Margie Balfour, MD, PhD�Connections Health Solutions�Chief of Quality & Clinical Innovation �Associate Professor of Psychiatry, University of Arizona��Sgt. Jason Winsky�Tucson Police Department�Mental Health Support Team Supervisor

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Roadmap to the Ideal Crisis System:

Lessons from Arizona

Photo by Margie Balfour. Driving into Sedona

Early Intervention, Deflection, & Diversion:

Intercept 0 (Community Services) & �Intercept 1 (Law Enforcement Collaboration)

About Connections Health Solutions

• Pioneering Leaders in Acute Crisis Care
• Our co-founders Drs. Chris Carson and Robert Williamson developed the crisis observation model in Texas in the 1990s
• Brought the model to Phoenix in 2004, which evolved to what is now known as the Arizona Model or sometimes “Crisis Now”
• We continue to advance the field via innovation, thought leadership, and research
• Serving over 35,000 adults and youth annually at large crisis facilities in Phoenix and Tucson. Services include:
• Urgent care
• Observation
• Inpatient
• Transitional and post-crisis outpatient care
• Expansion – 2022 and beyond
• To other states (MT, WA, others)
• Additional services (mobile)
• Value-based payment models like ACOs

The Sequential Intercept Model�Intercepts 0 and 1 focus on preventing arrest

What is the Sequential Intercept Model?

• Every person follows a path through the justice system: Arrest, detention, arraignment, pre-trial, etc.
• At every point along this path, there is an opportunity for the behavioral health system to “intercept” the person and either
• Stop them from progressing further (diversion)
• Mitigate the effects of justice involvement
• Crisis services are focused on Intercept 1:
• Interactions with law enforcement to prevent unnecessary arrest

Munetz MR and Griffin PA. (2006) “Use of the Sequential Intercept Model as an Approach to Decriminalization of People With Serious Mental Illness.” Psychiatric Services 57:4.

“Divert to what?”

Easy access to crisis care makes it easier for CIT officers to do their job.

Roadmap Vision

• Every individual/family in every community in the U.S. will have access to a continuum of best practice BH crisis services that are welcoming, person-centered, recovery-oriented, and continuous.
• An excellent Behavioral Health Crisis System is an essential community service, just like police, fire and emergency medical services (EMS).
• Every community should expect a highly effective BH crisis response system to meet the needs of its population. 
• A BH crisis system is more than a single crisis program.
• It is an organized set of structures, processes, and services that are in place to meet all types of urgent and emergent BH crisis needs in a defined population or community, effectively and efficiently.

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Joint project of the National Council & Group for the �Advancement of Psychiatry. Download at www.CrisisRoadmap.com

What’s so special about Arizona?

Arizona’s crisis system design incorporates many of the principles outlined in the Roadmap.

and

Successes in Arizona informed much of the development of the Roadmap.

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Key Feature: Systems Thinking

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Systems Thinking

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In a crisis SYSTEM, �the services �work together �to achieve �common goals.

A crisis system is �more than a collection of services.

The system is �more than the sum of its parts.

3 Key Ingredients for a SYSTEM

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Arizona Crisis System Financing & Governance Structure�creates the foundation for an organized, coordinated, & sustainable system

• A “braided” funding model maximizes the impact of multiple funding streams, creating a sustainable system that can serve everyone regardless of payer.

• A single “accountable entity” creates the structure for strategic planning and oversight.

• Contracted services are aligned towards common goals that are both clinically desirable & fiscally responsible:
• DECREASE use of ER, Hospital, Jail
• INCREASE community stabilization.

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Alignment of crisis services toward common goals�care in the least restrictive (and least costly) setting

Person

in

Crisis

Mobile

Crisis

70% resolved �in the field

Crisis Line

988

80% resolved �on the phone

60-70% discharged �to the community

Acute Crisis

Facilities

LEAST Restrictive = LEAST Costly

Balfour ME, Hahn Stephenson A, Delaney-Brumsey A, Winsky J, & Goldman ML. Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies. Psychiatric Services 2022 Jun;73(6):658-669. Epub 2021 Oct 20 https://ps.psychiatryonline.org/doi/10.1176/appi.ps.202000721.

