How to Make Behavioral Health Crisis Care More Universal

In Arizona, a woman calls 9-8-8 because her mother is refusing to take her antipsychotic medications and has threatened to hurt herself. In ten minutes after the Tucson Police Department’s Mental Health Support Team (MHST) shows up, the mom is transported to Connections Crisis Response Center where she is quickly seen by an interdisciplinary care team of psychiatrists, nurses, social workers, and behavioral health technicians. Upon evaluation, the team develops an appropriate care plan and after several hours under observation, has her crisis stabilized, scheduled for a follow up visit, and equipped with resources to recover back in her home.

Core to the Connections Health Solutions philosophy is that with rapid assessment, early intervention, and proactive discharge planning, most individuals (65-70%) can be stabilized and transitioned to community-based care within 24 hours, reducing the need for restrictive and costly hospitalization. In addition, our outpatient post-crisis transitional program keeps individuals stable in the community until they connect with a long-term outpatient provider. 

In far too many communities across the country, a person in a behavioral health crisis who dials 9-8-8 has a much different experience. According to a RAND Corporation study, only 28% of survey respondents stated their county behavioral health agency’s jurisdiction had access to a mental health urgent care; only 19% said they had sufficient psychiatric emergency bed capacity[1]. The gap in access results in the person in crisis being taken by police to a crowded emergency department where they “board" in a hallway for hours as patients with physical pain wheel by. After several hours or even days of receiving little-to-no treatment, they are admitted to an inpatient program, when it potentially could have been avoided altogether.

Arizona is often referenced as a national model for behavioral health services for its innovative approach to “braiding” its Medicaid, federal grant dollars and state and county mental health funding together to provide quality care, regardless of insurance coverage. It is critical to have a healthcare system equipped to serve the most highly acute individuals – including those who are agitated, violent, a danger to self/others, intoxicated, experiencing withdrawal, and those requiring involuntary treatment. But even here, gaps still exist, and the situation is even worse across the country.

While there are nationwide standards and expectations for medical emergencies, the response to behavioral emergencies varies widely and rarely delivers comparable quality of care. Medicare, which covers over 64 million people, and often drives private insurance company decisions, provides little-to-no coverage for community-based crisis services.[2] As a result, the crisis care for over 220 million Americans is subsidized by Medicaid, and other taxpayer funded safety net mechanisms such as federal block grants, and state/local and county funds -- creating both a public health issue and social justice issue.[3] 

Bi-partisan efforts in Congress and the Centers for Medicare and Medicaid Services (CMS) have recently taken significant steps to improve Medicare coverage for crisis stabilization services, including increasing payment rates for crisis psychotherapy services, requiring the U.S. Department of Health and Human Services to identify, publish, and update best practices for a crisis response continuum of care, and establishing a pilot program to allow for mobile crisis response teams. The Biden Administration should also be applauded for using its rule-making authority to seek comments on addressing current gaps in access and provision of a full continuum of behavioral health crisis services.  

To support consistency and health equity, CMS should collaborate with the Substance Abuse and Mental Health Services Administration (SAMHSA) to better define crisis services, develop specialized standards of care, and advance demonstration models under its Innovation Center to expand availability through Medicare and Medicaid. Additionally, Medicare coverage for the full continuum of community-based crisis stabilization services, including free-standing community crisis response centers, needs to achieve high-quality behavioral health care that is widely accessible. This approach would improve patient outcomes, mitigate healthcare provider shortages, and reduce crisis care costs, allowing patients in behavioral health emergencies to receive the care they need with the same level of support as those in medical emergencies.

Chris Santarsiero is the VP of Government Affairs for Connections Health Solutions.

 

[1] Preparedness for 988 Throughout the United States: The New Mental Health Emergency Hotline | RAND

[2] CMS Releases Latest Enrollment Figures for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) | CMS

[3] Health Insurance Coverage of the Total Population | KFF

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