It’s nearly three years into the development and implementation of the Central Maryland Regional Crisis System that interconnects crisis services in Baltimore City and three counties — Howard, Baltimore and Carroll. “We’ve had many successes but the process hasn’t been without its challenges,” says Chauna Brocht, director of Crisis Services at Behavioral Health System Baltimore.
She and her colleagues have recently renamed the regional crisis system. It used to be called the Greater Baltimore Regional Integrated Crisis System Partnership, GBRICS for short. “We are trying to change the system and position the region for sustainability but we aren’t an organization,” she says, “and that’s what many people thought.”
In 2020, the Health Services Cost Review Commission awarded the regional system a $45 million, five-year grant to strengthen behavioral health crisis response infrastructure and services. The commission is an independent agency that sets hospital rates in Maryland based on an all-payer model, including Medicare, Medicaid, and commercial insurance. It also plays a vital role in health reform, innovation and implementation.
The all-payer model is made possible because of a longstanding Medicare waiver. To keep the waiver, Maryland’s hospital readmission and care growth rates must be lower than the national annual per capita rates.
Sustainability is a constant consideration for Brocht. The Central Maryland Regional Crisis System is nearly halfway through its grant and the state hasn’t yet passed a telecom fee. However, this year, Maryland passed legislation appropriating $12 million to the 988 Trust Fund for fiscal year 2025. The funds will be used to implement statewide coordination and delivery of behavioral health crisis response services in the state. “The state is also moving toward billing Medicaid for mobile crisis services and crisis receiving centers,” says Brocht.
She hopes the next couple of years will transition the regional crisis system from grant funding to sustainable funding.
At the core of the Central Maryland Regional Crisis System is care traffic control and what Glenn E. Schneider of the Horizon Foundation, a health philanthropy in Howard County, Maryland, calls the conductor of a behavioral health orchestra, coordinating 988 triage, mobile crisis dispatch, a real-time bed registry, outpatient appointments and follow-up calls. The philanthropy provided seed money to support the coalition and consultants who developed the proposal for the Health Services Cost Review Commission.
The Central Maryland Regional Crisis System partners with three organizations that run care traffic control through the 988 contact center — Baltimore Crisis Response, Inc., in Baltimore City; the Affiliated Santé Group in Baltimore County and Carroll County; and the Grassroots Crisis Intervention Center in Howard County. “Originally, they only responded to their area,” says Brocht. “Now, they’re crossing jurisdictional lines.” All 988 calls go into one cloud-based phone software and, as of April, the organization that picks up first answers the call.
Developing a regional crisis system involved “lawyers and a lot of paperwork,” laughs Brocht. The partnership required a memorandum of understanding between the three providers and Vibrant Emotional Health, the nonprofit that runs the SAMHSA-funded 988 Suicide and Crisis Lifeline (formerly the National Suicide Prevention Lifeline). “It took five to six months.”
While establishing the memorandum of understanding caused a delay, the three partners used the time as an opportunity to hire and train roughly 40 additional 988 counselors. Altogether, they now have 100 counselors.
Brocht says that the regional model has been the best fit for the large metropolitan area. Regionalization has also provided logistical, staffing and funding benefits — together, they’ve been able to afford Behavioral Health Link’s cloud-based software that includes the contact center hub and central dispatch of GPS-enabled mobile crisis services. “That allows us to dispatch whatever team is closest to the person in need,” she says.
“We also now have the combined knowledge and experience of organizations that have been around for decades.”
A core component of the regional crisis system model is for all people who need an in-person response to be met by a two-person mobile crisis team comprising a clinician and a peer. “We still have co-responder teams,” she says. Central Maryland’s co-responder teams are often made up of a clinician and a police officer.
When the regional system began, each locality had its own mental health crisis responder model. Baltimore County historically only used co-responder teams, while Baltimore City primarily responded with mobile crisis teams. In Howard and Carroll counties, mobile crisis teams would do the in-person response but police would accompany them. “That’s one lesson learned — it takes a long time to change,” says Brocht.
“Localities didn’t want to give up their old model, so we are adding in the regional 24-hour mobile crisis teams.”
Brocht, her colleagues, and the regional crisis system providers are also developing standardized policies to determine what type of in-person response a person in crisis receives, mobile crisis or co-responder. They are consulting Dignity Best Practices to create a 988 triage matrix. “We plan to test it out this fall,” she says.
At present, the level of care and type of response a person needs is determined solely by clinician judgment. “It isn’t yet standardized but many of the 988 call counselor supervisors have been involved in developing the tool and are already incorporating what they’ve learned,” says Brocht.
She believes standardization is critical for eliminating disparities and ensuring that people who want a mobile crisis response get one. “There’s a bit of a scarcity model happening, where counselors hold on to teams in case they need them later.” She says that standardization and the infusion of more 24-hour regional mobile crisis teams will help promote a culture shift where counselors are less hesitant to dispatch mobile crisis teams. “Right now, counselors want to send mobile crisis to those they think really need it, whereas we’re trying to send it when someone might find it helpful.”
Using the cloud-based software by Behavioral Health Link, the regional system’s crisis services registry connects people to inpatient beds and outpatient same or next-day appointments. There are two inpatient providers in the registry, soon to be three. The system will also double its community providers from 16 to 32. “If the counselor assesses that the person just needs to get connected with outpatient care, then they send a referral through a secure portal,” says Brocht.
“The clinics pick up the referral the next business day to get the person in either that day or the next — it’s not 24/7 but it’s quick.”
The registry matches referrals to the person’s criteria, including where they live, insurance, and whether they’re a child or an adult. The 988 counselor will talk to the person and incorporate their preference before sending the referrals to several providers. “Whoever picks it up first — or gets in touch with the person first — will mark it as completed,” says Brocht. The contact center makes follow-up calls to see how the person is doing and ensure the provider has connected with them. “We don’t want anyone to fall through the cracks.”
In the future, she hopes the regional system becomes more accessible to third parties and increases coordination with 911 to divert people in a behavioral health crisis. “I live in Baltimore City and there are many people in crisis on the street right now — if you call 988, they probably can’t help.”