Crisis and Emergency Services

A Wisconsin colleague and friend had posed a question to the listserv last month, of which 20 of you provided some responses (thank you!).  The essence of the question was — do you have access to a specialized psychiatric crisis response center and/or do you interface with a general hospital’s crisis center.  Related questions sought to understand the good and the bad of each (e.g., we continue to move towards more integrated care and does specializing and isolating behavioral health/psychiatric crisis services undercut that effort? Or, are the needs so unique that having specialized psychiatric crisis services is really best care and coordination). 

  • 11 of you indicated that you only access emergency depts within general hospitals. 
  • 3 of you indicated that you only access specialized psych emergency depts/crisis stabilization units
  • 6 of you indicated that you have access to both.

Below are some questions and responses:

Does your area have problems with extensive emergency room department “boarding” – where the individual may sit for hours, even days, to access a bed and services?  16 (80%) responded YES.  Some clarified that it may be hours.  Here are some specific responses (with notation if they said general hospital, psych ED, or both above):

“Most all state hospitals in VA are over capacity following trickle down effects of “Bed of Last Resort”/Creigh Deeds incident.  Local, private hospitals deny admission for people that are aggressive, highly psychotic, etc. essentially sending them to state hospitals since they cannot deny admission.  It has created huge problems within the VA system which feels like it is nearing a breaking point.  ACT teams cannot get individuals hospitalized locally and if they do make it in the door and do not clear within a couple of weeks, they are generally discharged because there are no transfers to longer term care anymore.  Folks that are TDO’d for acute hospitalization are sitting in ER’s for days now waiting on a bed somewhere in the state.”  (BOTH)

“Our most recent experience involved a 22 year old held in the emergency room from Friday to Monday, then sent from (central Minnesota) to ND.  Put on 72 hour hold prior to transport, discharged after 2 days.  We scrambled for placement.  From there he went to an IRTS (very south-western MN).   That was a 16 hour trip to transport him.” (BOTH)

“Finding a bed for someone with significant psychosis AND physical health issues in the local area is impossible.  They have to go outside of our community.” (BOTH)

“Often clients can wait several hours to be seen by the Behavioral Health team at the hospital. If there is not a bed available on the Behavioral Health Unit they will be transferred to another hospital. This process could take upwards of 24-36 hours. During this time clients will become agitated, desire to leave, or become involuntarily hospitalized.” (General Hospital – but recently started a Crisis Intervention Team Assessment Center within the local hospital)

“The individual may sit for hours before being transported to the Psych “department” for that hospital; the other hospital is usually full and will keep individuals on a Psych hold in the general ER. The hold in the ER can last for days.”  (Gen Hosp)

“Clients will sit in holding for days waiting on a bed, and sometimes client get sent to hospitals quickly that don’t require an assessment but they don’t typically get the best care at those hospitals.”  (Gen Hosp)

“Many patients board regularly in the psych Ed while awaiting inpatient beds and or transfers within county to psych beds particularly in the weekend” (Psych ED)

“The certified pre-screener is responsible for typing up the assessment and collecting medical clearance. Sometimes medical clearance takes a long time if the client cannot pass urine or refuses labs. Both medical clearance and prescreen assessment are needed to start a bed search. The length of time to call each hospital, fax and follow up to see if the fax was reviewed can be extremely lengthy.” – ps this is in VA, similar to the first response above.  (BOTH)

“Hours, not necessarily days.” (BOTH)

“rarely, but it does happen. not for days, but to sit for a few hours waiting to get responses from hospitals for admission is common.” (Gen Hosp)

If you have access to a specialized psychiatric emergency department, or crisis stabilization unit, what has been helpful about how this has been designed?  Anything not so helpful (that could be better)?

“We have one regional Crisis Stabilization unit in our region (city of Richmond and surrounding counties) and they have provided excellent treatment, in many cases better than acute hospitalization with the requirement of active treatment vs being housed in a local hospital bed until the acute crisis passes.  They are also somewhat selective in who they accept and they are very reluctant to admit someone unless they have housing already in place or firmly lined up prior to admission.”

“There is a Crisis Unit in (MN).  We have to ensure that the individual brings their own meds and they will not prescribe/change medication.  Not changing the medication is a positive in cases where the individual was not taking meds.”

“Currently we just had a CITAC (Crisis Intervention Team Assessment Center) open at our local hospital. If someone is brought to the ED by police for evaluation they are met by a peer support, trained law enforcement, and mental health clinicians who support the client through the process. It has only been open a couple of months but we hope to see a positive impact with it.”

