Current Federal Initiatives Promoting Crisis Services

Richard McKeon Ph.D.

Chief, Suicide Prevention Branch

Centers of Excellence

On March 31, 2014, Congress passed the Protecting Access to Medicare Act (H.R. 4302), which included a demonstration program (Section 223) of Certified Community Mental Health Centers (CCBHCs). CCBHCs will increase Americans’ access

to community mental health and substance use treatment services while improving Medicaid reimbursement for these services.

Section 223 of Protecting Access to Medicare Act

• November 12th Listening Session

• Creates criteria for certified community behavioral health clinics

• Provides $25,000,000 that will be available to states as planning grants for the two year pilot. Only states that receive a planning grant will be eligible to apply for the pilot

• Stipulates that 8 states will be selected to participate in the pilot.

Section 223

• Selected states will receive a 90% FMAP for all of the required services provided by the Certified Community Behavioral Health Clinics

• Under the scope of services is listed:

• Crisis Mental Health Services, including 24 hour mobile crisis teams, emergency crisis intervention services, and crisis stabilization

• Medicaid demonstration project with recs from Sec. HHS to Congress at conclusio

Increasing Crisis Access Response Efforts

• $10m demonstration activity to help communities build, fund, and sustain crisis systems capable of preventing and deescalating behavioral health crises as well as connecting individuals and families with needed post-crisis services. In many incidences, responses to these situations are poorly coordinated and ineffective.

Behavioral Health at the Crossroads

Current system is:

• Fragmented

• Deficit-based

• Crisis-driven

– Ineffective

–Costly

–Harmful

Building a Crisis Services Continuum

Crisis Respite

Outpatient Provider

Family & Community Support

Crisis Telephone Line

WRAP

Crisis Planning

Housing & Employment

Health Care

23-hour Stabilization

Mobile Crisis TeamCIT Partnership

EMS Partnership

24/7 Crisis Walk-in Clinic

Hospital Emergency Dept.

Integration/Re-integrationinto Treatment & Supports

Peer Support

Non-hospital detox

Care Coordination

EARLY

INTERVENTION RESPONSE

POSTVENTIONPREVENTION

TRANSITION SUPPORTS

Critical Time Intervention, Peer Support & Peer Crisis Navigators

TO MATCH A CONTINUUM OF CRISIS INTERVENTION NEEDS

Components of Comprehensive Crisis Systems

• Mobile crisis response teams

• Crisis stabilization beds

• Hotlines and warmlines

• Crisis respite

• Psych emergency/walk in

• Post crisis follow up engagement and support

• Role of peers

• Report commissioned on crisis components

Comprehensive Crisis Response

Peer Respite

Second Story

Ten Essential Values of Crisis Services

1. Avoiding harm

2. Intervening in person-centered ways

3. Shared responsibility

4. Addressing trauma

5. Establishing feelings of personal safety

6. Based on strengths

7. The whole person

8. The person as credible source

9. Recovery, resilience, and natural supports

10. Prevention

Current SAMHSA initiatives

• Promoting Comprehensive Crisis Systems

• Work with CMS Community Care Transitions

• National Suicide Prevention Lifeline-expansion to 24 hour crisis chat coverage

• Focus on mobile outreach, Emergency Department Care, and Care Transitions/post discharge follow up

Comprehensive Crisis Systems

• SAMHSA interested in how comprehensive crisis systems are designed, funded and staffed

• While there are models in different states, comprehensive crisis systems are not generally available across the United States

• This leads to huge pressures on Emergency Departments and law enforcement, poor outcomes.

Comprehensive crisis services

• Growing evidence base on the effectiveness of comprehensive crisis services, particularly as diversions from hospitalization or incarceration

• Growing evidence of cost-effectiveness in ROI studies.

• Most crisis services have had to depend on multiple funding sources “collaborative funding”.

Recent SAMHSA crisis initiatives

• Paper-Crisis Services, Effectiveness, Cost Effectiveness and Funding Strategies

• Financing study of post discharge follow up

• Financing study of telemental health , including financing of crisis services

• Incorporation of postdischarge follow up/care transitions as a focus in GLS and NSSP grants

MISSED OPPORTUNITIES = LIVES LOST

• The numbers of people being seen in EDs for a suicide attempt has been increasing, while the proportion hospitalized has been decreasing (Larkin, 2008)

• Only 48% of adult Medicaid recipients seen in EDs for a suicide attempt received a mental health evaluation and only 52% received outpatient follow up within 30 days

MISSED OPPORTUNITIES = LIVES LOST

• For youth age 10-19 who receive Medicaid and were seen in the ED for a suicide attempt, almost 73% were discharged BUT only 39% received a mental health evaluation, and 43% received outpatient treatment within 30 days

• Best predictor of outpatient follow up was recent outpatient mental health treatment

EMERGENCY DEPARTMENT F/U• Fleischmann et al (2008)

– Randomized controlled trial; 1867 Suicide attempt survivorsfrom five countries (all outside US)

– Brief (1 hour) intervention as close to attempt as possible

– 9 F/u contacts (phone calls or visits) over 18 months

0

0.5

1

1.5

2

2.5

3

Died of Any Cause Died by Suicide

Pe

rce

nt

of

Pa

tie

nts

Results at 18 Month F/U

Usual Care Brief Intervention

major international efforts have reduced suicides

• Taiwan-nationwide effort to intervene with those who have attempted suicide, 50,000+

• 63.5% reduction in suicide attempts among those who accepted the program. Those who refused but then persuaded 22% reduction.

• English National Strategy- 24 hours crisis care strongly associated with reduction in suicides.

• Proactive outreach and discharge f/u 7 days

National Strategy for Suicide Prevention

Objective 8.4

• There is substantial evidence that discontinuities in treatment and fragmentation of care can increase the risk for suicide. Death by suicide in the period after discharge from inpatient psychiatric units is more frequent than at any other time during treatment.92

Promote continuity of care and the safety and well-

being of all patients treated for suicide risk in

emergency departments or hospital inpatient units.

NSSP Objective 8.8

• NSSP Objective 8.8-Develop collaborations between Emergency Departments and other health care providers to provide alternatives to emergency department care and hospitalization when appropriate, and to promote rapid follow up after discharge.

Contact information:Richard McKeon, Ph.D., M.P.H.

Branch Chief, Suicide Prevention, SAMHSA240-276-1873

Richard.mckeon@samhsa.hhs.gov