This report provides a wealth of detailed information, but the information is only worthwhile to the extent that it provides a roadmap to change. The intention of this report is to provide guidance for action both at the community level and at the system leadership and advocacy level. For this reason, we include specific recommendations for action steps that can be taken, using this report to advance the development of ideal behavioral health crisis systems at the state and local level. In addition, we are providing a Behavioral Health Crisis System Report Card that incorporates the essential elements and measurable indicators in this report and can be used to evaluate the current baseline in any community and measure progress over time (see Appendix for the Report Card).
We recommend that communities and systems do not hesitate to ask for help (e.g., consultation and technical assistance) at any step, in order to facilitate progress. The journey toward developing ideal crisis systems will be a new venture for most communities, and even where the community – or state system – may identify other systems to emulate, outside facilitation may be needed to help the community or state come to consensus on the best path to follow.
In order to make this information optimally accessible and useful for communities that wish to improve their behavioral health crisis system, the following 10 steps are a recommended approach:
Identify and convene community partners: Identify community stakeholders and potential partners who are interested in, or have a stake in, behavioral health crisis services within your community and develop a voluntary ad-hoc group for initial discussions. Remember to engage stakeholders and funding partners that represent the whole community, not just those who are indigent or funded by Medicaid. Behavioral health crisis systems are an essential community service for everyone.
Read and process relevant sections of the report: Share the report with your stakeholders and ask them all to read the Introduction. Then, have the stakeholders identify aspects of the report most relevant to them over a few sessions and have them present sections of the report to the group as a whole.
Develop a local vision: Have the stakeholders develop an initial vision for an ideal behavioral health crisis system in your community. Do not be discouraged if you are far from that goal right now. Every community with an improved behavioral health crisis system had to start at the beginning and make progress over time.
Disseminate the vision: Write down this vision with some initial action steps and actively share it with others.
Accountable entity: Identify one or more entities that may serve as the accountable entity within your community. It could be county leadership, city leadership, a managed care organization or an existing community collaborative addressing jail diversion or suicide prevention.
Planning and implementation team: Identify a team of people to meet regularly on an ongoing basis to begin to plan the ideal behavioral health crisis system. This could be a new group under the accountable entity or a component of an existing collaboration. Do not hesitate to seek consultation or outside facilitation if needed at this step or any other step along the way.
Baseline self-assessment: Using the measurable criteria in the report, rating each item from 1-5, have the planning team rate the current status of your behavioral health crisis system. No matter what you find, give yourselves a round of applause. See the Report Card in the Appendix to help you organize this step. Use the Report Card as well to track your progress over time.
Early wins: Identify 3-5 improvement opportunities that the team can address early on, within available capacity and resources. Develop and implement a collaborative plan to begin to make progress in small steps on each item. Give yourselves another round of applause for making progress.
Data and financing: At the same time, members of the planning team begin to gather clinical and cost data on current system performance and identify potential local, state and federal funding opportunities. Do not worry that your initial data are not perfect or that you do not find all the funding you will eventually need. Every community makes progress in steps, with slow improvement of data and using initial seed funds to attract further funding as the vision of the crisis system takes shape.
Comprehensive plan: Keep meeting and working together. Over a period of time, using the data you have gathered with consultation (if needed), use this report for guidance to develop a comprehensive, collaborative plan for the design of an ideal behavioral health crisis system for your community. Identify a step-by-step approach for multiple partners to begin to work together to make progress over a period of years.
What can system leaders at the state and regional/county level do that can facilitate the development of ideal community behavioral health crisis systems? What can advocacy organizations do to encourage state leaders, legislators, funders and policymakers to support progress at all levels? This report provides detailed guidance for how to address these issues at many levels. Here are 10 steps that can help focus and prioritize these efforts:
Establish, articulate and communicate a systemwide vision of ideal behavioral health crisis systems for all: The core of this vision is that behavioral health crisis systems are an essential community service that should be designed to be at least on par with the responsiveness of emergency and urgent medical care: Every person gets the right response every time. Incorporate core values in the vision: welcoming, hopeful, trauma-informed, recovery-affirming, integrated and designed with the goal of eliminating disparities in response for those who are most vulnerable and marginalized.
Develop an implementation plan: As part of the vision, articulate a 10-year plan for working collaboratively with all system intermediaries, funders and communities to make step-by-step progress toward achieving universal progress. Remember that implementing universal 911 response systems took a decade or more.
Disseminate this report as a guiding document: Highlight the essential elements of the system and encourage the development of a system wide conversation to adopt the vision. Essential elements that might be highlighted for purposes of conversation include local accountability (accountable entities), all-payer financing, system performance metrics, crisis continuum (call center, mobile crisis, urgent care, crisis center, various types of crisis residential programs, intensive community crisis intervention), response to all ages and population groups, clinical/medical leadership, peer support and best practices for crisis intervention.
Perform baseline self-assessment: Encourage communities to come together to perform a systemwide baseline assessment of the current behavioral health crisis system, using the enclosed Report Card. Use the report card to track progress across the system over the course of the 10-year plan.
Identify performance metrics: Using this report, convene system stakeholders to identify the most important quality metrics for behavioral health crisis system performance that all system intermediaries should be accountable to achieve.
Award planning and implementation grants: Develop a process to award community crisis collaboratives grants, possibly matching grants, for planning and implementation. This can begin with a few pilot communities and slowly be disseminated to the whole system. Continually measure progress in all communities across the system, rewarding small steps forward over time.
Create a framework for identifying and empowering accountable entities: Identify mechanisms for regional and local accountability for crisis system performance. These could be based on regional intermediary system structures and/or on existing templates for delineating community accountability for EMS.
Require all-funder participation: All private and public behavioral health funders should be required to contribute appropriately to the funding of the community behavioral health crisis system that serves the people covered by or affected by their funding. This includes all types of insurance plans.
Require coverage of, and adequate rates for all elements of the crisis continuum: Identify clear definitions of the various components and services in the behavioral health crisis continuum and require that Medicaid and other funders reimburse for those services (e.g., urgent care centers, crisis centers, residential crisis services, mobile crisis, intensive community crisis intervention) at rates that at least cover costs. Note that medical urgent care and emergency services do not operate at a loss; neither should commensurate behavioral health crisis services.
Incorporate best practice standards into system regulations: This report provides guidance for those regulations, addressing items such as no force first, advance directives, medical screening, integrated response to individuals with co-occurring mental health/SUD and behavioral health/IDD, and so on.