“It is helpful that we don’t always have to go through the hospital to do an admit if needed and we can just do a direct admit to the CSU.”  (CSU- crisis stabilization unit)

“The referral form is the pre-screening form, in the event they escalate to the level of need of a TDO (I think temporary detention order – Lorna) we are able to do this quite quickly.”

“We have access to state and privately ran crisis/triage hospitals and stabilization units.  It is most certainly easier on the clients to be in a facility that specializes in behavioral health.  The teams also develop great working relationships with consistent staff on the specialty units.    Those relationships have become tremendously helpful when collaborating during a hospitalization. Utilizing emergency departments was a procedure many many years ago and would, unfortunately, feel like going backwards if it were to occur in our area.    The facility that accepts mainly Medicaid has a unit with “23 hour beds”.  This becomes mainly an acute stabilization and if further care is needed, they will go to a “bed” on the longer term unit. We have a variety of resources, however, we still feel short of beds frequently.  When beds not available in our county, they will be driven, by sheriff deputies, to other county agencies in the state for treatment.”

Where did our respondents come from?  Virginia, Minnesota, Oklahoma, New York, North Carolina, Indiana, Florida, George, and Colorado

– Lorna


photo by Simon Matzinger

The Aftermath of Mass Shootings

Here in the U.S., we are once again reeling from a series of mass shootings and the unavoidable aftermath of debates and inaction. Harvey Rosenthal—the CEO of the New York Association of Psychiatric Rehabilitation Services and a staunch advocate for people with mental illness—wrote this opinion piece, published in USA Today yesterday, titled, “I have a mental illness. Don’t scapegoat, institutionalize people like me after shootings.”

Why share this particular piece of the many that are out there?

Because the discourse again has gone the direction of finger-pointing towards mental illness with proposed “solutions” involving coercion and control.  I suspect there are some people, including people getting ACT services, who could benefit from open discussion and processing following the events themselves, but also the de facto finger-pointing.  For many individuals getting ACT, we are their biggest advocate and it may be times like this when our advocacy needs to be the loudest. 

– Lorna


photo by Paul Earle

An Opinion on Clinical Peer Support

Peer Specialists are particularly underpaid and have a limited career growth trajectory within the “peer specialist” position. We’ve seen peers continue to invest in their own career development, furthering their education and training, and eventually moving into other ACT team positions or out of ACT all together. When they do move into the other positions, with their more advanced education in hand, they then get access to a salary boost. Whatever position they land in, they (hopefully) never lose their “peerness” and integrate that within the other position.”Peerness,” to me, is navigating the role of being part of a larger team of professionals, while aligning closely to the people served, helping serve as their voice within the team and larger system, while also teaching individuals the skills to be their own advocate. Peers carry an anchor of empathy – not only from the experience of struggling with mental illness (and/or substance use), it’s from being oppressed, overpowered, beaten down.

I get concerned when I see peers embracing or wanting a more “clinical” status — as it may reflect a drift from what is most sacred about their position. On the other hand, I think we create reason for this drift because we continue to undervalue this important position, both in fair compensation and career growth options.

A final thought, too, is that I hate how much we separate out peers from other team members who have not self-identified as such. All the unique qualities a peer brings are things we should all be striving to represent and offer to people we serve (advocacy, empathy, patience, broadened perspectives).

– Lorna


Photo by Michał Parzuchowski

When I Get That Feeling, I Want …

If you were not aware, “Virginia is for Lovers” — the travel slogan for this great state, which we’ve had the pleasure of working with the past couple of years. An apt slogan for a topic raised in training this week — how to support individuals around their desires to have sex and intimacy.  

As an ACT team, we are tasked to address the whole person with a full range of services.  Isolation and loneliness are not only common for many of the folks we serve, but deadly.  In spending time with teams, we often see many missed opportunities and/or lack of priority in helping people develop connections with other people.  People in settings beyond congregate settings for people with mental illness.  

Similarly, we viewed many savvy teams who are great at discussing preventative health measures, including safe sex, or the many side-effects of medications, including impotence, but that’s as far as the toe dips into the “sex” conversation.  

In the example raised by our Virginia audience, an older gentleman (late 50s) wants to have sex with a woman, has never had sex, and appears to be somewhat preoccupied with this desire, at times inappropriate with female staff.  The team members seemed to be doing their best to balance the desire to help him with what is an important need for him, while also sorting out how to address behaviors that are also concerning (for staff safety, but also his safety). While devoting only 5 minutes to discuss this particular situation, we could see how tricky it was.  

