Elements of the continuum


Twenty-three-hour evaluation and extended observation programs or services - sometimes referred to simply as 23-hour observation beds - provide a safe and secure space with the capacity for ongoing evaluation, observation and intervention by a multidisciplinary team, including psychiatric care providers, nursing personnel, crisis intervention specialists and/or peers for up to 23 hours during the acute phase of the crisis. Availability of this service for all individuals who need it, regardless of age, is an essential component of an ideal crisis system. The rationale for extended observation is threefold:

First, effective crisis evaluation and planning takes time, usually at least 2-4 hours, even in relatively straightforward cases. This requires a safe space designed for individuals in behavioral health crisis where crisis team members can engage clients and their natural supports to conduct a useful evaluation and determine the next best steps. For this reason, one of the essential features of a crisis hub or crisis center is the space and time to provide for an effective evaluation.

Second, the clinical picture can be very fluid during a crisis, especially within the first 12-24 hours.

Clients often present late at night at the culmination of a series of difficulties, many times in the context of intoxication and/or lack of sleep. At the time of presentation, they may express thoughts of violence or self-harm and/or may be agitated and/or disorganized in their speech and behavior. If such a presentation occurs within a setting or system with no capacity for extended observation (e.g., medical ER, walk-in center at an outpatient clinic), it is not at all uncommon for such clients to be admitted to inpatient units for safety, only to wake up the next morning in a very different state – calm, contrite, embarrassed or frustrated about being admitted. Conversely, individuals can present in a way that suggests the only problem they have is intoxication, but that presentation may be masking serious suicidality or psychosis. The 23-hour observation bed, associated with the evaluation and intervention capacity provided by the multidisciplinary team, can avoid unnecessary hospitalization and, conversely, prevent inappropriate discharge.

Third, access to a 23-hour observation bed allows individuals in acute decompensation to receive a more thorough evaluation and initiation of treatment. Like people presenting with medical crises, the response to initial interventions during the crisis can significantly determine the best next step. Rapid response to antipsychotic medication and an opportunity to sleep may mitigate a decompensation to the point that referral to a residential crisis program or even outpatient service can be an alternative to hospitalization. Similarly, observation beds can provide a safe place to initiate treatment for SUD withdrawal syndromes or to attempt to engage individuals who have presented with opioid overdose and responded to naloxone. Engagement of collaterals in crisis intervention can determine whether the individual can safely return home or if an alternative disposition is required

The location of extended observation services can vary and 23-hour beds can, ideally, be outside a hospital setting. The more crisis services are hospital-based, the lower the percentage of people successfully diverted from hospital admission.

The Tucson Model: A Collaborative Approach to Behavioral Health Crisis and Public Safety

Pima County, Arizona, has developed a robust crisis system over the past 20 years, beginning with CIT training for law enforcement in 2001. The evolution of the crisis system has been a collaboration between many diverse stakeholders, with the County and Regional Behavioral Health Authority acting as the primary conveners.

With a population of just over 1 million, Pima County is one of the oldest continually inhabited counties in the US, and one of the largest at 9,187 square miles. About half the population resides in Tucson, with the remainder living in small towns, Native nations, rural areas. Pima County shares 130 miles of international border with Mexico. The population is 51.2% White non-Hispanic, 37.8% Hispanic, 4.4% Native American, 4.3% Black and 3.3% Asian.

While it was the last state to implement Medicaid, Arizona was the first to finance Medicaid via a statewide managed care waiver. The state is divided into geographical service areas, and a Regional Behavioral Health Authority (RBHA) is selected via a competitive bid process to fund and oversee a variety of behavioral health services, including crisis services. The RBHA receives funding via Medicaid, SAMHSA block grants, and other state and county funds, and it uses this braided funding stream to contract with various provider agencies to deliver crisis services to anyone in need. By serving as a single point of accountability, the RBHA is able to ensure that its subcontracted providers function as a coordinated system aligned toward the common goal of achieving stabilization in the least-restrictive setting that can safely meet the individual’s needs. In this model, clinical and financial incentives are closely aligned, as the least restrictive levels of care also tend to be less costly. The RBHA during much of the early development of the crisis system was Community Partnership of Southern Arizona (CPSA), a non-profit owned by multiple service providers. In 2015, the RBHA contract was awarded to Cenpatico Integrated Care, now known as Arizona Complete Health, a subsidiary of Centene Corporation.

