Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
A recently released landmark study gives a snapshot of the national landscape of mobile crisis response across the United States. The authors, Preston Looper, M.S., LPC-S, founder of Full Tilt Strategies LLC, Dr. Matthew L. Goldman, medical director at King County Crisis Care Centers Initiative, and Dr. Rachel Odes, assistant professor at the University of Wisconsin-Madison, designed the study to inform local, state and federal crisis care systems. “There was a need for an analysis identifying the gap between the vision and reality of mobile crisis teams,” said Looper.
The vision is laid out in SAMHSA’s National Guidelines for Behavioral Health Crisis Care, which lists regional or statewide crisis call centers, coordinating in real time, centrally deployed 24/7 mobile crisis and 23-hour crisis receiving and stabilization programs as the essential components for a crisis system to function appropriately. Looper notes The National Suicide Hotline Designation Act, making 988 the national number for suicide prevention and mental health crisis hotline system, implies “the hotline, mobile crisis and receiving facilities should be operationally and digitally integrated.” A service fee, adopted by 10 states so far, can include costs ensuring efficient and effective routing of 988 calls to an appropriate crisis center, personnel and providing acute mental health, crisis outreach and stabilization services by directly responding to the 988 hotline. That includes mobile crisis teams.
In 2021, Looper told CrisisTalk it was time to standardize mobile crisis services. States and communities with well-funded behavioral health systems and centrally deployed 24/7 mobile crisis have impressive mobile stabilization rates. Among them are Utah and Arizona, with rates around 75% and 75-85% percent, respectively. In Tucson, the stabilization rate after mobile crisis dispatch is around 85%, regardless of whether the person called 911 or the crisis line. However, Johnnie Gasper, director of Justice and Crisis Systems at Arizona Complete Health, the state’s contracted regional behavioral health authority in central and southern Arizona, told CrisisTalk that when people call 911, they expect an in-person response, with roughly 60% of diverted behavioral health 911 calls resulting in a mobile crisis team dispatch.
Utah has a fund that supports all 988 services, including the call center, mobile crisis, receiving centers, stabilization services and other behavioral health crisis services. State Sen. Thatcher told CrisisTalk that the cost is about $400 for a mobile crisis team dispatch. “That’s far better for people than the emergency room — both to address their crisis, and there’s less financial burden,” he said. The SAMHSA guidelines emphasize that two-person mobile crisis teams “should be put in place to support emergency department and justice system diversion.”
Most mobile crisis programs are funded through braided funding, including insurance, federal block grants and state or local funding. Among survey respondents, programs serving larger areas were more likely than those with mid-size or smaller populations to rely only on state or regional funding. A large percentage of teams, 40 percent, couldn’t bill Medicaid. Looper has pointed out a chicken-and-egg relationship between funding and services — to get more funding, mobile crisis programs have to illustrate their effectiveness; however, programs must be adequately funded to be effective. “Unfortunately, there’s scant evidence of effectiveness, demonstrable return on investment, and expert consensus guidelines,” said Looper. Dr. Goldman echoed his sentiments, telling CrisisTalk that most studies on mobile crisis services have been quasi-experimental and retrospective. “… there’s no quality measure for programs to compare themselves to and no accountability metrics,” he said.
Today, Looper and Goldman still agree but now have a national survey to back up their concerns. The data set is comprehensive, including 562 anonymous respondents — there were originally 1,290 but many didn’t include a state — in 10 regions. “We wanted to provide survey respondents an opportunity to accurately report limitations and navigate perceived and actual risks vis-a-vis payers and oversight entities.”
The survey, open from Jan. 12 to March 31, 2022, includes respondents from a motley assortment of crisis response models, not just mobile crisis teams. This was intentional, notes Looper. He, Goldman and Odes wanted to get a snapshot in time of how communities were fulfilling the “someone to respond” component of SAMHSA’s three-pillar crisis continuum. Respondents included two-person mobile crisis teams, solo responders and co-responder teams; the latter typically comprise a police officer or emergency medical technician partnered with a behavioral health professional. The aim, they say in the survey summary, was to do the initial landscape analysis needed to “begin standardizing nomenclature, setting the foundation for comparison analysis and improving the quality and outcomes of MCT [mobile crisis teams] services nationally.”
The authors created a dashboard (page 16 of the report) that gives a quick visual glimpse into the mobile crisis response in early 2022. There were strengths — most served all people regardless of insurance, had a non-law enforcement voluntary transport option and fulfilled suicide prevention best practices — but the gaps were glaring. There was insufficient integration and coordination with other parts of the crisis continuum. Only 36 percent included peer specialists and 40 percent didn’t have two-person teams.
