Since launching in May 2019, we’ve highlighted challenges and innovations in the Behavioral Health crisis space. Many of our interviewees—emergency room physicians, law enforcement, people with lived experience, judges, mental health providers, and politicians—point to a fractioned, siloed system where people end up in the most intensive levels of care or custody instead of receiving the level of care that best aligns with their needs. It results in trauma, high-costs, and the extended removal of people from their community. Today, the Substance Abuse and Mental Health Services Administration (SAMHSA) took a landmark step for all people in the United States by publishing national guidelines for mental health and substance use crisis care; after all, anyone can experience a crisis anywhere and at any time. The National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit isn’t merely an aspirational document. It defines the guidelines while giving clear steps and tools for alignment, evaluation, and implementation.
In looking at the tangled web that is our current behavioral health care system, it may seem that the solutions too would be complicated. They aren’t. At present, the emergency department (commonly known as the emergency room) has become the default crisis provider of behavioral health crises. We know this work-around solution is a challenge for a multitude of reasons, including that it can be a traumatic experience, people can end up waiting for days, even weeks, for the care they need, and it removes people from their day-to-day lives. This results in all kinds of implications for their employment, finances, and relationships. It’s also more costly while simultaneously less effective. The answer is a continuum of crisis care that meets people where they are, but, of course, that means political will and smart allocation of resources. While public awareness is on the rise and the three-digit number 988 might usher in an era of equality for suicide and mental health crisis, the authors note that crisis care reimbursement remains behind the times, often just “a fraction of its physical health counterparts.” Without a “mechanism to adequately reimburse the cost,” crisis services continue to be delivered in a “model that falls short of best practice expectations.” Sometimes, these services are not offered at all.
A solution, points SAMHSA, is for mental health reimbursement to move toward that of other specialties, allowing mobile teams equipped with a licensed professional to reach individuals in crisis wherever they are and for facility-based crisis receiving centers to be staffed with 24/7 medical professionals in their multi-disciplinary team so they can accept any referral that comes their way. It would call for insurance providers to put in place “sustainable funding streams” that support best practice behavioral health care. Doing so might seem like a higher cost strategy, but ironically, it’s quite the opposite: untreated mental health drives massive avoidable costs that not only burden people in crisis but also the overall healthcare system and communities in the short- and long-term. Among them, say the authors, are the human cost of emotional pain for people and their families as they struggle to get the care they need and the financial cost to them when care unnecessarily defaults to inpatient healthcare instead of community-based services. There is also the psychological burden when people experience mounting economic challenges from high-cost stays and the potential toll from employment loss that can result from inpatient hospitalization. Furthermore, the community experiences lost contribution as “mental illness represents our nation’s largest source of disability.” Untreated crises also use a disproportionate amount of resources from law enforcement and the criminal justice system. None of these costs are mutually exclusive.
The authors say it’s time to “bridge the unacceptable gap” that exists in the current fragmented crisis care system—if it can even be called a system when in fact, it’s made up of mental and physical health care silos. For a community crisis system to function appropriately, it must include regional or statewide crisis call centers that coordinate in real-time, centrally deployed 24/7 mobile crisis, 23-hour crisis receiving and stabilization programs, and essential crisis care principles and practices. In building out these elements, communities can develop a vigorous spectrum of no wrong door crisis services and stop defaulting to law enforcement and the emergency department (ED) for crisis response and support. At present, far too many people with few options end up in the ED or face incarceration for misdemeanors. Neither the ED nor the judicial system is adequately prepared to appropriately address behavioral health crises. As crises in the United States increase, we are simultaneously witnessing rises in incarceration and ED overcrowding, both resulting in high costs and lost opportunity to help people with lower levels of intervention that are proven to have better outcomes.
Getting to the point of developing national guidelines along with evaluation and implementation tools has been a process, starting in 2005 when John O’Brien, Technical Assistance Collaborative senior consultant, and colleagues published A Community-Based Comprehensive Psychiatric Crisis Response Service, a detailed written study on the positive impact of a robust crisis continuum. Just over a decade later, in 2016, the National Action Alliance for Suicide Prevention: Crisis Services Task Force, led by David W. Covington, LPC, MBA, and Michael F. Hogan, Ph.D., published Crisis Now: Transforming Services is Within Our Reach. The framework describes three fundamental crisis components and gives implementation recommendations to help communities avoid the misuse of law enforcement and hospital resources while simultaneously ensuring rapid response to people experiencing a behavioral health crisis. A year later, in 2017, SAMHSA’s Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) made recommendations to Congress that included defining and implementing a national standard for crisis care. The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Families and Caregivers also recommended that Congress develop an integrated crisis response system to divert people with serious mental illness and serious emotional disturbance from the justice system. Today, building upon the foundation needed for an effective crisis continuum as defined above, SAMHSA published the national guidelines and best practices toolkit, redefining crisis care.
In the forward, Elinore F. McCance-Katz, M.D., Ph.D. Assistant Secretary for Mental Health and Substance Use at SAMHSA, says that the report “finally offers our communities true National Guidelines for Crisis Care within a user-friendly Best Practice Toolkit.” She shares that it contains innovative data-driven tools that can estimate the crisis services a community needs and the best resource allocation “to meet those needs within a few key variables.” Lastly, she highlights that developing a comprehensive system must be a collaborative effort. Ongoing relationship building and maintenance between stakeholders is an essential component of a high functioning crisis care continuum. Among critical partners are law enforcement, hospitals with EDs, fire departments, ambulance providers, community health providers, health plans, Medicaid team members, schools, faith-based communities, people with lived experience, peers, and families. Together, says Dr. McCance-Katz, “we can and will make a difference!”
Crisis Now partners included among the authors of the National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit are Stuart Gordon and Brian Hepburn from the National Association of State Mental Health Program Directors (NASMHPD), Michael Hogan, consultant, and Charles Browning, David Covington, Paul Galdys, Stephanie Hepburn, Wayne Lindstrom, Amy Pugsley, and Jamie Sellar from RI International.