​​ISSUE BRIEF:  Crisis Care Continuum
Ensuring timely access to effective services and supports.
Social and financial costs are high as unserved and underserved individuals with severe mental illness and/or substance use disorder repeatedly experience behavioral health crisis.  With mental health and substance use needs steadily increasing due to the pandemic [1], now more than ever, we must provide a comprehensive behavioral health crisis continuum for all ages, while also addressing foundational elements (see below) that reduce the need for crisis services. Funding and Grant information is also provided below. [Numbers in brackets refer to end-notes.]

Recommended Services and Supports — With 24/7 availability & Peer Providers Imbedded

 1. 988 Call Center/Crisis Line:  “The launch of the 988 hotline next summer [July 2022] gives people an easy-to-remember number to call for focused support during behavioral health emergencies.” CA HHS Secretary Dr. Mark Ghaly DHCS News
2. Crisis Intervention Team or Coordinator:[2] Many individuals in crisis, their families and supports, must navigate multiple transitions in care during a very vulnerable time.  It is difficult for individuals to move smoothly to higher or lower levels of service intensity as needs change.  A dedicated team or coordinator aids in providing continuity of care through a crisis episode, and facilitates a smooth transition through different levels of service.
3. Mobile Crisis Teams:
(conducted without law enforcement as much as possible)6 increase access to timely and appropriate services, and decrease unnecessary emergency room visits or arrests. Teams can respond to individuals and families in their own homes, or even on the streets, can de-escalate behavioral health crisis and facilitate appropriate follow-ups. They can also respond  to service settings such as emergency rooms, clinics, housing programs, criminal justice settings and schools. Examples:
· SMART (San Mateo County)
· Mobile Crisis Triage (Placer County)
 4. Crisis Stabilization Services are short-term treatment units that provide immediate care to individuals experiencing a mental health or substance use disorder crisis. Examples: 
· MH Urgent Care Center (Sacramento)
· BH Triage (School-Based) (Humboldt)
5. Sobering Stations provide a comfortable, safe environment for individuals intoxicated from either alcohol or drugs. Clinicians and peer staff engage clients in substance and/or mental health services, ensuring linkage and warm hand-offs to community-based services and follow-up. Examples:
· Bakersfield Recovery Station
· Mission Street Sobering Center
6. Peer Respites utilize peer providers (individuals with lived experience of mental illness and/or substance use) to engage people in services and supports.  In rural settings, services are provided on an as-needed basis (e.g. utilizing a room within a behavioral health agency or renting a room from a contractor for overnight stays). Medical, nursing or clinical services are provided as needed. Examples:
· Cedar Home (Trinity County)
· Hacienda of Hope (L.A. County)
7. Crisis Residential Treatment Programs: Short-term, intensive, supportive services in a home-like environment. Examples:
· Santa Clara County
· Santa Barbara County

Foundational Elements - Averting Crisis

A continuum of care must address factors that prevent entry into crisis care. The following are key components within a behavioral health continuum of care, along with a listing of CALBHB/C issue briefs, addressing specific issues and populations.

1. Engagement Tools including peer staff whenever possible.
  • Comprehensive Outreach
  • Shared Decision Making
  • Psychiatric Advance Directives [3]
  • Assisted Outpatient Therapy (AOT)/Laura’s Law see below
  • Conservatorship (As a last resort.)
2. Comprehensive Community Services that are accessible,
integrated, recovery-focused, trauma-informed,
culturally relevant, have significant use of peer staff, & address:
  • Housing (including Board & Cares)
  • Mental Health
    • Prevention/Early Intervention
    • Psycho-Social Services
    • Peer Support
    • Medication Management
    • Crisis Care
    • Hospitalization (As a last resort.)
  • Physical / Behavioral Health Integration
  • Public Guardians & Conservators
    • Appropriately trained
    • Manageable caseloads
  • Substance Use / Behavioral Health Integrated Services
  • Vocational / Behavioral Health Integrated Services
3. Inter-Agency Collaboration between crisis care programs, emergency services, hospitals, jails, law enforcement, prisons, schools and behavioral health departments (public & private) that include:
· Information Sharing
· Discharge/Aftercare Plans
· Warm hand-offs

Issue Briefs

Cost Savings

     In addition to addressing social costs, crisis continuum programs reduce financial costs associated with emergency services, incarceration, hospitalization and homelessness. Crisis Care Services, in Phoenix, AZ were estimated to reduce inpatient spending by $260 million in 2016, preventing $37 million in costs to the emergency room.
     California counties have recognized improved performance even in very small counties (e.g. Sierra County, Glenn County).

Assisted Outpatient Treatment (AOT)[4] / Laura's Law [5]

​Designed to help individuals with mental illness who have a condition known as “anosognosia” (a lack of awareness of their mental illness), specific criteria are required for consideration of AOT, related to a demonstrated history of repeat crises. AOT services are court-ordered, and include AOT status hearings. While medication is not forced, medication outreach is ordered when an individual agrees to medication as part of treatment (it is self-administered.) www.calbhbc.org/lauras-law

FUNDING

Fees & Medi-Cal

Below are links to recommended best practices for funding crisis services. Note: Medi-Cal (federally known as Medicaid) requires matching funds.  Common sources of matching funds: Mental Health Services Act (MHSA) and Realignment Funding (1991 and 2011 (AB 109).
 
