community case studies

Pima County (Tuscon), Arizona

The Tucson Model: A Collaborative Approach to Behavioral Health Crisis and Public Safety: Margaret Balfour, MD

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 convener.

With a population of just over one million, Pima County is one of the oldest continually inhabited counties in the U.S., and one of the largest at 9,187 square miles. About half of the population resides in Tucson, with the remainder living in small towns, Native nations and rural areas. 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, the Substance Abuse and Mental Health Services Administration (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 Crisis Response Center (CRC) opening, Jared Lee Loughner opened fire at a community forum held by U.S. 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 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 > 10-minute turnaround time 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 multiagency 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.

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