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How to Develop a Mobile Crisis Response Team
The footprint of EMS has expanded exponentially in recent years. Community paramedic programs have gained traction, and crisis mental health response has come to many EMS organizations. The pandemic placed the frailties of EMS on full display and hastened the looming mental health problems society faces.
Have you been tasked with developing a mobile crisis team to respond to mental and behavioral health emergencies? Are you concerned about what the needs and expectations are? Who are the players, who will contribute to the service, and where do you start? Here is a basic guide.
Expectations
In EMS we provide care 24 hours a day, 7 days a week. This is the same mantra adopted by the Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA has developed a tool kit of best practices for a behavioral health crisis management system of care.1 They include:
1. Regional crisis call centers that coordinate in real time. Calls for assistance may originate via the new 9-8-8 number as it becomes operational; or through 9-1-1, a 7-digit emergency line, or even via 3-1-1 and be transferred.
2. Mobile crisis units, staffed 24/7 and ready to respond immediately.
3. 24-hour crisis receiving and stabilization facilities. These can provide immediate care to anyone in crisis, stabilize them, and then, if necessary, admit them for longer-term treatment and help.
4. Essential crisis care principles and practices. Programs must be able to help patients in crisis, especially those who are suicidal or have homicidal ideation. The clinical pathways we develop to assist them, as well as our safety and screening plans, can be applied to every person we provide care for.
Needs Assessment
A needs assessment is a bedrock component to any health program, especially a mobile crisis unit. It will define your population and what services you provide. The information for needs assessments resides in databases in public health offices, emergency departments, Veterans Affairs facilities, CMS data, outpatient centers for behavioral/mental health, police, dispatch, and EMS. Your needs assessment will outline your current resources (behavioral health support, law enforcement capabilities, receiving centers, etc.) and resources you are lacking.
Resources must be robust and reliable. You are providing service around the clock 365 days a year. If it’s a holiday weekend, the person you are trying to assist may not be able to wait 3 days for help. Not every person will need to go to a receiving facility or be admitted; you must be able to make referrals for outpatient care. Housing, medications, and food may be things people need help with. These basic necessities may be at the root of why they are stressed, but they are not a reason to bring someone to a facility and pass the problem off to someone else.
You may have sufficient receiving centers and trained behavioral health clinicians who want to contribute in your delivery model, or you may determine you are lacking critical elements. Telehealth may help provide access to specialists like licensed clinical social workers (LCSWs) who may be in short supply.
For people who are violent and must be restrained, you must know who will do this and how it will be managed. Law enforcement restraint is different than medical or behavioral health restraint. If it’s the police, training is key. This is a competency that must be practiced.
Educational Gap Analysis
The National Suicide Hotline Designation Act of 2020 provided funds for training intervention teams.2 What do we need to provide for EMS? Training developed for behavioral health professionals may rely on their existing professional knowledge and thus be inadequate for our needs.
The basic EMT receives about 1–2 hours of classroom instruction, based on 15–20 pages in the average EMT textbook, on psychiatric and behavioral health emergencies. We provide them no clinical experience before they go out into the field. For the paramedic it is a little better, about 20–30 pages in most paramedic textbooks, with about 3–4 hours of didactic, but again there is no clinical practicum provided.
The LCSW has 6–7 years of education (a bachelor’s and a master’s) that includes clinical rotations. For EMTs and paramedics to function as effective members of a team, they need their own specific education. Topics might include:
- An overview of general/abnormal psychology
- Description of the behavioral health system
- Mental health disorders
- Mental health and addictions
- Counseling and treatment
- Crisis care
- De-escalation/provider protection
- Medical/behavioral restraint
- Clinical practicum
Team Composition
The stress of working on a mobile crisis unit is something most EMS providers are not prepared for. Mental health screening should be required for any provider joining such a team. The police department has extensive screening for officers because the incredible stressors they deal with put them at risk for substance addiction and self-harm. Psychiatrists and psychologists undergo psychotherapy as part of their training. LCSWs learn about wellness and self-help. We do none of this in EMS.
Staffing your response team will depend on a variety of factors—first, who has the capacity and wants to participate? SAMHSA favors a coresponder model, where you may have an EMT/paramedic, LCSW, and law enforcement who respond as a team.
Law enforcement needs to be a part of any plan, but in many places police are transitioning out of responding to low-threat mental health-type calls. Will police be part of every response, or only the ones where violence is threatened? Clarify roles and responsibilities and conduct joint training for all situations.
Is a behavioral health technician part of your team? Their training is comprehensive, and they will have spent many hours working directly with people who have behavioral health disorders.
The LCSW’s role also cannot be overemphasized. Their ability to respond directly to the scene facilitates a more accurate on-scene assessment. They can also monitor the mental health and wellness of team members. Like a good partner they will realize when things aren’t right.
Clinical Pathways
Clinical pathways help us organize and standardize care, improving patient outcomes and refining organizational efficiency. A single clinical pathway may encompass multiple clinical guidelines.
What type of assessment are you conducting? Ruling out medical problems requires gauging vital signs, skin signs, mental status, and decision-making capacity, but what if the person refuses basic exams? You may only be able to rely on answers to questions and what you observe.
What tool(s) are you using to screen for suicidal ideation? The Columbia-Suicide Severity Rating Scale (C-SSRS) and Ask Suicide-Screening Questions (ASQ) screens are 2 possibilities.3,4 Does your patient want to be treated as an inpatient, or will you need to institute an involuntary commitment? If you are involuntarily committing someone, who is performing it?
Safety plans are needed for patients who won’t seek treatment and aren’t being involuntarily committed. These are short written lists that include coping strategies and sources of support patients can use.5 These strategies can be used before or during suicidal crises. What template will you use to develop your safety plans? Does everyone know how to use them? Keep protocols uniform. Everyone should know how to utilize all the tools in your tool kit.
Summary
The ability to provide mobile crisis services is within reach of any EMS organization. Identifying the needs and capabilities of your community is the most important first step. Team composition and education developed specifically toward EMTs and paramedics are crucial for success. Clinical pathways will ensure you provide the best care to your community.
References
1. Substance Abuse and Mental Health Services Administration. National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit. Published 2020. www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf
2. Congress.gov. S.2661—National Suicide Hotline Designation Act of 2020. Updated October 17, 2020. www.congress.gov/bill/116th-congress/senate-bill/2661
3. Substance Abuse and Mental Health Services Administration. Columbia Suicide Severity Rating Scale. www.samhsa.gov/resource/dbhis/columbia-suicide-severity-rating-scale-c-ssrs
4. National Institute of Mental Health. Ask Suicide-Screening Questions (ASQ) Toolkit. Accessed June 28, 2022. www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials
5. Suicide Prevention Resource Center. Safety planning guide: A quick guide for clinicians. Accessed June 28, 2022. www.sprc.org/resources-programs/safety-planning-guide-quick-guide-clinicians
