Better together: Maximizing the benefits of behavioral health in a co-responder program Insight Article - September 10, 2020 Patient Access Population Health Sign in to save Christian Green MA Memphis, Tenn., 1987. A 27-year-old man with a history of mental illness and substance abuse is cutting himself with a butcher knife and reportedly threatening others outside his mother’s house. He is thought to be under the influence of cocaine. His mother calls 911, believing her son might kill himself. Police respond. The man purportedly lunges at them and is shot multiple times, dying on the scene. More than 30 years later, the leitmotif remains: Since 2015, approximately 5,606 people in the United States were fatally shot by police officers. Of those, 1,254, or 22%, were people with mental illness (PMI).1 Police-Mental Health Collaboration programs In response to Joseph DeWayne Robinson’s death, in 1988 the Crisis Intervention Team (CIT) training model was developed through a partnership of the Memphis Police Department, the Memphis Chapter of the Alliance for the Mentally Ill (AMI), mental health providers, University of Memphis and University of Tennessee to organize, train and implement a specialized unit of police officers. Today, CIT International describes this model, which is used by thousands of police agencies globally, as a “community partnership of law enforcement, mental health and addiction professionals, individuals who live with mental illness and/or addiction disorders, their families and other advocates.”2 From CIT sprung four additional Police-Mental Health Collaboration (PMHC) programs: co-responder teams, mobile crisis teams, case management teams and tailored approaches. There has long been a need for PMHC programs in the United States. As Terrence Cunningham, president of the International Association of Chiefs of Police, said in an interview with CBS Sunday Morning, law enforcement has to do its part to improve police/community relations, which starts with providing a different kind of training and support. “We need to change the way we recruit people,” Cunningham said. “Right now we still recruit like we’re 90% law enforcement and 10% social services, when quite frankly it’s just the opposite now — It’s 90% social services and 10% law enforcement actions we take.”3 At the heart of the issue is the belief that law enforcement is diverted from solving and preventing crimes by time spent responding to social issues — such as mental health, homelessness, and drug and alcohol abuse — which they are often not trained to address. This is where co-responder programs come in, which, according to a joint brief from Policy Research, Inc. (PRI) and the National League of Cities (NLC), offer proven alternatives to arrest and further options for law enforcement to respond to non-criminal calls. The authors of the brief postulate that “[c]ommunities and local leaders can use the model to develop a crisis continuum of care that results in the reduction of harm, arrests, and use of jails and emergency departments and that promotes the development of and access to quality mental and substance use disorder treatment and services.”4 Dig deeper: For more on the benefits of collaboration between law enforcement agencies and mental health providers, access the Bureau of Justice Assistance Police-Mental Health Collaboration (PMHC) Tool kit at bit.ly/2EC5gIH. Two of the most important benefits of co-responder programs are less strain on the justice system and better ties to community services. Additional benefits may include: Access/speed of access to care Cost avoidance or cost savings Efficiency of officer time Collaboration and communication between law enforcement and behavioral health practitioners.5 AllHealth Network’s co-responder program An example of a successful co-responder program is AllHealth Network, a nonprofit mental health organization in Arapahoe County, Colo. Established more than a decade ago, its co-responder program now serves six law enforcement agencies in the county, including the sheriff’s office. AllHealth’s co-responder model of support for law enforcement is built “so that they have alternatives to arrest,” said Cynthia Grant, PhD, MBA, LCSW, chief clinical officer. The program connects community health centers with law enforcement agencies and state and local governments that often help fund these programs. With some funding through the Colorado Department of Human Services’ Office of Behavioral Health (OBH), AllHealth typically parcels out that money to different law enforcement agencies, which then pay the balance to fund the program’s co-responders. Although AllHealth can’t bill commercial payers for their services, on rare occasions they are able to bill Medicaid after the co-responder hands the individual over to a case manager. “There’s what’s called secondary response, which is essentially a case manager who does all the follow-up calls after the call responder has been on the scene,” explained Grant. “So those staff occasionally are able to bill for some of their services.” Training AllHealth has 10 