A More Effective Approach for Managing Behavioral Health Emergencies
Some EDs struggle with boarding problems driven by many patients presenting with behavioral health issues. These patients might wait in the ED for hours or even days before they are connected with appropriate care, tying up precious resources and leaving everyone frustrated.
Often, law enforcement officers and EMS crews are dispatched to the scenes of behavioral health emergencies. EMS might transport these patients to the ED. Others might be taken to jail. But in recent years, stakeholders in Dallas have looked closer at these scenarios. At a time when resources are stretched thin, hospital staff, police officers, and communities all are asking questions.
Innovators from multiple entities have fashioned a new approach to the way behavioral health emergencies are handled. The collaborative effort is producing results in terms of accelerating appropriate care to patients while also diverting significant case volumes away from EDs and the criminal justice system.
The impetus emerged several years ago when Dallas-based Meadows Mental Health Policy Institute (MMHPI) approached Dallas Fire-Rescue to gauge interest in supporting a novel initiative aimed at providing better service, preserving scarce resources, and potentially producing better outcomes. S. Marshal Isaacs, MD, is medical director for Dallas Fire-Rescue and an emergency physician at Parkland Hospital. Isaacs was familiar with a program in Colorado Springs called the Community Response Team that was addressing mental health emergencies by pairing a community paramedic with a mental health peace officer, a licensed mental health practitioner, and a Crisis Call Diversion Program. He thought something similar might be a good fit in Dallas.
“I suggested to the [MMHPI] that they consider working with us to develop a grant to support the development of what became known as a RIGHT [Rapid Integrated Group Healthcare Team] Care team in a grant-funded pilot project,” Isaacs recalls.
Under the RIGHT proposal, appropriate patients would be paired with a Dallas police officer, a Dallas Fire-Rescue paramedic, and a behavioral health clinician from Parkland Hospital.
“It took some time to develop that, but, ultimately, we launched one RIGHT Care team that was available to respond to behavioral health emergency calls in the part of Dallas that historically had the highest volume of those calls,” Isaacs reports.
During the pilot phase, investigators determined the team could collaborate safely and effectively while also producing data to show this integrated team could deliver outcomes collaborators were looking for: better outcomes for behavioral health patients and less reliance on EMS, EDs, and law enforcement.
“In addition, behavioral health patients would no longer have to go to jail for minor civil disturbances that could now be viewed as behavioral health issues rather than criminal issues,” Isaacs adds.
Instead, many of these patients could be treated in place by the RIGHT Care team or directed to appropriate behavioral health resources in the community. In the first 18 months of operation, a RIGHT Care team responded to more than 4,000 calls in Dallas’s south central police district, diverting about 900 patients from the ED and close to 500 patients from jail. In addition, arrests were made in fewer than 2% of cases.
Armed with results from the pilot project, in 2018 Dallas officials funded the program and expanded the partnership to include the North Texas Behavioral Health Authority. The goal was to eventually form 10 RIGHT Care teams that could respond to behavioral health emergencies throughout the city.
As of the end of 2021, there were seven teams, one for each of seven police districts, operating 7 a.m. to 11 p.m., according to Kurtis Young, MSSW, LCSW, director of social work at Parkland Hospital.
In terms of volume, Young says RIGHT Care teams respond to anywhere from 850 to 1,000 mental health calls every month. “In [November 2021], that amounted to about 54% of all mental health calls that happened during the times when RIGHT Care teams were operating,” he says. “The goal is to respond to 90% to 95% of these calls.”
There is a wide range of circumstances RIGHT Care teams encounter. For example, the issue may be as simple as a patient needing a refill on his medication or a report that someone is acting strangely on a street corner and may need assistance. At the other end of the spectrum, RIGHT Care teams encounter patients who are suicidal, in withdrawal, or are struggling with other urgent mental healthcare needs. “We might have as much information as a name, date of birth, and a whole history of hospital [utilization], or we might have absolutely no data,” Young says.
If patients already are working with a mental health provider or a case worker, RIGHT Care team members can contact the relevant individual while they are on scene and obtain guidance on how to proceed. Team members also can help reconnect patients with care that may have lapsed.
When no provider or medical information are available, the RIGHT Care program has established agreements with outpatient mental health providers so patients can be seen that day. “RIGHT Care gets preference. If we need to bring someone into an outpatient behavioral health center for an assessment by a psychiatrist about medicine adjustments or to get put on medication, [the team] can get it done that day,” Young says. “We will take [the patient] there, and we can even bring them back home when they are done.”
How do 911 dispatchers know when to send a RIGHT Care team to the scene of a call as opposed to a traditional ambulance or law enforcement response? Parkland has placed behavioral health clinicians in the 911 call center to guide dispatchers when they receive what appears to be a mental health emergency call. Young acknowledges that discerning what is going on in some cases can be difficult.
