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Preston Looper on How It’s Time to Standardize Mobile Crisis Services 

Preston Looper on How It’s Time to Standardize Mobile Crisis Services

Mobile crisis services are increasingly in the limelight. Since the onset of the Covid pandemic, telehealth and mobile crisis teams have allowed for much-needed flexibility in care amidst lockdowns and physical distancing requirements. Simultaneously, a cultural push for reimagining public safety has resulted in communities demanding a clear pathway for 911 behavioral health emergency calls to triage to mobile crisis instead of police. 

However, peeling back why mobile crisis teams are often left out of the very emergency responses for which they’re suited reveals glaring gaps in protocols, availability, consistency, and funding. “Every mobile crisis provider is like a snowflake,” says Preston Looper, M.S., LPC-S, founder of Full Tilt Strategies LLC, which specializes in crisis care training, program design, and tech-enabled services. “No two are alike.” 

As states prepare for 988, they have a rare opportunity to standardize their crisis system. Centrally deployed, 24/7 mobile crisis, says Looper, saves lives, improves the experience for all involved, and is cost-effective. It can reach marginalized populations and divert people from the emergency room and criminal justice system. States and communities with well-funded behavioral health crisis systems have impressive mobile crisis stabilization rates. For example, in Utah, mobile crisis teams have a stabilization rate of 75%, and in Arizona, the rate is around 75-80%

However, Looper says there’s a chicken-and-egg relationship between funding and the services a community can provide. To get legislatures to adopt spending bills for mobile crisis services, legislators often have to illustrate their effectiveness. “Unfortunately, there’s scant evidence of effectiveness, demonstrable return on investment, and expert consensus guidelines,” he says.

The lack of data itself is surprising because mobile crisis services aren’t new. In fact, writings on it in the United States go as far back as the early 1970s, including a report by psychiatrist Henry N. Massie in the journal Comprehensive Psychiatry on his participation in the Judson Mobile Health Unit in 1972, which served two New York Lower East Side neighborhoods. The following year, researchers Pedro Ruiz, M.D., William Vazquez, and Kathleen Vazquez published an article in Community Mental Health Journal titled “The mobile unit: A new approach in Mental Health.” They found that the Mobile Crisis Intervention and Suicidal Prevention Unit at the Lincoln Community Mental Health Center mitigated mental health crises in the community. 

In the 90s, researchers tried to look into the impact of mobile crisis on emergency service delivery and hospital admissions. They said there was insufficient empirical evidence to determine its effectiveness. A retrospective study released in 2000 helped to move the marker. It revealed that the mobile crisis program of DeKalb County, Georgia, diverted 55% of the 73 psychiatric emergencies it responded to compared to 28% of the 58 where police responded. The cost per case was 23% less for people served by the mobile crisis team. Also, both law enforcement and consumers felt favorable about the mobile crisis program. 

In 2019, researchers found that Connecticut’s Mobile Crisis Intervention Services (formerly EMPS) resolved immediate crises among youths and mitigated reutilization, significantly reducing the likelihood of a subsequent behavioral health emergency room visit. The state’s Lifeline member call centers dispatch a trained mental health clinician to the youth’s location within 45 minutes.

Matthew L. Goldman, M.D., M.S., told #CrisisTalk in November that most studies on mobile crisis services have been quasi-experimental and retrospective. Dr. Goldman, medical director of Comprehensive Crisis Services at the San Francisco Department of Public Health, said these studies have typically focused on inpatient utilization at the time of crisis but not what happens to the person afterward, like reutilization. Without a benchmark, he said, “… there’s no quality measure for programs to compare themselves to and no accountability metrics.”

Looper points out it’s not simply the lack of data that’s problematic, but also, there’s no standardization. There isn’t even agreement on what defines a mobile crisis team, let alone best practices protocols. “The design of service organizations has historically been extremely idiosyncratic,” he says.

In 2016, the Action Alliance’s Crisis Services Task Force published a groundbreaking report on crisis mental healthcare services. The report states that most community-based mobile crisis programs have teams made up of professional and paraprofessional staff. For example, the team might include a clinician and a peer support specialist, with back-up from psychiatrists or clinicians. It stated that the peer support team member often takes the lead when engaging with a person in crisis.