Pima County also plays an important role as a leader and convener. As the operator of the jail and a primary funder of the safety net hospital emergency department, the County has long had an interest in improving care for individuals with behavioral health needs. The County created a dedicated Behavioral Health Department in 2010 to oversee its role in civil commitment evaluations and jail programs. As part of the MacArthur Foundation Safety + Justice Challenge, Pima County has developed data sharing agreements which it uses to identify opportunities for community-based alternatives to incarceration, and collaborates closely with the RBHA, law enforcement, and various service providers on a variety of self and grant funded programs.

By the mid-2000s, Pima County was serviced by a growing crisis system comprised of a crisis line, crisis mobile teams and a walk-in crisis clinic. An increasing awareness of the prevalence of mental illness in the Pima County jail, compounded by a series of tragic events related to untreated mental illness, created the momentum needed to mobilize the resources needed for a crisis center to service the needs of law enforcement and the community. Leaders from Pima County and CPSA (the RBHA at the time) collaborated on a bond to build a crisis center to serve as an alternative to arrest and emergency department use. The bond was passed in 2006 and the facility was completed in 2011. A few months prior to the CRC opening, Jared Lee Loughner opened fire at a community forum held by US Representative Gabrielle Giffords, killing six and wounding 14. This prompted leaders at the Pima County Sherriff’s Department and the Tucson Police Department to develop approaches that went beyond CIT. Both agencies created dedicated Mental Health Support Teams that seek to prevent crisis by identifying individuals at risk and connecting them to mental health services. Law enforcement and mental health collaborations have continued to grow, resulting in multiple specialty and co-responder teams and a robust training program for jurisdictions across the entire southern Arizona region.

The Crisis Response Center (CRC) is the centerpiece of the crisis system, serving approximately 12,000 adults and 2,200 children annually. In the year following its implementation, the percentage of Pima County Jail inmates with serious mental illness decreased by half, and the number of behavioral health visits to the adjacent emergency department decreased from 750 per month to 150. The facility is owned by Pima County, licensed to Banner- University of Arizona Medical Center, and managed by Connections Health Solutions, a private behavioral health provider. Services are primarily funded by the RBHA.

Services for adults and children are provided in separate areas of the facility and include 24/7 walk-in urgent care and 23-hour observation for 34 adults and 10 youth. Most patients arrive directly from the field via law enforcement, with the remainder arriving via transfer from outside EDs, mobile crisis teams or walk-in. Reasons for presentation include danger to self/other, acute agitation, psychosis, intoxication and withdrawal. In an ED, these patients would board waiting for an inpatient bed, whereas at the CRC, 60-70% return back to the community without the need for hospitalization via rapid assessment, early intervention and proactive discharge planning. Care is provided by an interdisciplinary team of psychiatric providers, social workers, nurses, behavioral health technicians and peers. The open design allows for continuous visualization to ensure safety and provides the opportunity for interpersonal interaction in a therapeutic milieu. For those who need it, a 15-bed adult short-term inpatient unit provides 3-5 days of continued stabilization.

Law enforcement uses the CRC as their central behavioral health receiving facility, dropping off both voluntary and involuntary patients via a secure gated sally port with a turnaround time of > 10 minutes or less for adults and 20 minutes for children. There are no exclusionary criteria for behavioral acuity, and officers are never turned away. Highly agitated or violent patients are cared for without the use of security by trained behavioral health technicians, with seclusion/restraint rates often lower than the national average for inpatient psychiatric facilities.

