Between the hours of 6 am and 10 pm, seven days a week, behavioral health call takers sit alongside 911 call takers at the Houston Office of Emergency Management, ready to meet the mental health crisis needs of Harris County’s 4.1 million people. The first of its kind in the nation, the Harris County 911 Crisis Call Diversion program embeds behavioral health specialists in the 911 call center to decrease reliance on preventable emergency and hospital services for people experiencing a mental health crisis. Innovative programs and partnerships like the diversion program in Harris County offer valuable lessons and insight as other crisis programs around the nation enhance their services in anticipation of the July 2022 launch of 988, the new three-digit number for the National Suicide Prevention Lifeline that Vibrant Emotional Health administers.
The diversion program is a partnership between the Houston Police Department, the Houston Fire Department, the Houston Emergency Center, and the Harris Center for Mental Health and Intellectual and Developmental Disabilities, one of the original members of the Lifeline network. By having crisis responders sitting in the Harris County 911 call center, and working on the same technology platform, they can rapidly respond to people’s needs, resulting in faster response times.
Initial concept of the diversion program and history of crisis services in Harris County
The idea for the crisis call diversion program began in 2015 as the Harris Center was considering ways to reduce the unnecessary burden on law enforcement responding to mental health crises and provide more appropriate, proactive care to people in need. The center reached out to their law enforcement partners, and together they landed on the 911 space. They asked, “What would happen if a mental health counselor sat at 911 dispatch?” To answer this question and develop a plan to move forward, they convened a group of stakeholders representing the police department and the center. The stakeholder group reviewed data to understand the type of calls 911 receives and to determine which calls law enforcement partners would consider safe for the behavioral health call takers to answer.
Relying on the data, including law enforcement representatives as partners in each step of the process, and developing a curriculum and training process were crucial to the successful launch and adoption of the diversion program. A history of collaboration, mutual respect, and trust between the police department and the Harris Center also allowed this partnership. The county started the crisis call diversion program as a three-year pilot in 2016 with grant funding from Houston Endowment, Inc., the Episcopal Health Foundation, and the Bureau of Justice Assistance. The pilot was so successful that the City of Houston and Texas Health and Human Services currently funds it.
Between March 2016 and March 2021, the program diverted nearly 7,500 calls from law enforcement response, equivalent to over 11,000 police hours and more than $2 million in resources saved for the police department. Between June 2017 and March 2021, it diverted more than 3,000 calls from fire department response, saving the department nearly $4.5 million over four years. Besides the time and resource savings the diversion program provides the police and fire departments, the program made over 3,000 community referrals and completed more than 2,500 safety plans with callers (Jaranilla, 2021). Before its launch, any calls the Harris Fire Department responded to had to be cleared by law enforcement. With the implementation of the diversion program, counselors can sign off on mental health crisis calls without the police department, saving both agencies significant time and resources.
Enhancing the crisis continuum
With the increased accessibility and demand for crisis services, the diversion program recognized a need to expand access to other crisis services in the continuum to ensure effective and appropriate care for people needing higher levels of care. So, in March 2021, it began a new collaboration with the police department to automatically dispatch mental health clinicians through the Harris Center’s Mobile Crisis Outreach Team (MCOT). The service offers an alternative to law enforcement response for non-violent, non-criminal 911 calls for service involving a mental health issue the crisis call diversion program couldn’t resolve over the phone. In the four months since the project launched, the teams have resolved 53% of calls they’ve received from the diversion program. In addition, only 31% of calls for MCOT were transported to a hospital for safety and stabilization, 13% required additional emergency response, and 3% couldn’t be located upon arrival (Jaranilla, C., 2021).
To be eligible for MCOT Rapid Response, people in need of care must be at least three years old, currently experiencing or at risk of experiencing a mental health crisis, have significant barriers to accessing mental health services on their own, can maintain safety until the MCOT arrives on the scene, and be within Harris County. In addition, the service isn’t appropriate if there’s any risk of violence to staff, if the person is intoxicated or displaying inappropriate sexual behavior, if unsecured weapons or drugs are present, if there are any criminal components to the call, or if there are any medical emergencies (including suicide-in-progress).
Integrating cultures: behavioral health, law enforcement, and emergency response
While the concept of the program gained a lot of support from both mental health and law enforcement stakeholders, “getting into the [911] building” proved to be more challenging. According to Jennifer Battle, director of access at the Harris Center and current co-chair of the Lifeline’s National Steering Committee, mental health crisis calls are “scary for 911 partners,” and relationship- and trust-building was necessary for the 911 partners to understand mental health call takers are well-trained and comfortable working with suicidal people.
Behavioral health call takers undergo rigorous training to encourage confidence in the program with the emergency communications team. They have a bachelor’s in psychology, sociology, or a related field. Each call taker receives training on crisis intervention theory, cultural awareness and trauma-informed care, rapport building and empathetic listening, privacy and confidentiality, an overview of adult and children’s mental health, substance use, and intellectual and developmental disabilities, assessing for suicidal and homicidal ideation, safety planning and de-escalation, and mandatory reporting scenarios. In addition to classroom-based training, they also shadow crisis providers: MCOTs, psychiatric ER providers, 911, the fire department, and police department dispatchers, and even take part in ride-alongs with officers from the police department. The training may take up to three months.
Like the diversion program, 988 Lifeline centers can collaborate with 911 to establish guidelines or decision trees for engaging the other system. For instance, states and localities can determine when 988 call centers need law enforcement to respond to behavioral health crises. Similarly, they can establish standards for transferring calls from 911 to the 988 Lifeline for those callers who don’t need a law enforcement response. Thus, the program provides a model showing that behavioral health can partner with 911 systems. These partnerships can improve outcomes for people with behavioral health crises while also saving law enforcement and emergency responders time and resources.
The crisis call diversion program: looking ahead
The call center diversion program has grown from two behavioral health call takers to five, and plans are underway to have them available 24/7. Being available 24/7 will help the program establish credibility within the emergency response system. Chiara Jaranilla, program manager at the crisis call diversion program, notes that “if we want to establish credibility, we need to mirror our environment” in the 911 system. With the pending implementation of 988 in the summer of 2022, Battle and Jaranilla anticipate that the program will continue and even expand to meet current demand and mirror the operations of 911. However, they note that for the full vision of 988 to be achieved, infrastructure enhancements and integration with a robust crisis continuum will be essential.
Battle and Jaranilla also recommend that communities considering an integrated 911 crisis response approach engage a wide variety of stakeholders to gain trust, ensure a diverse perspective, and manage stakeholders’ expectations of their roles. Relying on data is critical, as is relationship building across stakeholder groups. The biggest challenge in successfully launching the diversion program is integrating two very different cultures. Ultimately, Battle recommends, “Don’t give up. Be nice. Be persistent.”
For more information about the Lifeline and 988, visit www.suicidepreventionlifeline.org.
References:
Houston Police Department. (@021). Crisis Call Diversion. Houston CIT. https://www.houstoncit.org/ccd/
Jaranillia, C. (2021). 911 crisis call diversion: embedding behavioral health specialists in 911 call centers. The Harris Center for Mental Health and IDD. PowerPoint Presentation.
