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.