Elements of a good mental health crisis intervention system

A description of what advocates should look for in assessing a mental health crisis intervention system

ELEMENTS OF A GOOD MENTAL HEALTH CRISIS INTERVENTION SYSTEM

Prepared for NAPAS by
Center for Public Representation
Northampton, Massachusetts

Q:

What are the basic elements of a crisis intervention system to prevent unnecessary
admissions to an institution?

    Either as part of a negotiated, comprehensive community service plan or a systemic
litigation remedy, advocates should attempt to incorporate an effective crisis intervention
system. There are at least four distinct elements of such a system.

1.     Capacity to provide crisis intervention services

    A comprehensive crisis response system includes five service models:

    (1)    Emergency telephone response - area wide, accessible
telephone contacts with skilled crisis intervention workers who can
screen requests and respond with counselling, support, or other
telephonic interventions. This component is often referred to as
"hotlines" or "warmlines" and also include information and referral.

    (2)    Mobile outreach - a team of trained crisis intervention
workers who are available to visit a person in her home or other setting
where the crisis occurs, to provide counselling, support, and other
interventions on-site, to conduct an initial assessment and determine
whether additional on-site support is appropriate, and to remain with the
individual for as long as necessary until the crisis subsides.

    (3)    Evaluation - formal assessment to determine what
ongoing services, if any, are appropriate, including additional in-home
supports or interventions to address the crisis without requiring the
individual to leave her own home or other setting. In many programs
this capacity is provided as part of the mobile intervention program, in
order to avoid the unnecessary dislocation of the individual to a
centralized clinical site.

    (4)    Crisis residential setting - a specialized, staffed
environment where an individual can live for a brief (usually up to
seven days) period in order to be provided with intensive support and
intervention outside of the individual's home or other location where
the crisis occurs.

    (5)    Respite residential program - a residential program which

provides residential support, usually for up to one month, if a longer
residential alternative is needed then a crisis residential program.

    Each of these five service models can be staffed primarily by
consumers, although some licensed professionals are needed to make clinical
evaluations. Most importantly, the evaluation and residential services should
be provided outside of a hospital, in more integrated community settings, with
appropriate staff.

2.    Standard

    Most states have a statutory or regulatory standard for emergency detention or
involuntary admission to its mental health or retardation system. Since these standards
define the criteria for involuntary admission, it is appropriate for there to be a
different, lower standard for crisis intervention services, particularly because these
services are offered on a voluntary basis. Conversely, it is reasonable to establish even
more rigorous standards for involuntary hospitalization when crisis intervention
services are available.

    Once a community service system has established an adequate array of crisis
intervention services, there should be a significant decrease in involuntary admissions
to psychiatric or retardation facilities. The capacity not only diverts unnecessary
admissions but it also can prevent involuntary treatment which otherwise might have
been required under existing statutory or regulatory standards, in the absence of an
effective crisis response network. Therefore, states should narrowly define the criteria
for involuntary institutionalization after a crisis services have been utilized.

3.    Process

    Similarly, states' statutory and regulatory mechanisms define the procedures for
involuntary admission to psychiatric or retardation facilities. Usually certified
clinicians can involuntarily admit an individual to a public or private facility if the
statutory standards are satisfied. Further review of this clinical decision is not usually
required. However, once a comprehensive crisis network is established, it is
appropriate to limit the authority to involuntarily admit an individual to the staff of the
crisis assessment program. It is also reasonable to subject the admission decision to
further review by the public entity which funds and oversees the crisis system, in order
to assure that the evaluation and admission decision is consistent with the more
rigorous standards described above. Frequently, administrators from county or
regional public entities which fund and operate the entire community system have final
review and approval authority over admissions, as a safeguard to minimize costly
inpatient utilization.

4.    Funding

    Traditionally, funding for crisis programs, other community services, and
institutions were distinct. Many states are now experimenting with unifying the
funding so that community programs, and particularly crisis intervention services, are
financially responsible for inpatient hospitalization or other costly institutionalization.
This fiscal disincentive to transfer a person to a more restrictive setting has been
extremely effective in encouraging crisis response systems to address and resolve the
crisis without the need for segregated inpatient treatment.

    Advocates should consider consulting with mental health, retardation and other
developmental disability experts who have designed and operated comprehensive crisis
intervention systems. These experts are usually willing to assist in the design of new programs
and can be an invaluable asset to advocates in their negotiation of either systemic remedies or
comprehensive community services plan.