Background

Connections Health Solutions (Connections) reviewed the Mental Health Services Manual, with particular focus on Appendix G: Comprehensive Crisis Services.

With the launch of 988 Virginia’s existing crisis infrastructure, jails, emergency departments and inpatient psychiatric units, will face unprecedented demand. As Virginia’s current system is already facing demand beyond its capacity, and significant staffing shortages, without immediate intervention the state risks exacerbating current challenges.

Crisis receiving centers can alleviate the pressure on state inpatient psychiatric units, EDs and jails, while providing immediate access to mental health care of patients. However, the success of a crisis receiving center depends on the ability to implement a “no wrong door” strategy.  “No wrong door” embodies the philosophy that individuals in crisis should be able to receive care no matter how they arrive at the center.  This requires the ability to accept individuals that may need to be evaluated for court-ordered treatment, that may appear to be higher acuity, but can be successfully managed, and the ability to use seclusion and restraint only when necessary and by trained personnel. 

Connections has provided commentary below on the medical necessity criteria for 23-Hour Crisis Stabilization highlighting language that runs counter to the ‘no wrong door’ philosophy. Many thanks to the Department of Medical Assistance Services for the opportunity to provide comment.

Feedback on 23-Hour Crisis Stabilization Medical Necessity Criteria

Our founders pioneered the 23-hour crisis stabilization model in Texas in 1993. Within 30 days of opening, the state psychiatric hospital census had been reduced by 50% as a result. Subsequent studies found that regional readmission rates dropped to 6%. Dr. Carson subsequently ran a small study to understand if it was possible to predict at the time of admission to 23-hour crisis stabilization whether a patient would require continued stabilization at time 24-hours. His findings were telling, he was not able to predict who would require continued stabilization, in short, the 23-hour level of care was effective in stabilizing even high acuity patients. This underscored the need for the 23-hour crisis stabilization of care to effectively stabilize patients and provide immediate access to multidisciplinary teams and medication management before connecting to alternate levels of care.

In Appendix G of the Mental Health Services Manual the exclusion criteria for 23-Hour Crisis Stabilization specifies that those with “a presence of sufficient severity to require acute psychiatric inpatient, medical, or surgical care” are not appropriate for 23-Hour Crisis Stabilization. Connections recommends removing “sufficient severity to require acute psychiatric inpatient” from the exclusion criteria.

In Arizona, 100% of patients admitted to Connections’ 23-Hour Crisis Stabilization units (~20k annually) are suitable for admission to an inpatient level of care. Even so, 60 – 70% are released to the community in lieu of an inpatient stay. These outcomes are driven by a commitment to patient-centered care and the belief that even high acuity patients can improve clinically. As the clinical picture improves, Connections transfers patients to the least restrictive environment which will still support the patient’s needs. In essence, without a stay in a 23-Hour Stabilization unit for assessment and treatment, a determination cannot truly be made with respect to the need for psychiatric inpatient care.

The exclusion criteria as listed above runs the risk of violating the “no wrong door” policy. The ‘no wrong door’ policy is in part successful due to the ease of communication with all stakeholders. Law enforcement understands that they can drop-off any patient for treatment. Individuals can walk in through the front door and know they can be treated. The exclusionary criteria as it stands now, may open the door to crisis receiving centers refusing to accept certain high acuity patients. If law enforcement and the community aren’t clear on who is suitable for crisis receiving centers or meet challenges in gaining access to crisis receiving centers, they will be less likely to use the crisis receiving center and the system falls apart.   

About Connections Health Solutions

Connections is the founder of the 23-Hour Crisis Stabilization model. Connections’ clinical leadership Drs. Carson and Williamson created the first crisis observation units in Texas in the 1990s. Following their success in Texas, Drs. Carson and Williamson founded Connections in 2009 in Phoenix, Arizona to take over the management of the Urgent Psychiatric Center (UPC). Under Connections’ leadership, the UPC was transformed from a struggling facility with high employee turnover and variable outcomes into the nation’s premier crisis care center. Connections has set the national standard for urgent and emergency psychiatric services: 65% of patients who enter our crisis centers, inclusive of high-acuity and involuntary admissions, are successfully stabilized in <24 hours and safely discharged to the community in lieu of an inpatient psychiatric admission. 

In 2014, Connections expanded in Arizona by assuming management of the Crisis Response Center (CRC) in Tucson. Joined by Dr. Margie Balfour, the CRC underwent a full-scale quality improvement process. Dr. Balfour’s pioneering work on defining crisis outcome measures, developed at the CRC, has been adopted as a national standard by SAMHSA. Additionally, thanks to concerted investment in law enforcement partnership, the CRC’s collaboration with the Tucson Police Department has been recognized as a model Law Enforcement Mental Health Collaboration Learning Site by the U.S. Department of Justice. It is a frequent stop for counties researching crisis best practices. 

Connections’ leadership has been integral to the creation of the nationally recognized Arizona model. Most recently our work has been profiled in Roadmap to the Ideal Crisis System, released by the National Council for Mental Wellbeing and the Group for the Advancement of Psychiatry in 2021 (co-authored by Dr. Balfour).

Connections’ centers are an essential community resource with the ability to quickly triage, assess, and initiate treatment in a safe and healing environment.  Law enforcement is treated as a “preferred customer” with drop-off times of 5-10 minutes, to incentivize transport to treatment instead of jail. An interdisciplinary team of psychiatrists, nurses, social services staff, behavioral health technicians, and peer supports focuses on early intervention, crisis stabilization, and discharge planning.