SAMHSA’s National Guidelines for Behavioral Health Crisis Care states that mobile crisis teams should be centrally deployed and available 24/7. Teams should comprise two people, either two clinicians or a clinician and peer. Looper suggests taking this a step further, emphasizing that dedicated three-person teams would ensure there’s always a two-person team, even if one person is sick or on leave. “That would also allow programs to scale,” he said. The survey reveals that more than half respondents simply don’t have enough full-time staff to operate two-person teams 24/7. Even so, 70 percent reported having round-the-clock availability. According to Looper, the numbers don’t add up. “Many are using capacity enhancers,” he said, adding that includes on-call staff, a call-down list, telehealth and leveraging staff from a clinic, certified community behavioral health clinic, hotline or receiving facility. He says these should be supplemental and not core components of a mobile crisis program. “They’re desert, not the meal.”
Throughout the United States, there’s a trend in communities toward having mobile crisis as the fourth first responder. In Austin, when a person dials 911, the call taker asks, “Are you calling for police, fire, EMS or mental health services?” “That can’t happen,” said Looper, “when mobile crisis programs have insufficient person power and budget.” Only 40 percent of respondents reporting round-the-clock availability had the minimum full-time employee capacity to provide two-person, on-duty teams needed to do so. According to the authors, that requires more than 11 full-time employees to have the necessary backfill, the ability to refill a position when an employee is on leave, has been promoted or has left, and redundancy, having more than one person who fulfills the same role or function. “Once this baseline level is achieved, additional capacity can be added more efficiently,” noted Looper. Not only do capacity enhancers limit access to and efficacy of mobile crisis teams, but he says they also prohibit program growth. “If it’s not relatively easy for a mobile crisis worker to take the leave they’re due without a massive amount of guilt, that’s a problem. To take leave, they have to find coverage. No other first responder has to do that — police, fire and EMS all have backfill and redundancy.”
At least half of survey respondents used personal vehicles to transport people in crisis, with 68 percent of those in smaller service areas using their own vehicles. “Communities are scaffolding mobile crisis services as the fourth response and yet, people have to use their own cars because there aren’t program-owned ones,” said Looper. He highlighted that this places an undue burden on employees and that mileage reimbursement is rarely accurate, with some employers even paying less than the IRS rate. Many teams also partnered with law enforcement for patient transport, with 84 percent reporting they use law enforcement for transportation under some circumstances. It’s unclear whether this is a byproduct of not having program-owned vehicles or call assessment matrices and triage that require police presence.
According to the SAMHSA guidelines, mobile crisis teams should “respond without law enforcement accompaniment unless special circumstances warrant inclusion in order to support true justice system diversion.” Among survey respondents, 16 percent reported a police officer on their crisis response team. (Looper says there were far fewer clinician-EMS co-responder team respondents.) Co-responder models continue to endure nationwide even as communities across the U.S. build out their mobile crisis teams. When Chauna Brocht, director of Crisis Services at Behavioral Health System Baltimore, worked to regionalize mental health crisis services in Central Maryland, she found communities resistant to change. “Localities didn’t want to give up their old model, so we are adding in the regional 24-hour mobile crisis teams,” she said.
Looper says the more 911 trusts in civilian mobile crisis teams — specifically teams’ “capacity, responsivity and effectiveness” — the less likely they will dispatch law enforcement or law enforcement-led co-responder teams. “They’re risk-averse,” he said, adding that without daily 24-hour coverage and geo-routing, law enforcement has been hesitant to rely on mobile crisis teams. He believes the Federal Communications Commission’s proposal to have wireless carriers implement geo-routing would be pivotal to not only ensure 988 calls are routed based on geographical proximity instead of area code but also build confidence with 911 partners that people in a mental health or substance use crisis will get a timely response. Geo-routing isn’t the same as geolocation. In July, Dr. Tia Dole, Chief 988 Lifeline Officer at Vibrant Emotional Health, the nonprofit that runs the SAMHSA-funded 988 Suicide and Crisis Lifeline, shared with CrisisTalk how geo-routing differs. “We won’t be able to track people like 911 does,” she said. “The sole purpose of geo-routing is to connect people to their local call center.”
The survey revealed that crisis integration and coordination remained a persistent issue. Mobile crisis teams received most of their calls from healthcare providers, followed by crisis lines, public service answering points and direct referrals. Interestingly, only 32 percent of mobile crisis teams reported receiving calls from the National Suicide Prevention Lifeline, now the 988 Suicide and Crisis Lifeline. However, surveys were collected in early 2022 before 988 went live. Looper notes that he and his co-authors are planning a second version of the survey to further examine connectivity between 988 and mobile crisis teams. “We want to understand the impact of 988 implementation on configuration, capacity and integration with fellow crisis providers and gather information to support the stand up of an MCT finder database and search engine,” he said.
This article was originally published on July 2, 2024.