What I appreciated was the team not shying away from the discussion.  I bet most teams could do better in inquiring (beyond a stale assessment question)–  Are you satisfied with your sex life?  What is your own desires when it comes to having sexual relationships?  

I’ve only so far skimmed this, but here is a resource that may be worth checking out — designed as an intervention for us (staff) to help us have more deliberate conversations about sex and intimacy with people we serve.   

– Lorna


Photo by freestocks.org

Seeing Patients In Other Facilities

  • Hospitals
  • Nursing homes
  • Rest homes
  • Group homes
  • Family care homes
  • Jails

In creating any policy and funding in support of ACT intersecting with any institution, it’s best to consider the “spirit” of the program and how to support that best practice, and also consider the many ways it can be abused.  Overlaying ACT on institutional settings as a longer term practice is often not good (I can always identify an exception — where if it were not for ACT on top of a residential placement, that person would end up in even more of a restrictive setting).  The focus should be on community inclusion and integration, not community segregation, which is what many supervised residential placements feel like.  (Check this out — nod to Mark Salzer at Temple for pointing me towards this.) 

In the emergence of practices like Critical Time Intervention (CTI), I considered how ACT was designed to serve this role — going into institutions to identify people who would benefit from more intensive, wrap-around community supports, and then assisting with that transition and then providing the longer term care (and, per CTI model, if the person is found to actually not need ACT level of care, facilitate the transfer to another better fitting service — which sadly doesn’t exist in many communities (!)). 

Not sure if it remains true, but I believed Delaware was a state that actually had financial incentives (or consequences) for both ACT/ICM and hospital inpatient staff coordinating care — they basically were paid to communicate with each other when someone was inpatient.  I always loved that idea. 

– Lorna


Photo by Daniel Leone

Adjusting Service Intensity

I would bet we all can agree that service intensity should be tailored to what the individual wants and needs — but that response is also too simple, and not very helpful.  I’ll bullet point on some considerations…

  • What you are able to offer depends on what you have on deck for resources. 
    • Fully staffed team, with a ratio closer to 1:8, is going to have more resources for a given client than a team staffed with a ratio of 1:10.  BEWARE – ratios of 1:5 signal there are many people out there in need of ACT who could be getting ACT so start enrolling more individuals!
    • Limit and be thoughtful about staff doubling up to see individuals.  Aside from the obvious good clinical practices for sending two staff out to see a client, an example we are less fond of us when there is an expectation that a team member (often a nurse) has to accompany the psychiatric care provider out in the field to see people.  You are de facto reducing your staffing resource stock.
    • Manage your catchment area to control for excessive indirect time (which subtracts from possible direct time) due to travel.  Expansive rural areas, excessive mountain terrain driving, and pockets of dense urban areas with challenging gridlock traffic all can be a problem. 
    • A team with a comprehensive repertoire of skills that complete the “all inclusive team” simply has more to offer than a team with more limited skills and focus — person-centered planning will actual result in a rich compliment of services, vs a team that more narrowly focuses on case management and medication monitoring.
    • Planned service hours creates a space for doing more with individuals.  Teams that truly embrace the early evening shift (e.g., 11 – 7) and planned weekend hours (so much you can do to support people on Saturday and Sunday!) will naturally result in more intensive services than the team that believes team operations start and end at 8 – 4 or 9 – 5, then it’s simply crisis on-call coverage.
    • Offering groups (in compliment to individual services) may result in more options and increased service intensity.  BEWARE — too many groups is not a good thing — and if you are using terms like “programming,” I suspect you are down a path that is feeling institutional.  Consider offering workshops and changing the focus and topics periodically.
  • Decisions around how much service (frequency and intensity) may depend on several individual factors.  Here are some reasons why someone may be getting more intensive services from the team:
  • They have multiple and complex needs benefiting from multiple team member contacts across the week.  Someone may really want and benefit from 4 visits per week in part because they have a lot going on — struggling with family relationships; interested in getting a part-time job; working on nutrition to address hypertension; and just moved into a new apartment and is needing support in establishing their new home — that’s a lot to be working on all at once and may require several team members working in tandem across a single week.  Conversely, some individuals may not tolerate many visits (fragile engagement), and/or are in an “action” or “maintenance” stage of change in only a couple of life areas, but have other needs they are not willing to actively address at the time– in turn, you essentially “bundle in” other outreach and motivational interviewing type interventions with other services. 
  • They have significant impairments in functioning and/or cognitive impairments needing more frequent prompts, reminders, and assistance in structuring their day.
  • They present with some safety concerns and more frequent supervisory check-ins is important.  For some individuals served by ACT, the idea of this service being a “least restrictive alternative” is very evident — and although the team is working to provide a full range of person-centered services to help individuals be more independent and increase quality of life, there may be a need to see this person often to get ahead of any pending problem before it gets too big and has too serious of consequences.  For some, it may involve more intensive supports around medications.  Relatedly are the individuals who need more intensive supports to help reduce the risk for bigger crises, which includes those who are recently discharged from hospital (a high risk time for many people).
  • Finally — it is also important to revisit the question — do they really need ACT?  Teams serving people who do not benefit from this level of care likely will not see higher levels of intensity for those individuals.  This is not necessarily a consequence of people progressing through ACT and getting ready for graduation, but can be due to your area lacking reasonable alternative services.  A similarly important question (and lends to other threads on this listserv) is having opportunity to provide longer term services and not experience the pressure of (premature) discharges from the team.  So much of the first 1 – 2 years can involve careful rapport building to even get to the point of working on a bunch of life areas … teams under pressure to discharge, are caught up in a cycle of serving a larger proportion of individuals in an engagement phase.

