Margie Balfour, MD, PhD Connections Health Solutions VP for Clinical Innovation & Quality

1. The Tucson Model: Decreasing Justice Involvement Via Mental Health - Law Enforcement Collaborations Margie Balfour, MD, PhD Connections Health Solutions VP for Clinical Innovation & Quality Chief Clinical Officer, Crisis Response Center Asst Prof of Psychiatry, University of Arizona Sgt. Jason Winsky Tucson Police Department Mental Health Support Team

2. Scenarios to think about Police arrive at a call for public disturbance outside of a motel. One of the participants is intoxicated and says they are having thoughts of suicide. Police arrive at a woman’s home for to take her to the hospital on an involuntary commitment order. When police arrive, she is inside and refuses to come out. A store manager calls the police repeatedly to complain about a homeless person acting bizarrely and bothering customers. A man sends an email to a US Congressman about “going Loughner” on a college campus.

3. When mental health and criminal justice collide… It can get ugly.

4. “I’m having chest pain.” “I’msuicidal.”

5. Officer-involved shootings Washington Post Nationwide Database of Police Fatalities “36% of officer-involved shootings in this sample were found to be suicide by cop.” https://www.washingtonpost.com/graphics/national/police-shootings-2016/

6. The path to jail • There are over 2 million jail bookings of people with serious mental illness (SMI) each year.1 • Nearly half of people with SMI have been arrested at least once.2 • Officers want the person to get treatment • But they don’t know where else to take them except the ED • Where they have to wait. • Cops are busy and have crimes to fight. • So they take the person to jail instead.

7. Impact of incarceration1,2 MYTH “They’ll get the treatment they need in jail.” Only one quarter of men and 14% of women receive formal substance abuse treatment while incarcerated.3 3. Office of National Drug Control Policy https://www.whitehouse.gov/ondcp/in-custody-treatment-and-reentry • Jails and prisons lack the policies and trained staff to deal with this population. • Offenders with mental illness are • Incarcerated twice as long • Three times more likely to be sexually assaulted while incarcerated • More likely to be in solitary confinement which exacerbates psychiatric symptoms • Adverse effects post-release include • Interruption in Medicaid and other benefits • Difficulty finding employment • More likely to become homeless • More likely to be rearrested • At twice the cost to taxpayers.

8. If they do make it to an ED… Psychiatric boarding = long waits for beds with little/no treatment • 84% of EDs report boarding of psychiatric patients • Increased risk • Assaults, injuries, self-harm • Increased cost • Sitters, lost revenue • Unnecessary inpatient admits • Poor patient experience • Non therapeutic environment with untrained staff American College of Emergency Physicians (2014) http://newsroom.acep.org/download/ACEP+Polling+Survey+Report.pdf Zeller et al (2014) https://dx.doi.org/10.5811%2Fwestjem.2013.6.17848

9. The Sequential Intercept Model • 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.

10. Our Approach in Tucson • Close collaboration between mental health systems and law enforcement • Shared goals: • Care in the least-restrictive setting that can safely meet the person’s needs while balancing the need for public safety • “No wrong door” • Law enforcement is a preferred customer • Data driven system design • Work together to align • Training • Operational processes • Performance incentives to facilitate these goals

11. Behavioral Health Crisis Continuum A CONTINUUM OF CRISIS INTERVENTION NEEDS 23-hour Stabilization Mobile Crisis Team CIT Partnership EMS Partnership 24/7 Crisis Walk-in Clinic Hospital Emergency Dept. Crisis Respite Outpatient Provider Family & Community Support Crisis Telephone Line EARLY INTERVENTION RESPONSE Integration/Re-integration into Treatment & Supports Peer Support Non-hospital detox Care Coordination WRAP Crisis Planning Housing & Employment Health Care PREVENTION POSTVENTION TRANSITION SUPPORTS Critical Time Intervention, Peer Support & Peer Crisis Navigators

12. Law Enforcement Crisis Continuum Most interventions occur AFTER things have escalated to a crisis A CONTINUUM OF CRISIS INTERVENTION NEEDS CIT (Memphis Model) Mental Health Co –Responder Team (LAPD) ? EARLY INTERVENTION RESPONSE Mental Health Co –Responder Teams (LAPD) PREVENTION POSTVENTION ?

