In the City of Austin, when a person dials 911, the call taker asks, “Are you calling for police, fire, EMS, or mental health services?” Adding mental health as an option is groundbreaking and allows people in the community to identify whether a psychiatric concern precipitated the call or is a component, says Marisa Aguilar, LPC, practice manager of Integral Care’s Expanded Mobile Crisis Outreach Team.
Integral Care is the local mental health and intellectual and developmental disability authority serving Travis County, Texas. It’s also a Certified Community Behavioral Health Center. While Integral Care’s EMCOT has partnered with first responders and the criminal justice system since 2013 to provide a real-time response to people in mental health crisis, in 2019, its clinicians, called Crisis Center Clinicians or C3s, became co-located at Austin’s 911 Call Center. Aguilar points out that co-location has been transformative, allowing EMCOT to provide upstream services and divert mental health calls, when appropriate, from police response.
“We learned early on and throughout implementation that being on the operations floor is crucial,” says Aguilar.
That’s not how the diversion initiative began. Integral Care’s crisis center clinicians initially weren’t using the 911 center’s communication system, nor were they part of its automated dispatch system. “Because we didn’t share technology at the beginning, call takers were just transferring calls over to us on the phone,” she says, “and most calls were getting dropped.”
“Rightfully, so. A person in crisis doesn’t want to be put on hold and transferred over to talk to somebody else.”
Today, the diversion program is integrated into the 911 call center’s technologies. It’s been a game-changer, notes Aguilar. Working on the same platform has also allowed for faster response times. “We no longer have dropped calls,” she says. The EMCOT team can now view incoming calls to help identify those who might need mental health support early on. They also get real-time updates from call takers and dispatchers. When police go out on calls with a mental health component, the EMCOT team can update the system with pertinent details the officers will need.
“We want them to have our notes before they respond,” she says, “because it can help with de-escalation.”
Co-location has another vital benefit. It facilitates partnership, continued training, and a seamless feedback loop. Law enforcement and the EMCOT team have divergent cultures and roles, points out Aguilar. “We’re taking two different disciplines and trying to foster a similar lens on how to respond to mental health crises,” she says. Bridging the gap and focusing on a common goal takes trust and continuously strengthening those relationships.
Aguilar says robust partnership to this degree wouldn’t likely have happened if they weren’t in the same place. “We’ve been able to get to know each other,” she says. The EMCOT clinicians are accessible for rapid impromptu dialogue, going over calls with telecommunicators, or answering their questions. “We’re just steps away, and they know they can come over and chat with us.”
She’s also noticed a shift to more person-centered language resulting from call takers hearing how EMCOT clinicians speak with a person in crisis or their family. The goal at any 911 call center is to obtain information on the emergency quickly, determine the most appropriate response, and dispatch details to first responders. While timeliness is still of the essence, Aguilar says Austin’s 911 telecommunicators are increasingly aware of what happens to a person physiologically when experiencing a crisis. “They might not hear all the questions or process information quickly,” she says. Since working with EMCOT crisis center clinicians, call takers slow down and use language that’s empathetic and validates the caller.
“The idea is still to get to information quickly,” she says, “but instead of asking, ‘Are you bipolar?’ they’re asking, ‘Do you have a diagnosis of bipolar disorder?’” The language shift often helps deescalate the person before first responders arrive. These techniques, notes Aguilar, have permeated the call center, regardless of whether the person is calling about a mental health emergency or the caller’s a mom who dialed 911 because her child is choking. Either way, the call taker will use the same caring approach.
Working on the same floor with other crisis response services has bridged a previously existing gap—one where cultural differences often obscured the common goal. “We’re building a relationship with another discipline and working toward the same goal: keeping people safe within their community,” says Aguilar. However, what safety means can be quite different to law enforcement, EMS, and fire than mental health crisis service providers. Initially, the other first responders expressed concern, wondering whether an EMCOT-only response could ensure the scene was safe for the person in crisis and the two-person civilian EMCOT team.
Aguilar says dialogue helped first responders understand that most people in mental health crisis are more likely to be victims of crimes than perpetrators of crimes. “Crisis is dynamic, and that’s why we go out in two-person teams when diverting from the 911 call center,” she says. “However, we’re experts in assessing the level of risk for the person and the clinicians.”
