the individual programs outlined earlier may improve outcomes, the impact is multiplied when a robust continuum of programs and services works as a coordinated system to achieve common goals (52). This approach is illustrated in Figure 2. In this model, based on the crisis system in Tucson, Arizona, services are organized along a continuum of intensity, restrictiveness, and cost. At all points along the continuum, easy access for law enforcement facilitates connection to treatment instead of arrest. Governance and accountability are key to ensuring that crisis services operate as an organized and coordinated system in which needs are met effectively, efficiently, and sustainably (24). In the Arizona model, a Regional Behavioral Health Authority (RBHA) serves as the single payer and regulator for the crisis system. The RBHA contracts with multiple service providers to create the crisis continuum and sets expectations for system performance that are aligned with overarching system goals. Contracts confer a “preferred customer” status to law enforcement, so that, for example, response time targets for MCTs are faster for calls that involve law enforcement. The RBHA is financed through braided funding from a variety of sources (e.g., Medicaid, SAMHSA block grants, state and local funds) and is accountable to the state for both clinical and fiscal outcomes.
FIGURE 2. The crisis continuuma
aIn a high-functioning crisis system, the individual services in the continuum work together to achieve a common goal; in this case, stabilization in the least restrictive (which is also the least costly) level of care. Data were provided by Arizona Complete Health/Centene, and they apply to the southern Arizona geographical service area for 2019 (Cochise, Graham, Greenlee, La Paz, Pima, Pinal, Santa Cruz, and Yuma counties). “Crisis line resolved calls” pertains to the percentage of calls resolved without dispatching mobile crisis, law enforcement, or emergency medical services. “Mobile crisis resolved cases” refers to the percentage of face-to-face encounters resolved without the need for transport to a higher level of care. “Crisis facilities community disposition” refers to the percentage of discharges to levels of care other than a hospital, an emergency department, or jail. “Continued stabilization” refers to the percentage of individuals with a mobile crisis or crisis facility encounter who did not have a subsequent emergency department visit or hospitalization within 45 days.
The power of Arizona’s systems approach becomes apparent when considering the impact across multiple silos. For example, an analysis of the crisis system in Maricopa County, Arizona, which includes many of the elements described earlier, estimated that a $100 million investment in crisis care resulted in savings of $260 million in psychiatric inpatient spending, $37 million in ED costs, 45 years of ED psychiatric boarding hours, and 37 full-time equivalents of police officer time and salary (53).
Addressing Racism and Inequity
From Harm to Health: Centering Racial Equity and Lived Experience in Mental Health Crisis Response describes the crisis services in the United States as “a cauldron of the intersection of the criminal legal system with the health care system, both of which have well-documented histories of disproportionately negative outcomes for Black, Indigenous, and People of Color (BIPOC)” (54). This history underscores the importance of involving communities of color and people with lived experience in the design, delivery, and oversight of crisis services. Many are advocating for a “health-first” approach centered around public health rather than public safety (54). A public health framing shifts the focus away from law enforcement in favor of clinical services centered on crisis response, recovery, and prevention. Social determinants of health and systemic racism are framed as upstream risk factors for future crisis and thus become targets for ongoing prevention efforts after the acute crisis.
Data can be an important tool for addressing disparities and racial bias. Stratifying outcomes by race, gender, socioeconomic status, and other demographic characteristics reveals inequities in access to quality care; and disparities in key law enforcement outcomes such as use of force, arrest, and connection to care can reveal implicit bias in policing (55). Openly and transparently sharing such data with the public is an important first step toward gaining trust and implementing policies to address these problems.
Conclusions
The next several years present an unprecedented opportunity for the growing field of community-based crisis care. Nationally, there is a clear need for more rigorous guidelines, standards, and research. At the local level, stakeholders must work together to create crisis systems that meet the needs of their communities, especially groups that have been historically marginalized and criminalized. Psychiatrists are an important voice in these collaborative efforts, and new leadership roles are emerging for those who want to get involved (56). Even if not in a formal leadership role, psychiatrists can serve as effective advocates and educators; for example, volunteering to give a lecture for CIT training. Opportunities for psychiatrists will only increase as the field continues to evolve.
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Published in print: Winter 2023
Published online: 16 January 2023
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Dr. Zeller reports being a consultant for BioXcel. Dr. Balfour reports no financial relationships with commercial interests.
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