13. A preventative approach to crisis and public safety The Tucson Mental Health Support Team Model Sgt. Jason Winsky Supervisor Mental Health Support Team (MHST) Tucson Police Department

14. Typically Police Have to Balance the two...

15. MHST (Mental Health Support Team)seeks to find solutions to both.

16. The Mental Health Support Team ModelTucson’s preventative approach that builds on CIT • In 2011, Tucson already had one of the oldest and most respected CIT programs in the nation. • Yet someone like Jared Loughner fell through the cracks with tragic results. • A catalyst for taking a fresh look at our approach to mental health crisis: • CIT provided the tools to help officers respond to a person in behavioral health crisis. • But perhaps with a different approach we can preventsome crises and related threats to public safety altogether?

17. Purpose of MHST • Decrease risk to officers and deputies • Decrease risk to community • Decrease risk to persons with mental illness • Decrease waste of taxpayer dollars • BREAK THE CYCLE But also… It’s the right thing to do.

18. MHST Areas of intervention • Many people suffering from mental health issues fall between the cracks of the system • They always become the burden of law enforcement

19. MHST is a DEDICATED TEAM comprised of both Officers and Detectives • Officers = Support/Transport • Focuses on safety and service for people already in the civil commitment system • Centralized tracking and accountability • Specialized training • Develop relationships with patients and service providers • Detectives = Investigation • Focuses on public safety and preventing people from falling through the cracks • Investigate “nuisance calls” that otherwise wouldn’t be investigated • Recognize patterns and connect people to service before the situation escalates to a crisis

20. MHST Officers: A New Approach MHST officers wear plainclothes because it both decreases the anxiety of the person receiving services and also has an effect on the officer’s attitude.

21. TPD Civil Commitment Pickup Orders 2014-2016 Total Orders 926 Success Rate 93% Uses of Force 0 The success rate for 2016 was 98% Prior to MHST: Only 30% of these orders were served before they expired = people falling through the cracks. Served by MHST Team Served by Patrol Quashed Not Served Balfour ME, Winsky JM and Isely JM; Psychiatric Services. 2017;68(2):211–212. https://doi.org/10.1176/appi.ps.68203

22. Each SWAT call costs $15,000! 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. PMID: 28142392; DOI: 10.1176/appi.ps.68203

23. Officer Time Saved by MHST Jan-Jun 2017(This is how you make a case to police administration)

24. MHST Detectives: Investigations MHST Investigations: 2-Pronged Approach • Case Triage: • Cases reviewed based on circumstance code or referral • 4000+ cases per year • NOT a threat to public safety (danger to self) • Referred to mental health provider • Threat to public safety and/or criminal component • Routed to MHST for follow up • A full criminal/mental health investigation is conducted if needed

25. MHST Supports Community Stabilization OneMHST Detective 5months 88calls 28Civil Commitment Apps Filed 68% were resolved in the least restrictive setting BEFORE the crisis escalated. A “PAD” is a non-emergent application for court-ordered evaluation for the criteria “persistently and acutely disabled” under Arizona’s Title 36 Civil Commitment Statute.

26. Tucson Training Model: CIT vs. MHFA CIT International and National Council for Behavioral Health joint statement on MHFA vs CIT: https://www.mentalhealthfirstaid.org/cs/wp-content/uploads/2016/01/FINAL-MHFA-CIT-White-Paper-Annoucement.pdf

27. WHO is trained? CIT training is voluntary by design. CIT is most effective when training is voluntary and incentivized.* *Compton MT, Bakeman R, Broussard B, D'Orio B, Watson AC. Police officers' volunteering for (rather than being assigned to) Crisis Intervention Team (CIT) training: Evidence for a beneficial self-selection effect. Behav Sci Law. 2017 Sep;35(5-6):470-479. doi: 10.1002/bsl.2301.

