Elements of the continuum

RESIDENTIAL CRISIS PROGRAM CONTINUUM

A continuum of co-occurring capable residential crisis programs or services is an essential component of an ideal crisis system. Residential crisis programs of all types are designed and staffed to work with individuals in behavioral health crisis who do not need the full resources of a psychiatric inpatient unit or other secure treatment settings. These programs add considerable flexibility to the behavioral health crisis continuum, as they can respond to individuals in less restrictive, often more home like settings, at lower cost than a hospital. Residential crisis programs may be used for both hospital diversion, which reduces admissions, and hospital “step-down,” which can shorten length of stay. Both diversion and step-down promote access to less restrictive settings for residential crisis intervention and more effective utilization of scarce resources and expensive psychiatric beds.

Residential crisis programs have been utilized successfully in locations across the United States for more than 25 years but are still relatively scarce. Most communities in the US do not have access to any residential crisis programs, let alone a continuum of different types. Yet, there is emergent data that reinforces the necessity and value of such settings in the crisis continuum: In “Crisis Now,” the National Alliance for Suicide Prevention published crisis flow data based on experience in Phoenix, Arizona, indicating that 86% of all crisis presentations were diverted from hospitalization and of the total, 54% went to some form of crisis residential setting (LOCUS Level 5: Medically-Monitored Residential Services) (See “How Does Your Crisis System Flow?” diagram). Without the availability of that level of care, it would be expected that almost all those individuals would have needed hospitalization.

In contrast to what these data imply, SAMHSA’s 2020 National Guidelines for Behavioral Health Crisis Care includes short-term residential facilities and peer-operated respite programs as “additional” but not “essential” elements of a behavioral health crisis system. However, without a continuum of residential crisis programs, there would be more reliance on scarce hospital beds for the individuals who cannot be safely discharged after initial evaluation, which makes it more likely that there will be backup in the crisis center and ineffective and inefficient use of resources. Therefore, residential crisis services should be viewed as essential.

Information about established standards for crisis residential services is still very limited and inconsistent. Each state has its own definitions and criteria, as do different public and private payers – and not all systems or payers even have criteria. TBD Solutions conducted a national survey of crisis residential providers to develop a Crisis Residential Best Practices Handbook (2018), which has been a valuable resource for delineating standards for a continuum of residential crisis programs and services for an ideal system.

As reflected in the Handbook (TBD Solutions, 2018), “crisis residential” is a term that covers many types of programs and services with variable levels of service acuity, intensity, medical/nursing capabilities and costs. There is no standardized language to describe all the types of residential crisis programs – what is defined as a crisis residential unit in one state may be called a crisis stabilization unit in another state and vice versa.

Residential crisis programs can vary with respect to multiple clinical design factors, as listed in Table 3.

Table 3 Clinical Design Factors In Residential Crisis Programs

Psychiatric monitoring: May range from daily on-site visit to no direct access to psychiatric care providers.

Nursing coverage: May range from an RN three shifts, RN some shifts and LPN/emergency medical technicians (EMTs) on others, to no nursing on-site.

Staffing: Staffing ratios may vary from 1:2 to 1:8 and may be particularly thin on overnight shifts.

Peer staffing: May vary from fully peer-operated and staffed, to peers in the mix, to no peers.

Security: May be contained enough to prevent people from eloping, or may be completely open.

Size: Usually no more than 16 beds due to Medicaid Institutions for Mental Disease (IMD) restrictions, but may be quite small (e.g., as small as 1-2 beds).

Medical capabilities: May have varying access to medical care, labs, pharmacy, etc.

Mental health capabilities: May range in the degree of capability to respond to higher acuity.

SUD capability: May vary (e.g., sobering center with no medications, mental health, residential crisis program for people with mental health crises, with withdrawal management capability varying according to medical and nursing capacity).

Medication provision: May administer meds or may require clients to self-administer.

Programming: May have a full array of groups, just a few or none.

Crisis intervention: May provide one-to-one service, family intervention or just assistance with discharge planning.

Flexibility: May require all clients to be at the same level of care or may have a range in the same site.

Length of stay: Programs may have average length of stay ranging from 3-5 days to 7-10 days.

Cost: May range from $50 to $500 per day depending on the level of service and staff.

In addition to the clinical/staffing variables in the table, there may also be variation in the degree to which programs can accommodate people with physical disabilities, people who do not speak English or people with cognitive or self-care challenges.

Because of this variability in services and cost, an ideal behavioral health crisis continuum has a range of crisis residential settings that provide as much flexibility as possible to match services to the diversity of needs in the population in a cost effective manner. There must be similar availability of all applicable elements of the continuum for children and youth.

