The patch comes over the radio: A paramedic informs the local hospital’s ED that her team is en route with a suicidal male who requires psychiatric evaluation. The paramedic and her crew were on scene for an hour trying to convince him to consent to receive help.
At the hospital, the paramedic shares the information she collected with the ED staff, who assume responsibility for the patient. A lengthy ED stay—his fourth this year—is in this patient’s future.
This all-too-common scenario occurs across the country, spurring the same thoughts among emergency providers who attend to patients in crisis: Wouldn’t it be better if there was an efficient way to deliver definitive services to patients with psychiatric emergencies besides the status-quo inefficient field navigation and prolonged ED visits? Can the high recidivism of patients in behavioral health crisis be combatted with the proper tools and infrastructure to facilitate proper and timely navigation for these patients? Isn’t there a more appropriate primary option for helping patients with behavioral health crises than the already-stretched-too-thin EMS, law enforcement and ED resources?
Reforming Old Ways
Community stakeholders in Colorado Springs, Colo., decided to channel those lines of thought into action. In 2012, the Colorado Springs Fire Department (CSFD) started a mobile integrated healthcare/community paramedicine program to address the issue of frequent users of EMS and local EDs. The Community Assistance Referral and Education Services (CARES) program gave special attention to the 76% of frequent 9-1-1 users with behavioral health issues, with EMTs and paramedics making home visits and providing assistance with education and navigating patients to community resources.
The program achieved considerable success by dropping 9-1-1 one-year use by 50% among two-thirds of the program’s patients.
CARES program stakeholders recognized that if they didn’t find working solutions to underlying psychiatric concerns in the community’s population, the CARES programs would see limited sustainable success without additional community assistance/support.
However, CARES was set up as a nonemergent program, working with patients only after multiple 9-1-1 calls or ED visits. CARES doesn’t change the system’s response to initial, emergent psychiatric crises. Calls to 9-1-1 by patients experiencing an emergent behavioral health crisis would still be met with the same timely response that a patient who had suffered severe trauma, myocardial infarction, or stroke would see: three CSFD EMTs, one CSFD paramedic, one American Medical Response (AMR) paramedic, one AMR EMT, and one to three law enforcement officers. A psychiatric patient might need further evaluation and medication and perhaps placement in a psychiatric hospital. A patient with a mental health crisis might wait days to receive the help that they needed, even after arriving at the ED. Clearly, this one-size-fits-all approach was neither necessary nor effective.
Figure 1: Colorado Springs citywide time of day and day of week for behavioral health calls for service
Creating a new program and protocols that would effectively address the issue of psychiatric crises wouldn’t be easy. Years of history indicated that emergency personnel and other episodic care providers regularly experience complications in treatment and disposition of patients with underlying behavioral health conditions. The treatment modalities for psychiatric patients, in fact, reflect system-wide, multidisciplinary, resource utilization inefficiency.
Another challenge was that the training curriculum for firefighters, EMTs, paramedics and law enforcement doesn’t include comprehensive training on managing behavioral health crises, and even expanded protocols and training wouldn’t give them the necessary tools to efficiently and safely manage and disposition psychiatric patients.
Moreover, community collaborators were aware that for patients who truly need psychiatric treatment, interaction with local emergency responders often doesn’t result in optimum patient outcomes. When police respond and eventually contact EMS, there’s already been a delay in care, sometimes with adverse outcomes. And the arrival of EMS doesn’t necessarily translate into efficient care; EMS personnel aren’t equipped to perform a true medical clearance, psychiatric evaluation, or determine and facilitate a definitive disposition.
Thus, EMS essentially becomes a taxi service to the ED. And once the patient arrives at the ED, he or she can spend several hours or even days there before appropriate intervention and disposition or treatment occurs. So what really exists is a handoff from one agency to the next, each of which isn’t designed for effective management of behavioral crises.These suspicions would later be statistically confirmed by a retrospective evaluation of emergency calls in Colorado Springs that revealed 81.1% of all CSFD responses were medical in nature and 18.1% of the 49,297 medical 9-1-1 calls to CSFD in 2014 involved behavioral health emergencies, over 98% of which were transported the local EDs by AMR.
The Colorado Springs Community Response Team sees an average of 81 patients per month.
Vital Elements Identified
Cross-agency collaboration was key in working toward a solution. In 2012, a local summit to address the lack of mental health services brought 36 different agencies together to map the existing behavioral health patient navigation process and better understand the issues.
At the outset, the stakeholders identified three critical elements as being vital to a positive outcome: scene safety, medical clearance and definitive disposition—and for optimal results, all of these components must take place simultaneously on scene.
The first step toward program development involved conducting a comprehensive analysis of the treatment path for psychiatric patients in the EMS system as it already existed—from initial contact to definitive disposition. That exploration revealed that the system was surprisingly complex, involving more than 50 points of contact, including dispatch communication centers, crisis lines, law enforcement, the fire department, EMS, hospital EDs, physicians, nurses, lab technicians, social workers and behavioral health organizations.