28. Regional Training Center of Excellence • Provides training to a dozen local and federal agencies across Southern Arizona – urban and rural • Helping other departments set up mental health teams • Most content is delivered by mental health system partners Winner of the 2018 National Council for Behavioral Health MHFA Community Impact Award!

29. Increased Mental Health Transports = More people diverted to treatment vs jail

30. Decreased Arrests for “Nuisance Crimes”

31. The Tucson Model • Atransformational shift: in policy, in practice, in thinking about responding to persons in crisis • With dedicated NOT designated personnel • Saving time and resources • Being proactive versus reactive • Collaborating with community partners before there is a crisis

32. Being a good partner to law enforcement Strategies for crisis providers Margie Balfour, MD, PhD Connections Health Solutions VP for Clinical Innovation & Quality Chief Clinical Officer, Crisis Response Center Asst Prof of Psychiatry, University of Arizona

33. Arizona BH System Structure AZ Medicaid Regional Behavioral Health Authorities (RBHAs) Hospitals, Crisis Facilities, Clinics, etc.

34. What this means for collaboration • Centralized planning • Centralized accountability • Performance metrics and payment systems that promote desired outcomes • Coverage for all individuals in crisis regardless of insurance • RBHA Crisis Team includes liaisons for various stakeholders: • law enforcement, fire, DCS, Hospital/EDs, etc.

35. RBHA goals for the crisis system • Decrease preventable interactions with • Law Enforcement • The Criminal Justice System • Emergency Departments • Increase rates of community stabilization • Availability of services to assist in stabilizationand ongoing support • Collaboration with community partners

36. Example: Designing services to achieve strategic outcomes • State says: Reduce justice involvement for people with SMI • AHCCCS and RBHA use contract requirements and pay for performance incentives to create: • 24/7 Crisis Line • Some 911 calls are warm-transferred to the crisis line • Dedicated LE number goes directly to a supervisor • Mobile Teams: Law enforcement as a preferred customer: • CMTs have 30 minute response time for LE calls (vs. 60 min for community initiated calls) • Some teams assigned as co-responders (cop + clinician) • Specialized outpatient services: (FACT, MRT) • “Reach in” – work with members prior to release to set up benefits and outpatient plan

37. Crisis Mobile Teams cover 38,542 sq miles in 8 southern Arizona counties or 3 Marylands = + + 1,796 CMT activations per month 18% Law Enforcement initiated 33.5 min average response time 76.1% Stabilized in the community

38. The Crisis Response Center • Built with Pima County bond funds in 2011 to provide an alternative to jail, ED, hospitals • 12,000 adults + 2,400 youth each year • Law enforcement receiving center • 24/7 urgent care, 23 hour observation, and short-term inpatient • Space for community clinic staff • Adjacent to • Crisis call center • Inpatient psych hospital for Court Ordered Evaluations • Mental health court • Emergency Department (ED) • Managed by Connections since 2014 ConnectionsAZ/Banner University Medical Center Crisis Response Center in Tucson, AZ

39. The Crisis Response Center“We address any behavioral health need at any time.” • Referrals from: • Law enforcement • Crisis Mobile Teams • Walk-ins • Transfers from EDs • Foster Care • Studies show this model: • Critical for pre-arrest diversion2 • Reduces ED boarding3,4 • Reduces hospitalization3,4 CIT Recommendations for Mental Health Receiving Facilities1 Single Source of Entry On Demand Access 24/7 No Clinical Barriers to Care Minimal Law Enforcement Turnaround Time Access to Wide Range of Disposition Options Community Interface: Feedback and Problem Solving Capacity

40. “It’s easier to get into heaven than a psychiatric facility.”