(Community stabilization rates are based on FY2019 data from the Southern Arizona region and were provided courtesy of Johnnie Gasper at Arizona Complete Health/Centene)

85% remain stable �in community-based care > 45 days

Post-Crisis Care

Post-crisis wraparound

Crisis Residential

& Crisis Respite

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Services are easily accessible with a no-wrong door culture across the continuum, e.g., walk-ins at crisis facilities, police or mobile drops-offs to crisis residential, etc.

911 integration

Collaborative responses

5-10 min drop-off

No refusal policy

The Crisis Response Center

• Built with Pima County bond funds in 2011
• County owns the building, services funded by the RBHA
• Alternative to jail, ED, hospitals
• Serving 10,000 adults + 2,000 youth per year
• Managed by Connections since 2014
• Services include
• 24/7 walk-in urgent care
• 23-hour observation
• Short-term subacute inpatient
• Law enforcement drop-offs with NO WRONG DOOR�(no exclusions for violence, intoxication, payer, involuntary status)
• Space for co-located community programs
• Adjacent to
• Crisis Line Call Center
• Banner University Medical Center
• Emergency Department
• 66-bed inpatient psych hospital
• Mental health court

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A Solution to the “Divert to What?” Question�Connections Culture of Treating LE as a “preferred customer”

These two are the �hardest to do well.

It means

• Be easier to use than jail.
• Drop off time less than 10 min
• Never turn police away.
• Take everyone:
• High acuity: No such thing as “too agitated” or violent
• Can be highly intoxicated
• Involuntary or voluntary
• WithOUT using security guards

CIT Recommendations for �Mental Health Receiving Facilities¹

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1. Single Source of Entry
2. On Demand Access 24/7
3. No Clinical Barriers to Care
4. Minimal Police Turnaround Time
5. Access to Wide Range of Disposition Options
6. Community Collaboration

1. Dupont R et al. (2007). Crisis Intervention Team Core Elements. The University of Memphis School of Urban Affairs and Public Policy
2. Steadman HJ et al (2001). A specialized crisis response site as a core element of police-based diversion programs. Psychiatr Serv 52:219-22
3. Little-Upah P et al. (2013). The Banner psychiatric center: a model for providing psychiatric crisis care to the community while easing behavioral health holds in emergency departments. Perm J 17(1): 45-49.
4. Zeller S et al. (2014). Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med 15(1): 1-6.

Studies show this model:

• Critical for pre-arrest diversion²
• Reduces ED boarding^3,4
• Reduces hospitalization^3,4

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Quick and Easy Access for Law Enforcement �so that we’re the preferred alternative to jail or the emergency room

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Dedicated police entrance with secure gated sally port & workspace

Crisis Response Center - Tucson AZ

Officers don’t like:

• Waiting
• Being turned away
• Taking their guns off
• Parading people through �the front lobby

Studies show this model is critical for pre-arrest diversion,² reduces ED boarding,^3,4 and reduces hospitalization.^3,4

“For both officer-initiated events and 911 calls, the odds of arrest were lower for mental health/medical incidents than for violent crimes. This finding may be partly due to the role of Tucson’s Crisis Response Center, which provides an alternative to arrest and jail booking… the odds of arrest for mental health/medical versus violent crimes were far lower concerning officer-initiated events than 911 calls.”

In Tucson…

1. Dupont R et al. (2007). Crisis Intervention Team Core Elements. The University of Memphis School of Urban Affairs and Public Policy
2. Steadman HJ et al (2001). A specialized crisis response site as a core element of police-based diversion programs. Psychiatr Serv 52:219-22
3. Little-Upah P et al. (2013). The Banner psychiatric center: a model for providing psychiatric crisis care to the community while easing behavioral health holds in emergency departments. Perm J 17(1): 45-49.
4. Zeller S et al. (2014). Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med 15(1): 1-6.

