Us & Them: Our Brothers in Law Enforcement

policeWe had just exited the Urgent Psychiatric Center (UPC) when the radio announced an armed robbery in process at a convenience store just over a mile away. Nick and I jumped into his police cruiser and took off. My body slammed back into the seat from Nick’s swift acceleration and I barely noticed the scenery as my peripheral vision dropped away, my brain focused intently on the narrow view straight ahead of us. It was a pure adrenaline rush, my heart racing as Nick flipped on the lights and siren, his police car screaming down the street.  This was definitely not what I expected when I agreed to spend the evening with Phoenix Police Officer Nick Margiotta.

I was brand new in my role with Magellan Health Services overseeing the clinical system of care and wanted to see how the system worked first-hand. Was it safe, effective, and person-centered? Was it accessible? I met Nick through our community governance board, and he brought a wealth of experience and passion from his work as the city’s Crisis Intervention Coordinator. He suggested we spend a night on the street, with him dressed as a regular police officer and me in plain clothes as a ride-along without announcing our positions to anyone. Think “Undercover Boss,” and it seemed like a great idea.

As we rolled onto the scene of the armed robbery, we saw that another patrol car, which had arrived before us, was blocking the car that held the two armed men. We stopped in the street about 40 yards away and Nick and I got out and stood behind our doors. (Well, I stood behind the door after Nick yelled at me to get out of the line of fire!) It was dark, there was a lot of yelling, lights, a bunch of guns, and I was struck by what felt like chaos in the situation. Fortunately, the two men were safely taken into custody; the whole event did not take more than five minutes.

As Nick turned back towards the patrol car, he noticed a middle-aged Native American male, intoxicated, sitting with his legs in the street. We walked over and Nick began engaging him about his interest in getting some support that evening. The man was initially quite belligerent. What I didn’t realize as we engaged with this person was Nick was working to transition himself, too. He had felt what I felt during the attempted robbery. Cops are human, after all, and just moments earlier there had been real danger which had internal, physiological impacts on him just like me. With a new found respect for the skills of CIT-trained law enforcement, we transported the individual, connecting him with the local Community Bridges center, which has a detoxification unit.

Over the course of that shift, we interfaced with more than 15 individuals who were experiencing mental health and addictions issues. Less than 30 minutes earlier we were at a local apartment complex visiting a friend of Nick’s who has Schizophrenia, but was in recovery and had been clean from Heroin for more than two years. While we were there, we received a “pick-up order” for another individual in that same location who was on court-ordered treatment and needed to be transported to the UPC. After a brief discussion with that person, she agreed and we took her to 2nd Street and East Roosevelt.

I was struck by the near-instant transitions Nick was able to effectively navigate, from command and control of armed robbers to engagement and collaboration with those in behavioral health crisis. Crisis Intervention Team (CIT) does not turn law enforcement into social workers; they will always be cops first and foremost. However, more than 2,000 jurisdictions have adopted CIT and put it to use in developing more integrated and responsive community systems. It equips law enforcement with knowledge regarding the signs and symptoms of mental health and addiction, tools for effectively engaging individuals, and the resources to divert them from being sent to jail.

Five Key Pillars Crisis Intervention Team (CIT)

Officer Training The most visible component, the 40 hour, week-long training is most effective when officers have volunteered. In addition to a primer for behavioral health, generally two days are devoted to crisis de-escalation.
Community Collaboration A partnership of local advocates, law enforcement, and behavioral health providers formed the Memphis model. This community bridge has been one of the strongest elements of the program over time.
Robust Crisis System An integrated system that is focused and responsive to the needs of law enforcement is mandatory. Unless access to care is quick and responsive and hand-offs are smooth, the program will not result in decreased incarcerations.
Behavioral Health Staff Training Building positive working relationships between law enforcement and behavioral health means also training the mental health and addiction community of providers. Riding along with law enforcement can be a big eye-opener.
Advocate Training The local NAMI provided the energy and moral leadership that made the Memphis model so successful, and including peers, family members, and advocates is critical to embed a program in the community.

Ten years ago, 17 of us from the greater Atlanta area, including law enforcement, behavioral health providers, and NAMI leaders, traveled to Memphis, the “CIT Mecca,” to learn how to implement a statewide program in Georgia. The original founders of the program, Major Sam Cochran and Dr. Randy Dupont, were heavily involved and inspirational leaders. Naturally, as a part of the training, I did a ride-along with a local cop, Officer James.

James described his evening shifts as making trips into Mogadishu and recounted several harrowing stories of shoot-outs in which he had been involved. He added that working with individuals with mental health and addictions issues was easy; as he received excellent training through CIT and he proudly wore the unique badge that identifies these specially trained officers. I asked him about the most challenging situations faced by law enforcement.

James mentioned two scenarios, both of which occurred on our shift. In the first, we were called to the scene of a break-in, and we didn’t know if the perpetrators were still there. I remember being extremely anxious as he went inside and I stayed in the vehicle. It was palpable.