Last year, SAMHSA published national guidelines that further flesh out what a mobile crisis team should include. It states that for safety and optimal engagement, two people should make up a team. Teams must comprise “a licensed and/or credentialed clinician” who can assess people’s needs within the region where the service operates and incorporate peers.  

Looper says that while two-person teams made up of clinicians and/or a clinician and a peer specialist model are how he defines a mobile crisis team, many communities employ an array of blended and hybrid models. Some follow the Crisis Assistance Helping Out on the Streets framework, commonly called CAHOOTS, which launched in Oregon in 1989, where teams include a medic—a nurse, paramedic, or EMT—and a behavioral health crisis worker. Others use a co-responder model made up of a police officer and a clinician. San Francisco’s Street Crisis Response Team utilizes a three-person team comprised of a paramedic, clinician, and peer specialist.

Some mobile crisis services don’t have a team at all; instead, a solo practitioner goes out on calls alone. It’s a holdover from a bygone time, says Looper, resulting from insufficient funding, geographic challenges, and workforce scarcity. Over the years, mobile hasn’t always meant that mental health providers go out into the community, meeting people in crisis where they are. Instead, a single provider went to the emergency room, jail, or the mobile health unit was primarily stationary. For example, the Judson Mobile Health Unit in New York was a large trailer that moved every six months between two neighborhoods. It gave one area the resources it lacked for half the year and staffed the unit with a full-time physician, nurse, and social workers. Since its inception in 1969, the trailer included an office, a waiting room, and an examination room. 

Today, points out Looper, a solo clinician might provide mobile services to an entire community. “That’s especially true in rural areas,” he says. The clinician might have a schedule that’s a combination of on-call and on-duty for three to four 24-hour shifts. “Adequate sleep is a crucial driver for safety,” he says. “Back-to-back 24-hour shifts are a disaster waiting to happen and lead to significant burnout and staff retention challenges.”

The argument for the plethora of mobile crisis services models throughout the nation is flexibility and using resources a community already has in place. However, notes Looper, that often results in higher-cost solutions than simply investing in a robust clinician and peer specialist two-team model. Ron Bruno, executive director of CIT International, shared with #CrisisTalk in 2019 that embedded co-responder models, where law enforcement agencies have dedicated personnel who partner with clinicians to respond to psychiatric crises, is one of the least economical solutions. “You now have dedicated law enforcement officers waiting around for mental health crisis calls or, in some agencies, a clinician rides around with a police officer who is handling unrelated calls,” said Bruno.

Integrating law enforcement into behavioral health crisis response is far from new. The reason is threefold: 911 is the emergency number people know to call, law enforcement are GPS-enabled and can respond rapidly, and they’ve long been the default mental health provider. The previously mentioned study of the DeKalb County mobile crisis program looked at the program during a three-month period in 1995. It included four police officers and two psychiatric nurses. Two officers and one nurse made up a team and responded to calls seven days a week from 3 p.m. to 10:30 p.m. A psychiatrist was on-call for telephone consultation during those same hours.

Looper says what states need to prepare mobile crisis services for 988 is an expert consensus among leading organizations. “We need a playbook,” he says. Without standardization, he believes 988 hotline dispatchers and consumers will continue to face disparate services depending on where they live and the resources available in that community. 

The lack of continuity also makes integration with statewide crisis call centers a challenge. Looper points out that call hubs often have to navigate many mobile crisis services all with different data systems, capacity, and configuration. “They might work with twenty or more mobile providers,” he says. Sometimes, even call centers with highly integrated software have to build a redundant platform to loop in each mobile crisis provider. “It’s like statewide bed registries that are reliant on providers manually updating their availability,” points out Looper. From there, call centers, hoping the information is accurate, must find what teams are available and then negotiate a dispatch. 

If a call counselor determines that mobile crisis is the best fit during a call, they share their recommendation with the caller. If the caller agrees, the counselor then puts in a service request. Some call centers, notes Looper, allow all call counselors to dispatch directly or have a separate team. “Having a team specialized in mobile crisis dispatch is the most efficient when navigating high variability among mobile crisis providers,” he says. “They know what they’re doing, which makes the process far less chaotic than each counselor navigating the deployment process.”

However, it’s not as simple as a call center dispatching available mobile providers. Instead, the counselor or specialized team negotiates a handoff with a mobile crisis clinician. He says this is where there’s another layer of variability—the team might not be available, or if the practitioner works alone, they might look to exclude or avoid.