With fidelity reviews, we are often focused on calculating averages (medians – -what the middle person is getting after rank-ordering them high to low).  That information is important — and when on the lower end (under 90 minutes — which is not uncommon to see), I’m revisiting all of the above questions and considerations. 

I’m also paying attention to how high is high (looking at the top 10% in intensity and seeing how intensive that is) and how did you get there (i.e., there are ways to get high intensity by way of not so good practices — such as excessive use daily medication monitoring; excessive reliance on groups (you start looking like a day treatment program); or serving a high number of people in residential institutions, of which the team has easy access to (captive audience)). 

Again, interested in reactions and additional thoughts.  In short, service intensity depends on the: 1) resources available from the team; 2) the needs of the individuals served; 3) the team’s ability and opportunity to meet those needs across time

– Lorna


Photo by Alex Shutin

Grassroots Provider Efforts

North Carolina (NC) ACT Coalition was founded over 10 years ago, where a few NC agencies committed to providing ACT – and doing it well — joined together as a solid unit to share resources, ideas, and unite to be a single voice lobbying for more resources and better policy.  These few originating agencies spanned the state.

It was indeed a grassroots effort– no mental health authority was directing them to convene.  Agency executive leadership, clinical directors, and team leaders chose to meet because they believed in this service, and most importantly, the people served.  The growth of the NC ACT Coalition was well timed with my own move to NC – I was eventually enlisted to give some guest speaker talks, then slowly pulled in to facilitate and lead them (and thankful for it!). 

Although our Coalition meeting location shifted many times over the years (there was a  “Golden Corral” era – something only some of you will appreciate), our focus and commitment only grew.  At one point, we created committees to take on tasks such as : administrative advocacy; outcomes monitoring; fidelity monitoring;  and a training committee.  We pooled resources, we pooled data, and we negotiated differences in perspective and opinion about best practice ACT.  

As of 2019, the NC ACT Coalition remains and now essentially represents all agencies operating ACT in NC.  Given the size and spread of teams, we bifurcated into an “Eastern” and “Western” Coalition for the sake of our bi-monthly meetings.  We meet as one large Statewide Coalition annually for a conference.  In addition to these meetings, members have access to a listserv, received discounts on trainings, and engage in surveys used to collect data and generate reports to meet provider needs (e.g., we conduct a salary survey every three years and share data (de-identified) back to the teams).  

We do collect annual agency membership dues to help pay for the expenses related to facilitating and coordinating; but we’ve kept those rates steady over time.  One of my personal struggles with a Coalition like this is how to preserve it’s grassroots origin, as well as decisions around membership inclusion vs. exclusion.  Do we welcome all, or those who clearly show a demonstrated alignment with our mission statement of best practice ACT?  Analysis of fidelity data a positive correlation between the length of membership and participation in meetings and ACT fidelity (of course there are two different interpretations of this relationship).

I go on and on about this to share something cool happening in California, or at least in Solano County and it’s neighboring counties – led by a friend, and champion for best practices in general — Emery Cowan.  Emery arrived in NC to work with our DHHS/Division of Mental Health during the “Golden Corral” Days, and the Coalition so greatly appreciated her immediate interest in them and wanting to support the providers in delivering best practice ACT.  She eventually moved back to do some good things in Broward County, Florida (where she is from), before being scooped up by smart people in California.  Emery is working diligently to invite provides to get more involved in her area — become grassroots champions of their own right.  She kindly agreed to share this resource guide she developed. Check it out!

We’d love to hear more about your own local grassroots efforts!

– Lorna


Photo by Michał Parzuchowski