The composition of the ideal residential crisis continuum is determined by the size and geographical distribution of the population being served. Based on the Crisis Now “How Does Your Crisis Flow?” diagram, a significant percentage of the total adult crisis presentations (200 individuals per 100,000 residents per month) were served in crisis residential settings. If that percentage is even as low as 30%, a community of 500,000 people would generate 300 residential crisis admissions per month and, if we assume an average length of stay of five days, that would require 50-60 residential crisis beds (5 x 300 = 1,500 bed days, divided by 30 for approximate utilization).

Those 50-60 beds may be distributed in several different types of programs in a concentrated urban area. Note that the more highly staffed the residential crisis program, the more individuals can be safely diverted from hospitalization, but at higher cost. The more available lower cost options, the more individuals are able to get help earlier in their crisis less expensively. The right mix should include a balance of services that include higher acuity and lower acuity residential crisis programs as well as incorporating peer support into the crisis continuum to the greatest degree possible. Determining the right mix should be based on a data-driven assessment of community needs, including age mix and available resources under the auspice of the accountable entity and the community’s crisis collaborative.

The calculation shifts in rural areas. In a community with a lower population and/or a less dense population, there may not be enough volume to support a full range of residential crisis services. One approach in these communities is to set up programs that have flexibility to staff up or down based on need, including bringing in extra staff for individuals who are more acute. In very rural areas, the “residential crisis service” might be needed only a few times per month and can be provided by bringing in flexible on-call staff, including peers, for someone who is able to stay in a safe house on a day-today basis.

Categorization of Residential Crisis Programs

All residential crisis programs are considered Level 5 (medically monitored residential) on the Level of Care Utilization System (LOCUS or CALOCUS), but there is a significant range of possible service types. We are purposely not using the terms crisis residential unit or crisis stabilization unit, because these terms are used so variably across the nation. We recommend that future design of residential crisis programs within the ideal crisis system continuum utilize the following categorizations, which are intended to be more descriptive, for the purpose of service design, regulation and payment.

With the proviso that any categorization is only an approximation of the true flexibility with which these services can be designed, the following is a list of common categories:

Residential crisis programs with high medical and nursing involvement

These programs are often called crisis stabilization units or crisis residential units. Unit cost is usually $400-500 per day, compared to hospitals, which are $800-1,200 per day. The most intensely staffed examples are facilities such as Psychiatric Health Facilities in California or Baker Act Receiving Facilities in Florida. These function as secure “receiving units” for involuntary admissions and are nearly equivalent to freestanding psychiatric hospitals. While they are helpful in providing specialized psychiatric crisis response services in non-hospital settings, they are close enough in form and function to freestanding hospitals that in this report they will be considered variations of psychiatric inpatient care that are discussed later.

Residential crisis programs with high levels of medical and nursing involvement are non-hospital based voluntary programs with lengths of stay ranging from a few days up to two weeks and allow for relatively intensive 24/7 monitoring and support, as well as provision of medical, nursing and crisis intervention. They are often in secure settings permitting admission of individuals who may be more highly acute. A typical program will have 24/7 staffing, multidisciplinary team staffing including peers, nursing, and medical monitoring; however, the type and number of staff and monitoring capacity vary widely across programs.

Size can range from six to eight beds, up to 16 beds (so as not to invoke IMD restriction on payment), and staffing ratios usually range from 1:4 to 1:8 on evenings, nights or weekends, with capacity for additional coverage for individuals who may need one-on-one care for brief periods. Some programs may have skilled nursing (RNs) round the clock, others only one or two shifts a day, with LPN and/or EMT and/or RN phone coverage at other times. Some programs may have MDs or other psychiatric care providers on-site every day, every other day or twice a week. These programs provide active treatment, including withdrawal management for mild/moderate withdrawal as well as adjustment of psychotropic medications and have 24/7 access to psychiatric care providers, whether by phone or telehealth.

Residential crisis programs with moderate medical/nursing involvement (crisis residential or crisis stabilization)

The unit cost is usually $250-300 per day. These programs have lower levels of medical/nursing monitoring than high medical involvement programs and could have lower staffing ratios. There may be on-site nursing for a whole shift with LPNs/EMTs on-site at other times and an RN on call. Alternatively, the RN may only be present for a few hours a day, or only when needed. Similarly, medical or psychiatric care provider involvement is low as well and may involve visits once a week, only when needed or only via on-call.

