Amid the global pandemic, Nikki Highsmith Vernick and Glenn E. Schneider of the Horizon Foundation, a health philanthropy in Howard County, Maryland, received landmark news. The Greater Baltimore Regional Integrated Crisis System Partnership, an initiative the two helped develop, became the recipient of a $45 million five-year grant to strengthen behavioral health crisis care.
The Health Services Cost Review Commission, an independent state agency that establishes hospital rates and supports overall improvements in Maryland’s healthcare delivery system, granted the award through its Regional Partnership Catalyst Grant Program.
GBRICS partners include 17 hospitals, the behavioral health authorities and local governments of Baltimore City, Baltimore County, Carroll County, and Howard County, and community groups.
“Like all good things, it began on a napkin,” laughs Highsmith Vernick, president and CEO of the foundation. In the spring of 2019, she was having a breakfast meeting with Dr. Brian Hepburn, NASMHPD executive director and a board member of the foundation. “We discussed what was happening nationally in crisis care and what we could bring to Howard County.”
The county, says Schneider, the foundation’s chief program officer, was facing continued psychiatric boarding and higher patient readmissions rates. “Patients weren’t getting the timely, quality care they deserved,” he says, adding, “Regionally, a person in crisis often waits 24-hours or more before they receive care.”
Psychiatric boarding had become an issue throughout the state. For example, in December 2019, before her first psychiatric hospitalization, 15-year-old Reina Chiang waited 2.5 days in a Maryland emergency room. She and her mother, Kana Enomoto, a national behavioral healthcare leader, shared their experience navigating the Maryland crisis system with #CrisisTalk last month.
Dr. Hepburn told Highsmith Vernick and Schneider of a potential solution. He mentioned Crisis Now, a coordinated crisis system model designed to divert people from the emergency department and jail by effectively matching their clinical needs to care. Its core components include regional or statewide crisis call centers coordinating in real-time, centrally deployed 24/7 mobile crisis, and 23-hour crisis receiving and stabilization programs. The model also features essential crisis care principles and practices like Trauma-Informed Care, comprehensive peer integration, and a no wrong door approach for referrals and drop-offs as defined in SAMHSA’s National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit.
Schneider says he and Highsmith Vernick quickly became interested in determining what Crisis Now components Howard County could incorporate to create a better crisis system for their residents. “We knew we had to strengthen crisis care coordination, better response times, and improve crisis care in the community,” Schneider says, “rather than default to the emergency department.”
A Trip to Arizona
In July 2019, in 118-degree heat, the Horizon Foundation took a group of Maryland county, regional, and state leaders to witness elements of the Crisis Now model in Arizona. Among participants were representatives from the local and state health departments, regional behavioral health authorities, local behavioral health providers, county government, and local law enforcement.
When the team arrived in Arizona, what struck them was the level of coordination between the different stakeholders in Maricopa County’s behavioral health crisis care system. They visited the EMPACT-Suicide Prevention Center at La Frontera Arizona, a mobile crisis intervention service provider. From personnel requirements—like integrating peers—to their collection and analysis of data, EMPACT’s standardization caught Highsmith Vernick’s attention. “We’ve struggled on how best to evaluate the effectiveness of our mobile crisis teams,” she says. “The data they shared on how to look at metrics, quality, and performance was very helpful. I also loved that they have special teams that respond to kids with autism and veterans.”
The group also visited RI International’s Crisis Recovery Center, where they toured the facility’s short-term inpatient, respite, and 23-hour observation units. “The setup was efficient and effective,” says Schneider. “There are chairs arranged in a cluster instead of beds.” While there, they witnessed firsthand an officer drop off a person in crisis. In 2014, the center adopted the practice of no wrong door, accepting 100% of referrals and police drop-offs, which allows people in crisis to go directly to the facility without medical clearance from a hospital emergency department.
“We realized quickly,” says Schneider, “that this model could effectively get people into treatment faster and reduce boarding in jails and the emergency department in Howard County.”