Neusteter SR et al. (2020) Understanding Police Enforcement: A Multi-City 911 Analysis. Vera Institute of Justice

https://www.vera.org/downloads/publications/understanding-police-enforcement-911-analysis.pdf

23-Hour Observation: Open design that creates a safe & therapeutic environment

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Interdisciplinary care starting with the assumption that the crisis CAN BE resolved

Interdisciplinary Teamwork

• 24/7 psychiatric provider coverage (MD, NP, PAs)
• Peers, nurses, techs, case managers

Early Intervention

• Door to doc time 90 min
• Meds, detox/MAT
• Peer support & groups

Proactive discharge planning

• Coordination with clinics,� community & family � supports

~60% discharged to community-based care

~70% converted to voluntary status

The open design facilitates:

• Safety: Continuous observation
• Therapeutic milieu: Open area for therapeutic interactions with others
• Flexibility: Ability to accommodate surges in volume

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15% of CRC adults present with �SUD as the primary concern,

65% have a SUD diagnosis �or positive toxicology results.

Meth & alcohol account for�three quarters of SUD diagnoses.

but…

MH and SUD services are fully integrated at the payer level, which gives crisis providers the flexibility to treat co-occurring SUD based on the individual’s needs.

Youth and SUDs

• 28% of CRC youth obs patients have a SUD diagnosis or positive toxicology result.
• The most common diagnoses are Cannabis (66%) followed by Alcohol (12%) and Opiates (11%).

Tucson Police Dept. Organizational Approach

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Research shows that CIT is most effective when the training is VOLUNTARY. TPD mandates basic training for everyone, while more advanced training is voluntary. High rates of training are achieved through culture and by creating incentives to make the training desirable.

LEADERSHIP enacts organization-wide policies, procedures, training, culture

Use of Force Continuum

Implicit Bias Training

Officer Wellness

De-escalation Required

Guardian vs. Warrior

Community Policing

Collaboration

with behavioral health systems, social services, and other community partners

100% of the dept is MHFA trained

60% of first responders & 911 call-takers are �CIT trained

Specialty units are 100% CIT trained & receive ongoing Advanced CIT & other training

Balfour ME, Hahn Stephenson A, Winsky J, & Goldman ML (2020). Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies. Alexandria, VA: National Association of State Mental Health Program Directors. https://www.nasmhpd.org/sites/default/files/2020paper11.pdf

Tucson Police MHST Model: A Preventative Approach�Dedicated Mental Health Support Teams (distinct from CIT trained patrol officers)

• Locate and transport individuals with civil commitment pickup orders
• Thousands of people have been transported to treatment without uses of force
• Develop relationships and recognize patterns
• Helps with CIT calls when needed

MHST officers wear plainclothes because it decreases the anxiety of the person receiving services and also has an effect on the officer’s attitude.

Officers focus on service & transport.

Detectives focus on prevention & safety.

• Investigate calls that otherwise wouldn’t be looked at (e.g. “I’m concerned about my neighbor”)
• Connect people treatment before the situation escalates to a crisis
• Focus on public safety but avoid criminal justice involvement

The

“weird stuff” detectives

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Tucson’s Police-MH Collaborative Response Model

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Outreach & follow-up �can “break the cycle” by ensuring that the person is connected to the care they need to stay well in the community. Community-based peers and/or clinicians work with LE to help with engagement and navigating the mental health system.

Safety Risk

Urgency

Prevention

• Lower urgency
• Multiple touches
• Outreach
• Follow-up

Response

• Higher urgency
• Discrete event
• De-escalation & other interventions

Breaking the Crisis Cycle

With 911/crisis line integration, low safety risk calls are triaged to a clinician-only response as early as possible, with LE reserved for calls with higher safety risk and/or criminal nexus. Responding officers are CIT-trained and can request additional assistance to fit the situation. The more robust the crisis system, the more options.

Health-First Response

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Your Jedi mind tricks don’t work on me, only data.