Clients may have to visit outside providers for medical evaluation and may not be able to have their medications adjusted rapidly during their stay, though they can receive medications and be monitored for adherence and side effects. What they do receive, however, is crisis intervention and support, including peer support, and a chance to connect or reconnect with ongoing community resources and treatment services to facilitate the resolution of a crisis. Note that even though this type of residential crisis program has less medical/nursing capability, it still will be able to admit individuals in crisis situations that, were it not for the program, would necessitate a higher level of care, such as a hospital. For example, a person may be acutely suicidal but able to be safe with staff support in the program, or the individual may be acutely psychotic due to medication discontinuation but able to restart medication and regroup under supervision. This type of program can help individuals who are using substances have a safe place to get sober with staff support and generally will have capability to provide medication and monitoring for mild withdrawal.

Residential crisis services with minimal medical/nursing involvement (crisis respite services)

Unit cost is usually $100-200 per day. This is the lowest level of residential crisis service intensity. This program is appropriate for individuals who feel out of control in their usual environment but can settle down in a safe place with staff support. This can include people who are intoxicated or at risk of relapsing on substances. The program provides a viable alternative, a place to go for a few days with someone to help them think about next steps. Such a setting is typically home-like, often an apartment or a room in a house. Staffing and monitoring may range from one staff person around the clock to a person on call with staff who visit each day. Length of stay tends to be limited to a few days and no more than a week. Medical/nursing/clinician backup, if needed, is provided through an on-call system. Accordingly, effective and appropriately intensive short-term crisis case management is key (i.e., helping the person come up with realistic next step and connecting them with appropriate support services and treatment).

Crisis respite may be particularly important in rural crisis systems where individuals may be evaluated at crisis centers far from home and may need to be in a safe place to access necessary intensive ambulatory crisis services, but do not need around the clock staff monitoring once they are more stable. In many rural settings, access to crisis respite programs is infrequent, but can be provided by renting rooms on an as-needed basis, accompanied by on-call staff support. Crisis respite programs may also be valuable for families who are caring for children with significant emotional disturbances, including those who may have autism spectrum disorders. Having a safe space for children to go during periods of emotional dysregulation can provide opportunities to learn new skills and provide relief for the family. Peer support for the families provided by certified family partners can be a valuable component of this service.

Peer-run or peer-operated crisis respite

The unit cost is usually under $100 per day. These are variations on the crisis respite model in that they are either fully run and operated by peers or primarily or exclusively staffed by peers but operated by a conventional crisis program – a hybrid model. In peer services, those who use the services are often referred to as guests rather than clients or patients. They vary in the hours they are open and the amount of time people can stay: Some are only open certain hours of the day; most, but not all, have overnight capacity and others have capacity for people to stay up to several days at a time. Medical, nursing or clinical services are accessed only on an as-needed basis. The overwhelming value of peer services is the capacity to provide hope and engagement for individuals who are frightened, traumatized and wary of professional service settings, including people who may choose not to take psychotropic medications. The availability of peer services in the crisis continuum permits voluntary engagement of individuals with great need who might not otherwise access services until involuntary intervention is required.

Living Rooms

A highly recommended model is known as a Living Room, which cojoins the presence of a welcoming, no force first, highly staffed peer respite environment with the medical, nursing and clinical capabilities of one of the first two types of residential crisis programs. Sometimes peer respite programs are also referred to as Living Rooms. These programs combine the benefits of medical/nursing services for people with high levels of symptoms and acuity, with the inspiration of home and the capability for de-escalation and engagement characteristic of a peer-operated program.

The first Living Room model crisis program was established by Eugene Johnson and Lori Ashcraft at Recovery Innovations (RI) in Peoria, Arizona, in the 2000s. The following is edited from the RI website: Peer-operated “Living Room” programs ensure that participants are paired with a team of Peer Support Specialists in recovery. Each guest is encouraged to work with the team and empowered to develop their own recovery plan, RI (now Recovery International) is known for creating the best possible recovery experience for people in crisis, using healing spaces with recliners, soft colors and a home-like atmosphere. The teams, comprised of doctors, nursing staff and peers with lived experience weave recovery, clinical, and medical services together, providing comprehensive care. RI makes every effort to eliminate seclusion and restraint and to serve all people regardless of level of acuity, without resorting to physical interventions.

Residential crisis programs with varying levels of medical/nursing involvement for individuals with SUD crises

Often called detox programs, these sobering support units or sobering centers may provide withdrawal management capability, depending on the degree of medical/nursing/EMT involvement. Within residential crisis services, it is important to ensure a continuum of services is available for individuals who present requesting assistance with substance use disorders, many of whom also have co-occurring mental health conditions and other needs. These types of services can be categorized as Level 5 on the LOCUS but are more commonly categorized and described within the service array delineated as Level 3 by the American Society of Addiction Medicine (ASAM) Patient Placement Criteria (Mee-Lee, 2013).