However, the worst situation happened later that evening. Two officers on the southwestern side of the city were shot through a door as they served a warrant. I remember hearing almost the entire play-by-play over the radio as cops from all over the city raced at break-neck speed to the scene.

I’ve been on two police ride-alongs with CIT trained officers, and they were both wild rides! Yet, I saw both of these officers demonstrate compassion and finesse while working with individuals and families who were struggling with behavioral health crises. And, in both cases, I saw responsive behavioral health systems that focused on quick accessibility and humane, transitional hand-offs that helped avoid unnecessary trips to jail.

It’s easy for behavioral health professionals to disregard our brothers and sisters in law enforcement, but working together we are creating better community support systems (see December 2013 article from Spokane). How do you start making a difference in your own area? I would suggest starting with an evening or night shift in a patrol car observing the challenges and opportunities first hand.

*Note: David Covington co-authored this blog with Nick Margiotta. Nick is a member of the board of directors for CIT International and chair of its public awareness committee.

How to Avoid Tragedies and Near Misses

At the end of Novewatch towermber in 2013, Virginia State Senator Creigh Deeds told CNN that he was alive for just one reason: to work for change in mental health. Just a week earlier, his son “Gus” stabbed him 10 times and then ended his own life by suicide. This happened only hours after a mental health evaluation determined that Guss needed more intensive services, but unfortunately, he had to be released from custody before the appropriate services could be found.

Sadly, it is common for individuals in mental health crisis to initially receive support and then later “fall through the cracks.” The cracks occur because of interminable delays for services that professional assessments have determined individuals clearly need. They walk out of an Emergency Department “Against Medical Advice” and disappear from view until the next crisis occurs.

Far too many individuals like Gus are falling through the cracks. While they sometimes hurt themselves, it is infrequent that they harm others. When it does occur, it’s rarer still that the person is a public figure. However, every time there is a Columbine, Tucson, or Sandy Hook, we grieve… and we wring our hands and consider whether there is a better way.

Nearly 40,000 Americans die by suicide every year… and we assume nothing can be done. I contend it is time to raise the bar in crisis services and innovate with solutions that will drive a different set of results.

Learning from Air Traffic Control Safety

In 2006, the movie “Flight 93” chronicled the heroic efforts of passengers aboard a hijacked United Airlines plane. It also gave us an up-close and personal view of the way air traffic control works to ensure the safety of nearly 30,000 US commercial flights per day! When three individuals died in an Asiana crash in San Francisco in July 2013, it marked the end of a 12-year time span in the US without a passenger death on a large commercial airliner. Today, it is remarkably safe to fly.

The keys to advancements in aviation safety are simple. There are two vitally important objectives that, without them, make it impossible to avoid tragedy:

  • Objective #1: always know where the aircraft is – in time and space – and never lose contact;
  • Objective #2; verify the hand-off has occurred and the airplane is safely in the hands of another controller.

In the Air Traffic Control example, technology systems and clear protocols ensure that there is absolute accountability at all times, without fail. It was surprising to see in the movie the air traffic controllers using wooden blocks to represent each plane, given all the high-tech tools at their disposal. But when an air traffic controller has the block, they have responsibility for that plane… unless and until they physically give that block to someone else, who then assumes the same care and attention. They simply do not allow an airplane to be unsupported and left on its own.

These objectives easily translate to behavioral health. Always know where the individual in crisis is and verify that the hand-off has occurred, yet these objectives are missing from most of the US public sector behavioral health and crisis systems. Individuals and families attempting to navigate the behavioral health system, typically in the midst of a mental health or addiction crisis, should have the same diligent standard of care that air controllers provide.

Gregg GrahamIn 2006, I was part of the team that launched the Georgia Crisis & Access Line. Our goal was to have an “air traffic controller’s view” of individuals currently navigating the crisis system. We accomplished this goal through state-of-the-art technology, including an integrated software infrastructure that tracks individuals at a statewide level, with built-in insurance of consistent triage, level of care protocols, and warm hand-offs to the appropriate crisis service teams across the state. This is very different from traditional systems and can reduce the number the failures facing current systems across the country.

Making the Case for a Close and Fully Integrated Crisis Services Collaboration

In 2010, the Milbank Memorial Fund published the landmark “Evolving Models of Behavioral Health Integration in Primary Care,” which included a continuum from “minimal” to “close fully integrated” that would establish the gold standard for effective planned care models and change the views of acceptable community partnership and collaboration. Prior to this, coordination among behavioral health and primary care providers had frequently been minimal or non-existent and it would have been easy to accept any improvement as praiseworthy.

In fact, the Milbank report portrayed close agency-to-agency collaboration (evidenced by personal relationships of leaders, MOUs, shared protocols, etc.) at the lowest levels of the continuum and insufficient. They described these community partnerships and their coordination as minimal or basic, citing only sporadic or periodic communication and inconsistent strategies for care management and coordination. They called for frame-breaking change to the existing systems of care, and their report continues to reverberate throughout the implementation of integrated care.