Connections CRISES Framework: �Quality metrics for facility-based crisis services

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Balfour ME, Tanner K, Jurica PS, Rhoads R, Carson C. (2015) CRISES: Crisis Reliability Indicators Supporting Emergency Services. Community Mental Health Journal. 52(1): 1-9. https://doi.org/10.1007/s10597-015-9954-5

Adopted in national guidelines by SAMHSA and National Council

http://www.CrisisRoadmap.com

https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf

Regular Meetings & Data Review with Law Enforcement

• Monthly meetings with
• CRC leadership
• Law enforcement leaders
• Other first responders
• Regional BH Authority �first responder liaisons
• Review
• Trends
• Outliers
• Complex cases
• Customer service feedback
• Process improvement projects
• MOST IMPORTANTLY: �develop relationships & trust 🤗❤️

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Police Wait Times Data Dashboards

Outlier Analysis

• 95% are under 10 min
• Track outliers:
• 6 were 10-20 min
• 1 was 20-40 min
• Investigate why

Created by Sean Reed, Connections IT

MORE People Taken to Treatment…

Many drop-offs are voluntary because the officers are engaging people into treatment.

Officers like quick turnaround times so that it’s easier to bring people to treatment instead of jail.

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More people diverted to treatment instead of jail

… and LESS Justice Involvement

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Balfour ME, Winsky JM and Isely JM; The Tucson Mental Health Investigative Support Team (MHIST) Model: A prevention focused approach to crisis and public safety. Psychiatric Services. 2017;68(2):211-212; https://dx.doi.org/10.1176/appi.ps.68203

Fewer calls for low-level crimes that tend to land our people in jail.

Culture change in how law enforcement responds to mental health crisis.

Each one costs $15,000!

Dedicated Specialty Teams: �Prevention, outreach, & follow-up = more community stabilization

Mental Health Support Team (MHST)

• Mobile crisis clinician assigned to MHST detectives
• Investigations & follow-up for high-risk individuals

Substance Use �Response Team (SURT) Deflection Program

• Peer co-responders focused on SUD and overdoses
• Option not to arrest for possession of small amounts

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Homeless Outreach Team (HOT)

• Peer co-responders focused on homeless recovery
• Identify and engage with individuals instead of arrest

Percent of calls resulting in involuntary hospitalization decreased from �60% to 20%

In the first 2 years,

2,000 people

connected to treatment instead of arrest

500 people

housed

in the first 2 years of the program

Data courtesy Sgt. Jason Winsky at Tucson Police Department

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Tucson PD Substance Use Deflection Program

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Deflection Program Core Elements

1. Officers have discretion to deflect to treatment instead of arrest.
2. Angel Program provides connection to treatment for individuals who self-present asking for help.
3. Co-Responders: SURT Officer + peer for outreach and follow-up
4. Community partnerships:
• CODAC Health & Wellness provides the peers co-responders and operates a 24/7 MAT clinic
• The crisis system is always available for those who need it

• 69% of individuals offered deflection accepted it.
• 50% of deflection events resulted in immediate transport to a treatment provider.
• Deflections took less time (49m) than arrest/citation (77m)

Data courtesy Sgt. Ericka Stropka at TPD. Program Evaluation performed by:

Korchmaros J & Bentele K (2020). Tucson Police Department Deflection Program: Impact at 18 Months. Tucson, AZ: University of Arizona, Southwest Institute for Research on Women.

Arizona Model Return on Investment

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Adapted from https://crisisnow.com/wp-content/uploads/2020/02/CrisisNow-BusinessCase.pdf

A study of the crisis system in Phoenix estimated that

a $100 million investment in crisis care �resulted in savings of

$260 million in psychiatric inpatient spending

$37 million in emergency room costs

45 years of psychiatric ER boarding hours

37 FTE of police officer time and salary

Results: Fewer “Familiar Faces”

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Case Example: Ms. X becomes lonely during the weekend, which is a trigger for feeling overwhelmed and suicidal and coming to the CRC. She has a partner who is also enrolled in services.

​

Individualized Plan:

• The outpatient provider will proactively do welfare checks on nights and weekends to help plan for triggers that historically result in CRC visits.
• The team will explore working with her partner’s team (with consent) in order to assist both in recovery together.
• The CRC will call her clinic Peer Support Specialist immediately upon arrival to reinforce the relationship with her outpatient team and help connect her more quickly with outpatient support.

