When Paul Galdys sat down to write the National Guidelines for Behavioral Health Crisis Care, there was a clear, simple objective: advancing an emergency response system for mental health, substance use, and suicidal crises. That was the directive of the Substance Abuse and Mental Health Services Administration. “Communities don’t need just any kind of response,” points out Galdys, deputy CEO at RI International, “but one that gives people immediate access to care.”
Even before the Covid pandemic and increased dialogue on police reform and racial justice, SAMHSA and other leaders have long pushed for improved crisis response. Galdys says the guidelines draw from decades of SAMHSA-funded research and recommendations made by the National Action Alliance for Suicide Prevention’s crisis services task force in 2016. The recommendations resulted in the development of Crisis Now, a model that provides the fundamental components to a safe, effective crisis care system, diverting people in distress from the emergency department and jail by developing a full continuum of crisis care services that match their clinical needs.
In many communities, behavioral health crisis care remains piecemeal or non-existent, resulting in law enforcement as the primary mental health responder. The most common pathways for people in crisis continue to be the emergency department—where people might wait hours, days, and sometimes weeks, or jail. Ed Gonzalez, Harris County Sheriff, told the Texas Standard that the county’s jail is the largest mental health facility in the state. “In my opinion, jails are not the best place to be dealing with that type of medical issue,” he said. “That should be treated as a public health issue, not as a criminal justice issue.” Interactions with police can be deadly, especially for Black Americans and people experiencing a behavioral health crisis. So too can jail.
The national guidelines provide a framework that highlights the essential elements a crisis system must include to be effective and comprehensive: regional or statewide crisis call centers that coordinate in real-time, centrally deployed 24/7 mobile crisis, 23-hour crisis receiving and stabilization programs. Threaded throughout the guidelines are crisis care principles and practices like not requiring medical clearance from an emergency medical facility before admission and “no wrong door,” an approach where facilities accept everyone who comes. “Drop-off refusals and medical clearance requirements,” notes Galdys, “create problematic barriers for first responders, making it more likely that they’ll take people straight to the emergency department or jail.”
With 988 on the horizon—the three-digit number telecom companies must direct to the National Suicide Prevention Lifeline by July 16, 2022—states have turned to the guidelines to expand their crisis systems. Some have started by developing or building out their crisis call center to become a hub or “care traffic control,” modeling their 988 call center after the Georgia Crisis and Access Line or GCAL (1-800-715-4225). In March, Debbie Atkins, director of Crisis Coordination at the Georgia Department of Behavioral Health and Developmental Disabilities, told us the comprehensive and coordinated crisis services hub gives people in Georgia “a single point of entry to the behavioral health and developmental disabilities crisis systems.” It’s integrated into the local healthcare system, has real-time access to available crisis and detox beds throughout the state, and 24-hour mobile crisis response coverage within 100 miles of every community.
To ensure there’s an alternative to law enforcement for behavioral health and quality of life crises, other states have begun expanding their mobile crisis services—though standardization and coordination remain an issue. John Franklin Sierra, Ph.D., senior staff analyst at the Los Angeles County Department of Mental Health and lead for the county’s crisis system redesign, told us in September that capacity alone is not the answer. “We can’t simply build more capacity—whether that’s call center, mobile crisis, or crisis stabilization capacity—and expect the system to work better,” he said. “To produce different results, we also need to change the structure and inner workings of the system.” That includes ensuring first responders can easily and rapidly connect people to treatment and services at every potential entry point.
Furthermore, Galdys points out that building out just some of the core elements will also result in continued system challenges. Without a call center hub, even the most robust mobile crisis services will continue to be dispatched in patchwork and without coordination. “States have to address this in a way that allows them to meaningfully connect people to mobile crisis services,” he says. Otherwise, law enforcement, including co-response teams, will continue to be the default behavioral health responder. And without crisis facilities, the emergency department will remain the default behavioral health provider. “That’s not what communities need or want.”
That’s not to say Galdys doesn’t understand why states might start with statewide or regional crisis call center hubs and mobile crisis services. According to a 2018 survey of Lifeline centers, nearly 98% of crisis calls that go to Lifeline accredited call centers are de-escalated. Depending on the community, mobile crisis teams can also have high stabilization rates. For example, mobile crisis stabilization rates in Tucson have hovered around 85% during the pandemic, regardless of whether calls come in through 911 or the behavioral health crisis line. “Focusing on the call hub and mobile crisis services will quickly help the vast majority of people in crisis,” says Galdys. However, without sufficient 23-hour crisis receiving and stabilization programs, those most in need will continue to be marginalized.
He points out that people with the most intense symptoms and quality of life needs are more likely to come into contact with law enforcement. If there are no 23-hour crisis receiving and stabilization programs for law enforcement to drop off people in crisis, officers will have no option but to take them to the emergency department or jail. The same is true if existing programs require medical clearance or don’t have a “no wrong door” approach. “We can’t forget those with the greatest need—people who programs are most likely to turn away—simply because they’re not the highest volume of people,” says Galdys. “That’s why you have to work on all parts of the system simultaneously.”
The National Suicide Hotline Designation Act of 2020 and the American Rescue Plan Act have provided funding opportunities for states to redesign or expand their behavioral health crisis systems. However, most, aside from service fees—states can apply a monthly telecom customer service fee to pay for 988-related services—are short-term funding solutions. Galdys believes adequate reimbursement for behavioral health is dire as a sustainable funding stream for crisis systems. Lack of reimbursement equity has created system disparities where medical providers have reimbursement rates that allow them to expand and improve their services while those in behavioral health don’t. “Adequate reimbursement rates would allow behavioral health providers to take out construction loans to build and enhance their crisis facilities,” says Galdys. That’s why in some states, like Virginia, Medicaid and behavioral health agencies are working closely together on behavioral health reimbursement rates. In Arizona, the two eventually merged, becoming one state agency: AHCCCS. That’s positioned the state to evade interagency discord and instead address behavioral health through a shared lens. “It’s allowed Arizona to more readily leverage its available resources,” he says.
However, it’s not just Medicaid that must be on board but also Medicare and commercial insurers. For the most part, says Galdys, states and counties are shouldering the costs of crisis services because commercial insurance won’t pay for them. “Partnering with private insurers would reduce the local tax burden on communities and make crisis system expansion far more viable.”
Galdys points out that crisis facilities are lagging behind because providers don’t have the money to pay for them. “Reimbursement is so low,” he says, “that they could never sustain a mortgage or the capital investment.” If states don’t tackle this issue, Galdys says there won’t be stabilization facilities to care for people most in need. “Facilities are being left behind call centers and mobile crisis services because states are asking, ‘How are we going to get millions of dollars to build them,’ when the question should be, ‘How can we set the rates so providers can build them?’”