The CRC is part of a unique campus that has received national recognition for both its architectural design and multi-agency collaborative clinical model. In addition to the crisis services described above, the CRC houses the crisis call center for southern Arizona, which serves an “air traffic control” function, dispatching over a dozen mobile crisis teams throughout Pima County. A covered breezeway connects the CRC to the Banner emergency department and 66-bed inpatient psychiatric hospital, which contains a courtroom that is used for civil commitment hearings and some criminal matters. The CRC also contains space for co-located community partners, such as behavioral health clinics that can immediately enroll patients, and a peer run program that provides post-crisis wraparound services.

The governance and financing structure in southern Arizona has supported the continued development and oversight of the crisis system. The result is a robust continuum of crisis services, operated by a wide variety of provider agencies. A culture of “no wrong door” means that agencies work together to create a system in which anyone in crisis can get their needs met wherever they present. Regular stakeholder meetings, convened by the RBHA and the County, allow for ongoing analysis of data trends, problem solving and continuous improvement of the system.

Community-based (non-hospital based) crisis centers – particularly those in larger communities – should include 23-hour observation beds with capacity for adequate monitoring and initiation of treatment, including through telehealth. These settings should also make provision for space where children and adolescents can be served separately from adults.

In less populated areas, it is often more practical for the behavioral health crisis provider to collaborate with a local hospital to create space for extended observation near the ER and the resources it offers, but the service is in a more appropriate space than the medical ER. It is also important to recognize that in most larger communities there will be a significant volume of individuals who will present with both acute medical and acute psychiatric needs and will need to be evaluated and observed in the medical ER. The ideal response is to develop a designated psychiatric emergency service (such as the EmPATH model described on page 18 to serve those individuals. Regardless of location, 23-hour observation beds should maximize privacy and dignity on par with medical emergency services and the whole team should be focused on being welcoming, person-centered, hopeful and trauma-informed, especially in settings where there is a high volume of client flow.

Settings with 23-hour beds must also have close linkages to services on either side of the continuum, as a key outcome of the evaluation period is the determination of whether a step-up or step-down in services is indicated. The crisis system accountable entity must constantly monitor flow through the observation beds, so individuals are not backed up waiting for disposition because of lack of capacity at the next levels of care

Although the 23-hour limit on observation is required for the service not to be considered inpatient, it is important to provide for continuation if needed. If at the end of a 23-hour period, the next best step remains unclear but there is good reason to expect that it will become clearer within the next 12 hours or so, an ideal system would allow for readmission to that level of care up to an additional 23 hours.

Measurable Criteria for an Ideal System

The accountable entity working with the community collaborative and crisis providers ensures adequate availability of extended observation capacity for adults and children, as follows:

  • The community crisis center or crisis hub provides directly, or through collaboration, a location providing safe, secure extended observation for both voluntary and involuntary clients. Wherever possible, this location is outside of a medical ER.
  • There is provision of separate space for adults and children.
  • There is a welcoming, hopeful, person-centered, no force first philosophy that emphasizes customer experience, including for those who are involuntary.
  • The capacity of the extended observation service is adequate to meet community needs and there is enough space so individuals are diverted elsewhere less often than one day per month, if at all.
  • Staffing for the extended observation service includes a multidisciplinary team with 24/7 availability, including access to psychiatric care providers, crisis intervention specialists and peers.
  • The extended observation service welcomes individuals with intoxication and can initiate interventions for withdrawal management and overdose reversal.
  • The extended observation service welcomes individuals with psychosis and can initiate interventions for treating acute decompensation.
  • Match the availability of extended observation beds to the geography of the community.
  • If extended observation must be provided in an emergency room, there is separate space within the emergency room that is designed for behavioral health patients to be safe, comfortable and secure.
  • Continuously monitor the flow through the extended observation service to ensure that individuals are not backed up or boarded in that setting.
  • Hold inpatient units, residential crisis programs and other crisis intervention programs accountable to accept individuals who need to be transferred.
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