Tucson Shares Blueprint for Crisis System Success

The city of Tucson’s crisis response system, which was built in stages over the past 20 years, provides a continuum of care to individuals at any stage of a mental health crisis, from early intervention to acute stabilization and aftercare, explained Margie Balfour, M.D., Ph.D., chief of quality and clinical innovation at Connections Health Solutions and an associate professor of psychiatry at the University of Arizona. She spoke at the recent conference “REIMAGINE: A Week of Action to Reimagine Our National Response to People in Crisis,” sponsored by the National Alliance on Mental Illness.

The crisis hotline for the southern Arizona region receives about 10,000 calls a month involving individuals with mental health, suicidal, or substance use crises, 80% of which are resolved through telephonic counseling. That’s because the Regional Behavioral Health Authority overseeing the program contractually requires area mental health clinics to enter available appointment slots in the hotline’s computer system to serve callers in need.

“Part of what it takes to resolve someone’s crisis at 2 a.m. is being able to say ‘We can get you an appointment for that at 11:30 this morning,’ ” Balfour said. To help keep people in crisis out of jail, hotline staffers are co-located with 911 dispatchers, so they can intercept crisis calls that the police would have otherwise handled.

For situations that cannot be resolved by phone, hotline staff can dispatch one of 16 mobile crisis teams with specially trained clinicians. The teams resolve the crises of 70% of callers in the field, and the rest are transported for immediate care to one of several crisis stabilization centers. The largest of these is the Crisis Response Center (CRC), which is the heart of the crisis system in the Tucson area.

The CRC serves 12,000 adults and 2,400 youth a year, Balfour said. It offers a variety of services, including a 24/7 mental health urgent care and a 23-hour observation unit for patients who would otherwise be “boarded” in the emergency room. Staff can also initiate medication-assisted treatment (MAT) for individuals experiencing opioid withdrawal. The CRC was built with Pima County bond funds, with Medicaid payments funding the patient care.

It has been run by ConnectionsAZ since 2014 and staffs an interdisciplinary team, including psychiatrists, social workers, nurses, and peers. Balfour said many patients treated by the CRC are a danger to themselves or others, acutely psychotic, intoxicated, or experiencing withdrawal. “Our philosophy is that a lot of these people don’t need to be hospitalized if we start treatment early and very aggressively,” she said.

The facility is adjacent to an emergency department, inpatient psychiatric facility, and a mental health court, providing easy access to additional services for those who need them. Also, there are various post-crisis wraparound services that provide ongoing treatment, so that most people can remain in the community.

Tucson’s Crisis System Structure

The state’s Medicaid program—Arizona Health Care Cost Containment System (AHCCCS)—handles all of Tucson’s crisis services funds, pooling together funding from a variety of sources, including federal block grants and state and local crisis funds. Because of this braided funding model, service providers can accept any individual in crisis regardless of health insurance status or type, Balfour said.

The various components of the crisis response system are designed to work together seamlessly, Balfour explained. Three critical features are accountability, collaboration, and continuous improvement through collection of outcome data that drive decision-making. “Arizona has a lot of these features baked into how our crisis system is financed, so many communities are looking to our state as a model for how to set up their own crisis systems.”

For each part of the state, AHCCCS contracts with its Regional Behavioral Health Authority, which in turn contracts with various crisis services providers. It keeps them aligned on one simple clinical and financial goal: providing patient care in the least restrictive and least expensive setting possible.

Diverting Patients From Jail

Tucson’s CRC is set up to make it easier for law enforcement officers to bring people for treatment rather than to jail. “The whole crisis system treats officers as preferred customers,” Balfour said. With that goal in mind, staff process new patients in 10 minutes or less, a fraction of the time it would take officers to drop people off at the Pima County jail. Mobile crisis teams are contractually obligated to give officers its fastest response time—less than 30 minutes. Officers are given a secure, dedicated entrance for which they are not required to remove their weapons, thus removing an obstacle that might otherwise deter police.

The CRC has adopted a “no wrong door” approach, so it never turns away a person in crisis brought in by law enforcement officers. “We’ll work on getting patients stabilized and sent to where they need to go,” she said. “We take everybody. … We don’t use security but have highly trained behavioral health care staff. We feel that if we turn people away because they’re too acute, or too violent, or too agitated, they’re going to be taken to an emergency room and restrained on a gurney or they’re going to end up in jail. We feel that these people have the highest needs, and they belong in a specialized facility like ours.”

The city also has several dedicated “co-responder teams,” in which peers and plainclothes detectives or police officers work in tandem on homeless outreach, substance use response, and follow up on high-risk individuals with mental illness, all with the goal of connecting people with treatment before a situation escalates to crisis.

“A large part of the reason this all works is because the Tucson police department has really bought into this idea of being able to serve people with mental health and substance use issues, and it starts with the department’s leadership,” Balfour said. All officers receive basic Mental Health First Aid training. Officers receive incentives for completing more advanced voluntary training, and most of its officers (70%) have also completed the 40-hour Crisis Intervention Training course.

The program has grown every year: In 2013, officers transported fewer than 2,000 individuals for mental health treatment to the CRC, and by 2020, they had brought in nearly 6,000. The success of the crisis system can also be seen in the dramatic decline in the annual SWAT team calls and arrests for vagrancy, civil disturbance, and drinking in public. “From an advocacy standpoint, this is a really good argument for funding these types of programs because look at how much they save,” she said.

Studies of similar crisis services operating in Phoenix were found to save $37 million in emergency department spending in 2012. Phoenix police transported 22,000 patients to crisis service facilities in 2016, cutting $260 million in psychiatric inpatient costs that year. “This is how you can make an argument for communities to invest in these kinds of services,” Balfour said. ■