co-responders (and a manager) who are licensed clinicians. Each has been practicing for a minimum of two years and receives extensive on-the-job training. That ability to get face time with those who are experiencing a behavioral health crisis helps co-responders understand and reduce the threat of harm, oftentimes keeping these individuals out of jail or the emergency department. For PMI, it provides them with a needed connection and a direct link to mental health and substance use treatment. According to Grant, behavioral health education and training for law enforcement is important for two reasons: “It teaches them how to respond to individuals who are experiencing a behavioral health crisis so that they’re more prepared in the situation,” she asserted. “It also teaches them a lot about de-escalation … and how to interact with a person who might be having a mental health or substance use crisis.” In theory, this training is designed to “reduce the potential for harmful or fatal police encounters for people in crisis,” noted Grant about the need for law enforcement to be better prepared to de-escalate situations involving individuals with behavioral health issues. However, mental health training for law enforcement is often inadequate and/or varies by agency, from no formal training to as many as 40 hours for CIT programs. Co-responder programs can help fill this gap, as licensed clinicians receive 40 hours of crisis de-escalation training alongside officers, in addition to the training they get as licensed clinicians. They also attend CIT International’s annual conference for further training and to bring back new ideas for the program. “They know how to use cognitive behavioral therapy or … motivational interviewing to be able to work in a safe environment with people who are having behavioral health crises,” said Grant of the importance of using licensed clinicians in these calls. Their training goes well beyond what they learn as social workers. As Grant conveyed, they learn much of what’s taught in law enforcement training: the terminology used by police in patrol briefings, how to use a police scanner and how be adroit in safety and equipment. “They need to understand the field training that they get from the officers so that they know everything about where to stand or when it’s OK to intervene, and how they can be exposed to different techniques associated with being on the scene where there’s law enforcement,” stated Grant. Did you know? In July, the Federal Communications Commission (FCC) voted to finalize use of 988, which will replace the 10-digit 24/7 National Suicide Prevention Lifeline in July 2022. The transition period will make it possible to market the new emergency telephone number and prepare for an increase in call volume. As detailed in a 2019 FCC report to Congress, 911 emergency service responders are not equipped to provide counseling to individuals with suicidal thoughts or mental health issues. The 988 system will be a significantly better alternative for those who need access to suicide prevention resources or need to reach a mental health crisis center such as AllHealth, or a co-responder. Responding to a behavioral health crisis AllHealth has two co-responder models, both of which start with the 911 dispatcher. In the first model, according to Grant, the dispatcher notifies the responding officer that the individual has requested a co-responder in that district. “We essentially are monitoring the radio calls that are coming in,” said Grant. “And if our call signal comes through that says they need a co-responder, that’s our cue to be able to spot.” In some cases, the call comes directly to the co-responder; however, it typically comes from a CIT-trained police officer on the scene. After making sure it’s secure, he/she will radio the co-responder. If a co-responder is out on another call or it’s after hours, the officer will submit a referral for a clinician to follow up the next day. A variation to this is when the licensed clinician serves as a true co-responder, arriving on the scene with the CIT-trained officer. Some departments have designated officers who always respond with a co-responder. Conversely, in the expansive 712-square-mile area covered by the Arapahoe County Sheriff’s Office, co-responders employ a different model. “There isn’t bandwidth to put a co-responder in every car,” said Grant. “Instead, for that particular department, the co-responders have their own car through the police department, or in this case the sheriff’s office and then they get to respond.” When co-responders arrive on the scene, they are able to make a difference and engage in some powerful work, stressed Grant. “They are using their clinical skills to make a judgment in terms of what the needs are of the person,” said Grant of their import. “The co-responders have an opportunity to do some clinical intervention, to be able to try and prevent suicide … there might be a domestic violence situation, or an opportunity to be able to get someone connected with treatment and services.” Consequently, the co-responders take