“Someone might say that their husband is acting crazy, but what does that actually mean?” Young offers. “Does it mean that [he] has an actual mental illness, or does it mean there is a domestic dispute?”
In such cases, the dispatcher typically will patch the behavioral health clinician into the call so he or she can learn what is going on. “It is hard to get [the decision] correct 100% of the time,” Young admits. “Sometimes, we have to reclassify [the calls].”
Dispatchers tend to become better at managing mental health calls with more experience; regardless of the learning curve, the skills the behavioral health clinicians bring to the call center are essential. “Some of this stuff takes years of experience in working with the mental health population to really understand what is happening, what these diagnoses need, and how everything connects,” Young says. “Bringing in professionals who understand the complexity of the mental health system ... and how to get people to the right level of care is really important.”
In fact, for some low-acuity cases, there might be no need for any EMS or law enforcement response; the patient may only need to be referred to appropriate resources. Isaacs notes this type of response is one of the enhancements the RIGHT Care program has brought to the 911 process.
If there are any concerns regarding safety or property at the time of the 911 call, the dispatcher will send a Dallas police unit to the scene first to check for any threats. Then, once the scene is deemed safe, a RIGHT Care team will respond. At this point, the police officer who arrived on the scene as part of the RIGHT Care team takes charge of team safety while the paramedic assesses the patient.
The assessment consists of a basic clinical algorithm that requires the paramedic to check mental status and vital signs, along with any signs of trauma or other potential life threats. Paramedics will take a blood glucose reading when appropriate. “If the patient meets all those algorithm parameters, then [the paramedic] turns the patient over to the behavioral health clinician who will have access to pre-existing behavioral health records, if they exist,” Isaacs says.
If the patient is known to the system, the clinician can determine what medications the patient has been prescribed and the outpatient treatment plan. However, if there are no such records, the behavioral health clinician will develop a treatment plan, which may involve a simple referral to outpatient resources. The team also may transport the patient to a community behavioral health clinic or hospital. If, during the paramedic’s assessment, a patient records a persistently elevated heart rate, complains of chest pain, or exhibits any other medical concerns requiring urgent attention, the paramedic will request an ambulance to transport the patient to an appropriate ED.
Young says there were some early struggles to ensure patients who had been assessed by a RIGHT Care team received a warm handoff when they arrived in the ED. “Now, [ED providers] know what RIGHT Care is, they know that RIGHT Care has already assessed these patients, and they know what the RIGHT Care team thought,” Young says.
One of the keys to the successful implementation was the fact each partnering organization had a strong stake in making progress in this area. “Parkland had to buy in, but we have the busiest ED in the country. Anything we can do to prevent someone from coming to our ED [who does not require that level of care] is a positive thing, especially when it is not an immediate emergency,” Young says.
With all the focus in recent years on criminal justice and police reform, the Dallas Police Department recognized a need for improvement, too.
“They had buy in to change how they were handling mental health phone calls, and they talked pretty openly about that,” Young says. “[Police] knew they could get better, so they [embraced] the program.”
Similarly, Dallas Fire-Rescue was seeing a lot of cost related to unnecessary ambulance transports to hospitals involving patients with psychosocial or mental health issues.
Despite broad recognition of the need for change, that does not mean putting all the pieces together is easy. “When you are combining practitioners from different organizations and cultures, there are always challenges involved with getting those individuals to learn how to work closely together,” Isaacs shares.
Further, Young stresses just grouping a behavioral health clinician, a police officer, and a paramedic is only the start.
“You’ve got to have buy-in from your outpatient providers or from your behavioral health authority,” Young says. “You [need] a place to take people other than the ED or jail. You find out who is on your team and what the motivation is, and then use that motivation to really build a coalition.”
A good bit of this burden, at least from an organizational standpoint, falls on Tabitha Castillo, MPA, the RIGHT Care program manager. She works for the Dallas Office of Integrated Public Safety Solutions, the entity that oversees programs addressing public safety in nontraditional ways.
“I am responsible for program operations, policy planning, training, staffing, equipment needs, and collaboration with other internal city departments and external community partners,” she explains. “One challenge has been to merge, coordinate, and create policies from differing organizations to provide working protocols for a productive and effective team. Each organization works and communicates differently than the others.”
Castillo says continuous communication through weekly leadership meetings, team supervisor meetings, training meetings, and constant evaluation and operations reviews is the key to effective collaboration. “Although the creation of a multidisciplinary team has challenges, the benefits have not only increased efficiencies for each organization but have [also] resulted in a higher level of compassionate care for the clients we serve,” she says. (Editor’s Note: For more statistics and information about RIGHT Care, please click here.)
Often, law enforcement officers and EMS crews are dispatched to the scenes of behavioral health emergencies. EMS might transport these patients to the ED. Others might be taken to jail. But in recent years, stakeholders in Dallas have looked closer at these scenarios. At a time when resources are stretched thin, hospital staff, police officers, and communities all are asking questions.
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