National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit Knowledge Informing Transformation National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit Page 1 of 80 National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit Knowledge Informing Transformation Acknowledgments This document was produced for the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Public Domain Notice All material appearing in this document is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization from the Office of Communications, SAMHSA, HHS. Electronic Access and Copies of Publication This publication may be downloaded or ordered at www.samhsa.gov. Or, please call SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). Originating Office Center for Mental Health Services Substance Abuse and Mental Health Services Administration 5600 Fishers Lane, Rockville, MD 20857 Printed 2020 Page 2 of 80 National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit Knowledge Informing Transformation The National Guidelines for Crisis Care – A Best Practice Toolkit advances national guidelines in crisis care within a toolkit that supports program design, development, implementation and continuous quality improvement efforts. It is intended to help mental health authorities, agency administrators, service providers, state and local leaders think through and develop the structure of crisis systems that meet community needs. This toolkit includes distinct sections for: Defining national guidelines in crisis care; Tips for implementing care that aligns with national guidelines; and Tools to evaluate alignment of systems to national guidelines. In preparing this information, we could think of no one better to advise you than people who have worked successfully with crisis systems of care. Therefore, we based the information in this toolkit on the experience of veteran crisis system leaders and administrators as well as the individuals and families who have relied on these supports on their worst days. The interviews in this report’s addendum showcase the diversity and richness of this expertise and experience. Page 3 of 80 National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit Knowledge Informing Transformation Table of Contents Forward ............................................................................................ Page 7 Introduction ..................................................................................... Page 8 Overview ........................................................................................ Page 10 Core Services and Guidelines for Care ........................................... Page 12 Core Elements .......................................................................... Page 13 Crisis Call Hub Services .............................................................. Page 14 Mobile Crisis Team Services ....................................................... Page 18 Crisis Receiving and Stabilization Services .................................... Page 22 Additional Elements of a System of Care ..................................... Page 24 Crisis System Coordination ......................................................... Page 25 Essential Principles .................................................................... Page 26 Unique Challenges Rural and Frontier ............................................ Page 35 Funding Crisis Care ......................................................................... Page 36 Crisis Service Coding ....................................................................... Page 39 Assessing Adequacy of System Capacity ........................................ Page 42 Care for All Populations Throughout Lifespan .............................. Page 42 Crisis Resource Need Calculator ................................................. Page 42 Indicators of Insufficient Capacity ............................................... Page 43 Tips for System Implementation .................................................... Page 45 Workforce Development............................................................ Page 45 Technology in Crisis Care ........................................................... Page 47 System Evaluation Tools ................................................................. Page 48 Monitoring System and Provider Performance............................. Page 49 Marketing and Communication Efforts .......................................... Page 51 Page 4 of 80 National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit Knowledge Informing Transformation Conclusion ...................................................................................... Page 52 Continuous Quality Improvement .................................................. Page 53 Case Study #1: ConnectionsAZ.................................................... Page 53 Case Study #2: RI International ................................................... Page 56 Addendum ...................................................................................... Page 58 Interview 1 – Wesley Sowers, MD ............................................... Page 59 Interview 2 – Sandra Schneider, MD, FACEP ................................ Page 61 Interview 3 – Shelby Rowe ......................................................... Page 65 Interview 4 – Ron Bruno ............................................................ Page 67 Interview 5 – John Draper, PhD .................................................. Page 70 Interview 6 – Nick Margiotta, Retired Detective ........................... Page 72 Interview 7 - Anonymous Peer Recovery Coach ........................... Page 75 Visuals Table 1 - Continuum to Evaluate Crisis Systems ........................... Page 25 Table 2 - Health Crisis Response Analogies .................................. Page 39 Table 3 - Crisis Service Coding .................................................... Page 40 Figure 1 – Crisis Resource Need Calculator .................................. Page 44 Figure 2 - Crisis Facility Staffing Calculator ................................... Page 46 Figure 3 – Reliability Indicators Framework ................................. Page 55 Figure 4 – Law Enforcement Drop-offs ........................................ Page 57 Figure 5 – Fusion Model Centers Across States ............................ Page 58 Figure 6 – Law Enforcement/Crisis Triage Tree ............................ Page 69 Contributors ................................................................................... Page 79 Page 5 of 80 National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit Knowledge Informing Transformation Forward The Substance Abuse and Mental Health Services Administration (SAMHSA) is the U.S. Department of Health and Human Services agency that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. This National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit (National Guidelines for Crisis Care) responds to SAMHSA’s mission by providing science-based, real-world tested best-practice guidance to the behavioral health field. The Toolkit reflects careful consideration of all relevant clinical and health service research, review of top national program practices and replicable approaches that support best practice implementation. Select nonfederal clinical researchers, service providers, program administrators and patient advocates offered input on specific topics in their areas of expertise to reach consensus on the best practices chosen to be included in this Toolkit. The evolution of this National Guidelines for Crisis Care benefited from the 15 year catalog of work of the SAMHSA-funded National Suicide Prevention Lifeline, the National Action Alliance for Suicide Prevention’s Crisis Services Task Force that produced Crisis Now recommendations in 2016, the Interdepartmental Seriously Mentally Ill Coordinating Committee (ISMICC) report to Congress in 2017 and feedback from exceptional crisis providers and administrators from around the nation. Field reviewers then assessed draft content prior to publication. The talent, dedication, and hard work that the Toolkit contributors and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people in need of behavioral health services. We are grateful to all who have joined with us to contribute to advances in the behavioral health field. This report finally offers our communities true National Guidelines for Crisis Care within a user-friendly Best Practice Toolkit. You will also find innovative data-informed crisis system capacity modeling tools that can estimate the likely crisis service needs of your community and optimal resource allocations to meet those needs within a few key variables. Together, we can and will make a difference! Elinore F. McCance-Katz, M.D., Ph.D. Assistant