some pressure off the justice system, because the individuals in crisis are not incarcerated. Instead, they often get the behavioral healthcare they need. In addition, the co-responders also work closely with the individuals’ families to educate and support them, as well as keep the lines of communication open throughout the encounter. Follow-up After the initial encounter, case managers typically follow up with clients over the telephone or via text. This secondary response, according to Grant “is about trying to coordinate services to set up linkages to community support. The goal of that follow-up call is often to double-check to see what happened after the co-responder left the scene.” If clients are considered “shelter at home,” they stayed at their home and didn’t end up going to detox, the emergency department or jail. Taking it a step further, case managers then make sure the client is receiving the help and resources discussed on the scene, which closes the loop. A point of emphasis is that clients are engaged in their care, confirming that they are connected to mental health or substance use services. “Leaving a brochure on the scene is not enough,” said Grant. “It’s not just about, ‘here’s a phone number to call.’ Being able to do the follow-up helps to hold the person accountable to see what other support they need … if they’re still actually having a crisis.” Why co-responder programs work Quantifying the benefits to all involved, Grant noted three key outcomes of the co-responder program: Approximately 40% of calls result in a crisis intervention by the co-responder in which the individual does not need to be transported to an emergency department or jail Secondary response follow-ups result in nearly 70% of the clients being connected to mental health services The estimated cost avoidance to the community is $350,000 per year per co-responder based on an average of 60 in-person contacts per month. AllHealth also measures how quickly co-responders can get officers “back in service” for other calls. “To be able to put an officer back in service so that the officer is not functioning as a co-responder, as a social worker, as a clinician — the efficiency of the officer time is really important,” said Grant. Another important win is reducing the number of repeat calls from those in need. “In every community, there are some individuals who call 911 very frequently,” said Grant. “It may be because they’re lonely, it may be because of a psychiatric condition, it may be because of recurring substance abuse. What we find is that when a co-responder is involved, it actually helps decrease those repeat calls.” With fewer arrests comes a decrease in the use of force from law enforcement. Having a skilled clinician by their side, coupled with their CIT training and experience with these situations can significantly reduce the need to use force. The co-responder relationship also fosters better communication and collaboration. “We really want to be a resource for law enforcement … for psychological, psychosocial, substance use challenges that they’re experiencing during a behavioral health crisis,” emphasized Grant. “Our relationship with law enforcement entities is strengthened when we have a co-responder who’s embedded in their department.” The return on investment for the public has led some communities to fund the program through their general budgets. With the agencies they work with, AllHealth starts out by offering around eight hours a week of service, which is funded by the OBH. Grant notes that law enforcement often comes back within a few weeks requesting more hours. “Over the past couple of years, we have seen multiple municipalities that are stepping up and paying for these services,” Grant remarked. “And so it is definitely something that we’re being asked more and more to be able to provide co-responder services to different communities.” Ultimately, the most important aspect of co-responder programs is helping those with behavioral health needs, and the proof is in the pudding. “Individuals who are in crisis report feeling less threatened and stigmatized in interactions with co-responder teams, as compared to interactions with law enforcement alone, and that piece is a win for the individual and for law enforcement,” said Grant. “We’re really talking about an individual who has a compassionate, respectful response that actually aligns with what they need when they get a co-responder on scene. That’s one of the true gifts of the program.” Notes: Fatal Force: Police shootings database. Washington Post. Available from: wapo.st/2QKPQ7a. CIT International. ”CIT Is More Than Just Training … It’s a Community Program.” Available from: bit.ly/2YQNDLN. ”Calls for reform, from activists and police.” CBS Sunday Morning. June 21, 2020. Available from: bit.ly/3lC5Ma4. Krider A, Huerter R. “Responding to Individuals in Behavioral Health Crisis via Co-Responder Models: The Roles of Cities, Counties, Law Enforcement, and Providers.” Policy Research, Inc., and National League of Cities. January 2020. Available from: bit.ly/34T81Qz. Ibid.