Rockland Paramedic Services (RPS) is a not-for-profit EMS agency that operates a mobile mental health response team called the Behavioral Health Response Team (BHRT). This new, innovative program for EMS takes mobile integrated healthcare to a new level. Although these programs aren’t new, their integration by an EMS agency is a modern advancement.
For more than 25 years, RPS has provided 9-1-1 response services to Rockland County, N.Y.-a suburb of New York City with a population of about 350,000. In 2015, the RPS responded to over 25,000 calls, 645 of which included an emotionally disturbed person (EDP). As with most EMS agencies, our personnel had limited intervention skills and capabilities when it came to behavioral health issues. As healthcare delivery started to change, so did our role in treating a patient. A new approach could treat both physical and mental health issues in the community. With this in mind, we decided to think outside of the EMS box as to what role we could play in the new healthcare landscape.
Nearly every EMS agency has the infrastructure needed to accommodate a new healthcare delivery paradigm with regard to behavioral health. The new service would not only respond to medical emergencies, but respond to and treat behavioral health crises. When the New York State Office of Mental Health tasked the Rockland County Department of Mental Health with establishing a mobile mental health crisis team, a request for proposal (RFP) was produced. We strongly believed our agency was the natural choice to operate such a service, and that the BHRT could only enhance the services that we’d already been providing to the community.
The BHRT is a rapid response, interdisciplinary team comprised of mental health clinicians and EMS technicians. The team may initially provide phone advice and guidance to the caller. If the need is more urgent, the team will conduct an on-scene behavioral health intervention, or will physically respond to the individual to do a more in-depth evaluation and assessment, called outreach.
Ideally, the outcome would be stabilization and de-escalation, and a referral or navigation to a mental health provider or a facility for follow-up/long-term care. The program is designed to reduce unnecessary psychiatric hospitalizations and ED visits. The team is available 24/7 to respond and works closely with hospitals, mental health agencies, police and EMS.
BEHAVIORAL HEALTH & CRISIS INTERVENTION
EMS already responds to EDP and psychiatric calls-the difference now is that we’re better able to treat the behavioral health crisis by teaming up with mental health professionals on-scene. These calls can vary widely, and many have high levels of intensity such as suicidal ideations and violent outbursts requiring police assistance, or severe depression and medication non-compliance. The team is often more impactful in behavioral health situations that are less intense. Many calls just require someone to listen, de-escalate, intervene, advise and help navigate the person to mental health services as opposed to an ED visit. The team follows up with the individual, usually by phone within 24 hours (or sooner, as needed), to ensure they’ve received the necessary support going forward. The BHRT can also consult from the field with an on-duty psychiatrist in real time as necessary.
This is somewhat different from what other mobile mental health units are able to accomplish. Our relationships with the hospitals we serve have made our service a success. Most EMS agencies are able to capitalize on their unique relationships when putting behavioral health programs together, thus enhancing their capabilities. For example, we always have an ED physician as backup if a psychiatrist isn’t immediately available.
In the past, our response and intervention to EDPs was very limited. Our training in EMS curriculum was essentially focused on the safety of the crew and the individual experiencing the mental health crisis. Most, if not all, of these calls resulted in a transport to the local ED or a refused medical aid (RMA) signature. There was little else we could do for the person experiencing the behavioral health crisis.
The BHRT program addresses the increased healthcare initiatives to reduce ED utilization and unnecessary psychiatric hospital admissions by treating and resolving these mental health crises over the phone, or at the scene, whenever possible.
The BHRT members dress in casual, non-uniform clothing and are assigned to unmarked, nondescript vehicles. All outreaches are discreet and strictly confidential.
BUILDING THE BHRT
As we entered into the field of behavioral health, we knew our capabilities were going to be challenged and questioned by established mental health agencies, facilities and providers. We were faced with the phrase, “Thank you for your interest, but you’re not a mental health organization.” To counter that, we had to provide and document an “added value” component that established mental health organizations lacked.
What we brought to the table was our infrastructure and the relationships we developed over the years with healthcare organizations and the first response community. We were already part of the 9-1-1 system with a robust communications center and the Behavioral Health Center in the area hospital. We have relationships with the police, other EMS agencies and most healthcare providers, and a real-time medical and behavioral health consultation ability through access to an ED.
