An ideal behavioral health crisis system must have a mechanism to both finance a comprehensive continuum of crisis services and ensure the accountability and quality of the continuum’s performance. Because of the complexities and challenges associated with behavioral health crisis response, individual crisis programs and collection of crisis programs cannot hold themselves accountable to respond to broadly defined community needs or align effectively with multiple behavioral health crisis partners without a mechanism for oversight and accountability to ensure quality. This section describes the criteria for administrative and financial structures for a successfully operating crisis system.
The following definitions of key concepts are used in this section:
In this report, an ideal behavioral health crisis system is responsive to and responsible for a designated community or catchment area. The delineation of this community or catchment area will vary depending on the nature of the geography served.
In a large urban environment (say a county with a population of a million or more), the crisis system catchment areas may be defined by geographic regions within the county. The same may apply for a county in which the population may not be as large, but the county is geographically spread out. In a moderately-sized county, the crisis system catchment area may be the single county. In more rural areas, the crisis system catchment area may include multiple counties, depending on geography and population. In some states, counties do not represent meaningful ways to organize catchment areas and they may be defined by responsibility for cities and towns instead. Finally, tribal organizations may define catchment areas for behavioral health crisis response according to the dispersion of the tribal population across the geography defining the boundaries of tribal land.
In an ideal system, each state will have a consistent mechanism for allocating responsibility and accountability for behavioral health crisis systems to counties or other intermediate structures (e.g., cities, towns, regions, districts) throughout the state.
In this report, accountable entity describes the structure that holds accountability for behavioral health crisis system performance for a community or catchment area and may also have the role of providing funding and/or coordinating multiple funding sources to support the crisis continuum. The term purposefully indicates that there are many different structures that can carry out this function.
We are not recommending one particular type of structure. For example, an accountable entity can be a county behavioral health department, but it also can be a behavioral health managed care organization responsible for Medicaid and indigent funds, a nonprofit managing entity or a formal collaborative structure that is set up for crisis system oversight by one or more communities or counties. In a large county or city, the single accountable entity might be responsible for overseeing and coordinating crisis systems that are responsible for different catchment areas within that county or city. The same might be true in a small state or a state with a small population, where the state is the accountable entity coordinating and overseeing performance of catchment area crisis systems statewide.
In most states, regardless of the locus of accountability, the operation of the crisis system requires collaboration across multiple levels of government (state, county, local) and across multiple types of funding (e.g., health, law enforcement) and involving both public and private payment systems. The state may share elements of accountability with counties and/or local communities, or vice versa. However structured, the role of the accountable entity is to ensure appropriate management to ensure and continuously improve quality and outcomes for the population served.
In the context of our effort to emphasize the importance of core values (see Table 1) as the foundation for all service delivery, it is essential to build those core values into every aspect of the accountable entity. The first job of the accountable entity is to be responsible for maintaining core organizational values and incorporating them into all organizational processes, including contracting, incentives, data collection, quality improvement and outcomes. Priorities must include person and family driven values, such as welcoming, safe, accessible, recovery-oriented, resiliency enhancing and trauma informed care, emphasizing cultural humility and maximizing engagement, hope and empowerment and minimizing involuntary interventions to those situations where they are clearly needed to promote safety and well-being.
The accountable entity is also responsible for designing and coordinating funding for a continuum that meets the needs of the whole population served, emphasizing those that are more vulnerable and complex, as well as those with special needs or at risk of experiencing disparities in care. The accountable entity must proceed to design all services and processes in a collaborative quality improvement partnership that monitors indicators of all important values in service delivery but is flexible enough to engage providers as partners and support creativity and variability in how the services are provided.
The system is always responsible for person- and family-driven values based on effective evidence-informed care and embedded in cultural humility embedded in cultural humility (see Table 1 for additional information on values, including accessible, recovery-oriented, resiliency-enhancing and trauma-informed care). Internal review and systematically collected feedback from consumers, families, providers and other stakeholders that is reviewed to identify areas for improvement ensures maintained accountability for these core values. It is essential to regularly address Identified areas for improvement in the delivery of value-based services in systemic continuous quality improvement activities. In all the following indicators of system accountability, value-based services are fundamental features of every element of care.
The remainder of this section describes various elements of accountability and financing in an ideal system. For each element, there is a brief discussion of rationale, followed by measurable criteria for system implementation and oversight.
There are many possible mechanisms for structuring an accountable entity.
In Arizona, Medicaid-managed care intermediaries function as accountable entities for crisis systems that serve everyone, not just the Medicaid population.
Arizona has had a managed Medicaid system from its inception, which is called the Arizona Health Care Cost Containment System (AHCCCS). AHCCCS contracts via a competitive bid process with managed care organizations throughout the state, including a RBHA in each geographical service area. In southern Arizona, the RBHA is Arizona Complete Health (formerly Cenpatico Integrated Care, part of Centene). The RBHA braids multiple funding streams, including Medicaid, SAMHSA block grants, state and county funds to serve as a centralized point of accountability for the behavioral health system. Pima County has a full continuum of crisis diversion and behavioral health services, including for SUD, and services for both juveniles and adults through a larger provider network. In addition to funding the crisis response center (CRC) services, the RBHA contracts with multiple providers to operate the crisis call center, a dozen mobile crisis teams that are dispatched from the call center, residential and step-down facilities and various other crisis services not on the CRC campus (Manaugh, 2020).
In Pennington County (Rapid City), South Dakota, a county-led collaboration of agencies and providers oversees the operation of the crisis continuum, with the Sheriff’s Office holding ultimate accountability.
The Care Campus is a partnership of the Pennington County Sheriff’s Office, Pennington County Health and Human Services, the City of Rapid City and the Crisis Care Center operated by Behavior Management Systems, a private provider, under the oversight of the Pennington County Sheriff’s Office. The Care Campus includes a full continuum of co-located services addressing the crisis stage of mental health and substance use disorders and support services to assist Care Campus clients with attaining recovery and maintaining stability in the community (Manauge, 2020).
In Kent County (Grand Rapids), Michigan, the accountable entity is being formed as a new organization by a collaboration between the county, four major health systems, three behavioral health provider organizations and the Community Mental Health entity that manages specialty behavioral health Medicaid and indigent services.
In Kent County (Grand Rapids) MI, the county has organized a population health consortium to lead important community health projects, one of which is to develop a state of the art behavioral health crisis system. The consortium consists of the County Executive, a community business/foundation leader, CEOs of four health systems, CEOS of two psychiatric hospitals, the CEO of the local CMH/Medicaid managing entity and the CEO of a large community crisis provider. The consortium obtained consultation to operate under the Kent County Department of Health, which convened a Consensus Working Group representing over 25 key constituencies and organizations. This group has developed a consensus plan, with prioritization, and is working on transitioning this structure to a formal “Accountable Entity” governance model, using local EMS as a template.