Highsmith Vernick, Schneider, and the team also spoke with leaders from Behavioral Health Link in Georgia, which answers calls to the Georgia Crisis & Access Line (1-800-715-4225) and the SAMHSA-funded National Suicide Prevention Lifeline (1-800-273-TALK | 1-800-273-8255). In the Crisis Now model, the crisis call center, which GBRICS partners call “care traffic control,” is essentially the conductor of a psychiatric crisis care orchestra. It coordinates with mobile crisis, crisis facilities, and police to best serve people in a behavioral health crisis.
“With the care traffic control feature,” says Schneider, “the police, stabilization centers, and mobile crisis all know the role they play, and the public knows where to call to get help.”
It was their ah-ha moment, says Highsmith Vernick, and to make it happen, they quickly realized they had to think beyond just Howard County. “We needed to engage other regional partners from a care coordination and delivery perspective,” she says. “But we also had to pull in state government leaders.”
Maryland’s All-Payer System
Unlike other states, in Maryland, an independent state agency—the Health Services Cost Review Commission—sets hospital rates based on an all-payer system where third parties pay the same rate, regardless of if they’re Medicare, Medicaid, or private insurance. This decades-old system, notes Highsmith Vernick, makes hospital care highly equitable.
“The system protects uninsured and underinsured people from price gouging and ensures that all residents can receive care in the hospital of their choosing,” she says.
Maryland’s all-payer model exists because of a 36-year-old Medicare waiver exempting the state from inpatient and outpatient prospective payment systems, which allows the state to set its own rates for these services. “As a state, we have to meet financial and quality targets, which drives innovation,” says Highsmith Vernick. Consequently, the HSCRC, the hospital rate-setting authority, plays a critical role not only in setting rates but also in health reform innovation and implementation.
However, says Schneider, there’s a catch to the waiver. Hospital readmission rates must be lower than the overall rate nationwide and so too must the total growth rate for hospital care. If they aren’t, Maryland risks losing the waiver, which translates to a loss in millions of Medicare federal dollars. “That provides,” says Schneider, “a powerful incentive for crisis care innovation to ensure we keep quality care high and unnecessary readmissions and costs low.”
In 2019, the pressure to innovate increased, not only because of psychiatric boarding but also because the CMS waiver renewal came with a new set of conditions for Maryland to outperform the country in hospital readmissions. “The waiver applies to all hospitalizations, but it’s behavioral health that drives hospital admissions,” says Highsmith Vernick.
As opposed to going through Medicaid, which Arizona did to develop their comprehensive crisis system, when Highsmith Vernick and Schneider returned from visiting Phoenix, they reached out to their state’s rate-setting commission, the HSCRC, and discovered the agency was also thinking about ways to solve Maryland’s crisis care problem.
The HSCRC Regional Partnership Catalyst Grant and Buy-In
In a short amount of time, roughly 1.5 years, the regional integrated crisis system went from a concept to the HSCRC funding $45 million for implementing it in the four GBRICS jurisdictions: Baltimore City, Baltimore County, Carroll County, and Howard County. Between them, there are 17 hospitals, with most in Baltimore City.
The Horizon Foundation, where Highsmith Vernick and Schneider work, provided seed money to support the coalition and consultants who developed the proposal for the HSCRC. Schneider points out that the process has been an immensely collaborative effort. For example, after returning from the Arizona trip, Adrienne Breidenstine, vice president of policy and communications at Behavioral Health System Baltimore, the local behavioral health authority for Baltimore City and new GBRICS administrative lead partner, convened the 17 hospitals in the four jurisdictions.
Breidenstine and the BHSB team gathered hospital leadership to see if they were interested in working together. All the hospitals said they were, which Schneider points out was a miracle in itself. “To have all the hospitals rally around one solution [Crisis Now] and be willing to put in the time, talent, and treasure to see it succeed is exceedingly rare,” he says.