Another surprise that emerged from the analysis was the significant number of contacts by law enforcement with individuals experiencing behavioral health issues that never resulted in EMS or ED contact. The analysis indicated that law enforcement officers were requesting EMS assistance on only 20% of calls in which they dealt with such patients. This data clearly demonstrated the enormity of law enforcement resource utilization in behavioral health issues.
With this information in hand, the Colorado Springs Police Department (CSPD) and CSFD collaborated with AspenPointe, a local behavioral health organization, to form a specially staffed mobile integrated mental emergency response team to efficiently and expertly evaluate and disposition behavioral health patients directly from the field.
First deployed in December 2014, the Community Response Team (CRT) consists of a CSFD medical provider, a CSPD officer and a licensed behavioral health clinician. Deployment was originally set at 40 hours per week from 10 a.m. to 7 p.m., Monday through Thursday, based on the days of the week and times of day with the highest behavioral health 9-1-1 call volume. (See Figure 1, above.)
Figure 2. Colorado Springs Fire Department Community Response Team protocol
From December 2014 through May 2015, the unit responded to 764 incidents and saw 488 patients, averaging 81 patients per month, with 86% of patients being managed in place or dispositioned directly to a mental health facility, and only 14% of patients requiring transport to local EDs for further medical evaluation. These initial successes within the first six months led to the deployment of a second CRT unit on July 1, 2015.
CRT2 is scheduled an additional 40 hours each week to cover the weekend—Friday through Monday. The two units overlap deployment to address the higher volume of 9-1-1 psychiatric incidents that occur on Mondays and, together, the units ensure daily coverage to respond to 9-1-1 and crisis hotline calls where a patient is or may be experiencing a behavioral health crisis.
Prior to the CRT program, 98% of patients seen by the CSFD and AMR for a behavioral health crisis were transported to the ED. In a matter of months, this new approach has significantly reduced strain on local emergency services, law enforcement and local EDs by intersecting, diverting and redirecting behavioral health patients to appropriate community resources directly from the field.
The local 9-1-1 call center helps by diverting qualified calls directly to the CRT, therefore decreasing the burden of these calls from the regular EMS, FD and PD dispatch.
The success of the CRT can primarily be attributed to the team’s unique, multidisciplinary composition. When the CRT arrives on scene, it carries an assortment of personnel and skills: an EMS provider, law enforcement officer, and a licensed clinical behavioral health social worker.
A fire department medical provider performs a medical clearance in the field. (See Table 1, above.) The medical clearance algorithm includes a physical exam, serum labs, a urine toxicology screen and a urine pregnancy test. This medical clearance system allows the team to decrease and eliminate unnecessary evaluations in the ED. Additionally, the FD medical provider screens every patient by facility admission eligibility, using criteria pre-designed by the partnered psychiatric facility. (See Figure 2, above.)The medical provider also has the ability to employ chemical sedation when needed.
A police officer provides scene safety and addresses law enforcement needs. Scene safety is often a challenging obstacle for EMS providers in traditional behavioral health crises, and the presence of the officer on scene helps to mitigate potential negative outcomes for both the patient as well as for the EMS personnel. Having an officer on scene also helps prevent the need for EMS calls for PD assistance in the traditional response model.
A medical clearance algorithm for behavioral health patients in an emergent crisis helps decrease prolonged field assessment times and eliminate unnecessary evaluations in the ED.
A licensed clinical social worker provides guidance on how to manage the patient, including on-scene crisis de-escalation, navigation to outpatient resources or disposition to a behavioral health facility.
The CRT unit has the authority to transport patients to designated receiving facilities, reducing the overuse of limited resources. Implementation of the CRT unit has resulted in an unprecedented streamlining between the initial 9-1-1 call for an acute behavioral crisis and patient receipt of definitive behavioral health services. Of the 2,519 patients treated by both CRT units from Jan. 1, 2015 through June 30, 2016, 49% were treated in place and 27% were transported to the local Crisis Stabilization Unit (CSU).An additional 9% were transported by CRT to a non-CSU psychiatric facility, including the County Detoxification Facility and local in-patient psychiatric hospitals. About 15% didn’t meet CRT criteria for scene clearance or disposition to an alternate destination and were therefore transported to the ED for further evaluation.
CRT refers patients requiring long-term stability to the CARES program for navigation to non-emergent medical, social and behavioral health resources.
Early indications reveal behavioral health patients are benefiting from ongoing navigation: ED recidivism for CARES patients has been reduced by nearly 50%, and 88% of patients seen by the CRT in 2015 were only seen once by the CRT.
The CRT has also proven to be a marked workforce multiplier for police, EMS and ED resources. From Jan. 1, 2015 through June 30, 2016, the CRT unit has responded to 3,984 calls and treated 2,519 patients, which resulted in a release of 906 fire/EMS crews and 2,448 police units back into service. When you take into account that each call consumed an average of 45 minutes, this adds up to a tremendous amount of personnel hours saved for other vital FD, EMS and PD services.
Initial support came from a combination of statewide grant funding and partner contributions. Continued partnerships with behavioral health organizations, FD and PD are generating opportunities for sustainability.
In evaluating the effect of the CRT program, one thing is clear: This innovative approach to responding to behavioral health crisis has shifted the EMS paradigm for Colorado Springs, and may serve as a model for other communities to achieve that same goal.