These services range from residential withdrawal management or detox services, primarily intended as first steps to enter into continuing SUD treatment rather than an intervention in itself, which can include a range of levels of service intensity and medical monitoring (e.g., ASAM Level 3.7D: Medically Monitored Withdrawal Management down to Level 3.1D: Socially Supported Withdrawal), as well as simple “sobering centers” that are designed to create safe places for individuals who are intoxicated to become sober, usually with some peer support and access to counseling, but without requiring intent to receive crisis intervention or to enter ongoing SUD or mental health treatment.

Defining and Integrated Continuum of Residential Crisis Programs With Varying Levels of Medical/Nursing Involvement for Individuals With Substance Abuse Disorder

Crisis systems traditionally develop parallel service lines for people entering with mental health crises and SUD crises, but that is not essential and is not necessarily recommended for an ideal crisis system. The ideal crisis system is designed on the assumption that co-occurring mental health/SUD is an expectation and should be an integrated continuum that is matched to people’s needs and requests, not historical service divisions. What is essential is that all services – including residential crisis programs – are planned with the expectation of co-occurring mental health/SUD, with the best matched and most clinically and cost-effective and integrated capacity to respond to community needs. For example, withdrawal management can be provided in any level of medically monitored residential crisis program, which may be the best intervention for an individual with COD in acute mental health/SUD crisis who needs to stabilize but has no intention of entering ongoing SUD services in the near future.

By contrast, withdrawal management can also be provided in a co-occurring capable SUD withdrawal management or detox program that is more appropriate for someone in SUD crisis with co-occurring mental health needs whose goal is entry into continuing SUD services. Similarly, a sobering center can be a form of peer respite and there should not necessarily be a requirement that someone needs to be intoxicated (or not intoxicated) to be admitted. The community collaborative and accountable entity need to use service data to develop the most effective continuum that matches the type and volume of behavioral health crisis needs in the designated service area.

Measurable Criteria for an Ideal System

The accountable entity working with the community collaborative and crisis providers, plans, designs, funds and implements a continuum of co-occurring capable crisis residential services for all ages to meet community needs provided that:

  1. There is a comprehensive array of residential crisis services for adults and youth. The components of the array are centered on a data-based analysis of community needs and resources to maximize hospital diversion and stepdown and facilitate easy access for individuals in need.
  2. All components of this continuum are funded with adequate cost-based rates by multiple public and private payers. Any necessary service (e.g., medication evaluation) that is not part of the cost-based all-inclusive rate should be billed separately.
  3. All residential crisis services are designed so individuals can move smoothly in any direction through the continuum, including hospital step-down, and do not fall through the cracks. Each residential crisis program is monitored for quality indicators related to denial of admissions, facilitation of transitions and appropriateness of discharge.
  4. All residential crisis services are monitored for co-occurring capability and designed to welcome individuals who may be actively using substances along with mental health symptoms.
  5. The continuum is designed using consistent LOC criteria (e.g., LOCUS Level 5, ASAM Level 3) to determine appropriateness of utilization with the expectation that there will be minimum utilization of 50% and maximum utilization of 95%, with the programs being full no more than 5% of days each.
  6. The continuum of residential crisis services has adequate volume and flexibility to meet the needs of the population. Services in urban areas require a diverse array of specific programs, while services in rural areas require flexibility to adjust capacity according to need.
  7. The essential elements of this continuum include provision for:
    • Residential crisis programs with higher medical/nursing involvement to maximize hospital diversion capability for individuals seeking services voluntarily.
    • Residential crisis programs with lower medical/nursing involvement to facilitate access for individuals who are in less severe crises, to prevent further decompensation.
    • Peer respite services and/or Living Rooms should have peer support incorporated in all residential crisis services, in addition to the availability of services that are peer-operated or peer-driven.
    • Adequate services for individuals who are intoxicated, including those who need medically monitored withdrawal that may include integration of services for individuals who are intoxicated into the continuum of programs previously listed, as well as specific programs designed for individuals seeking entry into SUD treatment and/or a safe place to get sober.

IN THE STORY OF MR. Y:

In the convenience store, Mr. Y was frightened and very symptomatic. While he might have required hospitalization, his behavioral health crisis might also have been appropriately addressed in a residential crisis program with medical and nursing monitoring and peer support. A Living Room model program might have been particularly effective in engaging him and helping to overcome his fearfulness of service providers.

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