By Margie Balfour, MD, PhD, Chief of Quality & Clinical Innovation, Connections Health Solutions and Brad McKinney, LMSW, MPH, CPHQ, Behavioral Health Division Administrator, Banner – University Medicine

Editor’s Note: This blog post is part of a series highlighting winning practices at Joint Commission accredited organizations.

Our colleagues in behavioral health are all too familiar with the saying, “it’s easier to get into heaven than to access psychiatric care.” This is especially the case during a crisis.

Unlike medical emergencies, a 911 call for a behavioral health emergency often results in a police response. Individuals in mental health crisis account for a quarter of officer-involved shootings, and the prevalence of individuals with mental health conditions in jails and prisons is three to four times that of the general population. 

Those who make it to the hospital don’t fare much better. More than 80% of emergency departments (EDs) report boarding psychiatric patients on any given day, and 64% report they have no psychiatric services available while patients are awaiting admission or transfer, according to a survey by the American College of Emergency Physicians. All of this comes at a high cost—approximately $2,300 per patient and a poor experience for patients, families, and ED staff.

Our community wanted to change that.

In 2009, the citizens of Pima County, Arizona, voted to build a crisis center to meet the community need for psychiatric emergency care. The Crisis Response Center (CRC) opened in 2011, eight months after the Jan. 8 shooting that occurred outside a Tucson grocery store in which six people were killed. In addition, the former U.S. Representative, Gabrielle Giffords and 12 others were wounded by the gunman who was diagnosed with schizophrenia. 

“No Wrong Door” in a Crisis
The revolutionary mission of the CRC is to reduce the number of individuals with mental illness in jails and EDs by making it easier and faster for law enforcement to bring them to the crisis center for treatment. The CRC’s “no wrong door” policy means that officers are never turned away, eliminating the need for them to navigate a complicated system of hospitals, detox centers or clinics. The drop off process is less than 10 minutes, which is considerably faster than what it would be at a jail or ED.

Today, the CRC serves 12,000 adults and 2,400 youth annually. Services include 24/7 walk-in urgent care and 23-hour observation. About half of our patients are brought directly from the field by law enforcement, with the remainder arriving via mobile crisis teams, walk-in or transfer from emergency rooms. Reasons for presentation include:

• danger to self/others
• acute agitation
• psychosis
• substance intoxication and withdrawal

Even highly acute and potentially violent patients are accepted and cared for without the use of security staff. Care is provided by an interdisciplinary team of:

• psychiatrists and other psychiatric practitioners
• social workers
• nurses
• behavioral health technicians
• peer support specialists

Through rapid assessment, early intervention, proactive discharge planning and close collaboration with community providers, the majority of patients are stabilized and connected to appropriate community-based care without the need for hospitalization. For those who need it, a 15-bed adult subacute unit provides three to five days of continued stabilization.

Unique Collaborations
The CRC is built upon partnerships. Pima County owns the building and operations are financed by Arizona Complete Health, the regional behavioral health authority, via a combination of Medicaid and other federal, state and local funds. The clinical services are provided via a partnership between Connections Health Solutions and Banner - University Medicine.

The CRC’s unique campus facilitates multi-agency collaboration. Located at the Banner - University Medical Center South Campus, a covered breezeway connects the CRC to Banner’s 66-bed inpatient psychiatric hospital and emergency department, making it convenient to address virtually any medical need. An on-site courthouse allows patients to attend hearings and staff to testify in mental health court. The CRC also houses the Southern Arizona Crisis Line, which provides 24/7 crisis counseling and serves a “care traffic control” function, dispatching over a dozen mobile crisis teams throughout Pima County.

In addition, the CRC collaborates closely with the many external partner agencies and stakeholders that comprise the southern Arizona crisis system. For example, we partnered with the regional behavioral health authority to reduce the numbers of patients who frequently utilize the crisis system for needs and care that can be delivered by community outpatient providers. Beyond the benefit to patients, these collaborations are also fiscally responsible, as the least  restrictive level of care is also the least expensive.

The Joint Commission’s Role
Safety is critical in the extremely dynamic and highly acute environment of the CRC. The Joint Commission provides a helpful framework for creating high reliability clinical operations in this challenging setting.  

By establishing and affirming the clinical and operational standards that make the setting a safe and effective site for staff and patients, accreditation gives Connections and Banner Health both the structure and resources to improve the quality of care for some of our community’s most vulnerable.

More information about crisis best practices and the Tucson model is featured in The National Council for Mental Wellbeing’s Roadmap to the Ideal Crisis System and the Substance Abuse and Mental Health Services Administration’s National Guidelines for Crisis Care. Technical assistance and support for site visits are also available via the Department of Justice Law Enforcement Mental Health Learning Sites Program. 

We are increasingly hearing from other communities looking to establish similar models and are happy to share the lessons we’ve learned. Please email Dr. Balfour at margie.balfour@connectionshs.com with any questions.

Dr. Margie Balfour is a psychiatrist and national leader in quality improvement, behavioral health crisis care, and law enforcement responses to mental illness.  She is the Chief of Quality and Clinical Innovation at Connections Health Solutions and an Associate Professor of Psychiatry at the University of Arizona.  Dr. Balfour was named the Doctor of the Year by the National Council for Behavioral Health for her work at the Crisis Response Center in Tucson and received the Tucson Police Department’s medal of honor for her efforts to help law enforcement better serve the mentally ill population.  Her pioneering work on defining crisis metrics has been adopted as a national standard by SAMHSA, and she co-authored Roadmap to the Ideal Crisis System: Essential Elements, Measurable Standards, and Best Practices.  Dr. Balfour is a Distinguished Fellow of the American Psychiatric Association and serves on the Council on Quality of Care.  She has also served on the board of directors of the American Association of Community Psychiatrists, The American Association for Emergency Psychiatry, and NAMI Southern Arizona.  

Brad McKinney, LMSW, MPH, CPHQ, is Behavioral Health Division Administrator, Banner – University Medicine.