Required Elements of a Statewide Crisis Services “Air Traffic Control System”

Crisis Access Holdings, LLC has modified the Milbank collaboration continuum (original citation Doherty, 1995) for the purposes of evaluating crisis system community coordination and collaboration (see table below).

Milbank Memorial Fund, Close and Fully Integrated

In our model, the highest level requires shared protocols for coordination and care management that are “baked into” electronic processes, not simply add-ons.

For a crisis service system to provide Level 5 “Close and Fully Integrated” care, it must implement an integrated suite of software applications that employ online, real-time, and 24/7:

Key Elements Level 5 Crisis System (Air Traffic Control Approach)

Status Disposition for Intensive Referrals There must be shared tracking of the status and disposition of linkage/referrals for individuals needing intensive service levels, including requirements for service approval and transport, shared protocols for Medical Clearance algorithms, and data on speed of accessibility (Average Minutes Till Disposition).
24/7 Outpatient Scheduling Crisis staff should be able to schedule intake and outpatient appointments for individuals in crisis with providers across the state, while providing data on speed of accessibility (Average Business Days Till Appointment).
Shared Bed Inventory Tracking Intensive services bed census is required, showing the availability of beds in crisis stabilization programs and 23-hour observation beds, as well as private psychiatric hospitals, with interactive two-way exchange (individual referral editor, inventory/through-put status board).
High-tech, GPS-enabled Mobile Crisis Dispatch Mobile crisis teams should use GPS-enabled tablets or smart phones to quickly and efficiently determine the closest available teams, track response times, and ensure clinician safety (time at site, real-time communication, safe driving, etc.).
Real-time Performance Outcomes Dashboards These are outwardly facing performance reports measuring a variety of metrics such as call volume, number of referrals, time-to-answer, abandonment rates and service accessibility performance. When implemented in real-time, the public transparency provides an extra layer of urgency and accountability.

In addition, the system should provide electronic interconnectedness in the form of secure HIPAA-compliant, and easy-to-navigate web-based interfaces and community partner portals to support communication between support agencies (including emergency departments, social service agencies, and community mental health providers) with intensive service providers (such as acute care psychiatric inpatient, community-based crisis stabilization, inpatient detoxification, and mobile crisis response services).

Interfaces should also include web-based submission forms for use by community partners to support mobile crisis dispatch, electronically scheduled referrals by hospitals as a part of discharge planning, and managed care and/or authorization requirements.

I currently lead a joint venture, Crisis Access, LLC, and the five call centers across our companies have received over ten million crisis calls over the last twenty years from individuals, their families, and the social service agencies that work with them. We utilize sophisticated software to help the crisis professional assess and engage those at risk and track individuals throughout the process, including where they are, how long they have been waiting, and what specifically is needed to advance them to service linkage. Their names display on a pending linkage status board, highlighted in green, white, yellow, or red depending on how long they have been waiting.

Average Minutes Till DispositionWhen a person contacts one of our call centers, they have metaphorically put their hand out and our crisis teams have taken it. We continue holding their hand until we have confirmation that someone else has taken hold. We verify that we have successfully connected them with another agency/entity that will have clinical responsibility. If there is a referral to mobile crisis, law enforcement, or an emergency department, we ensure they were connected with care. These approaches also apply for those with routine needs met by our mobile teams or crisis call center staff because we follow up with everyone, 100%. As a result, despite increasing numbers of referrals flowing through the system, individual are being accepted into care faster and faster (AMTD, Average Minutes Till Disposition).

Going Beyond Agency-to-Agency Relationships

“Knowing your neighbor agency” is just not good enough, as evidenced by the Deeds tragedy. Even organizations with numerous close relationships can be extremely inefficient and ineffective when their protocol relies on telephonic coordination of care (voice mails, phone tag, etc.) This seemed to be the principal challenge with the Virginia tragedy, and when the time period for hold lapsed, there was no tracking or follow-up.

There have been several national discussions as of late about current system failures and the frequency by which individuals fall through the cracks. Crisis systems must take seriously the need to avoid both near misses and tragedies, and I believe statewide community collaboration for Level 5 crisis systems are needed. The approaches described above are not notional; they have been employed on a statewide basis for nearly eight years in Georgia. New Mexico and Idaho added statewide crisis and access lines in 2013; Colorado is launching its statewide system in 2014, and Arizona is currently soliciting feedback considering a similar model.

If the National Transportation Safety Board settled for a 99.9% success rate on commercial flights, there would be 300 unsafe take-offs and/or landings per day!  Air controllers only settle for 100% success, and so should we.

To see the Georgia system in action, click on the PowerPoint or YouTube.

*Note: I would like to extend special acknowledgments to partners at the Georgia Department of Behavioral Health and Developmental Disabilities, The National Council for Behavioral Health and Qualifacts (the latter of whom sponsored the 2014 Impact Award for Health Information Technology). Also, thanks to Mark Livingston, BHL’s Chief Innovation Officer, and the entire team involved with advancing the “air traffic control” integrated system.