Crisis Call Center:  Cell-Phone & Land-Line Fee+
Substance Abuse and Mental Health Services Administration (SAMHSA) Toolkit  Page 38+
 
Crisis Care Coordination:
CalAIM Enhanced Care Management Policy Guide, Page 48, CA Department of Health Care Services (DHCS), September 2021
 
Crisis Stabilization Services & Crisis Residential:  
Mobile Crisis:
Substance Abuse and Mental Health Services Administration (SAMHSA) Toolkit, page 39+
 
Respite Services:
Medi-Cal Community Supports (Previously called "In Lieu of Services") Policy Guide, Page 28+, DHCS, September 2021
 
Sobering Centers:
Medi-Cal Community Supports (Previously called "In Lieu of Services") Policy Guide, Page 48

Private Insurance

Rates should be established that can be applied to all payers. Establishing reasonable reimbursement rates for crisis services reduces the demand on communities to cover health care expenses that should be covered by insurers. This supports the existence of critical safety net services that are timely and accessible to all.[8] 

Local Funds

It is in the interest of cities, counties, schools, law enforcement and private hospitals to collaborate and partner with funding due to the shared value that a robust crisis care continuum can provide.
 
Funds administered by local Behavioral Health Agencies include: Mental Health Services Act (MHSA) funding (from the Community Services and Supports (CSS) component), and    Realignment  Funding.

Grants

Infrastructure
Behavioral Health Continuum Infrastructure: Grants to construct, acquire, and rehabilitate real estate assets, or invest in mobile crisis infrastructure, w/a portion of funding available for increased infrastructure for children and youth, 25 and younger.
 
Workforce
HCAi—Loan Repayment, Scholarship or Grant Program, Health Care Access and Information (HCAi) (formerly OSHPD)
 
Coming Soon
CA’s Mental Health Services Oversight & Accountability Commission (MHSOAC) is expected to open up additional SB82 Triage Grant Opportunities.

End Notes

  1. The Implications of COVID-19 for Mental Health and Substance Use, Kaiser Family Foundation, February 2021:  During the pandemic, about 4 in 10 adults in the U.S. have reported symptoms of anxiety or depressive disorder, a share that has been largely consistent, up from one in ten adults who reported these symptoms from January to June 2019 (Figure 1). A KFF Health Tracking Poll from July 2020 also found that many adults are reporting specific negative impacts on their mental health and well-being, such as difficulty sleeping (36%) or eating (32%), increases in alcohol consumption or substance use (12%), and worsening chronic conditions (12%), due to worry and stress over the coronavirus.
  2. Roadmap to the Ideal Crisis System: Essential Elements, Measurable Standards, and Best Practice for Behavioral Health Crisis Response, page 79. The National Council for Behavioral Health, 2021
  3. Psychiatric Advance Directives (PADs) are legal documents, drafted when a person is well enough to consider preferences for future mental health treatment. PADs allow appointment of a health proxy to interpret preferences in a crisis, and the PAD is used when a person becomes unable to make decisions during a mental health crisis. More at: www.calbhbc.org/pad
  4. Assisted Outpatient Treatment (AOT): CA’s  Department of Health Care Services 2018-19 Report highlighted: Hospitalizations were reduced by a 33 percent change during AOT, as compared to prior to the program. All counties reported a decrease in the number of days hospitalized, frequency of psychiatric hospitalizations, and/or crisis interventions per individual. Law enforcement contacts were reduced by a 43 percent change during AOT, as compared to prior to the program. Five counties reported all participants avoided law enforcement contact while receiving services. Four of the six counties that reported incarcerations of participants during AOT, noted reductions in the number of days incarcerated per individual.
  5. Laura’s Law: [Important Note:  Research evidence has shown very little correlation between mental illness and any violent behavior.6] Signed into law in 2002, Laura’s Law was adopted by the California Legislature after a man with mental illness fatally shot Laura Wilcox, a 19-year-old volunteer at a Nevada County mental health clinic. The legislation allows each county in the state to decide whether to adopt the provision. To qualify for Laura’s Law, an individual must have a serious mental illness that resulted in a psychiatric hospitalization or incarceration twice in the previous three years or resulted in violent behavior within the past 48 months. 2020 legislation, AB 1976 requires counties to participate in Laura's Law unless they opt out.
  6. “While an estimated 18.3 percent of Americans suffer from some form of mental illness, only about 4 percent of community violence is attributable to psychopathology per se (Swanson, 1994).” 2016 “Civil Commitment and the Mental Health Care Continuum: Historical Trends and Principles for Law and Practice”, SAMHSA, 2019, page 18.  Also see Law Enforcement
  7. CalAIM Enhanced Care Management Policy Guide, Page 48, CA Department of Health Care Services, September 2021
  8. “National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit”, Page 38, Substance Abuse and Mental Health Services Administration (SAMHSA), 2020
 
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OFFICE

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mission

cALBHB/C supports the work of california's 59 local mental/ behavioral health boards and commissions by providing resources, training, and opportunities for communication and statewide advocacy.

Local boards are responsible for reviewing community mental health needs, services, facilities and special problems, and serve in an advisory capacity to local governing bodies and local mental/behavioral health directors per CA Welfare and Institutions Code 5604.2.
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