Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
When the Huntsman crisis receiving center in Salt Lake County, Utah, shuttered temporarily for new construction to expand, Kevin Curtis, crisis service director at the Huntsman Mental Health Institute, saw it as an opportunity to shift work culture.
The center was experiencing what Curtis calls “a fundamental mismatch.” “We weren’t serving the community the way we should.”
For a crisis receiving center to function properly, it must have a no-refusal policy, accepting all drop-offs from law enforcement and EMS. That wasn’t happening, pointed out Curtis. Instead, the center’s staff defaulted to wanting first responders to call first and get the person medically cleared.
“Almost none of our cases were coming in directly from law enforcement,” he said, adding that the center was functioning as a post-emergency room intervention instead of providing emergency room diversion.
Requiring medical clearance may sound appropriate and safer, but it often only creates a barrier for first responders and those needing crisis care. Not to mention, law enforcement and EMS are trained to identify — and, in the case of EMS, treat — medical emergencies.
“When the person gets to us, first responders have already checked to see if the person is having a medical crisis,” he said.
Staff wanted to maintain the medical clearance requirement and other control points out of a desire for predictability and safety. They felt they couldn’t take on specific patients, like those in need of substance use detox or who might be highly combative.
Curtis shared with staff that reopening the facility was an opportunity to address what wasn’t working and align the center’s model with the expansion’s funding source, which requires a no-refusal approach. In November 2022, Salt Lake County’s city council voted unanimously to fund the expansion using federal American Rescue Plan Act dollars.
The temporary center is providing crisis services until the Kem and Carolyn Gardner Crisis Care Center opens in 2025. It will be the first building on the nine-acre Huntsman Mental Health Institute Campus of Hope. The new building will allow for increased capacity, bumping up from 12 to 30 people the center can receive. The facility will also have a unit for people who need more intensive care.
Curtis asked staff what feelings came up when they heard “no refusal.” They shared their fears and the existing challenges they faced. He and the crisis center staff could have remained at an impasse. Instead, they developed workgroups to address concerns together.
Staff knew how to identify someone in need of detox and could set up the protocol but shared they felt ill-equipped to manage a person going through detox. Also, they found the toxicology tests at the center, such as urine drug tests, not user-friendly.
“We realized we needed to hire the correct people to manage detox, but we also had to expand our training and protocols.” A workgroup of nurses and physicians worked together to develop comprehensive protocols for safely managing different types of detox.
Staff also believed that law enforcement would drop off highly combative, assaultive people, making it more likely that they’d require medical clearance before police could do so. Curtis used the center’s data to combat the misperception.
“They were perceiving this as a 20% of all drop-offs problem when it was more like .01%,” he said, adding that sending people off for medical clearance was a far bigger problem, statistically, than people being combative.
Data have also illustrated that a triage-first approach is far better than medical clearance. The center now does medical triage, including taking the person’s medical history and vitals. Curtis noted that both he and staff over-projected the number of first responder drop-offs who might be medically unsafe or unstable.
“We estimated the percentage would be around 10%, but we’ve only had to refer 3% of people for further medical care.”
Shifting culture within a workplace is no easy feat. Curtis worried that those employees most active in sharing concerns about the changes would be among those who would no longer want to work at the center. He was wrong.
“Our biggest naysayers just didn’t feel like they had or were going to be given the tools to do this successfully,” he said. He credits the collaborative problem-solving process for changing their minds.
When the center reopened, about half of the staff was established and half was new, with the latter less likely to try to revert to old practices. “That helped to reinforce the importance of no-refusal,” said Curtis.
When staff members try to implement a control point, the team discusses and identifies what’s behind the desire. An example is when a staff member asked to be paged when first responders reached out. The center doesn’t require first responders to first call — “They’re welcome just to bring people and we can sort it out here,” said Curtis — but some jurisdictions do so as part of their own protocols.
“It was leading to discussions about whether or not the person should come to the center,” he said. “That’s not no-refusal.”
But Curtis did understand that staff wanted access to information first responders could provide on the people they’d be dropping off. He made a minor tweak to the center’s medical record system.
“Staff can now see first responder calls as they come in and have access to any additional information.”
Using data to alleviate and address staff concerns has been incredibly useful. “It helped that we had years’ worth of data of us doing it wrong,” he laughed.
That’s also true for what the center has been doing right, helping with fee-for-service reimbursement from Medicaid, commercial insurers and state funding for uninsured patients.
The state legislature has allocated funding through Salt Lake County to ensure uninsured people can access crisis-receiving services. The center registers the person with Salt Lake County as their insurer.
“We then bill the county, which reimburses us for the person’s care.”
What appealed to commercial insurers is that the center’s diversion rates, from inpatient hospitalization and people returning to the community, were higher than the emergency room. “We showed cost comparisons between those who show up to the ER versus those we serve in our small receiving center,” said Curtis. Not only was the center more successful at diverting people from inpatient care but it did so at a lower cost.
“The receiving center rate and code are now inserted into all of our commercial contracts.”
Getting commercial insurers on board wasn’t easy. Data helped but getting the center’s figures in front of them required having a legislator in their corner. Utah State Rep. Steve Eliason met with commercial insurance lobbyists and shared the numbers. Among commercial insurers now reimbursing the center are Regence BlueCross BlueShield of Utah, Cigna, and Aetna, setting a precedent for other Utah counties and also other states.
“We’re hoping communities across the nation take this on and get commercial insurers to see crisis receiving as a valuable service and reimburse,” said Curtis, “because that makes the model more resilient, more sustainable.”