As a part of the RFP requirement, we recruited credentialed and licensed social workers, psychologists, psychiatric nurses, psychiatrists and other mental health professionals. We teamed up mental health clinicians with EMTs/paramedics who had street knowledge and experience. The dynamic team composition enabled them to really hit the ground running and allowed for a seamless acceptance of the team by other emergency service agencies (e.g., police, fire, EMS and our own field paramedics and EMTs) because members of the team were from their ranks. The BHRT was trained extensively in behavioral health crisis management, de-escalation and stabilization, focused therapeutic intervention, scene safety, defensive driving, documentation, mental health law, and other required subjects.
The BHRT is equipped with mobile and portable radios that can have direct communication with police and EMS. The vehicle is equipped with a first responder bag of medical equipment including Narcan (naloxone) and an AED. The clinicians are trained in CPR and basic first aid. The team is assigned to an unmarked, nondescript vehicle and members are dressed in casual, non-uniform clothing.
An important part of the BHRT’s activity is that all outreaches are discreet and strictly confidential. This allows them to maintain credibility and trust within the community. All vehicles are registered in every police department in the county, so when they’re on or traveling to a scene, police will know immediately that it’s a BHRT vehicle.
Figure 1: Projected vs. actual monthly average contacts and outreaches of the Rockland County Department of Mental Health
HOW THE TEAM OPERATES
All calls for the BHRT come through our 24/7 communications center, and are immediately forwarded to the on-duty clinician. If the team is on assignment, the caller will be advised and the dispatcher will determine, based on information received, if there’s a danger to the caller or other persons. If there’s a danger, they’ll immediately advise the police department to respond.
Team clinicians are responsible for screening all calls that come into the BHRT hotline. We’ve developed a script with focused questions that are asked of the caller.
The first and most important determination by the clinician is that there’s no danger to anyone. During the call, the clinician will determine the level of response necessary to address the caller’s needs. This could be referral to available behavioral health services, or an outreach to the individual-which is the highest level of response.
Under the New York State Mental Hygiene law, the team has authority to have someone involuntarily transported to a mental health facility if they pose an imminent danger to themselves or others. This action is always conducted in consultation with “medical/behavioral health control” and the police department.
In conjunction with the Rockland County Department of Mental Health and the Office of the Rockland County Executive, we’ve been working to educate the public about the BHRT. We’ve gone to roll calls at every police agency in the county to advise them of the program, and we’ve presented it at many health fairs in the community that are sponsored by behavioral health agencies and healthcare facilities.
The team has also presented the program in many schools in the county to inform the administration, teachers and educators of BHRTs availability and capabilities.
- Provides crisis intervention;
- Gives supportive telephone counseling;
- Meets individuals at their location;
- Helps develop strategies for reducing recurring crises;
- Supports in addressing drug/alcohol use;
- Helps cope with past traumatic experiences;
- Facilitates communication with family, friends and physicians;
- Arranges peer-to-peer interactions and support;
- Connects individuals to local mental health agencies;
- Counsels and refers individuals with suicidal ideations;
- Arranges psychiatric evaluations as necessary; and
- Provides information and referrals.
The BHRT doesn’t address:
- Domestic violence mediation;
- Hostage negotiation;
- Medical clearance;
- Active suicide intervention;
- Medication administration; or
- Long-term therapy.
Figure 2: Calls to the BHRT hotline vs. BHRT outreach visits vs. resulting ED visits (2015-2016)
We strongly believe the EMS community is perfectly suited and positioned to be the lead agency in behavioral/mental health crisis interventions and management. The BHRT has been widely accepted by the public, first response agencies, the courts, healthcare facilities and the mental health community. We’ve exceeded all expectations on activity and helped many individuals in behavioral health crisis situations. (See Figure 1, above.) We’ve also avoided many unnecessary ED transports and psychiatric hospitalizations. The data in this article reflects a full year of the team’s activity. (See Figure 2.)
We anticipate that the program will continue to increase its services. The team is also impacting the strain on the 9-1-1 system by providing an alternative contact and resource for behavioral health situations. We hope to expand the service by adding additional units and providing enhanced counseling and intervention services in the future, as funding allows.
This new area of EMS service to our community was long overdue. The BHRT’s value has become self-evident in the government, the healthcare community and the public through its steady increase in utilization and the impact on those suffering with mental health issues.
The BHRT developed a 30-second commercial that airs locally on cable TV and a monthly radio show entitled “Healthy Attitudes” that streams online at www.wrcr.com. Find out more at www.rocklandhelp.org, @RocklandBHRT and www.facebook.com/BHRTGetHelp.