Dispatch of mobile crisis becomes even more complicated when the call comes into 911. While it’s best if behavioral health emergency calls go directly to a crisis call center, until 988 becomes ubiquitous, most will continue to go to 911. Some communities like Maricopa County have 911 call diversion where dispatchers in the Phoenix Police Department refer 911 calls to the Crisis Response Network. They can also simultaneously dispatch so that both mobile crisis and police arrive on the scene. In Eugene, Oregon, CAHOOTS units respond directly to 911 non-emergency behavioral health crisis calls. 

This, says Looper, is again where every community is different. In some, 911 dispatchers can’t dispatch mobile crisis teams directly, while in others, they can dispatch either law enforcement or mobile crisis, not both

However, in communities where 911 and law enforcement can dispatch or reach out directly to mobile crisis, teams might not be available, or they’re overly reliant on police to remain on the scene. “This is particularly true in places where mobile crisis is under-funded, or there’s a scarcity of behavioral health workers willing to do the job,” says Looper. 

A mobile crisis scene is often in flux and unpredictable. Without standardized practices, Looper says crisis teams respond in highly variable ways. That creates tremendous variability from whether they’re willing to go out on a call to how they react on the scene. “The service people receive will differ depending on who shows up,” he says. “You have teams that are skittish and others that entirely ignore the risks.”

When mobile crisis dispatch is inconsistent, “officers will stop calling,” Nick Margiotta, a retired Phoenix police officer and president of Crisis System Solutions, told #CrisisTalk in 2019. For law enforcement to outreach mobile crisis services, they need to be able to depend on a consistent rapid response 24/7. 

When officers in Rochester, New York, handcuffed, pepper-sprayed, and put a nine-year-old in crisis in the backseat of a police vehicle, people asked, “Where was mobile crisis?” While 911’s protocols didn’t allow the dispatchers to dispatch the fledgling Person in Crisis (PIC) teams simultaneously with police (or even allow for law enforcement to reach out to them while on the scene), the Forensic Intervention Team (FIT) was available to respond. 

However, Monroe County police chiefs told Spectrum News that officers often can’t get anyone from FIT to respond to calls. The service is made up of two clinicians who work five days a week, Monday through Friday. They aren’t available on weekends.

James Van Brederode, a police chief in Monroe County, said mobile crisis services need to be available 24/7 every single day of the year. Otherwise, it’s just “window dressing.” 

Margiotta pointed out that even if mobile crisis shows up, in many communities, they often ask law enforcement to stick around, which “… makes sense only if the person is violent, and suicidal ideation alone doesn’t mean police need to be present.” It makes it far less likely that a warm handoff will be time-efficient and no more than 5-15 minutes, which deters officers from reaching out.

Looper emphasizes that clear safety protocols help mitigate fear-based requests by mobile crisis teams that law enforcement remain on the scene. On the flip side, he points out that across the United States, solo clinicians often provide mobile crisis services. Local agencies expect the person to go out to calls by themselves to minimize the unnecessary use of law enforcement. 

“Many states haven’t set the guideline that mobile crisis teams must be made up of two people,” he says. “Nor have they provided sufficient funding for them to do so in practice.”

Fortunately, funding for mobile crisis services is becoming increasingly prioritized. For example, on March 11, President Biden signed into law the American Rescue Plan Act of 2021. It includes a state option to provide quality community-based mobile crisis intervention services, with an 85% match in Medicaid funds for qualifying states—language incorporated from the CAHOOTS Act bill.

The American Rescue Plan Act defines a multidisciplinary mobile crisis team as having at least one behavioral healthcare professional and other expert professionals or paraprofessionals, including nurses, social workers, peer support specialists, “and others.” Looper says the new law is a fantastic step in the right direction. However, without standardization, inconsistency in mobile crisis services will continue to be widespread.

That’s why Looper and Dr. Goldman are mapping and surveying existing mobile crisis providers nationwide. “Understanding the landscape will help drive evidence-based policy and objective comparison of the various models,” he says. “What are their gaps in funding, capacity, workforce, and tech? And how can we help them operationalize best practices?” 

To learn more about the survey, please reach out to Matthew Goldman, M.D., M.S., at  matthew.goldman@ucsf.edu and Preston Looper, M.S., LPC-S, at preston@fulltiltstrat.com.