41. Low clinical barriers to access • “No wrong door” • We do our best to take everyone: • No such thing as “too agitated” • Can be highly intoxicated • Can be voluntary or involuntary • Fewer medical exclusionary criteria than many inpatient psych hospitals • Law enforcement is never turned away Otherwise, where would these patients go?

42. Crisis Response Center, Tucson AZ The CRC provides safe environment where people can be under continuous observation and lack the means to hurt themselves or others, while being as comfortable and welcoming as possible

43. Law Enforcement is a “Preferred Customer” Gated Sally Port Crisis Response Center, Tucson AZ

44. Easy access for law enforcement Crisis Response Center Tucson AZ

45. 23-Hour Observation Unit • Staffed 24/7 with MDs, NPs, PAs • Medical necessity criteria similar to that of inpatient psych (danger to self/other, etc.) • Diversion from inpatient: • 60-70% discharged to the community the following day • Early intervention • Median door to doc time is ~90 min • Interdisciplinary team • Including peers with lived experience • Aggressive discharge planning • Collaboration and coordination with community & family partners • Assumption that the crisis can be resolved Peers with lived experience are an important part of the interdisciplinary team.

46. What should we be striving towards? • Values-Based Outcomes and Services • Start by defining core values • A Critical-to-Quality (CTQ) tree can be used to translate values into desired outcomes • Then create processes that are designed to achieve these outcomes Timely Safe Accessible Least Restrictive Excellence in Crisis Services Effective Consumer and Family Centered Balfour ME, Tanner K, Jurica PS, Rhoads R, Carson C. (2015) Community Mental Health Journal. 52(1): 1-9.http://link.springer.com/article/10.1007/s10597-015-9954-5 Partnership

47. Values-Based Outcome Metrics • Door to Diagnostic Evaluation • Left Without Being Seen • Median Time from ED Arrival to ED Departure for ED Patients: Discharged, Admitted, Transferred • Admit Decision Time to ED Departure Time for ED Patients: Admitted, Transferred Timely CRISES: Crisis Reliability Indicators Supporting Emergency Services • Rate of Self-directed Violence with Moderate or Severe Injury • Rate of Other-directed Violence with Moderate or Severe Injury • Incidence of Workplace Violence with Injury Safe • Denied Referrals Rate • Provisional: Call Quality Accessible • Community Dispositions • Conversion to Voluntary Status • Hours of Physical Restraint Use • Hours of Seclusion Use • Rate of Restraint Use Least Restrictive Excellence in Crisis Services Effective • Unscheduled Return Visits – Admitted, Not Admitted Consumer and Family Centered • Consumer Satisfaction • Family Involvement Balfour ME, Tanner K, Jurica PS, Rhoads R, Carson C. (2015) Community Mental Health Journal. 52(1): 1-9.http://link.springer.com/article/10.1007/s10597-015-9954-5 • Law Enforcement Drop-off Interval • Hours on Divert • Provisional: Median Time From ED Referral to Acceptance for Transfer • Post Discharge Continuing Care Plan Transmitted to Next Level of Care Provider Upon Discharge • Provisional: Post Discharge Continuing Care Plan Transmitted to Primary Care Provider Upon Discharge Partnership

48. Outcomes: Police Turnaround Time • Law enforcement is an important customer. • Half of our patients arrive via law enforcement. • Many of these people would otherwise be taken to jail (or an ED). • Quick turnaround time (faster than a jail booking) is critical to providing a viable alternative to jail. Our Phoenix facility achieves similar results with twice the volume.

49. CRC Key Performance Measures Balfour ME, Tanner K, Jurica JS, Llewellyn D, Williamson RG, Carson CA; Joint Commission Journal on Quality and Patient Safety. 2017;43(6):275-283. https://doi.org/10.1016/j.jcjq.2017.03.008

50. The best measure of effective collaboration…