Soon after, says Highsmith Vernick, GBRICS partners got word that they were eligible to compete for an HSCRC Regional Partnership Catalyst Grant, which came out in January 2020. Originally due in May, the commission delayed the proposal deadline until June because of the Covid pandemic. During the summer, the GBRICS team revised the proposal application to further address racial disparities.
In Maryland, African Americans make up 35% of identified Covid cases and 39% of deaths. Schneider says the virus harms Black people more not because of race “but widespread structural inequities that put them in harm’s way for contracting the disease in the first place.” In a retrospective study, researchers found no difference in all-case, in-hospital mortality between Black and White patients when they adjusted for age, comorbidity, treatment hospital, insurance status, sex, and neighborhood deprivation—an index that looks at poverty, education, employment, housing, and poverty.
“What we are witnessing is the interplay between a public health pandemic and underlying health injustices,” says Highsmith Vernick. “We felt it was essential to speak to this unique moment in time in our proposal.”
Covid disparities, says Highsmith Vernick, are the backdrop to another inequity: “The number of Black men shot and killed by law enforcement.” The Washington Post’s police shooting database shows that nearly one-fourth of people shot and killed by a police officer in the line of duty since Jan. 1, 2015, were African American. People who are Black and have a psychiatric illness are also disproportionately affected, making up 15% of people with mental illness killed by police. According to an ACLU of Maryland study, 38% of the 109 people killed by police in the state between 2010 and 2014 “…presented in a way that suggested a possible medical or mental health issue, disability, substance use or similar issue.”
The varying stakeholders, including police, says Schneider, have different reasons to participate in the new GBRICS system. The 17 hospitals want to be part of the Crisis Now model implementation to improve quality care delivery, eliminate psychiatric boarding, and reduce unnecessary readmissions. Local governments are taking part because they want to fill in behavioral health crisis care gaps. Law enforcement are interested in the model because they want to minimize police involvement in behavioral health crises. As Ron Bruno, executive director of CIT International, told #CrisisTalk in 2019, “It fell to us [law enforcement], but we aren’t the best solution or help to a person in an escalated state.”
Core Crisis Services Integration
At GBRICS’ core is a care traffic control center modeled after GCAL in Georgia. The data-driven center will use technology and crisis counselors to triage and monitor incoming 988 calls—988 is the nationwide three-digit behavioral health and suicide crises number that must be available nationwide no later than July 16, 2022—matching people to the level of care they need when they need it by coordinating with mobile crisis, 911, and crisis facilities.
“The idea,” says Schneider, “is that care traffic control will triage all behavioral health crisis calls, determining next steps, if needed, such as dispatching mobile crisis or directing the person to a nearby walk-in clinic.”
Ample marketing will encourage people who identify a behavioral health crisis to reach out to 988 instead of 911. The GBRICS partners will work with the Maryland Institute for Emergency Medical Services System to determine what 911 calls can get diverted to 988. They will also collaborate with law enforcement and fire and rescue—who might encounter behavioral health crises on the ground—to develop protocols for diversion to 988.
GBRICS will place standalone walk-in clinics wherever the four jurisdictions determine they need additional behavioral health urgent care. “The clinics will have open appointment slots every day so that patients can just walk in,” says Schneider, “which will provide immediate relief for people who are mobile and need additional support.”
Many people in crisis aren’t mobile, which is why the new regional integrated crisis system will also include 24/7 mobile crisis in every jurisdiction, with best-practice standardization so that no matter where the person is in the region, they will receive consistent quality care. “We’ll track response times, how long teams are in the field, and the quality of care delivered,” says Schneider.
It will take two years for the partners to develop the new crisis system infrastructure and for implementation to begin. Eventually, the partners hope to expand the system to include crisis stabilization and collaborate with additional counties in the state.
Highsmith Vernick and Schneider believe part of the reason GBRICS came to fruition is that there was a foundation willing to invest in it. “I know every state has a different catalyst,” says Highsmith Vernick, “but getting nonprofit philanthropic organizations focused on behavioral health crisis care is vital.”