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There were 64 “Familiar Faces” on the original high utilizer list.

One year later, only 7 of the original 64 remained high utilizers.

And only 37 individuals met high utilizer criteria

Year 1

Year 2

Balfour ME, Zinn T, Cason K, Fox J, Morales M, Berdeja C, Gray J; Provider-Payer Partnerships as an Engine for Continuous Quality Improvement; Psychiatric Services; 2018;69(6):623-625; https://doi.org/10.1176/appi.ps.201700533

“Be a detective, not a bouncer.”

• A better clinical approach for our “Familiar Faces.”
• Go beyond “They don’t need to be here”
• Figure out what they ACTUALLY need
• Explore reasons for using the crisis center to meet their needs
• What do they need?
• Why haven’t they been able to get it?
• What is reinforcing their repeat visits?
• What do we want to reinforce instead? (Replacing the behavior)
• Partner with patient and ”the system” to get their actual needs met

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Emergency Rooms: Quick wins to improve collaboration

• Find out the process for what happens when law enforcement brings an individual to the ED.
• Can these processes be improved to make it easier?
• Do officers have to bring people through the main waiting area? Is there a faster and less stigmatizing alternative?
• Do officers have to wait with individuals under an involuntary hold? Is there a way to transfer custody to the ED so that officers can get back on the street?
• When looking for solutions, try to move beyond “we’ve always done it this way.”
• Set up regular meetings to talk through issues and work on improvements.

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It took a LONG time and LOTS of collaboration to get where we are today.

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2000

< City (Tucson)�MH Court

2001

CIT Program�started >

2002

< Mobile Crisis Teams

2004

Felony >

MH Court

2006

Bond passes > �to build crisis facility

2007

Jan 8 2011 shooting >

at Congress On Your Corner

2011

< Peers in the Jail

< Crisis Response Center�opens Aug 2011

2013

Law Enforcement MH Support Teams

MacArthur Grant >�awarded to Pima County

2018

< Learning Site�designation by �Dept of Justice

​

​

< MHFA Impact Award�National Council for BH

< Repeat Jail Detainees Task Force

< Co-responders�(cop + clinician)

< Repeat T36 Utilization�(civil commitment/AOT)�Data Sharing Task Force

< 24/7 access to MAT

< 100% MHFA training achieved TPD + PCSO

​

2017

Jail Based > Restoration to Competency

< Pima County Office of BH Administrator

< DTAP Program �Drug Treatment Alternative to Prison

2010

2012

< Rural�MH Courts

< PCSO

TPD >

< MH First Aid�Training for law enforcement begins

2016

2015

Jail + MH �Data Exchange

< JHIDE

Analytics >

2014

2019

< 911/crisis line�co-location

< CoMPaSS Court

Consolidated misd. problem-solving court

< Drug Deflection�UMATTER �program

< Homeless Outreach Team�

< STEPS Court pre-adjudication diversion

(2020)

2021

Questions?

Sgt. Jason Winsky

Tucson Police Department

Supervisor

Mental Health Support Team

Jason.Winsky@tucsonaz.gov

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Further Reading:

• Roadmap to the Ideal Crisis System: Essential Elements, Measurable Standards, and Best Practices for Behavioral Health Crisis Response. http://www.CrisisRoadmap.com
• Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies. �Paper: https://bit.ly/CopsCliniciansBothPaper�Podcast: https://bit.ly/CopsCliniciansBothPodcast
• Psych News overview of Tucson model: https://doi.org/10.1176/appi.pn.2022.1.7

Tucson is one of the DOJ’s

Law Enforcement - Mental Health Collaboration

Learning Sites

Funding for a visit may be available.

https://csgjusticecenter.org/law-enforcement/projects/mental-health-learning-sites/

Margie Balfour, MD, PhD�Connections Health Solutions�Chief of Quality & Clinical Innovation �Associate Professor of Psychiatry, University of Arizona

margie.balfour@connectionshs.com