New Approaches to Behavioral Health Crises

My name is Madeline Gray, I am a Behavioral Health Consultant at Steadman. I’m excited to share with you my experience in behavioral health crisis response innovation. From 2017 to mid 2021, I had the great opportunity to serve as a program and quality assurance manager for New York City’s Behavioral Health Crisis Response Pilot. With my former colleagues at Mount Sinai Health System, we set out to revamp the New York state model for mobile crisis response and turn this existing, underutilized resource into a viable option for diversion from 911/emergency medical services (EMS) response. Additionally, we aimed to make crisis response a comprehensive and person-centered service by providing rapid intake referrals to an array of community behavioral health and social services providers. And so, after establishing a partner provider network to work with mobile crisis team (MCT) patients, we operationalized a 2-hour response time and let the data guide us. After exhaustive reviews of mobile crisis referrals, patient charts, and discussions with city and state health officials and community health providers across the city, these are the main lessons I’ve taken with me:

1. MCT is an effective emergency services diversion for mental health crises

Members of NYC’s Kings County MCT, Source: WNYC, 2017

MCT is an effective mental health crisis diversion from the hospital and paramedic emergency medical services. Around 90% of all cases are appropriately addressed and resolved in the community without any need for police, EMS, or hospital involvement. EMS, on the other hand, removed patients in around 63% of mental health crisis cases over the same time. While EMS and MCT cases are not an ‘apples to apples’ comparison, the reality is that mental health crises are poorly addressed by paramedics and police. Indeed, police often exacerbate mental health crises by triggering reactive behavior, especially among clients with any history of negative interactions with law enforcement. Due to the nature of systemic racism in America, the clients most likely to experience adverse interactions with law enforcement–low-wealth and BIPOC populations–are also the most likely to  perish at the hands of untrained police while experiencing mental health crises.

2. Crisis Prevention is Crisis Response

Source: AJay – stock.adobe.com

Early in the course of the pilot, we identified two specific buckets of MCT referrals: 

(1) “True Crisis” referrals were those made by providers, friends, family, and other community members noticing an individual’s departure from baseline behavior or expression of other acute symptoms of decompensation; and

(2) “Outreach” referrals were those made explicitly by behavioral health providers and follow-up outpatient services for recent inpatient or emergency department (ED) psychiatry discharges due to missed intake appointments.

As a result, we began to see crisis prevention among recent hospital discharges and unengaged patients as itself a form of crisis response. The week following hospital-based psychiatry service discharge is well-established as one of the most vulnerable periods for decompensation, suicidal behavior, and hospital re-admission. Further, reducing the number of “outreach” referrals handled by the MCT would increase the team’s capacity to respond to more urgent crises. To that end, we created a “Mobile Outreach Team” (MOT), comprised by a master’s level social worker (LMSW) and a certified peer specialist, to provide intensive transitions of care with motivational interviewing for inpatient and ED psych discharges, as well as unengaged outpatient clients who have missed appointments. This model was premised on the idea that getting a patient set up in outpatient care with a warm handoff and rapid, concrete support before discharge would enhance treatment attendance and reduce hospital readmissions. We achieved an over 90% first-appointment attendance rate for MOT clients, which you can read more about here.

3. Without a safe and stable psychosocial environment, healing is incredibly difficult

Unhoused folks packed into NYC’s 30th St. Men’s Shelter. Source: THE CITY, 2020

In 1943, Maslow debuted the concept of a hierarchy of needs. In that hierarchy, he defines human needs as existing in two levels, one of which is utterly dependent on the other. The first and most important group of needs, “deficiency needs,” represent those resources that humans cannot survive without, including physiological (food, clothing, shelter), safety (job/income security), love and belonging (friendship), and self-esteem. The hierarchy asserts that until all four of these needs are sufficiently met, an individual cannot begin to self-actualize nor easily motivate themselves to do the same. 

This concept could not be more important to my understanding of effective crisis response. People without safe and secure housing face a sharply up-hill ascent in achieving psychological stability. Our catchment served many shelter and group-residence populations, in which patients were frequently experiencing crises as a response to the hectic and often unsafe conditions within those residences. To complicate the psychological challenges of living in such an environment, patients in need of acute care treatment were often hesitant to engage because, if they were out past the shelter curfew for even one night at the hospital, they could lose their bed and any stability they might have gained. People need to be able to live with dignity in order to move beyond a survival situation to one of processing that trauma and beginning to heal. Until we can organize a compassionate response to homelessness and poverty, mental health and substance use crises will continue apace.

Altogether, these findings have influenced the development of NYC’s new B-HEARD initiative, a paramedic-mental health worker dyad response similar to Denver’s STAR program. Co-response, a crisis response model in which a social worker or mental health peer is paired with a law enforcement officer for dispatch, is also an excellent method of integrating behavioral health competency into local first-responder networks. Additional innovative Colorado programs for behavioral health crisis response, like Longmont’s Angel Initiative and CARES in Colorado Springs, further demonstrate the power of compassionate response to the complex health crises of our neighbors.

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