Panel: People in crisis need support, not handcuffs

Key Takeaways

Counties can better serve people experiencing a behavioral health crisis by engaging behavioral health specialists instead of law enforcement, experts told county officials at a recent meeting held at NACo headquarters.

County leaders shared local behavioral health crisis challenges and solutions at play in their communities, at a Jan. 30 intergovernmental roundtable. Engaging behavioral health specialists instead of law enforcement and diverting people from the justice system to treatment and long-term support were identified as ways counties can better serve people experiencing a behavioral health crisis.

“People that are in a crisis, they need that support, they don’t need the handcuffs,” said Dan Gillison, NAMI’s chief executive officer of the National Alliance on Mental Illness.

Dallas County’s Rapid Integrated Group Healthcare Team

Dallas County, Texas has found success in implementing a Rapid Integrated Group Healthcare Team (RIGHT Care), which provides people experiencing a behavioral health crisis with proper support and diverts them from the justice system. 

The RIGHT Care model brings in dispatch and field behavioral health clinicians to support paramedics and law enforcement in providing crisis de-escalation and stabilization and help people experiencing a behavioral health crisis navigate resources for long-term support. It was piloted through a revolving fund, in which the county helped fund the teams to get them off the ground, said Dallas County Judge Clay Jenkins. 

“If you’ve got cities that aren’t in RIGHT Care interdisciplinary teams, talk to your county about starting a revolving [fund] to help get them started,” Jenkins said. “Because once you take your part of the money back, they’re going to keep it going, because they’re going to see this is really good for public safety in their communities.”

Pima County’s mental health crisis line

In Pima County, Ariz., when someone calls the county’s mental health crisis line, which receives about 6,000 calls monthly, if the crisis isn’t resolved over the phone (roughly 85% are), a team of two clinicians is dispatched to the individual’s home. Within those face-to-face interventions, about 70% of crises are resolved, and for the 30% who need a higher level of intervention, the county has crisis facilities, including its High-Intensity Behavioral Health Emergency Center, according to Margie Balfour, Connections Health Solutions’ chief of quality and clinical innovation.

“We use that word ‘emergency’ very strategically, because it has implications for parity, it has implications for EMTALA [The Emergency Medical Treatment and Labor Act],” Balfour said. “So, start to make that argument that these are behavioral health emergencies that should be funded and treated as such.”

After people are stabilized and discharged back into the community, Pima County provides follow-up services, “because a crisis doesn’t just flip off like a light switch,” including step-down facilities that are lower intensity, a transitions clinic and a peer-run agency that checks in with people, according to Balfour.

“The community has really galvanized around common goals, and that common goal is getting care in the ‘least restrictive’ setting,” Balfour said. “For those of us in the justice world, that means keeping people out of jail, keeping people out of law enforcement contact. For those of us in the healthcare world, least restrictive means out of the ER, out of the hospital, but we’re all aligned toward that common goal — that’s kind of our thread.”

The “least restrictive” option is also the most cost effective — providing adequate community care is less expensive than putting people experiencing a behavioral health crisis in the justice system, Balfour said. It’s important to make it as easy as possible for law enforcement to “do the right thing,” she added, which can include providing them with training in crisis intervention and trauma-informed care and making the process to divert an individual experiencing a behavioral health emergency to a crisis center quicker than booking them into jail. It takes more than 30 minutes on average to book somebody into the county jail, and it’s around 10 (sometimes, even as quick as 5) minutes to get them into the crisis center, according to Balfour.

“So, whether you’re talking about it from social justice or healthcare, clinical or just responsible stewardship of taxpayer funds, that thread argument makes sense to a lot of different people,” Balfour said.

Ending competency evaluation orders in Miami-Dade County 

Steve Leifman, a retired Miami-Dade County, Fla. associate administrative judge, said his time in the justice system showed him how ineffectively mental health funding is used for the most vulnerable. 

Florida spends one-third of its entire adult mental health budget on determining people’s competency in court, meanwhile 70% of people in jail in the United States either have a serious mental illness, substance use disorder or both, Leifman said. Simply determining whether someone who is justice-involved is “competent” doesn’t help them, and he said that during his time as a judge, there were times people would leave the courthouse, without receiving any access to treatment, and get arrested before they hit the parking lot, because they were still floridly psychotic.

Community mental health was designed in America to serve people with moderate mental illness, not acute, and programming needs to shift to accommodate those with higher need or else the cycle will just continue, Leifman said. In Miami-Dade County, getting police officers with PTSD treated greatly helped outcomes, as did ending competency evaluation orders for people experiencing a behavioral health crisis, and instead assessing them for treatment, so that they can be sent to a crisis stabilization unit instead of jail.

“If you want to really fix government, stop spending money on stuff that doesn’t work, like competency, and spend it on treatment,” Leifman said. “… Not one party, not one person, not one institution created this nightmare. And it’s not going to be one party or one person or one institution that’s going to fix it. It truly has to be a collaborative effort.”

Leifman said he was part of a delegation that went to Trieste, Italy to study its mental health system, which is among the best in the world. There, people experiencing a behavioral health crisis are provided with a bed and three case managers who work in 8-hour shifts, so the individual is constantly covered, which is significantly cheaper than housing someone in a hospital, he said. After an individual’s been stabilized, they go through a vocational education program and are connected to employment. 

“We shouldn’t, nor do we need to, accept the system we have today,” Leifman said. “What other illness is it permissible to discharge people in the middle of the night with no medication, with no services?

“And then when they fail — because, God, why would they succeed? — we blame them instead of us for setting up this ridiculous system and put them in jail. So, we can, and we must, do better by this population.”

Streamlining access to resources is key, said Milwaukee County, Wis. Executive David Crowley, who highlighted the county’s “No Wrong Door Model,” which puts housing, the commission on aging, children youth and family services and veterans services, all under the umbrella of the county’s department of health and human services.

“No matter how you are entering our door, we want to make sure you get access to all of our services,” Crowley said. “Just because you’re a veteran doesn’t mean you don’t need access to housing and all the other things, including behavioral health services, so we wanted to make sure that we were addressing all the underlying needs without people having to make multiple phone calls to us.”

Milwaukee County builds center where it’s needed

Milwaukee County used American Rescue Plan Act funding to build its emergency behavioral health center closer to the city of Milwaukee to better serve its at-risk population (it was previously in a more affluent area that had less need and was harder for low-income people in crisis to access). The county is also building single family and affordable housing units and has established additional behavioral health services in the same area as well, Crowley added.

“The data showed us that all the individuals that we were seeing coming through our doors came from seven particular ZIP codes that were nowhere near the former complex,” Crowley said. “So, by building this complex right near many of the other health and human services that we provide, we’ve almost created a health and human service campus within our city.”

How to fund behavioral health solutions

Jonah Cunningham, chief executive officer of the National Association of County Behavioral Health and Developmental Disability Directors, said the organization created a funding chart of federal, state, local and philanthropic funding streams that counties can use to build out a component of their crisis continuum, and the Department of Agriculture can be a resource for funding brick-and-mortar investments through community development and the Health Resources and Services Administration can help fund some of the workforce to fill that.

“All of our communities are different, but if we’re going to be extensions of the state, like many of us are, doing the work that the state doesn’t want to do around behavioral health, those resources should be coming directly to us,” Crowley said. “Because we’re the closest ones on the ground to those who are affected, but also the voices that contribute to the solutions we have better access to.”