At the beginning of the initiative, because of these safety concerns, 911 telecommunicators weren’t sending EMCOT clinicians on “check welfare” calls. “Particularly if a second party made the call, like a parent,” Aguilar points out. For instance, a dad might dial 911 and ask that an officer checks on his adult child who stopped taking their medication and won’t respond to calls.
“After relationship and trust-building, the other departments know we’re ideally suited to go out on these calls if there’s no imminent safety risk,” she says. “The person is more likely to engage with two clinicians knocking on their door as opposed to police.”
Frequent communication within the 911 call center has shattered the wall between mobile crisis services and all other first responder divisions. An Austin Police Department lieutenant oversees the call takers and dispatchers on the operations floor, all of whom are civilians. “He and I communicate regularly—we share and discuss data and outcomes,” says Aguilar. “It takes open and frequent communication to address the hiccups that come with any new project and to keep improving upon our partnership and the call center system.”
As previously mentioned, Austin 911 telecommunicators immediately ask callers whether they need police, fire, EMS, or mental health services. However, many callers don’t know if the subject is in a mental health crisis or might not self-identify if they’re experiencing a mental health emergency. That’s why 911 telecommunicators stay on the line when the call transfers to police or fire services, and call takers for EMS can conference in an EMCOT crisis center clinician if mental health is a call factor.
“Even if the caller doesn’t initially request or identify the need for mental health services,” says Aguilar, “both APD and EMS call takers are still on alert that it could be a component to the call.” If needed, departments can simultaneously dispatch services.
Another element of the initiative is that Austin police officers carry around telehealth iPads to connect directly to EMCOT crisis center clinicians. Officers who come across a person who appears to be experiencing mental health issues, says Aguilar, can “just press a button to connect the person to mental health crisis services instantly.”
Diversion integration into the 911 crisis center has allowed EMCOT response times to improve dramatically. When the service began in 2013, multiple steps took place before a team could even respond to a crisis. “We were immediately available to first responders,” says Aguilar, “but they had to reach out to us.” The call taker would transfer to police, fire, or EMS, and then first responders would arrive on the scene and determine whether the person was experiencing a mental health crisis. “The officers and call subjects might have a 15-30 minute conversation before that happens, and then it could take another 30 minutes for us to arrive and release the first responders.”
“Back then, we were looking at roughly an hour from the time the person called 911 to when we could get a mental health expert out to them to start an assessment.”
Now that EMCOT clinicians are integrated into the 911 call center, people are rapidly screened and triaged, and a team can go out immediately. “That’s far quicker than our previous system of having to wait for a first responder to contact us.” The crisis coordination also allows for increased flexibility, allowing EMCOT teams to meet people where they are and when works best for the person in crisis. Sometimes, right away isn’t ideal. “A parent might prefer we wait until they drop their kids off at school,” notes Aguilar.
While the outreach team can get reimbursement for mobile services, they bill on a sliding scale and accept insurance—they don’t receive reimbursement for services they provide at the 911 call center. That includes safety planning and follow-up calls. Instead, the City of Austin fully funds EMCOT on the 911 operations floor: $2.5 million and $3.8 million for fiscal years 2020 and 2021, respectively. “This pays for our integration into the system and telehealth services,” says Aguilar, “and allows us to have our clinicians at the center 24/7.”
The diversion program, she notes, wouldn’t have happened without the support of Austin’s City Council. “Several of our council members pushed for this initiative,” says Aguilar. “To have that ambassadorship and the council’s support helped it come to fruition.”
Between December 2019, when the diversion program launched, and September 20, 2020, the center transferred 944 calls to EMCOT clinicians, 83% diverted from police. Half of the remaining percentage went back to law enforcement because the caller requested it. “That’s even after we said, ‘We can send a clinician out and help identify your needs,’” says Aguilar. “We give people the opportunity to say, ‘I still want police,’ and we honor that.” Since then, the 911 call center has diverted over 1,440 calls to crisis center clinicians.
The initiative helps people get the care they need at the right time, allowing the recovery process to start sooner. It’s also cost avoidant. The program’s first eight months alone saved $1.6 million in police response, transport, and involuntary commitment costs. If the 2021 fiscal year results in the projected 5,135 calls transferred to the program, the cost avoidance will be over $12.6 million. “That’s huge savings for the community and the person in crisis,” says Aguilar.