Elements of the continuum

INTENSIVE COMMUNITY-BASED CONTINUING CRISIS INTERVENTION

A behavioral health crisis episode is not a single event and is rarely resolved with a single intervention. Whether the individual is presenting early in the crisis process to seek services at a behavioral health urgent care center or is in a post-crisis phase transitioning out of a crisis center, 23-hour observation unit or residential crisis program, there is frequently a need to provide a continuing bridge of best practice crisis intervention at an appropriate level of intensity – usually for days, weeks or even a few months – until the individual or family is sufficiently stabilized to continue in more routine care at the appropriate level of intensity, ranging from ACT to routine outpatient. Many individuals and families with complex challenges who present with an immediate crisis that needs urgent resolution (e.g. acute suicidality, psychosis), will remain far too unstable to participate in routine community care, even after addressing the most acute need. These may be individual adults who are homeless or unstably housed, who have active substance use with poor adherence to medications, who have complex unstable relationships, who have difficult medical and physical disability issues or who have cognitive challenges, and so on. These may also be families with multiple problems whose situation remains unstable even after addressing the child’s acute need.

For some of these adults or families, there will be an eventual need for a long-term intensive community based service (LOCUS Level 4), such as ACT or wraparound, but for many of them, a shorter term of two weeks to three months of intensive community-based crisis intervention (also LOCUS Level 4), using evidence based strategies such as critical time intervention or (for families) multisystemic therapy or functional family therapy will provide enough stability for the clients to continue in ongoing care at lower intensity. One way to think about these teams is that they essentially have many of the features of an ACT team (e.g., multidisciplinary team with psychiatric care providers, nursing, case managers, clinicians and/or peers with capacity for office based or home-based visits up to several times per week), but they are organized for short-term crisis work rather than long-term work with individuals with very chronic disabilities. These services are essential within the ideal crisis continuum because otherwise the individuals and families who need these services continually fail to make the transition from higher end crisis intervention (e.g., crisis center, crisis bed, hospitalization), to more routine outpatient care and cycle back into crisis or get into trouble in other areas (e.g., arrest, homeless, child welfare involvement).

In some systems, there is provision for intensive outpatient crisis services in the form of partial hospitalization programs (PHP) that are commonly 20 hours per week or mental health intensive outpatient group programs (IOP) that are commonly nine hours per week. These can also be effective for those individuals in crisis who are able to participate effectively in group structure. The development of these programs is often influenced by available reimbursement models rather than by a comprehensive assessment of the needs of individuals in crisis. In an ideal system, the intensive outpatient crisis service includes a combination of flexible team based wraparound care along with opportunities for engagement in structured groups that can be embedded in the intensive crisis team services or included in a separate PHP or group-based IOP depending on the size and availability of resources in the community being served. Intensive community-based intervention is a certification requirement for CCBHCs.

Oregon’s Crisis And Transition Services Model Intensive Community-Based Crisis Intervention For Youth

The Crisis and Transition Services (CATS) program is an innovative partnership between the Oregon Health Authority, Oregon Health & Science University (OHSU), county mental health programs and community-based clinical and peer organizations. CATS provide rapidly accessible short-term intensive transitional community-based care for youths and families after a youth in mental health crisis has presented to an emergency department. CATS serve youths up to age 18 who meet criteria for psychiatric inpatient admission but have the potential to safely transition home with sufficient support after initial evaluation and safety planning in the emergency department. The program lasts 14–60 days and serves as a bridge from ED discharge to engagement with long-term outpatient providers.

The goal is for the program to be “insurance blind” and to balance adherence to uniform state guidelines with local flexibility. Generally, urban programs have a stronger focus on providing intensive clinical stabilization and connections to longer-term services, whereas rural programs focus on crisis response and coordinating rapid access to community providers. The programs providing clinical care generally use master’s-level clinicians and psychiatric providers, whereas most rural programs utilize qualified mental health associates. OHSU has provided ongoing program implementation support, including a learning community across the state, as well as program evaluation. Strong collaboration among stakeholders has helped to expand the program’s funding and availability. Funding began with collaboration between Oregon Health Authority (Medicaid) and local funds, but now commercial insurance plans have begun to develop reimbursement for CATS (Ribbers, 2020).

Measurable Criteria for an Ideal Crisis System

The accountable entity works with the community collaborative and the crisis provider network to design, fund and implement adequate capacity for intensive community-based crisis intervention for both adults and children, that includes both home-based and office-based capability. The ideal system includes:

Adequate access

Intensive community-based services are located within 30-minute drive or one-hour in rural areas for both adults and children and/or can be provided through home visits and telehealth. All services welcome the opportunity to work with individuals and families who may continue to actively use substances.

Rapid access

Services are expected to be initiated within 72 hours of request.

Intensity

The intensive community crisis services can see clients up to three times per week and provide/plan daily support if indicated.

Medication evaluation

All services provide routine access to medication evaluation and re- evaluation, in person or through telehealth.

Length of stay

All services can be provided for brief periods of two weeks up to three months, during which time transition to continuing services at the right level of intensity can be arranged.

Volume and adequacy

The accountable entity monitors access and utilization of intensive crisis intervention services to ensure there is rapid access from both front-end services – mobile crisis or urgent care – and stepdown. The accountable entity monitors services for both adults and children/families to ensure that all who need these services can receive them (office-based, home-based or telehealth), while maintaining effective transitions to routine service provision so that capacity continues to be available for initial referrals.

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