Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at editor@crisisnow.com.
Developing statewide youth mobile crisis intervention services has been an iterative process, says Tim Marshall, director of Community Mental Health at the Connecticut Department of Children and Families. Today, the face-to-face service will soon be available 24-7, and their motto is “just go.”
When the program began over a decade ago in 2009, pediatric mental health and substance use emergency department visits in the state were on the rise. However, Marshall says the majority didn’t need inpatient care. For example, pre-pandemic reports from one of the local hospitals, Connecticut Children’s Medical Center in Hartford, revealed that 74% of kids showing up at their emergency department didn’t need to be there, and staff sent them home right away. “The remaining 26% would need careful assessment, with roughly half going into inpatient care.” He notes that during the pandemic, a lower percentage of kids showing up in the emergency department can be discharged home.
In the emergency department, children can sit around for hours waiting for an opening in an inpatient unit or sub-acute psychiatric residential treatment facility. “It can be traumatizing,” he says. Like law enforcement, hospitals must have adequate training to identify and connect kids to the behavioral health crisis system, but they’re not the correct intervention.
Mobile crisis services divert children and adolescents from the ED and criminal legal systems. Marshall says that having mental health crisis assessments by someone in the community, in the child’s location—often at home or school—is strength-based, family-centered, child-centered, and developmentally appropriate.
Yet, before 2009 and the implementation of the new system, parents weren’t calling the mobile crisis service. When Marshall spoke with the family advocacy community, they told him, “We don’t call mobile crisis because they never come out.” Data collection on the service was skeletal, but he and his colleagues could glean that they often weren’t meeting kids in the community. “Face-to-face assessment was happening less than 50% of the time,” he says. “In some parts of the state, provider data showed the mobile crisis service was going out less than 25% of the time.”
To better serve young people in the community, the state partnered with the Child Health and Development Institute of Connecticut as its performance improvement center. “We hired them to scan the research to see if there was any evidence-based mobile crisis program for kids,” says Marshall. “They discovered there wasn’t.”
The state has long invested in evidence-based practices, so Marshall and his colleagues took the existing principles and implementation standards of these practices and applied them to developing a youth mobile crisis program. The approach included a substantial investment in evaluation, continuous quality improvement, and workforce development. “Evidence-based practices don’t just focus on initial workforce training but a constant coaching to the model,” he says.
Another critical component in the program’s development was ensuring a single access point. “One of our challenges is that we had around 12 providers with 12 different phone numbers,” says Marshall. “It left each provider on their own to advertise the phone numbers for their districts, and there was no standardization or uniformity.”
The state reached out to United Way 211—the state’s largest information and referral system—and asked if the program could use it for mobile crisis intervention. United Way agreed. The 211 system in the state receives 400,000 calls annually, with an average wait time of 6 to 7 minutes. “That wouldn’t work,” says Marshall. So he and his team developed an off-ramp that prompts 211 callers to press one for mobile crisis. “It typically connects callers to a call specialist within 30 seconds.”
In Connecticut’s adult and youth mobile crisis model, mobile crisis services comprise multi-disciplinary teams. While they can connect to a second person (via telehealth), typically, a single clinician responds to calls. However, the state is considering shifting to a standard two-person, in-person team model.
When developing the program, Marshall and his colleagues needed to streamline their number of providers. They decided on one contractor for each of the state’s six regions. The primary complaint from families was that they’d call mobile crisis, and no one would come. Parents told Marshall, “They’re just talking to me on the phone, and that’s not helpful.” So with the redesign, the mobile crisis service adopted a “just go” approach.
Unlike crisis care models for adults, where 988-Lifeline crisis call centers can stabilize most people who reach out to them through phone, chat, or text, Marshall says children and adolescents in crisis need an in-person, face-to-face response. People calling for youth mobile crisis services are typically third parties, often a parent or school official. “You can’t rely on their judgment about a child who they say is in ‘some kind of mental health situation.’” He points out that the parent themself might be in crisis, or the school official may have another motivation—like removing the kid from school property. “That’s why mobile crisis must go out and do a face-to-face assessment.”
Going in-person to any child in crisis is the underpinning of the program. However, that doesn’t mean the state didn’t experience pushback. Most of the 6 providers were from the original 12, which means they had to shift from a 25-50% in-person response to 90%. This frustrated providers who felt the state was undermining their expertise. He told them, “No, we are buying face-to-face assessment, not phone triage.”
He and his team met monthly with managers from all the providers. During one meeting early in the program’s development, a manager shared a call that became commonly known among them as the “peanut butter and jelly sandwich incident.” A distraught parent called the mobile crisis line and told the call specialist, “My son won’t eat his peanut butter and jelly sandwich.” The call specialist dispatched a youth mobile crisis clinician who quickly found that both the parent and child were in a mental health crisis. It shifted how other managers thought of the service—a phone call from a third party could never fully reveal the nuances they’d quickly discover when on scene and face-to-face with the child.
The data showed that the longer the specialist stayed on the call, the less likely they would dispatch mobile crisis. “We timed the calls, and once a clinician spoke to a caller for 2-3 minutes doing triage, the likelihood of them going out dropped,” says Marshall. “We want the call specialist to get information on the general crisis, the location, and safety information, and mobile crisis go meet the kid.” Providers quickly began noticing acuity was often higher than they thought through triage. “We also told them the mere fact that a caregiver or school was calling, asking for help, was enough to activate dispatch.”
Marshall and his colleagues have developed a school-based diversion initiative, partnering with school districts with the highest arrests, data provided by Connecticut’s judicial system. “We get the information by school and district,” he says. “We then approach the superintendent and say, ‘The judicial system has named your district for overuse of law enforcement and arrests of children on school property.’” The initiative includes basic training on child development, and the team puts together a dashboard with the school’s data on attendance, detention, suspension, and expulsion.
In many schools, notes Marshall, kids experiencing mental health or substance health challenges often face detention, suspension, police or ambulance, or expulsion. “Those are the default responses,” he says. That’s why, when able, the mobile crisis intervention service program provides professional development training at schools at the beginning and middle of the academic year. “We do basic training on why it’s better and healthier for kids to have mobile crisis come out to the school, not law enforcement or an ambulance.”
The program also tracks how often schools call for help and support from mobile crisis. The data shows that partnering schools have started turning to the intervention instead of law enforcement. Some schools taking part in the initiative have gone from calling law enforcement 90% of the time and mobile crisis 10% to the inverse, where the default now is to reach out to mobile crisis.
In May, Whitney Bunts shared with #CrisisTalk that Connecticut’s youth mobile crisis program has been a vital tool for decriminalizing mental health. One she hopes legislators pay attention to as they scaffold their 988 implementation. “… if we just implement it [988] with no real consideration or emphasis on a young person’s experience, we will continue the system we already have, which criminalizes and dehumanizes young people for their mental health needs.” Bunts is a youth policy analyst at CLASP, a nonprofit that advances policy solutions to improve the lives of people with low incomes.
Schools partnering with Connecticut’s school-based diversion initiative have experienced a 40% to 100% drop in school arrests, depending on the school.
Marshall points out that just like kids can’t learn if they’re hungry, they also can’t learn if they’re experiencing mental health challenges and trauma. “Across the country, free breakfast and lunch are standard,” he says. “If states and communities didn’t invest millions of dollars in feeding children, kids wouldn’t be getting the educational outcomes and opportunities they need.” Similarly, if schools can identify a student’s mental health needs and link them to the right services, it would create a fundamental shift for young people. “It’s really that simple.”
